Average — CMS composite of the measures below.
A standard survey is most likely before around September 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Desert Mountain Care Center during CMS and state inspections, most recent first.
A resident with an indwelling catheter for urinary retention had low and then no urine output over an 8-hour period. The RN later irrigated and replaced the Foley, found sediment but no additional output, and sent the resident to the ER for urinary retention and abnormal vital signs. The care plan called for monitoring intake/output and reporting no output, but staff stated the low output should have been identified earlier.
A facility failed to follow infection control practices for residents on contact and droplet precautions. Staff reported using shared BP cuffs, thermometers, and pulse oximeters on isolation residents, wiping the equipment down between uses, while others were unsure of the correct process. The IP stated each isolation resident should have dedicated vital sign equipment in the room, and record review showed one resident on droplet precautions for Klebsiella pneumoniae with ESBL/CARBA markers and two residents on contact isolation for C. diff.
A resident with severe cognitive impairment was re-admitted with an existing sacrococcygeal PU, but the admitting RN did not complete or document the required admission skin assessment. The next day, the TxN identified and documented an unstageable PU and initiated a care plan, yet no corresponding MD wound care orders were obtained or transcribed, and no treatments were recorded for several days. Later, a wound care physician evaluated the same wound and ordered daily cleansing with normal saline and barrier cream, but the TxN acknowledged receiving these orders and failed to enter them into the medical record, resulting in a delay before any documented wound treatments were started.
A resident with respiratory failure, muscle weakness, CHF on diuretics, impaired mobility, and a tracheostomy was care planned for occasional bladder incontinence with use of briefs and checks "as required," but had no toileting program despite being frequently incontinent and able to ambulate and make her own decisions. The resident reported delays in staff response to call lights, attempted to toilet independently, lost balance, fell, and soiled herself. Documentation showed she had balance problems, decreased coordination, and required assistive devices, yet a bowel and bladder evaluation labeled her an unlikely candidate for retraining, and the MDS reflected no toileting program. The DON later acknowledged the resident should have been re-evaluated for a bowel and bladder toileting program, despite a facility policy requiring bowel/bladder retraining and care plan inclusion for residents with potential to benefit.
A resident with chronic pain from osteoarthritis and fibromyalgia received PRN Dilaudid despite a documented pain score of 0/10, contrary to the physician’s order limiting use to pain levels of 4–10. The MAR showed multiple such administrations, and the ADON confirmed staff should not give PRN opioids when pain is 0/10. Additionally, a physician-ordered pain management consult for uncontrolled pain was not successfully scheduled for months, with progress notes reflecting repeated calls that only reached voicemail and no completed appointment, while the resident reported ongoing pain and an unmet request to see a pain specialist.
Surveyors found that two mechanical lifts with identified or suspected problems remained on the floor and one was used for resident transfers despite visible Coban wrapped around its casing and another being labeled as not working. CNAs and an LVN reported they used one of the lifts without noticing or questioning the Coban, and the DON acknowledged the lift should not have been in use and that this posed a safety problem. The Director of Maintenance confirmed there were no TELS work orders or maintenance requests for either lift, even though facility policy requires routine inspection, documentation, and removal from service when equipment is not working properly.
Surveyors found that the facility did not maintain a safe and sanitary environment when laminate flooring in a main hallway was deformed with multiple raised areas, which staff, including a CNA and the DON, acknowledged as a tripping hazard. A maintenance staff member stated the bubbles in the flooring could result from inadequate glue during installation. In addition, a resident room previously affected by roof leaks had a cracked, lumpy ceiling with possible water damage and cracked, chipped paint directly above a resident’s bed. These conditions did not comply with the facility’s maintenance policy requiring smooth, dry, and cleanable floor, wall, and ceiling surfaces without cracks.
Surveyors found that discontinued IV fluids, antibiotics, and oral medications remained accessible in medication storage areas, and that staff did not consistently follow physician orders for medication administration and lab testing. For example, a resident received midodrine despite blood pressure parameters indicating the dose should be held, and another resident did not receive Hgb A1c testing at the ordered intervals for diabetes management. These issues were confirmed by staff interviews and record reviews.
Wooden shelves in the kitchen's dry goods supply area were found to be chipped, splintered, and had peeling varnish, exposing bare wood. Staff and dietary leadership acknowledged the risk of staff injury and possible cross-contamination of food, and the Registered Dietician had previously reported the issue to facility management. The facility's food storage policy requiring cleanable shelving was not followed.
A resident was found with two open containers of zinc oxide ointment on the overbed table and reported self-applying the ointment as needed. Review of records showed no documented assessment for safe self-administration, despite facility policy requiring interdisciplinary evaluation and physician authorization. Nursing staff confirmed the absence of assessment and acknowledged that medications should not be kept at bedside without proper evaluation.
A saline nasal spray was discovered on a medication cart without any labeling to identify the intended resident. An LVN confirmed the absence of a name or room number on the bottle or box and stated that proper labeling was required to ensure correct administration. Facility policy requires all prescription medications to be labeled with the resident's name and prohibits sharing medications between residents.
A resident with missing upper teeth and a tracheostomy requested upper dentures on multiple occasions, but the facility failed to follow up on her dental needs. Despite documentation of her requests and recommendations from the dentist, there was no evidence that Social Services or Nursing pursued her eligibility for dentures, and staff interviews confirmed the lack of follow-up.
