Palm Springs Healthcare & Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Palm Springs Healthcare & Rehabilitation Center, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF908Feb 11, 2026

  Based on observation, interview, and record review, the facility failed to maintain proper use of Low Air Low (LAL) Mattresses (A specialized air-filled mattress used to treat and prevent the development of pressure ulcers - skin damage caused by prolonged pressure to one area of the body), when the resident's LAL pump/air pressure was not maintained at the proper setting for four of 6 residents reviewed (Residents 1, 2, 3 and 4).This failure had the potential to contribute to the development and/or prolonged healing of pressure ulcer's (PUs). Findings: On February 11, 2026, at 1012 a.m., an interview was conducted with Registered Nurse (RN) 1, who stated a facility medical intervention to help residents avoid development and assist with healing of PU's includes the use of an LAL mattress. […]

• No harm, potential for more than minimal, patternF695Feb 26, 2025

  Based on observation, interview, and record review, the facility failed to ensure that the ventilators (vent -a medical device that helps a patient breathe), for eight of 12 residents, Residents 1, 2, 3, 4, 5, 6, 7, and 8, were serviced by the due dates indicated on the label at the back of the vents and according to the manufacturer ' s recommendation. This failure had the potential to result in Residents 1, 2, 3, 4, 5, 6, 7, and 8 ' s increased risk for infection and improper ventilation. Findings: On February 26, 2025, an unannounced visit was conducted at the facility. […]

• No harm, potential for more than minimal, patternF880Feb 26, 2025

  Based on observation, interview, and record review, the facility failed to ensure for 12 of 14 residents, Residents 2, 3, 4, 5, 6, 8, 9, 10, 11, 12, 13 and 14, infection control practices where in place when multiple respiratory equipment was not changed and dated according to the facility ' s policy and procedure. Findings: On February 26, 2025, an unannounced visit was conducted at the facility. On February 26, 2025, at 8:36 a.m., during an interview, Respiratory Therapist (RT) 1 stated respiratory equipment was changed routinely and as needed (PRN). RT 1 stated they have a schedule to follow. […]

• No harm, potential for more than minimal, patternF638Dec 12, 2024

  Based on interview and record review, the facility failed to timely (within three months) complete the quarterly MDS (Minimum Data Set - an assessment tool used to evaluate the health status of nursing home residents) assessment for six of 81 residents still in the facility (Residents 57, 14, 38, 28, 30 and 35). This failure had the potential to negatively impact the residents' quality of care and had the potential for staff to not be aware of the residents' care needs and provide appropriate treatment. Findings: On December 11, 2024, at 10:05 a.m., an interview and concurrent record review was conducted with the MDS nurse. The MDS nurse stated Resident 57's MDS quarterly assessment was over three months old. The MDS quarterly assessment was reviewed for all 81 residents in the facility. […]

• No harm, potential for more than minimal, patternF755Dec 12, 2024

  Based on observation, interview, and record review, the facility failed to ensure the accountability of controlled medications (those with high potential for abuse and addiction) and the appropriate use of pain medications when: 1. The Controlled Drug Records (accountability records, an inventory sheet that keeps records of the usage of controlled medications) for five of six residents reviewed (Residents 7, 53, 54, 68, and 70) did not reconcile with the Medication Administration Records (MAR). This failure resulted in inaccurate accountability and the potential for abuse and diversion of controlled medications; and 2. Nursing staff failed to administer one medication as ordered by the prescriber for one of five residents reviewed (Resident 70). […]