Health inspection·December 15, 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 interview and record review, the facility failed to ensure STAT (immediately) urinalysis (UA) and urine culture and sensitivity (C&S-isolation of microbes and sensitivity to drugs for treatment) specimens were pick up by the laboratory (Lab) within the time frame of 4-6 hours, for one out of three residents (Resident 1).This failure could have resulted in a delay in laboratory values being reported to the residents physician and a delay in necessary treatment for Resident 1.Findings:A review of Resident 1's Patient Information, indicated Resident 1 was admitted to the facility on [DATE], with a diagnosis of osteomyelitis (infection of the bone).A review of Resident 1's Brief Interview of Mental Status (A cognitive assessment), indicated Resident 1 had a score of 15, cognitively intact.A review of Resident 1's Progress Notes, dated November 9, 2025, at 6:18 p.m., by Licensed Vocational Nurse (LVN) 1 indicated, . (Resident 1) has had a change of condition (COC-a deviation from baseline clinical conditions), (resident) states she sees a cat in the chair in front of her, and has episodes of disorientation. MD (Dr) informed and has ordered a STAT UA with C&S .A review of Resident 1's, Change of Condition, dated November 9, 2025, at 11:32 p.m., by LVN 1 indicated, . (COC) Altered Mental Status . increased confusion . abrupt significant change . (Dr) notified (with) Recommendation (collected a) STAT UA (C&S) . urine test to (rule out) UTI (Urinary Tract Infection) . A review of Resident 1's, Drs Orders, dated, November 11, 2025, at 6:10 p.m., transcribed (placed) by LVN 1, indicated:- -STAT Urinalysis (UA); and- -STAT Urine Culture (C&S).A review of Resident 1's, Medication Administration Record (MAR), for the month of November 2025, indicated, a urine sample was collected on November 9, 2025, at 8:05 p.m., by LVN 1, and was . WAITING to be Sent (to the lab) .A review of Resident 1's Laboratory UA results report, indicated:- -Collection date, November 10, 2025 at 3:57 a.m.;- -Received date November 10, 2025, at 3:52 p.m.; and- -Reported date, November 10, 2025, at 6:10 p.m.On December 11, 2025, at 4:35 p.m., a concurrent interview with the Director of Nursing (DON) and record review of Resident 1's COC, dated December 9, 2025, was conducted. The DON stated it is the facility policy for STAT labs (U/A C&S) to be collected by the nurse, then picked up by the outside lab within 4 to 5 hours of the Drs order, and to ensure STAT labs are picked up within the 4-to-5-hour time frame, the nurse can follow-up with the lab by calling to verify the STAT order was received. The DON further stated she would expect the nurse to document in the resident's medical record a call was made to the lab to notify them of the pending STAT lab order. The DON verified LVN 1 documented the COC on Resident 1, December 9, 2025, and LVN 1 received STAT orders from the Dr at 6:10 p.m., for a UA to rule out a urinary tract infection. The DON further verified the UA was picked up by the lab on December 10, 2025, at 3:57 a.m., later than 5 hours. The DON verified LVN 1 did not document a call was made to the lab to notify them of the STAT UA order.On December 11, 2025, at 4:50 p.m., a concurrent interview with LVN 1 and record review of Resident 1's COC on November 9, 2025, and STAT urine specimen orders was conducted. LVN 1 stated when STAT lab orders are received, the process is to place the Residents Affected - Few Page 1 of 2 555226 555226 12/15/2025 The Springs Healthcare Center at the Carlotta 41505 Carlotta Drive Palm Desert, CA 92211

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few order in the resident's electronic medical record, at which time the lab should also receive the STAT order, then call the lab to ensure the STAT order was received. The lab should pick up the specimen within 4 hours. LVN 1 stated she remembers reporting to the Dr on December 9, 2025, that Resident 1 had confusion and was reportedly seeing cats, and the Dr ordered a STAT U/A with C&S. LVN 1 verified she placed the STAT UA order at approximately 6:30 p.m. LVN 1 stated her shift ended at 11:00 p.m., and according to the policy, the STAT lab should have been picked up before the end of her shift. LVN 1 further stated she could not remember if she called the lab regarding the STAT U/A with C&S order prior to the end of her shift. A review of the policy, provided to the facility, titled, Policy on Laboratory STAT Orders, undated, indicated, . When there is a STAT order for laboratory testing, facility must call in the order to the laboratory immediately, upon getting the order from the physician . identify the order as a STAT order . Laboratory will prioritize and expedite all qualified stat orders. It is our goal to complete STAT orders promptly within a 4-6-hour timeframe . 555226 Page 2 of 2