Two residents with documented dislikes for pork were served meals containing pork, despite their preferences being clearly indicated on their dietary meal tickets. Both residents were cognitively intact and had relevant medical conditions, including end-stage renal disease, diabetes, and dysphagia. Dietary staff and the RD confirmed that food preferences should have been honored, and facility policy required alternate menu items to be provided for disliked foods.
Two residents with complex medical needs were affected by lapses in infection control practices: a stand fan in one room was found with accumulated dust, and a used plastic urinal was improperly stored in another resident's closet. Staff interviews confirmed that these actions did not follow facility policies for cleaning and storage, increasing the risk of contamination.
Two residents used wheelchairs with unresolved safety and maintenance issues, including non-functioning brakes, loose wheels, and cracked upholstery. Despite reports and assessments by staff, the necessary repairs and replacements were not completed, resulting in continued use of unsafe equipment and potential infection control concerns.
A resident with respiratory failure and hypoxia experienced critically abnormal vital signs, including elevated pulse and low O2 saturation, but staff did not promptly notify the physician or closely monitor the resident as required. Despite repeated abnormal findings and refusal of oxygen therapy, there were significant gaps in assessment and escalation, and no timely follow-up to ensure physician evaluation, contrary to facility policy and staff expectations.
Housekeeping staff, without prior training in behavioral health or 1:1 supervision, were assigned to monitor a resident with severe cognitive impairment and wandering behavior. Despite physician orders and care plan interventions requiring 1:1 supervision, these staff members were not trained before being assigned, and the facility lacked a policy for managing residents needing sitters. The DON and DSD confirmed the lack of training and policy.
A resident with severe dementia and a history of wandering did not consistently receive the required 1:1 supervision as ordered by the physician and outlined in the care plan. Staff interviews and documentation revealed multiple shifts where no assigned sitter was present, and supervision was informally shared among staff or assigned to non-clinical personnel. Facility records confirmed gaps in direct supervision, and leadership acknowledged the lack of a formal policy for managing residents needing a sitter.
During an infectious disease outbreak, a CNA was observed exiting a resident's room, removing gloves, touching a linen cart, and re-entering the room without performing hand hygiene. Staff interviews and policy review confirmed that hand hygiene was required before and after resident contact and after touching potentially contaminated surfaces, but these procedures were not followed.
A resident with diabetes had a blood sugar reading of 403 mg/dl, which exceeded the threshold in the physician's order requiring notification. The physician was not notified as required, and this was confirmed through record review and staff interview. The resident also expressed dissatisfaction with their care.
During an unannounced visit, surveyors found that three direct care staff members, including a CNA and two LVNs, were wearing artificial nails, contrary to the facility's infection control policy. The staff acknowledged the risk of bacterial transmission associated with artificial nails, and the Infection Preventionist confirmed that such nails are prohibited for staff providing direct care. This breach occurred despite the facility's policy discouraging artificial nails to prevent infection spread.
A resident with a history of altered mental status and high risk for elopement was able to leave the facility undetected due to a door alarm not being activated. The Director of Staff Development forgot to turn on the alarm after using the door, and staff interviews confirmed the alarm should always be on to prevent such incidents. The resident had previously attempted to leave the facility, highlighting the importance of maintaining active alarms.
A resident with intact cognition eloped from the facility unsupervised to visit a bank and post office, resulting in minor injuries. The facility failed to report the incident to the CDPH within the required 24-hour timeframe, as per their policy on unusual occurrences.
The facility failed to maintain a comfortable environment as room temperatures exceeded acceptable levels due to malfunctioning air conditioning units. Despite temporary cooling measures, residents experienced discomfort, and the issue was not reported to the California Department of Public Health as required. Additionally, the facility's carpets were observed to be dirty with persistent stains, affecting the overall cleanliness and homeliness of the environment.
Two residents experienced delays in receiving incontinent care, with one resident left wet for over 10 minutes and another waiting over 30 minutes for assistance. Both residents had the capacity to make decisions and expressed dissatisfaction with the care delays. The facility's policies on timely care were not followed, as observed during the survey.
The facility failed to maintain environmental conditions to prevent insects from entering, as observed during an unannounced visit. Issues included a missing window screen, tears and gaps in other screens, and entrance and exit doors with gaps. The Maintenance Supervisor and Director of Nursing confirmed these deficiencies, which violate the facility's policy requiring intact window screens and properly functioning doors.
A resident's wounds were not assessed and treated within the required timeframe, leading to a delay in care. The facility's policy requires a comprehensive admission assessment and timely wound assessment and treatment, but the resident's wounds were not measured and treated until the third day after admission.
Delayed Response to Low Urine Output With Indwelling Catheter
Penalty
Summary
The facility failed to ensure timely care and treatment for a resident with an indwelling catheter when the resident had low and/or no urine output for eight hours. Resident A was admitted with diagnoses including chronic respiratory failure and obstructive and reflux uropathy, and the care plan identified increased infection risk related to prolonged use of invasive devices and risk for infection and trauma due to the indwelling catheter. The care plan also directed staff to monitor and document intake and output and to report signs of UTI, including no output. Resident A had an order for an indwelling catheter with a closed drainage system for urinary retention. The record showed urine output of 650 ml in the early morning and 50 ml later that afternoon, and later that day the resident was sent to the hospital for abnormal vital signs, urinary retention, and leaking brown contents from the G-tube. The progress note stated the RN tried to irrigate the Foley and replace the catheter to retrieve urine output without success, with sediment present but no additional output noted. In interviews, the RN stated she assessed the resident and found no urine output, irrigated the Foley, replaced the catheter, notified the physician, and sent the resident to the ER; she also stated the nursing staff should have noted the low or no urine output before the 8-hour period ended.
Failure to Use Dedicated Patient-Care Equipment for Isolation Residents
Penalty
Summary
The facility failed to ensure infection control and prevention measures were implemented according to its policy and national guidelines for dedicated patient-care equipment on residents requiring contact and droplet precautions. Surveyors observed that a Licensed Vocational Nurse came out of a resident’s room marked for droplet isolation and stated he had taken the resident’s blood pressure earlier using a disposable BP cuff, then threw the cuff away in the medication room. He also stated he should have disposed of the cuff in the resident’s trash bin. A Registered Nurse was present and stated she was uncertain of the process for taking vital signs on residents placed on isolation precautions and where disposable BP cuffs could be obtained. During interviews, a Certified Nursing Assistant assigned to the resident stated she was not sure whether the resident required contact or droplet precautions and said vital signs on residents on isolation precautions were taken by wiping down the BP cuff, thermometer, and pulse oximeter before using them on other residents. Another LVN stated the facility used the BP stand central supply for vital sign supplies and that she had taken a resident’s vital signs with the multi-resident-use BP pump, cuff, and thermometer, then disinfected the equipment with bleach wipes and used it for other residents as well. She stated residents on isolation precautions did not have dedicated vital sign equipment and was uncertain whether disposable BP cuffs were supposed to be used for isolation residents. Record review showed one resident had chronic respiratory failure and tested positive for Klebsiella pneumoniae with ESBL and CARBA resistance markers and was placed on droplet precautions. Two other residents had diagnoses including respiratory failure, anoxic brain damage, and cerebral infarction, and both had physician orders for contact isolation due to C. diff. The infection preventionist stated each resident on isolation precautions should have dedicated BP cuff, pump, stethoscope, and disposable thermometer strips in the room, and that multi-resident equipment should not be used on isolation residents. The DON stated it was preferred that staff use dedicated equipment on isolation residents. The facility policy stated dedicated or disposable patient-care equipment was preferred, and the cited guideline stated that in long-term care settings, disposable noncritical patient-care equipment or patient-dedicated use should be used for contact precautions.
Failure to Complete Admission Skin Assessment and Implement Timely Pressure Ulcer Treatment Orders
Penalty
Summary
The deficiency involves the facility’s failure to complete and document a required admission skin assessment and to obtain and implement timely physician orders for pressure ulcer treatment for one resident. The resident was re-admitted with pneumonia and had severe cognitive impairment, with a BIMS score of 3. On re-admission, RN 1 was responsible for completing the admission skin assessment and transcribing admission orders, but RN 1 did not complete or document the admission skin check, despite facility policy and the admission checklist requiring a skin assessment upon admission. RN 1 later confirmed that he had transcribed the admission orders and was responsible for the admission skin check but did not perform or document it. On the day after re-admission, the Treatment Nurse (TxN) completed a skin check and identified an unstageable pressure ulcer on the resident’s sacrococcygeal area, measuring 9 cm by 11 cm with surrounding skin discoloration, and documented it as present on admission. The resident’s care plan was initiated to address the unstageable pressure ulcer, including an intervention to administer treatments as ordered. However, there were no corresponding physician’s wound care treatment orders in the medical record at that time, and the Treatment Administration Record for March showed no wound care treatments provided to the sacrococcyx pressure ulcer during the days immediately following its identification. On a subsequent visit, the wound care physician evaluated the same sacrococcygeal wound, documented it as a deep tissue injury/unable to determine depth, and recommended a treatment plan of cleansing with normal saline and applying barrier cream daily. The TxN acknowledged receiving this wound care note and the associated treatment orders but did not transcribe the orders into the resident’s medical record, and no treatments were documented as provided until several days later, when new orders for Medihoney and dressings to the coccyx were entered and treatments began. The DON confirmed that the admission skin check was not documented by RN 1 and that the TxN did not obtain or transcribe treatment orders when the pressure ulcer was identified, contrary to facility policy and expected practice.
Failure to Implement Toileting Program for Continent/Incontinent Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate treatment and services to restore or maintain bladder continence for a resident who was frequently incontinent and able to make her own decisions. The resident, admitted with respiratory failure with hypoxia, muscle weakness, and a tracheostomy, had care plans noting diuretic therapy for CHF with increased fall risk and occasional bladder incontinence related to COPD, respiratory failure, impaired mobility, and obesity. Her care plan interventions included use of a brief per her request, maintaining an unobstructed path to the bathroom, and checking her when incontinent "as required." A Bowel and Bladder Evaluation documented that she was an unlikely candidate for bowel and bladder retraining, and the MDS later documented that she did not have a toileting program and was frequently incontinent with bladder. The resident reported that it could take a while for staff to respond when she called for assistance, and that she attempted to take herself to the bathroom, lost her footing, fell, and soiled herself. A Change in Condition Evaluation documented that she was found on the floor after attempting to go to the bathroom unassisted, with pain in her lower back and right wrist, and that she stated she lost her balance and landed on her backside. A Fall Risk Evaluation identified balance problems while walking, decreased muscular coordination, and the need for assistive devices. The DON acknowledged that the resident fell when she went to the bathroom by herself and stated that the resident should be re-evaluated for a toileting program, as she had been in the facility a long time, could ambulate, and could be a candidate for a bowel and bladder toileting program. The facility’s own toileting program policy required bowel and bladder retraining for residents with potential to benefit and directed that toileting programs be addressed on the care plan and reassessed at least quarterly and as needed.
