Health inspection·August 20, 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure an evaluation of elevated blood pressure and notification to the physician was conducted, for one of three residents reviewed (Resident 1). This failure had the potential for a delay in the care and treatment of Resident 1's uncontrolled hypertension (high blood pressure) and had the potential to experience complications related to high blood pressure. Findings:On July 22, 2025, at 8:25 a.m., during observation of medication pass conducted by Licensed Vocational Nurse (LVN) 1, LVN 1 was preparing medications for Resident 1. LVN 1 stated she checked Resident 1's blood pressure and was 171/70 mm HG (millimeters of mercury - a unit used to measure pressure, specifically blood pressure; normal blood pressure is 120/80). LVN 1 stated Resident 1 had a PRN (as needed) Clonidine (medication to treat high blood pressure) every eight (8) hours if more than 160. LVN 1 was observed to explain to Resident 1 the medications she prepared to be administered including the resident's blood pressure medication. LVN 1 was observed to tell Resident 1 that she will come back later to check her blood pressure again later as she administer the medications as the BP was high. On July 22, 2025, at 9:17 a.m., an interview was conducted with Resident 1. Resident 1 stated her BP went up and she was transferred to the acute hospital.On July 22, 2025, at 9:35 a.m., LVN 1 was observed to rechecked Resident 1's BP and it was 190/82. LVN 1 was observed to explain to Resident 1 she would prepare to give her PRN BP medication. On July 22, 2025, at 9:42 a.m., LVN 1 was observed to administer to Resident 1 PRN Clonidine and explained to the resident she will recheck her BP in a little while. On July 22, 2025, at 11;56 a.m., a follow up interview was conducted with Resident 1. Resident 1 stated her BP was rechecked and was still a little high at 170 over something (unable to recall). Resident 1 stated she would feel her eyes get wavy when her BP was high, and stated it felt less now. A review of Resident 1's record indicated Resident 1 was admitted to the facility on [DATE], with diagnoses which included heart failure and hypertension (high blood pressure).A review of Resident 1's History and Physical Examination, dated June 10, 2025, indicated Resident 1 had the capacity to understand and make decisions. A review of Resident 1's, care plan (Plan of care specific to a health condition, with interventions, and time framed goals), titled, .Altered Cardiovascular status (related to) . (HTN) ., initiated June 10, 2025, indicated, resident's care plan was not re-evaluated, or updated, after Resident 1's return from GACH on July 6, 2025.A review of Resident 1's Order Summary Report, included the following medications to address hypertension:- Losartan Potassium, 50 MG (milligram - a unit of measure) one time a day for HTN, Hold if SBP < (less than)110 or (Heartrate {HR}) <60, date ordered June 9, 2025;- Hydralazine 25 MG , two times a day (BID) for HTN, hold if SBP is under 110, date ordered June 24, 2025, - Clonidine 0.1 MG, every 8 hours, as needed for HTN. Give if SBP (Systolic BP - top number of BP) is 160 or higher, date ordered June 26, 2025; and- Metoprolol ER (Dose changed to) 50 MG, Daily, Hold if SBP <110 or HR <60; date ordered June 26, 2025.A review of Resident 1's Medication Administration Record (MAR), Residents Affected - Few Page 1 of 6 056328 056328 08/20/2025 Premier Care Center for Palm Springs 2990 East Ramon Road Palm Springs, CA 92264

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few for the month of July 2025, indicated PRN Clonidine was administered to Resident 1 13 times from July 1, 2025 to July 23, 2025, when the resident's BP was above 160. Further review of Resident 1's MAR indicated BP being checked twice daily and Resident 1's BP was above 160 almost daily. - A review of Resident 1's Progress Notes, dated, July 6, 2025, at 5:37 p.m., by Registered Nurse (RN) 1, indicated, .(Resident 1) had a Hypertensive episode. BP of 223/111. Nurse Administered Clonidine.and Hydralazine (Both medications to control HTN).(Resident 1's) BP went down to 183/79.(Resident's representative) (notified) and requested (resident) be sent. (to GACH) for HTN. (Resident 1) sent to (GACH).for further evaluation . A review of Resident 1's Progress Notes, dated July 7, 2025, at 7:28 a.m., indicated (Resident 1) back from (GACH) at (7:20 a.m.). returned in stable condition. No new orders for HTN noted.A review of Resident 1's Progress Notes, dated July 23, 2025, at 6:42 a.m., indicated, .At 0600 (6 a.m.) BP was 198/95 gave patient evaluated BP medication PRN as ordered 15 mins (minutes) later recheck BP was 205/95 called 911. Patient was sent out to (name of acute hospital) due to hypertension .Further review of Resident 1's record indicated there was no evaluation conducted or referral to the physician of Resident 1's elevated BP after readmitted from GACH on July 7, 2025, despite Resident 1's BP still above 160 almost daily. On July 24, 2025, at 2:03 p.m., an interview was conducted with the DON. The DON stated the process to treat uncontrolled HTN included documenting a change of condition (COC), notification to the physician of COC, and follow-up monitoring of the resident's BP, documented every shift, for 72 hours. The DON stated if a resident was transferred to GACH due to uncontrolled BP, he would expect the desk nurse to follow-up with the physician and communicate the resident's readmission, so the physician could re-evaluate the resident's HTN plan of care, and make adjustments as needed, including possible new medications and/or additional monitoring orders. In a concurrent review of Resident 1's record, the DON verified Resident 1 transferred to GACH for uncontrolled HTN, on July 6, 2025, and returned to the facility on July 7, 2025, at 7:28 a.m. The DON verified he did not see documentation by the desk nurse that the physician was notified of resident's return from GACH on July 7, 2025. The DON further stated the physician should have re-evaluated Resident 1 within a couple of days, of resident's return from GACH. The DON stated if blood pressure medications were not effective, and the systolic blood pressure (top BP value) was still high, the resident had an increased risk of stroke.A review of the facility's policy and procedure titled, Significant Change in Condition, Response, revised January 2022, indicated, .It is the policy of this facility to ensure each resident receives quality of care and service to attain and maintain the highest practicable physical mental and psychosocial well-being .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 License Nurse or Nurse Supervisor should be made aware. Examples would be.Change or trending change in vital signs, to include.blood pressure.The Nurse will perform and document an assessment of the resident and identify need (sic) for additional interventions, considering implementation of existing orders or nursing interventions or through communication with the resident's provider (DR) using SBAR (COC) or similar process to obtain new orders or interventions.Nursing will provide no less than three (3) days of observation, documentation, and response to any interventions. An attempt to identify the cause for decline, when it occurs.nursing will be responsible for notifying the appropriate department for evaluation. The nurse shall use his/her clinical judgment and shall contact the (DR) based on the urgent of the situation. The Medical Director shall be notified in the event that the Attending Physician or on-call Physician cannot be reached. The interdisciplinary team (IDT - a group of healthcare professionals) shall collaborate with the attending physician, resident, and/or resident representative to review risk indicators and the plan of care. The IDT will document this 056328 Page 2 of 6 056328 08/20/2025 Premier Care Center for Palm Springs 2990 East Ramon Road Palm Springs, CA 92264

