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 (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: 555226 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 555226 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/15/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Springs Healthcare Center at the Carlotta 41505 Carlotta Drive Palm Desert, CA 92211 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)