Failure to Follow PRN Pain Orders and Arrange Timely Pain Management Consult
Penalty
Summary
The facility failed to provide appropriate pain management for a resident with chronic pain conditions, including bilateral hip osteoarthritis with artificial hip joints and fibromyalgia. The physician had ordered pain to be monitored using a 0–10 scale, Dilaudid 8 mg PO every three hours as needed for moderate to severe pain rated 4–10, and Morphine ER 15 mg PO twice daily for pain management. The resident’s care plan identified acute pain with interventions to give medications as ordered and monitor pain levels. However, review of the Medication Administration Record showed that Dilaudid, which was ordered only for pain levels of 4–10, was administered on multiple occasions when the documented pain level was 0/10, indicating no pain at the time of administration. The ADON confirmed that licensed staff should evaluate pain before administering PRN pain medication and that the resident should not receive PRN pain medication when pain is 0/10. The facility also failed to ensure timely follow-through on a physician’s order for a pain management consultation due to uncontrolled pain. The order for a pain consult was written in late October 2025, but the resident had not yet been seen by a pain management specialist at the time of the survey. Progress notes showed repeated attempts to contact the pain clinic, with staff reaching only voicemail on several occasions and no documented successful scheduling of an appointment. During interview, the resident reported generalized pain, difficulty moving, and stated she was supposed to receive Dilaudid every three hours but felt it was not being given as ordered, and that her request to see a pain doctor had not yet been fulfilled. The ADON acknowledged that the pain management consult ordered months earlier had not resulted in an appointment and that the resident’s pain management needed to be re-evaluated.
Unsafe Mechanical Lifts Left in Use Without Maintenance or Removal From Service
Penalty
Summary
The deficiency involves the facility’s failure to ensure mechanical lifts used for resident transfers were maintained in safe operating condition and removed from service when potentially unsafe. During an unannounced complaint visit focused on the physical environment, surveyors observed mechanical lift #7 with Coban wrapped around its casing while it remained in use on the unit. A CNA stated the lift might be broken and should not be used, and the DON confirmed the lift should not be wrapped with Coban or in use and identified this as a safety problem. Another mechanical lift in the same hallway was labeled with a sign stating it was “not working,” yet it remained on the floor rather than being removed from service. Staff interviews showed that CNAs and an LVN had recently used mechanical lift #7 for resident transfers without noticing or questioning the Coban wrapped around the equipment. CNA 3 and LVN 1 both acknowledged the lift should not have been used and that they did not investigate the Coban or report a potential problem. The Director of Maintenance later reviewed monthly inspection logs and the TELS work order system and confirmed there were no work orders or maintenance requests for either of the two lifts in question, despite the facility’s written policy requiring routine inspections, documentation in the preventive maintenance log or TELS, and daily review of maintenance requests. This sequence of observations and interviews demonstrated that two lifts with identified or suspected problems remained on the floor and in use without being removed from service or entered into the maintenance system as required by facility policy.
Failure to Maintain Safe Flooring and Intact Ceilings After Water Damage
Penalty
Summary
Surveyors identified that the facility failed to maintain a safe, functional, and sanitary environment in Hallway 100 and in a resident room. During an unannounced complaint investigation, staff interviews and observations revealed that the flooring in Hallway 100 was deformed with multiple raised areas or “bumps.” A CNA stated the floor was not safe for residents or staff because someone could trip and fall. The DON also observed the hallway flooring and acknowledged that it should not have bumps and that this condition was a safety hazard. The Maintenance Assistant explained that the laminate flooring could develop bubbles if insufficient glue was used during installation and agreed that this condition posed a tripping hazard, indicating that the affected tiles would need to be removed and replaced. Surveyors also observed a ceiling defect in a resident room that had previously experienced water damage from roof leaks. The DON and Director of Maintenance reported that there had been multiple roof leaks in the facility in November and December, with one leak affecting a resident room where drywall had been cut and repaired. During observation with the Maintenance Assistant, the ceiling in the identified room was noted to have a crack from prior water damage and was described as needing to be repatched, while a resident lay in bed beneath the cracked area. In a later observation with the resident, the ceiling was described as lumpy with possible water damage, and the paint was cracked and chipped. The facility’s maintenance policy required maintaining a clean and safe facility, including floor, wall, and ceiling surfaces that are smooth, dry, and cleanable, and stated that any cracks may harbor bacteria, which was not met in these observed conditions.
Failure to Remove Discontinued Medications and Follow Physician Orders for Medication Administration and Lab Testing
Penalty
Summary
The facility failed to ensure proper provision of pharmaceutical services to meet the needs of residents, as evidenced by the improper storage and handling of discontinued medications and failure to follow physician orders. During inspections, surveyors observed four discontinued bags of 0.45% normal saline and one discontinued IV bag of vancomycin stored in the medication room and refrigerator, respectively, despite being no longer needed for the residents for whom they were ordered. Additionally, a discontinued blister card of ondansetron and a discontinued blister card of generic Norco were found in the medication cart, available for use, even though both medications had been discontinued by physician order. Staff interviews confirmed that these medications should have been removed and stored separately or discarded according to facility policy. Further review of medication administration practices revealed that midodrine was administered to a resident with heart failure, chronic kidney disease, and hypertension, even when the resident's systolic blood pressure exceeded the physician-ordered parameter to hold the dose if above 120 mmHg. The Medication Administration Record showed that the medication was given on two occasions when the blood pressure was above the specified threshold, contrary to the physician's instructions. The Assistant Director of Nursing acknowledged that these doses should not have been administered. Additionally, the facility failed to consistently obtain laboratory tests as ordered for a resident with adult-onset diabetes mellitus. The physician had ordered Hgb A1c tests every three months to monitor diabetes management, but there were missed intervals where the test was not completed as required. The Assistant Director of Nursing confirmed that the tests were not performed every three months as ordered. These findings demonstrate failures in medication management, adherence to physician orders, and compliance with facility policies.
