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 provide wound treatment in accordance with
the physician order for one of three sampled residents (Resident 1).
Residents Affected - Few
This failure had the potential to delay wound healing for Resident 1.
Findings:
On June 6, 2025, at 8:05 a.m., an unannounced visit was made to the facility to investigate quality-of-care
issues.
A review of Resident 1 ' s admission record indicated that the resident was admitted to the facility on
[DATE], with diagnoses which included peripheral vascular disease (narrowed blood vessels reduce blood
flow to affected limbs).
A review of Resident 1 ' s Minimum Data Set (MDS- an assessment tool) dated March 26, 2025, indicated
the resident ' s Brief Interview for Mental Status (BIMS- a cognitive assessment) had a score of 15
(cognitively intact).
A review of Resident 1 ' s Skin Issues, dated June 2, 2025, indicated resident had a front left (outer) chronic
leg wound, measuring 8 centimeters ({cm} – a unit of measure) in length X (times) 2 cm in Width (W)
X 0.1 cm Depth (D), in stable condition.
A review of Resident 1 ' s Order Summary Report, active as of June 11, 2025, indicated, Left lower
extremity, Venous Ulcer: Cleanse with NS (normal saline), pat (dry), apply Oil emulsion (moist gauze) and
(wrap) with Kerlix (woven absorbent cotton wrap) . secure with retention tape . Every Other Day for 30 days
.Order date: 05/23/2025. Start Date: 05/24/2025 .
On June 6, 2025, at 10:34 a.m., a concurrent observation of Tx nurse providing Resident 1 ' s left leg Tx,
and interview with Tx nurse were conducted. The Tx nurse was observed removing a Coban (self-adherent
wrap) then Kerlix wrap, a 4 X 4 gauze pad, a Calcium alginate (absorbent dressing), then Xeroform
(petroleum/bacteriostatic impregnated gauze) dressing from the resident ' s left leg. The Tx nurse stated
that the resident ' s wounds appeared to be Stage 2 (shallow open ulcers with partial skin loss). The Tx
nurse verified the dressing she applied to Resident 1 ' s left leg wounds the day prior was not the current
TX ordered by the physician. The Tx nurse stated, she did not have a physician order to apply Calcium
alginate and a Xeroform dressing to Resident 1 ' s left leg. The TX Nurse stated the Tx she provided was
from her memory of past treatments.
(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 2
Event ID:
056428
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
056428
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
06/24/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
California Nursing & Rehabilitation Center
2299 North Indian Canyon Drive
Palm Springs, CA 92262
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 0684
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
On June 9, 2025, at 11:24 a.m., an interview was conducted with Resident 1 ' s Wound doctor, who stated
wound treatments are discontinued or changed because sometimes wounds would drain, and sometimes
wounds are dry, so different treatments are intermittently ordered.
On June 17, 2025, 11:45 a.m., an interview was conducted with the Director of Nursing (DON), who stated
the process when Tx nurse removes wound dressing, and identifies a COC, she would expect the nurse to
cover the wound with a 4X4 gauze, or apply the current ordered tx, then notify the physician of the COC for
further orders. The DON further stated the Tx nurse should have received further clarification of Tx orders
from the physician at the time she unwrapped Resident 1 ' s left leg and assessed the wound.
A review of the facility ' s Policy & Procedure (P&P) titled, Medication-Administration, revised, January 1,
2012, indicated, . Purpose: To ensure the accurate administration of (treatments) for residents in the Facility.
Policy: 1. (Treatment) will be administered directed by a Licensed nurse and upon the order of a physician
or licensed independent practitioner. II. No (treatment) will be used for any patient other than the patient for
whom it was prescribed . Procedure: I. Administration of (Treatments) A. (Treatment) . orders will be receive
by a licensed Nurse prior to administration . F. If the (Dr) increases or changes a (treatment) order, this is an
automatic stop of discontinue . for the original order . VI. Medication Rights A. Nursing staff will keep in mind
the seven rights of (treatments) when administering (treatments) B. i. The right (treatment) .
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
056428
If continuation sheet
Page 2 of 2
