Premier Care Center For Palm Springs

F 0684

collaboration.in the next scheduled Comprehensive Care Plan Meeting or sooner if deemed necessary by

the IDT.

Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/20/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Premier Care Center for Palm Springs

2990 East Ramon Road Palm Springs, CA 92264

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

initiated when Resident 1 returned from GACH on July 7, 2025, with a new diagnosis of a UTI. On July 22, 2025, at 4:42 p.m., an interview was conducted with LVN 2, who stated Resident 1's urinary catheter was removed on July 19, 2025, at 8:50 p.m., after RN 1 asked her to remove the urinary catheter. LVN 2 stated

she did not check if there was a physician's order to remove or discontinue the urinary catheter. LVN 2 stated there should be a physician's order to remove an urinary catheter before removing the catheter, document the procedure conducted, and monitor the resident's urine output, presence of pain, or distention, after the urinary catheter was removed. On July 22, 2025, at 4:55 p.m., an interview was conducted with the DON, who stated he would expect the nurse who removed Resident 1's foley catheter to document the procedure, including, results, such as, any trauma and/or blood in urine. The DON verified there was no physician's orders to remove Resident 1's urinary catheter. The DON stated he confirmed LVN 1 removed Resident 1's urinary catheter, and LVN 1 stated she did not document the removal of the resident's urinary catheter. The DON stated staff are required to document every procedure. On July 24, 2025, at 2:03 p.m., a concurrent interview with the Director of Nursing (DON), and review of Resident 1's July Medication Administration Record (MAR), COC's, and monitoring notes was conducted. The DON verified Resident 1 returned from GACH on July 7, 2025, with new orders from the physician for a bladder infection (UTI) and new medication orders were also written on July 11, 2025 for Rocephin (a medication to treat UTI). The DON verified a COC and care plan for a UTI was not completed by nursing staff at the time, and should have been completed. The DON stated, when a resident receives a foley catheter due to complaints of urinary retention, it was his expectations that nursing staff complete a COC and monitor the resident for signs and symptoms of adverse effects from the catheter, including urinary output, pain/discomfort & bladder distention, every shift for 72 hours. The DON further stated, urinary output should be documented in the MAR, while other signs and symptoms of adverse effects from the catheter, should be documented in a monitoring note, each shift. The DON stated he would expect a care plan to be developed for urinary retention and/or foley catheter to be initiated at the time of the complaint, or placement of the catheter. The DON verified a care plan for Urinary Retention was not completed and should have been. A review of the facility's policy and procedure titled, Significant Change of Condition, revised January 2022, indicated, .If, at any time, it is recognized by any one of the team members that the condition or care needs of the resident have changed, the Licensed Nurse or Nurse Supervisor should bed made aware.The nurse will perform and document an assessment of the resident and identify need for additional interventions, considering implementation of existing orders or nursing interventions.Nursing will provide no less than three (3) days of observation, documentation, and response to any interventions . A

review of the facility's policy and procedure, Catheter, Indwelling Removal of, revised February 2025, indicated, .It is the policy of the facility that indwelling Foley catheters will be removed per (Dr's) order.PROCEDURES.Document all appropriate information in medical record.Document Procedure.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/20/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Premier Care Center for Palm Springs

2990 East Ramon Road Palm Springs, CA 92264

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0697

Provide safe, appropriate pain management for a resident who requires such services.

Level of Harm - Minimal harm or potential for actual harm

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

observation, interview and record review, the facility failed to ensure a complete pain assessment was conducted, which included the location of pain, for one out of three residents (Resident 1).This failure had

the potential for Resident 1's pain not to be managed effectively. Findings:On July 22, 2025, at 8:22 a.m.,

an unannounced visit to the facility was conducted to investigate a quality-of-care issue.On July 22, at 8:32 a.m., an interview was conducted with Resident 1, who stated she had a urinary catheter (a long tube insert into the bladder to drain urine) and the licensed nurse pulled it out (removed/discontinued it).

Resident 1 stated she still had burning sensation when she urinated. Resident 1 stated Tylenol (acetaminophen - a non-steroidal anti-inflammatory medication to relieve pain) helps the irritation and discomfort (resident pointed towards her bladder). Concurrently, Licensed Vocational Nurse (LVN) 1, asked Resident 1 what her pain rate was (on a scale from 1-10, 10 being the worst), and resident responded, 6 or 7.On July 22, 2025, at 8:47 a.m., an observation was made of LVN 1, returning to Resident 1's bedroom to administer Tylenol for bladder discomfort.A review of Resident 1's record indicated Resident 1 was admitted to the facility on [DATE REDACTED], with diagnoses of Urinary Tract Infection (UTI - a bladder infection). A review of Resident 1's care plan (an individualized plan of care specific to a related problem, including time framed goals, and nursing interventions), initiated on June 9, 2025, which indicated, .Has acute pain (related to) disease process .Intervention to help relieve resident's pain .Monitor/document for probable cause of each pain episode.A review of Resident 1's physician's orders, dated June 22, 2025, indicated, . Acetaminophen Extra Strength 500 mg (milligrams - a unit of measure), Give 2 (two) tablet (sic) by mouth every 4 (four) hours as needed for Severe Pain 7-10 (on pain scale) .A review of Resident 1's Medication Administration

Record (MAR), for July 2025, indicated, Acetaminophen was administered to Resident 1 on July 22, 2025, at 8:45 a.m.A review of Resident 1's Progress Notes, dated July 22, 2025, at 8:45 a.m., by LVN 1, indicated Tylenol was administered to Resident 1 for a pain scale between 7-10. There was no documentation of the location of the pain. A review of Resident 1's Progress Notes, dated, July 22, 2025, at 1:25 p.m., by LVN 2, indicated, . PRN Administration was: Effective. Follow-up Pain Scale was: 5 . Location of the pain not documented.On July 23, 2025, at 8:47 a.m., an interview was conducted with Registered Nurse (RN) 2, who stated the process to document administration of pain medications, includes documenting the medication administered, location of the pain, and effectiveness of the medication.On July 23, 2025, at 1:42 p.m., an interview was conducted, with LVN 1, who verified, on July 22, 2025, (at 8:45 a.m.) she administered acetaminophen to Resident 1 for discomfort from her urinary tract infection. LVN 1 further stated, when she monitors and documents administration of pain medications, she would include documenting the resident's pain rating on a scale of 1-10, the time the medication was given, and the location of the pain. LVN 1 stated when she administers a PRN pain medication, and she did not document

the location in the progress notes, she would sometimes document under Condition Monitoring.A review of Resident 1's, Condition Monitoring, dated July 22, 2025, indicated there was no documentation of the pain location from LVN 1.On August 4, 2025, at 4:20 p.m., an interview was conducted with the Director of Nursing (DON), who stated he expected the nursing staff to assess a resident for pain, including the location prior to administration of the pain medication, and document the location in the progress note or condition monitoring.A review of the facility's policy and procedures titled, Medication Administration, revised December 2019, indicated, .When PRN (as needed) medications are administered, the following documentation is provided .Complaints or symptoms for which the medication was given .

Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet