Health inspection·June 24, 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 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. Page 1 of 2 056428 056428 06/24/2025 California Nursing & Rehabilitation Center 2299 North Indian Canyon Drive Palm Springs, CA 92262

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) . 056428 Page 2 of 2