Average — CMS composite of the measures below.
The next survey window likely opens around August 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Desert Springs Healthcare & Wellness Centre during CMS and state inspections, most recent first.
Improper Storage of Refrigerated Medications: A medication refrigerator at nursing station 1 was found at 28 degrees F and contained Afluria, Tuberculin PPD, and several insulin products. The RN confirmed refrigerated meds should be kept between 36 and 46 degrees F, and the temperature log showed multiple out-of-range readings on the PM shift. The DON confirmed the expected range and that freezing was 32 degrees F or less, while the maintenance log showed no documented contact with maintenance or corrective action when the refrigerator was out of range.
Clean pillows were found stored in the soiled laundry area in a partially open plastic bag, with the LD stating there was not enough room to store them elsewhere and acknowledging the infection control concern. The PM also stated the pillows were not fully covered and could cause contamination. Facility policy required separate storage for clean and soiled linen and handling of soiled laundry to prevent gross microbial contamination.
A resident with bipolar disorder and major depressive disorder was not informed or involved when her Depakote was reduced from BID to once daily as part of a GDR. The resident, who had a BIMS score of 13, said she felt more suppressed after the change and did not know why the dose was changed. The DON stated the IDT recommended the GDR but did not tell the resident, and acknowledged the resident should have been involved in her care plan.
Advance Directive Not Available in Resident Record: The facility failed to ensure a resident’s AD was readily available in the chart. The resident had mild cognitive impairment and a Social Services Assessment documented that an AD existed but was not on file. Record review found no copy in either the electronic or paper chart, and the DON confirmed the AD had not yet been obtained by the SSD.
Failure to monitor antipsychotic side effects for two residents. One resident with schizoaffective disorder and schizophrenia received aripiprazole without documented nursing monitoring of adverse effects, despite a care plan calling for shift monitoring. Another resident with bipolar disorder, psychosis, dementia, Parkinsonism, and depression received quetiapine, but the DON could not find the lipid monitoring documentation required by the manufacturer. The DON confirmed the missing monitoring documentation during record review.
Inaccurate MDS Coding for Resident Weight Loss: A resident with dementia and palliative care had a documented 12.58% weight loss in one month, but the MDS Section K indicated no weight loss in the last month. The DON stated the prior MDS coordinator incorrectly coded the weight loss, and the facility followed RAI Manual guidance for MDS assessments without a specific policy on accuracy.
Consultant Pharmacist failed to identify and report irregularities during MRRs for two residents receiving antipsychotic medications. One resident on aripiprazole for schizophrenia had no documented side effect monitoring, and the CP did not recommend monitoring in monthly reviews. Another resident on quetiapine for schizoaffective disorder had no documented lipid monitoring per manufacturer guidance, and the CP’s monthly reviews also lacked recommendations for that monitoring. The DON confirmed the missing documentation and that the expected monitoring and CP recommendations were not present.
A resident with severe cognitive impairment passed away, and the facility did not provide the legal representative with timely disbursement of personal funds or itemized financial statements, despite multiple requests. Staff interviews and record reviews confirmed that required policies for prompt refunds and transparent accounting were not followed.
A resident with a chronic skin condition refused a bed bath due to concerns about soap residue and was not offered any alternative hygiene options when regular showers were unavailable. CNAs were unaware of further steps to take, and documentation did not show that alternatives were provided or that the reason for refusal was addressed, despite facility policy requiring person-centered care.
A facility failed to conduct proper orthostatic blood pressure monitoring for a resident with a history of falls and Alzheimer's disease. The care plan required monitoring every Thursday due to medication use, but records showed only lying and sitting blood pressures were recorded, omitting standing measurements. Staff interviews revealed a lack of adherence to correct procedures, with the DON admitting the failure to identify the appropriate position for monitoring.
Two residents at the facility experienced multiple falls, and the care plans were not updated with new interventions despite recommendations from the IDT. Resident 7, with conditions like dementia and difficulty walking, and Resident 8, with a history of falls and multiple health issues, both had high fall risk scores. The facility's policy required care plan updates post-fall, but this was not done, as confirmed by the RN.
A resident who underwent spine surgery experienced severe pain due to the facility's failure to administer prescribed pain medications in a timely manner. Despite the resident's repeated requests and high pain levels, necessary medications were delayed due to authorization and delivery issues. The facility's staff did not adhere to the pain management policy, resulting in the resident being transferred to a hospital for pain management.
The facility failed to respect the rights of two residents by opening their mail and packages without consent. Both residents, who were cognitively intact, reported that staff opened their packages and removed items without permission. The facility's protocol involved processing mail through various departments before delivery, contradicting the policy that mail should remain unopened unless requested by the resident.
A resident admitted after spine surgery did not receive timely pharmaceutical services, resulting in significant pain and distress. The facility failed to acquire prescribed medications, including narcotic pain medications and a nicotine patch, in a timely manner. Despite follow-ups, the medications were delayed, impacting the resident's care and treatment.
A resident's wheelchair at the facility had a non-functioning left brake, which was not addressed, posing a risk of injury. The resident reported difficulties in transferring to the wheelchair due to the broken brake. Interviews with staff revealed that the facility had protocols for maintaining equipment, but these were not followed in this case.
A resident with a history of stroke and epilepsy experienced a fall and subsequent symptoms such as altered consciousness and abnormal vital signs. Despite these changes, CNAs and LVNs failed to communicate and document the resident's condition properly, leading to a deficiency in care. The facility's protocols for post-fall evaluation and change of condition notification were not followed, resulting in the resident's transfer to the hospital with cardiac issues.
A resident with a history of stroke and epilepsy experienced a fall and subsequent abnormal vital signs, which were not adequately addressed by the facility staff. Despite elevated blood pressure and pulse rate being recorded, there was a lack of communication and failure to follow protocols for reporting changes in the resident's condition. The resident was eventually transferred to the hospital, where further complications were identified.
A resident with severe cognitive impairment and a history of falling was found unresponsive after becoming stuck in a sunken dirt area on the facility's patio. The resident was later hospitalized for syncope and elevated D-dimer levels. The facility lacked specific accident prevention policies, contributing to the unsafe environment.
The facility failed to provide information on Advance Directives (AD) to three residents or their representatives. A resident with severe cognitive impairment signed an AD form without RR involvement, another resident did not receive AD information upon admission, and a third resident capable of making decisions was not informed about AD formulation. These oversights were confirmed through record reviews and staff interviews.
A facility failed to develop a comprehensive care plan for a resident prescribed apixaban for atrial fibrillation, neglecting to address the risk of bleeding. The DON confirmed that a care plan should have been completed within seven days of admission, as per facility policy.
The facility failed to ensure the Consultant Pharmacist identified and reported irregularities during monthly medication regimen reviews. A resident was given aripiprazole without monitoring for hallucinations, and three residents on anticoagulants were not monitored for bleeding. The Director of Nursing confirmed the lack of monitoring and absence of recommendations from the Consultant Pharmacist. The facility also lacked specific policies for anticoagulant medications.
The facility failed to monitor three residents for adverse effects while on anticoagulant medications, such as apixaban and enoxaparin. Despite having conditions like atrial fibrillation and a history of falls, these residents were not observed for signs of bleeding. The DON and Administrator confirmed the absence of specific monitoring policies for these medications.
The facility failed to follow the prescribed menu and portion sizes during meal preparation, affecting three residents with specific dietary needs. A resident on a renal diet received an incorrect portion of tacos, another resident on a large portion renal diet was served a regular portion, and a third resident on a pureed diet received a smaller portion than required. These discrepancies were due to the use of incorrect measuring tools and lack of clarity on portion sizes, potentially impacting the residents' nutritional status.
The facility failed to implement proper Infection Prevention and Control practices, as staff were unaware of which residents required Enhanced Barrier Precautions (EBP). A CNA incorrectly practiced EBP on a resident not listed for it, and two residents were inappropriately roomed together despite one being colonized with C. diff. The facility's policy on EBP was not followed, leading to potential infection risks.
Two residents were not treated with dignity during meal times as CNAs fed them while standing, contrary to facility policy requiring staff to sit at eye level. One resident required extensive assistance due to severe impairment, while the other had severe cognitive impairment and needed limited assistance. The facility's policy emphasizes promoting dignity and respect, which was not upheld in these instances.
Two residents were not provided necessary assistance during mealtime, resulting in incomplete meal setups. One resident, with severe cognitive impairment and other health issues, was unable to open food items, while another resident, with multiple health conditions, could not access her drink. Facility policies require proper meal preparation and assistance, which were not followed.
A resident with a history of hip fracture and malnutrition experienced a delay in treatment due to the facility's failure to address abnormal chest x-ray results in a timely manner. The x-ray, showing bilateral infiltrates, was not acted upon until two days after the results were received, and the prescribed antibiotic was not administered until four days later. This delay was due to a lack of communication between the physician, DON, and nursing staff, contrary to the facility's policy for timely notification of significant changes in a resident's condition.
A resident with severe cognitive impairment and blindness experienced multiple falls due to the facility's failure to implement necessary interventions, such as a 1:1 sitter and frequent monitoring. Despite being at high risk for falls, the resident was often left alone, leading to injuries. Staff interviews confirmed the lack of appropriate fall prevention measures, and the DON acknowledged the ineffectiveness of the current care plan.
A facility failed to accurately account for controlled medications for a resident when Norco was signed out but not documented on the MAR. During a survey, it was found that the medication was not recorded as administered on two occasions. The LVN acknowledged the discrepancy, and the DON confirmed the facility's process for medication administration, which includes immediate documentation in the MAR. The facility's policies require accurate documentation of controlled substances.
A resident with schizoaffective disorder was given aripiprazole without adequate behavioral monitoring for hallucinations. The facility's policy lacked guidelines for such monitoring, and the DON confirmed the absence of documented monitoring over a year.
A resident was inappropriately prescribed and administered Macrobid for a UTI despite not meeting McGeer's criteria. The physician's order to discontinue Macrobid and switch to Avelox was not followed, leading to non-compliance with the facility's antibiotic stewardship program.
Improper Storage of Refrigerated Medications
Penalty
Summary
The facility failed to ensure refrigerated medications and biologicals were stored at temperatures in accordance with facility policy and manufacturer specifications. During observation at nursing station 1, a medication refrigerator was found at 28 degrees Fahrenheit and contained Afluria influenza vaccine, Tuberculin PPD, and multiple insulin products, including insulin lispro, human insulin, and insulin glargine. The RN confirmed that 28 degrees Fahrenheit was within the freezing range and stated refrigerated medications should be stored between 36 and 46 degrees Fahrenheit per facility policy. Review of the September 2025 refrigerator temperature log showed multiple documented out-of-range readings on the PM shift, including 35 degrees Fahrenheit on September 1, 31 degrees Fahrenheit on September 7, 32 degrees Fahrenheit on September 8 and September 9, 34 degrees Fahrenheit on September 10, and 34 degrees Fahrenheit on September 12. The RN stated evening and overnight nursing staff were responsible for documenting refrigerator temperatures and acknowledged that staff should adjust the thermostat and recheck the temperature after 15 minutes if the refrigerator was out of range. Review of the maintenance log showed no documented evidence that maintenance staff were contacted and no documented corrective actions were taken when the refrigerator was below 36 degrees Fahrenheit on the identified dates. The DON confirmed the expected temperature range was 36 to 46 degrees Fahrenheit and that freezing was 32 degrees Fahrenheit or less. Facility policy and the manufacturer instructions for Tuberculin PPD, insulin lispro, human insulin, insulin glargine, and Afluria all indicated the products should be refrigerated and not frozen.