Unsanitary Food Storage Shelving in Kitchen
Penalty
Summary
Surveyors observed that the facility failed to maintain safe and sanitary food storage practices in the kitchen's dry goods supply area. Specifically, wooden storage shelves were found to be chipped, splintered, and had peeling lacquered varnish, exposing bare wood. During an observation with the Dietary Supervisor (DS), it was noted that staff wore gloves to avoid splinters when accessing food items, indicating an awareness of the risk of staff injury. The Plant Director (PD) confirmed that the shelves should not be in such a condition due to the potential for staff injury and cross-contamination of food. The Registered Dietician (RD) reported being aware of the damaged shelving and had previously notified both the PD and the Administrator about the issue. The facility's policy on food storage requires that all food items be stored on shelves that facilitate thorough cleaning, which was not met due to the condition of the shelves. No specific residents were mentioned as being directly affected at the time of the deficiency, but the report notes the potential for food-borne illness in a highly susceptible resident population.
Failure to Assess Resident for Safe Self-Administration of Medication
Penalty
Summary
A facility failed to ensure that an assessment for safe self-administration of medication was conducted for a resident when two open containers of topical ointment were found on the resident's overbed table. During observation and interview, the resident stated she applied the ointment to her lower legs when she felt itchy and would use more if she wanted. The containers were labeled as zinc oxide 25%. Review of the resident's admission record showed a history of infectious and parasitic diseases, and a history and physical indicated the resident was mentally capable of making decisions. However, there was no documented evidence that a self-administration assessment had been completed. A registered nurse confirmed that no assessment for self-administration of medications had been conducted for the resident, and stated that it was not safe for the resident to have medications at the bedside without such an assessment. The assistant director of nursing stated that licensed nurses were expected to follow the facility's policy and procedure regarding self-administration assessment and medication administration. Facility policy required an interdisciplinary team assessment and periodic re-evaluation for residents wishing to self-administer medications, and that self-administration was only allowed when specifically authorized by the attending physician. These procedures were not followed in this instance.
Unlabeled Medication Found on Medication Cart
Penalty
Summary
During an inspection of Medication Cart Rx 2, a saline nasal spray was found that was not labeled with the name or room number of the resident for whom it was intended. The LVN present confirmed that there was no identifying information on either the spray bottle or its manufacturer box and acknowledged that the medication should have been labeled with the resident's name. The LVN also stated that, without the name on the medication, she would not know which resident the medication was for. Review of the facility's policies confirmed that prescription medication labels are required to include the resident's name and that medications supplied for one resident are never to be administered to another resident.
Failure to Follow Up on Dental Needs for Resident Requesting Dentures
Penalty
Summary
The facility failed to follow up on the dental needs of a resident who was missing upper teeth and expressed a desire to receive dentures. The resident, who had a tracheostomy and was able to make her own decisions, reported that she had requested to be seen by the facility dentist but was not updated on whether she would receive dental services. Record review showed that the resident's oral assessment at admission indicated she was unable to function without natural teeth and dentures, and subsequent nutrition evaluations noted several missing teeth. Dental notes documented that the resident requested upper dentures on two separate occasions, with recommendations to check eligibility for a full upper denture, but there was no documented evidence of follow-up by Social Services or Nursing regarding her eligibility. Interviews with facility staff, including a registered nurse, the Social Service Director, and the Director of Nursing, confirmed that no follow-up was conducted for the resident's dental requests. Staff acknowledged that the dental requests should have been followed up and that failure to do so could delay dental care services. Review of facility policies indicated that the facility is responsible for ensuring residents have access to needed dental services and that Social Services is responsible for scheduling such appointments, but these procedures were not followed in this case.
Failure to Honor Resident Food Preferences During Meal Service
Penalty
Summary
The facility failed to honor the documented food preferences of two residents during a lunch meal service. One resident, who had a documented dislike of pork on his meal ticket, was observed eating a substitute burrito after being served a main entrée containing pork. The resident stated he disliked pork and frequently received it despite his preference being noted. Review of his record showed he was cognitively intact and had diagnoses including end-stage renal disease and diabetes. An LVN confirmed that pork should not have been served, and the kitchen staff should have followed the diet slip instructions. Another resident, also with a documented dislike of pork and a history of dysphagia, was observed eating a meal that included chopped pork. The resident consumed only a few bites of the pork and stated a dislike for it. Both residents' meal tickets clearly indicated their dislike for pork, and the facility's policy required adherence to food preferences and provision of alternate menu items as dictated by resident dislikes. The Registered Dietician confirmed that residents' preferences and dislikes are to be printed on meal tickets to guide dietary staff, and that the residents should not have been served pork.
