Health inspection·March 14, 2025

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure, for five of five residents reviewed (Residents 1, 4, 5, 6, and 7) received medications timely, when Residents 1, 4, 5, 6, and 7 ' s scheduled 9 a.m. medications were administered to the residents passed the required timeframe. Residents Affected - Some This failure had the potential for the residents to experience discomfort, and a delay in the intended therapeutic effect of the medications. Findings: On February 25, 2025, at 9:25 a.m., an unannounced visit was conducted at the facility to investigate a complaint regarding quality of care. On February 25, 2025, at 11 a.m., Resident 1 was observed sitting up on the edge of bed. In a concurrent interview, Resident 1 stated she had some missed medications in the past. Resident 1 further stated the main medication she cared about was her Ritalin (methylphenidate - medication to treat used to treat attention deficit hyperactivity disorder). On February 25, 2025, at 1:30 pm, a concurrent interview and record review was conducted with the Director of Staff Development (DSD), and Licensed Vocational Nurse (LVN) 1. LVN 1 stated Resident 1 ' s Medication Administration Record, indicated the following medications scheduled at 9 a.m., on February 8, 2025, were administered to Resident 1 at 1:15 pm p.m. by LVN 2: - Amlodipine (medication to treat high blood pressure) 5 mg (milligram - unit of measurement); - Ascorbic acid 500 mg; - Cardizem (LA - long acting) (medication to treat high blood pressure) 300 mg; - Docusate sodium (medication to treat constipation)100 mg; - Duloxetine HCL (medication to treat nerve pain) 30 mg; - Famotidine 20 (medication to treat excess stomach acid) mg; - Ferrous sulfate (medication to treat anemia [a condition in which the body does not have enough healthy red blood cells or hemoglobin]) 325 mg; Page 1 of 3 056328 056328 03/14/2025 Premier Care Center for Palm Springs 2990 East Ramon Road Palm Springs, CA 92264

F 0684 - Methylphenidate HCL (medication to treat attention deficit disorder) 20 mg; Level of Harm - Minimal harm or potential for actual harm - Multivitamin (vitamin supplement); - Oxybutynin chloride (medication to treat loss of bladder control) 5 mg; Residents Affected - Some - Pro-stat (protein liquid supplement) oral liquid; - Sertraline HCl (medication to treat depression) 50 mg; and - Apixaban (medication to help prevent stroke or blood clots) 5 mg. In a concurrent interview, the DSD stated Resident 1 ' s medications scheduled at 9 a.m. should have been administered within one hour of the scheduled time frame. The DSD further stated delayed medication administration could cause a disruption in the intended therapeutic effects of the medication. On February 25, 2025, at 2;30 p.m., during an interview with LVN 2, LVN 2 stated she administered Resident 1 and other resident ' s 9 a.m. medications on February 8, 2025, at around 1 p.m. LVN 2 stated she got busy and was not able to ask for assistance from her co-workers. LVN 2 stated she should have prioritized her tasks better so she could administer the residents ' medications on time. On February 25, 2025, at 4:00 pm a concurrent interview and record review was conducted with the Director of Nursing (DON). The DON stated LVN 2 was assigned to Residents 1, 4, 5, 6, and 7 on February 8, 2025. The DON stated LVN 2 administered Resident 1 ' s 9 a.m. medications on February 8, 2025, at 1:15 p.m. The DON stated Resident 4 ' s Depakote DR (delayed release [medication to treat seizures]) scheduled at 9 a.m., on February 8, 2025, was administered to Resident 4 at 1:44 p.m. The DON stated Resident 5 ' s following medications scheduled at 9 a.m., on February 8, 2025, were administered at 1:43 p.m.: - Amlodipine besylate (medication to treat high blood pressure); - Docusate sodium 100 mg; - Levetiracetam (medication to treat seizures) Oral 500 mg; and - Memantine (medication used for dementia [memory loss]). The DON stated Resident 6 ' s following medications scheduled at 9 a.m., on February 8, 2025, were administered at 10:37 a.m.: - Amlodipine 10 mg; - Aricept 5 mg (medication used for dementia); - Buspirone HCl 5 mg (medication to treat anxiety); 056328 Page 2 of 3 056328 03/14/2025 Premier Care Center for Palm Springs 2990 East Ramon Road Palm Springs, CA 92264

F 0684 - Escitalopram Oxalate (medication to treat depression) 20 mg; Level of Harm - Minimal harm or potential for actual harm - Folic Acid (medication to treat anemia) 1 mg; - Gabapentin (medication to treat nerve pain) 100 mg; Residents Affected - Some - Isosorbide Monotitrate (medication to treat high blood pressure) 30 mg; - Keppra (medication to treat seizure) 500 mg; and - Metoprolol 25 mg (medication to treat high blood pressure) 25 mg. The DON stated Resident 7 ' s following medications scheduled at 9 a.m., on February 8, 2025, were administered at 1:53 p.m.: - Ascorbic Acid (vitamin supplement) 500 mg; - Aspirin (medication to treat fever, pain, and prevent stroke) 81 mg; - Docusate Sodium (stool softener) 100 mg; - Furosemide (diuretic) 20 mg; - Levetiracetam 500 mg; The DON stated Residents 1, 4, 5, 6, and 7 ' s medications scheduled at 9 a.m. on February 8, 2025, should have been administered within one hour of the scheduled time frame. A review of the facility ' s undated policy and procedure titled Premier Care Center Policy/Procedure-Nursing Clinical, indicated, .It is the policy of this facility to accurately prepare, administer and document oral medications . 056328 Page 3 of 3