Clean Pillows Stored in Soiled Laundry Area
Penalty
Summary
Provide and implement an infection prevention and control program was deficient when clean pillows were observed stored in the soiled area of the laundry room. During a tour of the laundry area, multiple clean pillows wrapped in a clear plastic bag were found stacked in the soiled area, and the bag was tied in one knot but had open areas that allowed access in and out of the bag. The Laundry Director stated there was not enough room to store the clean pillows and acknowledged that keeping them in the soiled area could pose an infection control issue. The Plant Manager also stated the pillows were not fully covered and could cause contamination. Facility policies reviewed indicated that clean and soiled linen were to be stored separately and that staff were to handle soiled laundry and bedding in a manner that prevents gross microbial contamination.
Failure to Involve Resident in Depakote Dose Reduction
Penalty
Summary
The facility failed to ensure that Resident 7 was involved in the care planning process when the resident’s Depakote was gradually reduced from twice daily to once daily without the resident being notified or included in the decision. Resident 7 was admitted with diagnoses including bipolar disorder and major depressive disorder, and her MDS dated July 14, 2025, showed a BIMS score of 13, indicating she was cognitively intact. During an interview on September 16, 2025, Resident 7 stated that her Depakote dosage had been reduced about two weeks earlier and that she felt different and more suppressed since the change. She also stated that no one asked her how she was coping with the change. Review of the record showed that on August 30, 2025, the IDT recommended a GDR of Depakote and the medical order for Divalproex Sodium 250 mg twice daily for bipolar disorder was discontinued and replaced with an order for 250 mg once daily in the morning. On September 18, 2025, Resident 7 stated that her plan of care was not clear and that she was not involved in meetings regarding the dose reduction or changes in Depakote. She said she was not aware of the change and that staff could not explain why her second daily dose was discontinued. The DON stated that the IDT had discussed a plan for GDR and implemented it, but she did not mention the change to Resident 7. The DON acknowledged that Resident 7 should have been involved in her care plan and that her rights were violated due to not being notified of the changes made.
Advance Directive Not Available in Resident Record
Penalty
Summary
The facility failed to ensure that a copy of Resident 4’s Advance Directive was readily available in the chart. Resident 4 was admitted with diagnoses including rhabdomyolysis and had a BIMS score of 11 on the July 2, 2025 MDS, indicating mild cognitive impairment. A Social Services Assessment dated June 26, 2025, documented that Resident 4 had an AD but that it was not on file, and that a copy was requested from the resident or resident representative. Further review of the resident’s record showed there was no copy of the Advance Directive in either the electronic or paper chart. During a concurrent interview and record review on September 18, 2025, the DON stated that Resident 4’s record did not have a copy of the AD and that the SSD had not yet obtained it. The DON confirmed that a copy should be in Resident 4’s record and the SSD’s AD binder. The facility policy stated that if a resident has an Advance Directive, the facility shall request a copy from the family or resident representative and place it in the medical record if provided.
Failure to Monitor Antipsychotic Side Effects
Penalty
Summary
The facility failed to ensure that two residents were free from unnecessary psychotropic medication use when monitoring and documentation requirements were not followed for antipsychotic therapy. Resident 10, who had diagnoses including schizoaffective disorder and schizophrenia with visual hallucinations, had been receiving aripiprazole in various doses since July 2023. Although the resident’s care plan identified a risk for adverse side effects from psychotropic medication and called for monitoring every shift, the medical record contained no physician order for side-effect monitoring and no documented nursing monitoring of side effects during the period reviewed. Resident 5, who had diagnoses including bipolar disorder, psychosis, dementia, Parkinsonism, and depression, had been receiving quetiapine in various doses since June 2023. The current orders included quetiapine 200 mg at bedtime for schizoaffective disorder with angry outbursts, and a separate order to monitor for side effects of antipsychotic medication every shift. However, the DON confirmed that documentation for lipid monitoring required by the manufacturer could not be found in the record. During interview and record review, the DON acknowledged that nursing staff did not monitor or document side effects during aripiprazole administration for Resident 10 and could not locate lipid monitoring documentation for Resident 5’s quetiapine use. The facility policy titled Behavior/Psychoactive Medication Management stated that residents will be observed and/or monitored for side effects and adverse consequences, and that complications and side effects should be reported to the healthcare practitioner.
