Health inspection·February 9, 2026

F 0880 Provide and implement an infection prevention and control program. 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 implement infection control interventions and treatments to help decrease the spread of scabies (a contagious skin infestation caused by the microscopic mite, which burrows into the upper layer of skin to live and lay eggs, characterized by intense, nocturnal itching and a pimple-like rash), for one of five residents (Resident 1), when:1.The dermatologist's (a doctor who specializes in skin issues) orders for Permethrin (a topical medication to treat scabies) was not administered as ordered;2.The physician's order for skin scraping for scabies (involves a doctor or clinician taking a sample of skin from a burrow or rash using a scalpel or needle, mixing it with mineral oil on a slide, and examining it under a microscope to find mites, eggs, or fecal pellets for a definitive diagnosis) was not completed as ordered by the physician;3.The dermatologist's recommendation to place Resident 1 in contact isolation precautions ({CIP}-an intervention to prevent the spread of infection through touch, which includes isolating the resident to their room, staff's use of Personal Protective Equipment {PPE} of gowns and gloves when working with the resident, and contact isolation signs placed at resident's door to notify others to don {put on} PPE before entering and doff {take off PPE} before exiting the room) was not implemented;4. Coordinate treatment and infection control precautions for close contacts (residents and staff) were not implemented according to the facility's policy and procedures.These failures had the potential for Resident 1 to continue to experience symptoms of scabies and contribute discomfort due to itching and could potentially spread scabies throughout the facility to other residents and/or staff members. FindingsOn January 12, 2026, at 1 p.m., an unannounced visit were made to the facility for an infection control issue. On January 12, 2026, at 4:50 p.m., an interview was conducted with the Infection Prevention Nurse (IP). The IP stated the following measures were to be implemented when a resident is suspected of or diagnosed with scabies: -Notify the physician for appropriate physician's orders;-Place resident on contact isolation precautions; -Collect specimen through skin scraping to confirm diagnosis of scabies; -Exposed residents will be assessed and treated prophylactically; and -Residents are to be monitored On July 12, 2026, Resident 1's record was reviewed. Resident 1's, Resident Information, indicated the resident was admitted to the facility on [DATE], with a diagnosis of hemiplegia (paralysis of one side of the body) following a stroke (blood blow to brain is interrupted causing damage to cells). A review of Resident 1's Brief Interview for Mental Status (BIMS -a cognitive assessment), dated December 3, 2025, indicated a score of 13 (cognitively intact). A review of Resident 1's Progress Notes, dated, November 17, 2025, at 1:11 p.m., indicated, . Change in Condition. Nursing observations, evaluation . (Resident 1) is noted with self inflicted (sic) scratches to upper right arm and back of right (forearm).rash noted to chest and arms.Recommendations.triamcinolone (medication to treat skin conditions) for rash A review of Resident 1's, care plan titled, Resident (1) has a new (skin integrity) impairment self inflicted (sic) open areas to upper right arm and back of right forearm, initiated on Residents Affected - Few Page 1 of 4 056328 056328 02/09/2026 Premier Care Center for Palm Springs 2990 East Ramon Road Palm Springs, CA 92264

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few November 17, 2025, indicated a Goal of . Resident's skin issue will begin the healing process ., with the Intervention of . Administer treatment as ordered . A review of Resident 1's document titled, Visit Note, from (name of dermatology), dated November 17, 2025, indicated the following: - . (Resident 1) is following up for (an) insect bite (prior exam September 29, 2025) . An exam was performed .; - .An examination was performed including the neck, chest, abdomen, back, right upper extremity, left upper extremity, right lower extremity, left lower extremity, right forearm, left forearm, right lower leg, left lower leg, right hand, left hand, right foot, and left foot.; - .Impression/Plan: Scabies . Linear burrows (tiny tunnels caused by tunneling female mites). - .Plan: Prescription.Permethrin 5% topical cream (a treatment for scabies that works by paralyzing and killing the skin mites). Apply cream from the neck down to the toes leave on overnight wash off in the am (a.m.) then repeat 1 (one) weeks (sic) later.; - .Scabies is an infestation of mites that is very contagious. Household contacts should be treated. Contaminated clothing should be isolated x (times) 72 hours and washed and dried on high heat. A review of Resident 1's physician's orders indicated no orders written for Resident 1 to receive Permethrin cream, after dermatology consultation on November 17, 2025. A review of Resident 1's, Treatment Administration Record (TAR), for the month of November 2025, indicated Permethrin cream was not administered post dermatology consultation on November 17, 2025. A review of Resident 1's, Doctor's orders, dated, November 26, 2025, at 12:34 p.m., indicated, . May (scrap) for scabies . Further review indicated this order was discontinued on the same date, November 26, 2025, at 8:03 p.m. A review of Resident 1's, Progress Notes, indicated no documentation stating why the doctor's order to scrap for scabies on November 26, 2025, was discontinued. A review of Resident 1's physician order, dated December 17, 2025, indicated, Contact Isolation for a Dx (diagnosis) of scabies. A review of Resident 1's dermatology consultation, dated December 1, 2025, untimed, indicated, . (Follow-up) Scabies evaluated on November 17, 2025, ., Impression/Plan: Scabies, Linear Burrows.Plan: Prescription.Permethrin 5% topical cream, apply cream from the neck down to the toes leave on overnight wash off in the am then repeat 1 week later. A review of Resident 1's physician's orders, indicated Permethrin cream was ordered on December 1, 2025, at 11:31 a.m., then the order was discontinued on the same date, December 1, 2025, at 11:45 a.m., and again at 1:50 p.m. A review of Resident 1's Medication Administration Record (MAR), for December 2025, indicated resident's Permethrin cream treatment was not administered on December 1, 2025, or repeated one week later, after residents December 1, 2025, Dermatology consultation. A review of Resident 1's Progress Notes, indicated there was no documentation stating why resident's Permethrin cream's treatment for Possible scabies, was discontinued, and not administered on December 1, 2025, or repeated one week later, after the residents' dermatology consultation on December 1, 2025. On January 20, 2025, at 11:47 a.m., a concurrent interview and record review of Resident 1's, was conducted with the IP. The IP stated the following: -When a resident returns from a dermatology consultation, the visit notes was to be reviewed by the licensed nurse, notify the resident's primary physician, and receives orders to implement the treatment recommendations; -Resident 1 was seen by the dermatologist on November 17, 2025, and indicated Resident 1 to have scabies, and to treat the resident with Permethrin cream. The IP stated Permethrin cream is used to kill scabies. The IP verified Resident 1 did not receive the treatment of Permethrin. The IP stated Permethrin cream should have been administered to Resident 1; -The infection prevention interventions of placing Resident 1 on Contact Isolation, prophylactically treating his roommates with permethrin and starting a close contact list was not implemented after Resident 1 returned from his dermatology consult on November 17, 2025, with the impression of scabies. The IP verified Resident 1 had an order for a skin scraping (to rule out scabies) on November 26, 2025, which 056328 Page 2 of 4 056328 02/09/2026 Premier Care Center for Palm Springs 2990 East Ramon Road Palm Springs, CA 92264

