Health inspection·December 24, 2025

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 ensure infection control precautions were implemented in accordance with the policies and procedures for two of six sampled residents (Residents 4 and 3), when: 1.Certified Nurse Assistant (CNA) 1 was observed at Resident 4's bedside wearing a face mask, and not wearing gown, gloves, and face shield. The resident requires a droplet precaution; and 2. CNA 2 was observed with Resident 3 at bedside wearing a face mask, and not wearing gown, gloves, and face shield. The resident requires a droplet precaution. These failures had the potential to increase the spread of influenza (a contagious viral infection of the respiratory tract) and cause serious illness in high-risk individuals.Findings: 1.On December 23, 2025, at 12:34 p.m., three signage and stocked PPE were observed outside Resident 4's room.A review of the three signage indicated the following: First signage, .Sequence for Putting On Personal Protective Equipment (PPE).1. Gown.2. Mask or Respirator.3. Goggles or Face Shield.4. Gloves.; Second signage, .Droplet Precautions.Everyone Must: Clean their hands, including before entering and when leaving the room.Make sure their eyes, nose and mouth are fully covered before room entry.or Remove face protection before room exit.; and Third signage, How to Safely Remove Personal Protective Equipment (PPE). 1. Gown and Gloves.2. Goggles or Face Shield.3. Mask or Respirator.4. Wash Hands or Use an Alcohol-Based Hand Sanitizer Immediately after removing all PPE. On December 23, 2025, at 12:36 p.m., during concurrent observation and interview, CNA 1 was observed at Resident 4's bedside wearing a face mask. CNA 1 stated the staff were required to gown up, wear face mask, face shield and gloves prior to entering rooms with droplet precautions. CNA 1 stated Resident 4 was on droplet precautions due to influenza. CNA 1 stated she should have been wearing a gown, gloves, and face shield while talking to Resident 4. On December 23, 2025, at 3:55 p.m., an interview was conducted with the Infection Preventionist (IP). The IP stated that for droplet transmission-based precautions, all staff including visitors, family members, and contractors were required to don PPE prior to entering the resident's room. The PPE included a face shield, face mask, gown, and gloves due to the potential exposure from residents who may be coughing or sneezing. The IP further noted that if a staff member was answering a call light, picking up a meal tray, speaking to a resident, or providing direct contact care, they were required to wear all PPE. On December 24, 2025, at 10:09 a.m., a concurrent interview and record review was conducted with the IP. The IP stated that anyone entering the room must follow transmission-based precautions by donning all PPE, including a face mask, face shield, gown, and gloves, as directed on the droplet precautions signage outside the resident's room when communicating or providing direct care for all residents in the room. Resident 4's record was reviewed. Resident 4 was admitted to the facility on [DATE], with diagnoses which included immunodeficiency (failure of the immune system to protect the body). A review of Resident 4's Minimum Data Set (MDS- an assessment tool), dated November 3, 2025, indicated Resident 4 had a BIMS (Brief Interview of Mental Status) score of 12 (moderate cognitive impairment). A review of Residents Affected - Few Page 1 of 3 555339 555339 12/24/2025 Desert Springs Post Acute 74-350 Country Club Drive Palm Desert, CA 92260