Inaccurate MDS Coding for Resident Weight Loss
Penalty
Summary
The facility failed to ensure an accurate MDS assessment was completed for one resident reviewed for nutrition. Resident 41 was admitted with diagnoses including senile degeneration of the brain, Alzheimer's dementia, and palliative care. The resident's Weights and Vitals Summary showed a weight of 155 lbs. on June 2, 2025, and 139 lbs. on July 2, 2025, reflecting a 12.58% weight loss in one month, which is significant weight loss. The resident's MDS, dated [DATE], Section K for nutrition assessment, indicated no weight loss in the last month. On September 18, 2025, the DON stated the previous MDS coordinator incorrectly coded the weight loss and that the loss exceeded 5% in 30 days and should have been coded on the MDS. The DON stated the facility followed the RAI Manual guidelines for MDS assessments, without a specific policy on their accuracy. The facility policy titled Evaluation of Weight and Nutritional Status defined significant weight loss as 5% or 5 lb in one month, and the RAI Manual stated to code weight loss when the resident has experienced weight loss of 5% or more in the past 30 days and it was not planned and prescribed by a physician.
Consultant Pharmacist Failed to Identify Missing Monitoring for Antipsychotic Medications
Penalty
Summary
The facility failed to ensure the Consultant Pharmacist identified and reported irregularities during the monthly medication regimen review for two residents receiving antipsychotic medications. One resident had schizoaffective disorder and had been receiving aripiprazole since July 2023; the current order was for aripiprazole 2 mg by mouth each morning for schizophrenia with visual hallucinations. The resident’s care plan included monitoring for adverse side effects of psychotropic medications every shift, but the medical record did not contain a physician order to monitor side effects related to aripiprazole, and there was no documented evidence that nursing staff monitored or documented side effects during the period reviewed. The Consultant Pharmacist’s monthly MRRs for this resident, reviewed for multiple months, did not include recommendations related to side effect monitoring during aripiprazole use. During interview, the DON confirmed that nursing staff did not monitor or document side effects during administration of aripiprazole and acknowledged this should have been done according to the facility’s psychotropic and antipsychotic monitoring process. The DON also confirmed there were no CP recommendations for monitoring side effects on the reviewed MRRs. A second resident with diagnoses including bipolar disorder, psychosis, dementia, parkinsonism, and depression had been receiving quetiapine since June 2023 and had an order for quetiapine 200 mg at bedtime for schizoaffective disorder. The resident also had an order to monitor for side effects of antipsychotic medication every shift, but the DON could not find documentation for lipid monitoring as required by the manufacturer’s instructions. The CP’s monthly MRRs for this resident did not include recommendations related to manufacturer-specified lipid monitoring during quetiapine use, and the DON confirmed there should have been such recommendations. The facility policy required the consultant pharmacist to review laboratory results, evaluate whether the resident was monitored for adverse consequences and side effects, and document and report resident-specific irregularities, and the behavior/psychoactive medication policy required residents to be observed and monitored for side effects and adverse consequences.
Failure to Timely Disburse and Account for Deceased Resident's Personal Funds
Penalty
Summary
The facility failed to ensure that the personal funds of a deceased resident were provided to the resident's legal representative within the required timeframe. After the resident, who had severe cognitive impairment due to dementia, passed away, the legal representative made multiple attempts to obtain information and the remaining funds from the facility. Despite repeated calls and requests, the facility did not provide timely callbacks, accurate information about the account balance, or an itemized breakdown of the funds. The legal representative received checks at different times, but these were not accompanied by the required itemized statements or invoices, and in one instance, an invoice was sent requesting payment without a breakdown of the amount due. Interviews with facility staff, including the DON, SSD, and BOM, confirmed that the facility's policy required refunds and final accountings to be processed and provided within 30 days of a resident's death, and that requests for itemized statements should be fulfilled immediately. However, the facility did not adhere to these policies, resulting in delays and lack of transparency regarding the resident's personal funds. The deficiency was identified through interviews, record reviews, and policy examination during a complaint investigation.