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 056328 Page 3 of 6 056328 08/20/2025 Premier Care Center for Palm Springs 2990 East Ramon Road Palm Springs, CA 92264

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, for one of three residents reviewed (Resident 1), the facility failed to ensure:1. A physician's order was obtained to discontinue or remove a urinary catheter prior to removal of the catheter; and 2. Monitoring and documentation of the resident's urine output, any signs and symptoms of pain and/or bladder distention, after the urinary catheter was removed. These failures had the potential for a delay in the care and treatment to address possible adverse effects from removal of the catheter. Findings: On July 22, 2025, at 8:22 a.m., an unannounced visit was conducted at the facility to investigate a quality-of-care issue. On July 22, 2025, at 8:32 a.m., Resident 1 was observed alert, oriented, and was lying in bed. In a concurrent interview, Resident 1 stated she had a urinary catheter (a flexible tube inserted into the bladder to drain urine) and the facility staff recently pulled it out. Resident 1 stated she had burning sensation when she urinated and was being given medication to help her urine to come out. On July 22, 2205, at 9:35 a.m., a follow up interview was conducted with Resident 1, who stated she was having symptoms of painful urination and was sent to the General Acute Care Hospital (GACH) for an unrelated health concern, and returned to the facility diagnosed with a Urinary Tract Infection (UTI - a bacterial infection of the bladder, which can cause a sense of unrelieved urination, burning and/or painful urination). A review of Resident 1's, Resident Information, indicated Resident 1 was admitted to the facility on [DATE], with a diagnosis of heart failure, and hypertension (elevated blood pressure). A review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), Brief Interview for Mental Status (BIMS}-A cognitive assessment), indicated a score of 13 (cognitively intact). A review of Resident 1's Progress Notes, dated July 7, 2025, at 10:02 p.m., indicated, .DURING PM (3 p.m. to 11 p.m.) SHIFT PATIENT REPORTED THE URGE TO VOID WITHOUT ANY URINARY RELIEF. PATIENT BECAME DISTENDED (sic) AND EXPRESSED PAIN. PATIENT WAS STRAIGHT CATHETED (a procedure where a thin, flexible tube (a straight catheter) is inserted into the urethra to drain urine from the bladder and then removed) WITH A review of Resident 1's Order Summary Report, indicated Resident 1 had a physician's order, dated July 7, 2025, which indicated, .INDWELLING CATHETER .DX (diagnosis) TO SUPPORT USE; urinary retention (refers to the condition where there is an inadequate amount of urine produced and excreted, leading to a buildup of urine in the bladder) . A review of Resident 1's Progress Notes, dated, July 7, 2025, at 7:28 a.m., indicated, (Resident 1) back from (GACH) at 7:20 a.m.in stable condition with new order for Bactrim (a medication to treat UTI's).two times a day for 7 (seven) days. A review of Resident 1's care plans indicated there was no care plan initiated for UTI after Resident 1 was readmitted from GACH on July 7, 2025, with diagnosis and treatment for UTI. On July 22, 2025, at 3:27 p.m., an interview was conducted with Registered Nurse (RN) 1, who stated Resident 1 had a foley catheter inserted on July 7, 2025. RN 1 stated Resident 1 had completed her antibiotics, and requested to have the catheter be removed. RN 1 stated Resident 1's catheter was then removed by Licensed Vocational Nurse (LVN) 1. RN verified, there was no physician's order to remove Resident 1's urinary catheter. RN 1 further stated she could not recall the exact date Resident 1's urinary catheter was removed, as there was no documentation the urinary catheter was removed. RN 1 stated there should be a physician's order before removing a urinary catheter and documentation when the procedure of removal was conducted and monitoring of the resident's response after the urinary catheter was removed. RN 1 stated there should be documentation of monitoring of any signs and symptoms after the urinary catheter was removed. RN 1 further stated, a care plan should be initiated with any new diagnosis or change of condition. RN 1 verified there was no care plan 056328 Page 4 of 6 056328 08/20/2025 Premier Care Center for Palm Springs 2990 East Ramon Road Palm Springs, CA 92264

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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. 056328 Page 5 of 6 056328 08/20/2025 Premier Care Center for Palm Springs 2990 East Ramon Road Palm Springs, CA 92264

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], 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 056328 Page 6 of 6