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
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 4
Event ID:
056328
Printed: 05/15/2026
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
056328
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/09/2026
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 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
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
056328
If continuation sheet
Page 2 of 4
Printed: 05/15/2026
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
056328
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/09/2026
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 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
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
056328
If continuation sheet
Page 3 of 4
Printed: 05/15/2026
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
056328
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/09/2026
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 0880
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
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.
Event ID:
Facility ID:
056328
If continuation sheet
Page 4 of 4