Failure to Offer Alternative Hygiene Options After Bath Refusal
Penalty
Summary
The facility failed to ensure that a resident who refused a bed bath was offered an alternative option for personal hygiene. During a period when regular showers could not be provided due to a plumbing issue, the resident, who has eczema and a physician's order for topical cream to manage skin dryness and scabs, was offered a bed bath as an alternative to a shower. After initially accepting, the resident refused a subsequent bed bath, expressing concern that soap would not be rinsed off properly, potentially aggravating his skin condition. There was no documented evidence that any other alternative was offered after the refusal, nor was there documentation that the reason for refusal was explored or addressed. Interviews with CNAs revealed a lack of awareness regarding alternative options when a resident refuses a bed bath, with staff indicating they would simply notify licensed nurses but did not know what further steps to take. The DON confirmed that staff were expected to offer alternatives, such as coordinating with family for a shower at home, but this was not done. Facility records and policy review confirmed the absence of documented alternative options or follow-up actions to support the resident's hygiene needs in a person-centered manner.
Failure in Orthostatic Blood Pressure Monitoring
Penalty
Summary
The facility failed to conduct appropriate orthostatic blood pressure monitoring for a resident, identified as Resident 6, who was at risk for falls due to a history of multiple falls and a diagnosis of Alzheimer's disease and osteoporosis. The resident's care plan required orthostatic blood pressure monitoring every Thursday due to the use of Escitalopram, as recommended by a pharmacist. However, the facility's records showed that only lying and sitting blood pressures were recorded, with no standing blood pressure measurements taken, which are crucial for accurate orthostatic blood pressure monitoring. Interviews with the facility's staff, including two Licensed Vocational Nurses (LVNs) and the Director of Nursing (DON), revealed that the nurses were not following the correct procedure for orthostatic blood pressure monitoring. The LVNs acknowledged that standing blood pressure should have been taken instead of sitting blood pressure, especially since the resident was ambulatory and had a tendency to stand and walk abruptly. The DON admitted that the facility failed to identify the appropriate position for obtaining orthostatic blood pressure, which was a deviation from the facility's policy and procedure for managing orthostatic hypotension.
Failure to Update Care Plans After Resident Falls
Penalty
Summary
The facility failed to adequately assess and revise interventions for two residents who experienced multiple falls. Resident 7, who was admitted with conditions including cellulitis, hypertension, anxiety disorder, difficulty walking, and dementia, was identified as being at high risk for falls. Despite having a care plan in place, Resident 7 experienced falls on several occasions, and no new interventions were added to the care plan following these incidents. The Interdisciplinary Team (IDT) recommended activities to prevent further falls, but these were not incorporated into the care plan. Similarly, Resident 8, who had a history of repeated falls and was admitted with conditions such as atrial fibrillation, hydrocephalus, hypertension, diabetes, chronic kidney disease, and chronic obstructive pulmonary disease, also experienced multiple falls. The care plan for Resident 8 did not include new interventions after the falls, despite recommendations from the IDT for more frequent checks. The facility's policy required that interventions be documented and updated in the care plan following falls, but this was not done for Resident 8. The Registered Nurse (RN) confirmed that no new interventions were added to the care plans of Residents 7 and 8 after their falls, despite the facility's policy and the IDT's recommendations. The RN acknowledged the importance of updating interventions to prevent recurring falls. The facility's policy on fall management emphasized the need for care plans to be updated with interventions following falls, but this was not adhered to in these cases.