Infection Control Lapses in Equipment Cleaning and Urinal Storage
Penalty
Summary
The facility failed to implement proper infection control practices in two separate instances. In the first case, a black stand fan in a resident's room was observed with accumulated black and gray dust on both the front and back guard covers. Both a CNA and a respiratory therapist confirmed that the fan was dusty and should have been cleaned. The resident in this room had a history of respiratory failure with a tracheostomy and was on enhanced barrier precautions due to a gastric tube and trach. Facility staff, including the infection preventionist and assistant director of nursing, acknowledged that dust on equipment could contribute to the spread of germs and potentially cause respiratory infections, especially for residents with tracheostomies. In the second instance, a used plastic urinal was found inside another resident's personal belongings storage closet. The CNA present stated that the urinal should not have been placed on the closet shelves and should have been stored in a urinal holder or discarded if not in use. The resident involved had diagnoses including kidney failure, malignant melanoma, and abdominal surgical dehiscence, and also had a trach. Both the LVN and infection preventionist confirmed that improper storage of urinals could lead to surface contamination and the spread of infection. The DON stated that proper storage procedures were expected to be followed according to facility policy. Facility policies reviewed indicated requirements for maintaining clean and sanitary equipment and resident rooms, including damp wiping surfaces with germicidal solution and proper storage of bedpans and urinals. The observed failures to clean the fan and properly store the urinal were not in accordance with these policies and procedures.
Failure to Maintain Safe Wheelchair Equipment for Residents
Penalty
Summary
The facility failed to maintain wheelchairs in safe operating condition for two residents. For one resident with spinal stenosis, joint replacement aftercare, and diabetic neuropathy, the wheelchair had multiple issues including a non-functioning left brake, a loose and wobbly left armrest, and a right wheel with a missing metal hand rim that left sharp edges exposed. The resident reported these problems, describing the situation as dangerous. The Plant Director confirmed the need for parts replacement and acknowledged that the cracked upholstery posed an infection control risk and that the broken metal and inoperative brake could result in injury. The Physical Therapy Assistant also confirmed the issues and stated that a work request had been submitted for repairs, but a suitable replacement wheelchair was not available. Another resident with osteoarthritis, right knee pain, and hemiplegia reported that their wheelchair, though previously repaired, remained shaky with a loose left wheel and cracked, peeling upholstery on the left armrest. The resident had reported these issues, and the Plant Director, upon assessment, agreed that parts replacement was needed. The cracked upholstery was again identified as an infection control issue, and the loose wheel was recognized as a risk for injury. Facility policy requires equipment to be maintained in good working order for resident safety and for staff to communicate specific accommodation needs, but these requirements were not met in these cases.
Failure to Provide Timely Care and Physician Notification for Change in Condition
Penalty
Summary
A resident with a history of respiratory failure and hypoxia experienced a significant change in condition, including an elevated pulse rate and decreased oxygen saturation. On multiple occasions, the resident was found with abnormal vital signs, such as a pulse ranging from 107 to 163 beats per minute and oxygen saturation levels as low as 65%. Despite these findings, there was no timely notification to the physician regarding the resident's deteriorating condition, and vital signs were not closely monitored at the recommended intervals. Documentation shows gaps in monitoring, with several hours passing between assessments, and a lack of consistent follow-up on the resident's status. The nursing staff did not notify the physician when the resident was found unresponsive with critically low oxygen levels and an elevated pulse. Subsequent assessments continued to show abnormal vital signs, but the physician was still not informed in a timely manner. The resident also refused oxygen therapy and transfer to the emergency room, but there was no evidence of persistent or immediate escalation to the physician or further intervention until much later. The facility's own policy required prompt assessment, physician notification, and close monitoring in the event of a change in condition, but these steps were not followed as documented in the records and confirmed by staff interviews. Interviews with facility leadership and nursing staff confirmed that the expected protocol was not followed. Staff acknowledged that the physician should have been notified, vital signs should have been monitored every 10–15 minutes, and 911 should have been called when the resident's oxygen saturation and pulse were critically abnormal. There was also no documentation that the physician came to evaluate the resident as promised, nor was there follow-up to ensure the physician's timely assessment. The failure to provide timely care and treatment according to orders and facility policy had the potential to delay necessary interventions and affect the resident's overall health condition.
Untrained Staff Assigned to 1:1 Supervision of Resident with Wandering Behavior
Penalty
Summary
The facility failed to ensure that staff members assigned to provide one-on-one (1:1) supervision for a resident with wandering behavior were properly trained and competent to meet the resident's behavioral health needs. Housekeeping staff were utilized as sitters for a resident with severe cognitive impairment and a history of wandering, despite not having received training on how to manage residents with such behaviors. Interviews with both a CNA and the Director of Staff Development confirmed that housekeepers were assigned to provide 1:1 supervision for the resident throughout April, and that these staff members had not been trained for this responsibility prior to their assignment. The resident in question had diagnoses including unspecified psychosis, altered mental status, impulse disorder, and unspecified dementia, with a severely impaired cognition score on the most recent assessment. Physician orders and the care plan specified the need for 1:1 supervision due to wandering risk. Despite this, the facility did not have a policy for managing residents requiring a sitter, and the Director of Nursing acknowledged that housekeeping staff should have received proper training before being assigned as sitters. Documentation and staff interviews confirmed that the housekeepers did not receive relevant training until after they had already been assigned to supervise the resident.