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few was also discontinued on the same date. The IP stated she was not sure why the order was discontinued, as it was not communicated to her, and there was no documentation by the nursing staff. The IP verified, there were no results from a skin scraping on Resident 1 for the month of November 2025; and - Resident 1 was seen by the dermatologist on December 1, 2025, indicating an Impression, of scabies, and Plan to treat resident with Permethrin cream, and repeat in one week. The IP verified Resident 1 did not receive his Permethrin treatment as ordered on December 1, 2025. The IP further verified the infection prevention interventions of scraping resident's skin for testing, placing Resident 1 on Contact Isolation, prophylactically treating his roommates with permethrin and starting a close contact list was not implemented, and should have been, after Resident 1 returned from his dermatology consult on December 1, 2025. On January 20, 2026, at 3:08 p.m., a concurrent interview and record review of Resident 1's, dermatology consultations on November 17, 2025, and December 1, 2025, progress notes, November and December 2025 MAR and TAR, physician's orders and skin scraping results was conducted with the Director of Nursing (DON). The DON stated she expected the nursing staff to do the following: -Document the resident's return from a dermatology consult; -Review the dermatologists plan and transcribe the orders in the resident's electronic medical record; -Administer the treatments as ordered; -Document treatments and resident's ongoing plan of care; -Skin scraping should be performed for a definitive diagnosis; -The resident should be placed on contact isolation precautions until their ordered treatment is completed; -Assess and prophylactically treat the resident's roommate(s), and -The IP should start a Close Contact List of all caregivers and residents who had been in contact with the resident in the past 72 hours. Further interview with the DON verified the following: -Resident 1's dermatology consultations on November 17, 2025, indicated an Impression, of scabies, with a Plan to treat with permethrin cream and repeat the treatment in one week; -Resident 1 did not receive the ordered permethrin treatments, and there was no documentation from nursing staff stating why resident did not receive the treatment. The DON stated Resident 1 should have received his Permethrin treatment as ordered; -The infection prevention interventions of placing Resident 1 and his roommates on CIP, prophylactically treating the roommates, and starting a Close Contact List were not implemented. The DON stated these interventions should have been implemented after Resident 1's, November 17, 2025, dermatology consultation, indicating diagnosis of scabies; -A skin scraping was not performed on Resident 1 after his November 17, 2025, dermatology consultation. The DON stated, it is best nursing practice to complete a skin scraping for a definitive diagnosis of scabies. The DON verified on November 26, 2025, Resident 1 had a doctor's order to collect skin scraping for scabies, which was discontinued on the same date without being completed, and there was no documentation stating why the procedure was not completed. The DON verified there were no skin scraping results from Resident 1 in November 2025. The DON stated the skin scraping should have been done; and -Resident 1's dermatology consultation, dated December 1, 2025, indicated an Impression, of scabies, with a Plan to treat with Permethrin cream and repeat treatment in one week. The DON verified Resident 1 did not receive his ordered permethrin treatments, and there was no documentation stating why resident did not receive the treatment. The DON stated Resident 1 should have received his Permethrin treatment as ordered. A review of the facility's undated policy and procedure titled, Nursing Administration, Communicable Diseases, indicated, .Policy: any instances of scabies will be immediately contained and eliminated. A systematic approach to scabies prevention and management will be taken.Procedures: 2. A diagnosis is made by a licensed provider via physical examination and/or skin scrapings with microscopic exam.Treatment of Affected Resident(s) If evidence of scabies is identified, caregivers will.Obtain an order and implement treatment.Implement procedures to eliminate infestation and 056328 Page 3 of 4 056328 02/09/2026 Premier Care Center for Palm Springs 2990 East Ramon Road Palm Springs, CA 92264

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few prevent transmission.Use contact precautions to care for the infested individual until 24 hours after treatment is administered.Use a private room if the resident cannot maintain good hygiene. c) Ensure staff handling linen are also using PPE (long-sleeved gown that covers wrists and gloves).Simultaneously treat roommate (if applicable).Educate anyone who has had skin-to-skin contact with the infested resident in the last 2 months (including staff, family, visitors, etc) on signs and symptoms, incubation period and transmission prevention.Documentation. Be sure to document.Treatments administered.Daily skin checks.Completion of all steps outlined in this procedure.for post treatment monitoring of infested residents. 056328 Page 4 of 4