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Resident 4's Care Plan, dated December 21, 2025, indicated, .Isolation Precautions: Resident requires contact, droplet precautions isolation.Goal: Isolation using (contact, droplet) precautions will be maintained while medically necessary.Intervention: Follow universal precautions when working with residents in isolation. Education of patients, families, visitors, and care providers about how infections are transmitted and how illness can be prevented. Safe handling of potentially contaminated equipment or surfaces in the resident environment, and respiratory hygiene/cough etiquette. Use of personal protective equipment as recommended for type of infection. A review of Resident 4's Care Plan, dated December 21, 2025, indicated, .Influenza: Resident has diagnosis of influenza .at risk for complications.Goal: Influenza will resolve without signs and symptoms of complication. Will not exhibit signs of malnutrition or dehydration secondary to influenza symptom.Intervention: Isolation precautions. Administer medication as ordered. A review of Resident 4's physician order dated December 25, 2025, Tamiflu Oral capsule 75 mg. for Flu until December 29, 2025. A review of the facility's policy and procedure titled, Isolation-Transmission-Based Precautions & Enhanced Barrier Protection, revised date September 2022, indicated, .transmission-based precautions are additional measures that protect staff, visitors and other residents from becoming infected.droplet precautions are implemented for an individual documented or suspected to be infected.that can be generated by the individual coughing, sneezing, talking.gloves, gown, and googles are worn if there is a risk of spraying respiratory secretions. A review of the facility's policy and procedure titled, Infection Prevention and Control Program, revised date October 2018, indicated, .prevention of infection.educating staff.ensuring that they adhere to proper techniques and procedures.implementing appropriate isolation precautions.outbreak management.preventing the spread to other residents.educating the staff and public. 2.On December 23, 2025, at 2:52 p.m., three signage and stocked PPE were observed outside Resident 3's room. A review of the three signage indicated the following: First signage, .Sequence for Putting On Personal Protective Equipment (PPE).1. Gown.2. Mask or Respirator.3. Goggles or Face Shield.4. Gloves.; Second signage, .Droplet Precautions.Everyone Must: Clean their hands, including before entering and when leaving the room.Make sure their eyes, nose and mouth are fully covered before room entry.or Remove face protection before room exit.; and Third signage, How to Safely Remove Personal Protective Equipment (PPE). 1. Gown and Gloves.2. Goggles or Face Shield.3. Mask or Respirator.4. Wash Hands or Use an Alcohol-Based Hand Sanitizer Immediately after removing all PPE. On December 23, 2025, at 3:04 p.m., a concurrent observation and interview was conducted with Resident 3. Resident 3 was observed resting in bed, alert, and well groomed. Resident 3 stated she was aware that she had the flu and was in isolation. Resident 3 stated the staff did not always wear a gown and a face shield when providing care. Resident 3's record was reviewed. Resident 3 was admitted to the facility on [DATE], with diagnoses which included bronchitis (inflammation of the bronchial tubes (airways to your lungs). A review of Resident 3's MDS, dated [DATE], indicated Resident 3 had a BIMS (Brief Interview of Mental Status) score of 12 (moderate cognitive impairment). A review of Resident 3's Care Plan, dated December 17, 2025, indicated, .Isolation Precautions: Resident requires contact, droplet precautions isolation.Goal: Isolation using (contact, droplet) precautions will be maintained while medically necessary.Intervention: Follow universal precautions when working with residents in isolation. Education of patients, families, visitors, and care providers about how infections are transmitted and how illness can be prevented. Safe handling of potentially contaminated equipment or surfaces in the resident environment, and respiratory hygiene/cough etiquette. Use of personal protective equipment as recommended for type of infection. A review of Resident 3's physician orders indicated the following: On December 18, 2025, Isolation with contact and droplet precautions d/t (due to) 555339 Page 2 of 3 555339 12/24/2025 Desert Springs Post Acute 74-350 Country Club Drive Palm Desert, CA 92260

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few exposure to the flu. Special Instructions: All nursing care and Therapy to be completed in room. Private room if possible or cohort with other flu-positive residences every shift for 7 Days; and On December 18, 2025, Tamiflu Oral Capsule 75 MG (Oseltamivir Phosphate) Give 1 capsule by mouth two times a day for FLU for 5 days. On December 23, 2025, at 3:14 p.m., a concurrent observation and interview was conducted with CNA 2. CNA 2 was observed entering Resident 3's room wearing a face mask. CNA 2 was observed speaking to Resident 3. CNA 2 stated the staff were required to gown up, wear face masks, face shield and gloves prior to entering rooms with droplet precautions. CNA 2 stated Resident 3 was on droplet precautions due to influenza. CNA 2 stated she should have been wearing a gown, gloves, and face shield while talking to Resident 3. On December 23, 2025, at 3:55 p.m., an interview was conducted with the Infection Preventionist (IP). The IP stated the process for droplet transmission-based precautions are all staff including visitors, family, contractors were required to don PPEs prior to entering the resident's room; a face shield, face mask, gown, gloves due to exposure from residents in room that may be coughing and sneezing. The IP stated if a staff member was answering the call light, picking up a meal tray, speaking to a resident, or providing direct contact, the staff member was required to wear all PPEs. On December 24, 2025, at 10:09 a.m., a concurrent interview and record review was conducted with the IP. The IP stated that anyone entering the room will follow transmission-based precautions by donning all PPE face masks, face shields, gown, gloves as indicated on the droplet precaution signage outside of resident's room, when communicating or providing direct care for all residents in the room. A review of the facility's policy and procedure titled, Isolation-Transmission-Based Precautions & Enhanced Barrier Protection, revised date September 2022, indicated, .transmission-based precautions are additional measures that protect staff, visitors and other residents from becoming infected.droplet precautions are implemented for an individual documented or suspected to be infected.that can be generated by the individual coughing, sneezing, talking.gloves, gown, and googles are worn if there is a risk of spraying respiratory secretions. A review of the facility's policy and procedure titled, Infection Prevention and Control Program, revised date October 2018, indicated, .prevention of infection.educating staff.ensuring that they adhere to proper techniques and procedures.implementing appropriate isolation precautions.outbreak management.preventing the spread to other residents.educating the staff and public. 555339 Page 3 of 3