Failure to Provide Required 1:1 Supervision for Resident with Wandering Behavior
Penalty
Summary
The facility failed to provide one-on-one (1:1) supervision for a resident with severe cognitive impairment and a history of wandering, as required by the physician's order and the resident's care plan. Multiple staff interviews and record reviews revealed that there were several occasions when no assigned sitter was present for the resident, and the responsibility to monitor the resident was informally distributed among all available staff. Assignment sheets and sitter schedules showed blank entries for numerous shifts, indicating the absence of a designated sitter during those times. The resident in question had diagnoses including unspecified psychosis, altered mental status, impulse disorder, and dementia, with a Brief Interview for Mental Status (BIMS) score of 3 out of 15, indicating severely impaired cognition. The care plan specifically identified the resident as an elopement risk and required 1:1 supervision due to wandering behaviors. Despite this, staff reported that when no sitter was available, they were instructed to "keep an eye" on the resident while also attending to their other assigned duties, and sometimes non-clinical staff such as housekeepers were assigned as sitters. Documentation reviewed for the month showed multiple periods where no staff signatures were present to confirm 1:1 supervision, and staff confirmed that these blank periods meant the resident was not being directly supervised as required. The Director of Nursing acknowledged that the resident should not have been left without a sitter at any time while the order was in place, and the facility did not have a specific policy for managing residents who require a sitter.
Failure to Perform Hand Hygiene During Infectious Disease Outbreak
Penalty
Summary
A deficiency was identified when a Certified Nursing Assistant (CNA) failed to follow proper infection prevention and control practices during an infectious disease outbreak. Specifically, the CNA was observed exiting a resident's room, removing gloves outside the room, and touching the linen cart in the hallway without performing hand hygiene. The CNA then re-entered the resident's room without using hand sanitizer or washing hands. This lapse in protocol was acknowledged by the CNA during a concurrent interview, where she admitted she should have used hand sanitizer to prevent the spread of germs. Further interviews with other staff, including another CNA, the Infection Prevention Nurse, and the Director of Nursing, confirmed that facility policy and standard precautions require hand hygiene before and after entering a resident's room and after contact with potentially contaminated surfaces. A review of the facility's infection prevention and control policy, as well as CDC guidelines, reinforced the importance of hand hygiene in preventing the spread of infection. The failure to adhere to these procedures was observed during an unannounced visit investigating an infectious disease outbreak.
Failure to Notify Physician of Critically High Blood Sugar
Penalty
Summary
A deficiency occurred when a resident with diabetes mellitus had a blood sugar reading of 403 mg/dl, which exceeded the threshold specified in the physician's order for notifying the physician. The physician's order required staff to call the physician if the resident's finger-stick blood sugar was less than 60 or greater than 400. On the specified date, the resident's bedtime blood sugar was recorded as 403 mg/dl, but there was no documented evidence that the physician was notified as required by the order. During a review of the resident's record and an interview with the Assistant Director of Nursing (ADON), it was confirmed that the physician was not notified of the elevated blood sugar level. The facility's policy on physician orders outlines procedures for timely implementation and follow-up of orders, but in this instance, the required notification did not occur. The resident expressed dissatisfaction with their care during an interview conducted as part of the investigation.
Infection Control Breach Due to Artificial Nails
Penalty
Summary
The facility failed to adhere to proper infection prevention and control standards when three direct care staff members were observed with artificial nails, which is against the facility's infection control policy. During an unannounced visit to investigate a complaint regarding quality of care and infection control, as well as a reported gastrointestinal outbreak, surveyors observed a Certified Nursing Assistant (CNA) and two Licensed Vocational Nurses (LVNs) with long artificial nails. Each staff member acknowledged that wearing artificial nails was against the facility's policy due to the risk of collecting bacteria and potentially transmitting infections to residents. The facility's Infection Preventionist confirmed that staff members providing direct patient care should not have artificial nails, as they pose an infection control risk. The facility's policy on infection prevention and control, as well as hand hygiene, explicitly discourages artificial nails among staff with direct resident-care responsibilities and prohibits them for those caring for severely ill or immunocompromised residents. Despite these policies, the presence of artificial nails on staff members was noted, indicating a lapse in adherence to infection control protocols.
Failure to Activate Door Alarm Leads to Elopement Risk
Penalty
Summary
The facility failed to ensure an environment free of accident hazards for a resident at high risk for elopement when the door alarm was not activated. During an unannounced visit, it was observed that the door alarm on the exit door in hallway 200 was not functioning because it had not been turned on. The Director of Staff Development admitted to forgetting to activate the alarm after using the door to enter the facility. This oversight was confirmed by a Registered Nurse who stated that the door alarm should always be on, regardless of its use as an entrance or exit, to prevent residents from leaving undetected. The resident involved had a history of altered mental status and unspecified psychosis, and was identified as having a high risk for wandering and elopement. The resident had previously attempted to leave the facility, as noted in an evaluation indicating active exit-seeking behavior. Interviews with the Maintenance Supervisor and the Assistant Director of Nursing revealed that the responsibility for ensuring the alarm was activated fell on the staff, and failure to do so could lead to repeated elopement incidents, posing a risk of accidents or injuries to the resident.
Failure to Timely Report Resident Elopement
Penalty
Summary
The facility failed to report an unusual occurrence to the California Department of Public Health (CDPH) in a timely manner, as per their policy and procedure, when a resident eloped from the facility. The incident occurred when the resident, who had intact cognition and was able to walk using a walker, left the facility unsupervised to go to the bank and post office. The resident was later found at a bus stop by facility staff and returned to the facility with minor abrasions on the forehead and shin. The Assistant Director of Nursing (ADON) acknowledged that the incident was initially debated as either an elopement or leaving against medical advice. It was eventually classified as an elopement, which required reporting to the CDPH within 24 hours. However, the report was submitted later than the required timeframe. The facility's policy on unusual occurrences mandates that such incidents be reported within 24 hours to the local health officer and the Department, which was not adhered to in this case.
Facility Fails to Maintain Comfortable Environment and Cleanliness
Penalty
Summary
The facility failed to maintain a comfortable and homelike environment for its residents, as evidenced by excessively high temperatures in resident rooms and hallways, which exceeded the acceptable range of 71 to 81 degrees Fahrenheit. This issue was observed during an unannounced visit, where multiple residents expressed discomfort due to the heat. The facility's air conditioning units had been malfunctioning for approximately three weeks, and despite the provision of portable fans and AC units, the temperatures remained high, reaching up to 87 degrees Fahrenheit in some areas. The Plant Director confirmed the malfunction and acknowledged that the internal temperature should be within the specified range. Additionally, the facility did not report this disruption of services to the California Department of Public Health as an unusual occurrence, which is required when events threaten the welfare, safety, or health of residents. The Administrator admitted awareness of the air conditioning issues but believed the situation was manageable with the temporary cooling solutions provided. However, the failure to report the incident in a timely manner was acknowledged as a lapse in protocol. The facility also failed to maintain clean and sanitary conditions, as evidenced by dirty carpets with black circular stains in various areas, including the entrance, nurse's station, and resident hallways. Despite weekly cleaning efforts by the Plant Director and a previous attempt by an outside agency, the stains persisted, leading to dissatisfaction among residents and visitors. The Administrator recognized the poor condition of the carpets and acknowledged the need for improvement, as the facility's policy requires a safe, functional, and comfortable environment for all residents and staff.
Failure to Provide Timely Incontinent Care
Penalty
Summary
The facility failed to provide timely incontinent care for two residents, resulting in a delay of care needs. Resident 11, who had been at the facility for two weeks, reported being left wet for over 10 minutes before receiving assistance. Resident 11's medical history included myocardial infarction, pneumonia, cirrhosis of the liver, heart failure, hypertension, and anxiety, and she was cognitively intact with the capacity to make decisions. During an observation, Resident 11 was found lying in bed and expressed dissatisfaction with the delay in care. Resident 12, who had diagnoses including Wernicke's Encephalopathy and dysphonia, also experienced delays in receiving care. She reported that staff took 30 minutes to an hour to change her brief and was observed waiting for 15 minutes with the call light on, which remained unanswered for an additional 20 minutes. The CNA assigned to Resident 12 acknowledged being occupied with another client and informed the nursing staff, but the call light was still on when she returned. The DON stated that the facility's call system should alert staff to assist residents promptly, but was unaware of Resident 12's prolonged wait time. The facility's policies emphasized providing necessary care to maintain residents' well-being, but these were not adhered to in these instances.
Facility Fails to Maintain Environmental Conditions to Prevent Insect Entry
Penalty
Summary
The facility failed to maintain environmental conditions that prevent insects from entering the building, as observed during an unannounced visit. A missing window screen, tears and gaps in other screens, and entrance and exit doors with gaps large enough for insects to enter were noted. These deficiencies were confirmed through observations and interviews with the Maintenance Supervisor (MS) and the Director of Nursing (DON). The MS acknowledged that the front door was not completely closed or latched due to it being locked, which was supposed to be unlocked by the charge nurse. The DON also verified the presence of gaps in the front lobby door and other areas, which could allow insects to enter the facility. Further observations revealed additional issues with window screens and doors throughout the facility. The lunch staff lounge had a window screen with a large gap, the small dining room had no screen on the window, and a fly was noted inside. Rooms with window screens containing holes and hallway exit doors with gaps were also identified. The facility's policy, revised in December 2019, requires window screens to be intact and doors to fully close and latch, with no daylight visible on the door frame. These findings indicate a failure to adhere to the facility's policy, potentially allowing insects to enter areas frequented by residents.
Failure to Provide Timely Wound Treatment
Penalty
Summary
The facility failed to ensure treatments were provided upon admission for a resident's wounds located on the right lower extremity and left achilles. The resident was admitted with multiple wounds, including an unstageable pressure injury to the sacrococcyx, a surgical incision to the sternum, scabs on the upper abdomen, discolorations on both arms, an AV shunt to the left upper arm, a diabetic ulcer to the left achilles, and a diabetic ulcer to the posterior right lower extremity. The physician orders for wound treatment were not initiated until two days after admission, leading to a delay in care. Interviews with staff revealed that admission skin assessments are expected to be completed within 24 hours, and treatments should be initiated promptly. However, the wound nurse did not complete the wound measurements until the third day, and the treatment orders were not clarified until then. The delay in documenting and clarifying the wound measurements resulted in a delay in the initiation of the prescribed treatments. The facility's policy requires a comprehensive admission assessment and timely wound assessment and treatment. Despite this policy, the resident's wounds were not assessed and treated within the required timeframe, leading to a delay in care. The Director of Nursing and other staff confirmed that the admission assessment and treatment orders were not completed as per the facility's policy, resulting in a deficiency in the care provided to the resident.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 119 citations issued within 25 miles in the last 12 months — including the 1 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Indio
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Desert Springs Healthcare & Wellness Centre | 0.9 mi | ★★★★★ | 13 | 0 |
| The Springs Healthcare Center At The Carlotta | 6.4 mi | ★★★★★ | 2 | 0 |
| Monterey Palms Health Care Center | 9.2 mi | ★★★★★ | 1 | 0 |
| Rancho Mirage Health And Rehabilitation Center | 9.9 mi | ★★★★★ | 2 | 0 |
| Desert Springs Post Acute | 10.9 mi | ★★★★★ | 39 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.