Failure to Provide Timely Pain Management
Penalty
Summary
The facility failed to provide effective pain management for a resident who had undergone spine surgery, resulting in severe pain and a decline in the resident's quality of life. Upon admission, the resident required specific pain medications, including Methadone, Fentanyl, and other analgesics, which were not administered as ordered due to delays in obtaining authorization from the physician and delivery from the pharmacy. The resident expressed severe pain and distress, with pain levels consistently reported as high as 10 out of 10, indicating excruciating pain. The Director of Nursing (DON) and Licensed Vocational Nurse (LVN) acknowledged that the necessary medications were not available upon the resident's arrival and were still pending delivery two days later. Despite the resident's repeated requests for pain relief and the facility's awareness of the situation, the medications were not administered in a timely manner. The resident's care plan and physician's orders clearly outlined the need for specific pain management interventions, which were not followed, leading to the resident experiencing severe pain and muscle spasms. The facility's policy on pain management emphasized the importance of assessing and managing pain to maintain residents' well-being. However, the staff failed to adhere to these guidelines, resulting in the resident being transferred to an acute hospital for pain management. The lack of timely medication administration and inadequate communication between the facility, pharmacy, and physician contributed to the deficiency in care provided to the resident.
Violation of Resident Mail Privacy
Penalty
Summary
The facility failed to respect the rights of two residents, identified as Residents B and C, by opening their mail and packages without their prior consent. Resident B, who was cognitively intact with a BIMS score of 13, expressed dissatisfaction with the staff opening his packages, which he perceived as a violation of his rights. Similarly, Resident C, also cognitively intact with a BIMS score of 14, reported that staff opened his packages, including health plan letters and supply catalogs, and removed items he ordered without his permission. Both residents did not recall giving consent for their mail or packages to be opened by the facility staff. The Director of Staff Development (DSD) explained the facility's protocol, which involved mail and packages being received at the nurse's station, processed through the business office, and then divided between the case manager and the activities department before being delivered to residents. The DSD stated that staff would open all packages in front of the residents to conduct an inventory. However, this practice contradicted the facility's policy, which clearly stated that residents' mail should be delivered unopened unless the resident requested assistance. The facility's policy on resident rights also emphasized the right to receive unopened mail and packages, highlighting the failure to adhere to established procedures.
Delay in Medication Delivery for Resident Post-Surgery
Penalty
Summary
The facility failed to provide timely pharmaceutical services to meet the needs of a resident, identified as Resident A, who was admitted after spine surgery. Upon admission, Resident A was prescribed several medications, including narcotic pain medications and a nicotine patch for smoking cessation. However, the facility did not acquire these medications in a timely manner, resulting in Resident A experiencing significant pain and distress. Interviews with the Director of Nursing (DON) and Resident A revealed that the resident was in pain and had not received the necessary medications, leading to a delay in care and treatment. Resident A's medical records indicated that several prescribed medications, such as Gabapentin, Diclofenac Sodium, Baclofen, Methadone, and Fentanyl, were not administered as ordered by the physician. Progress notes documented multiple instances where medications were pending delivery from the pharmacy, and the facility was awaiting authorization from the physician. Despite efforts to follow up with the pharmacy and the physician, the medications were not delivered promptly, leaving Resident A without adequate pain management for nearly 48 hours after admission. The facility's policy on medication ordering and receiving from the pharmacy was not effectively implemented, as evidenced by the delay in obtaining the necessary medications for Resident A. The DON acknowledged the delay and the potential for withdrawal symptoms due to the lack of pain management. The report highlights the facility's failure to ensure timely pharmaceutical services, which impacted Resident A's overall health condition and had the potential to affect other residents similarly.
Wheelchair Maintenance Deficiency
Penalty
Summary
The facility failed to maintain essential equipment in a safe and operable condition for one of the residents, identified as Resident A, whose wheelchair had a non-functioning left brake. This deficiency was discovered during an announced visit to investigate a complaint regarding quality of care. Resident A reported difficulties in transferring herself to the wheelchair due to the broken brake, which made it challenging for her to go to the bathroom. The observation confirmed that the left brake of the wheelchair would not lock, posing a potential risk of injury to the resident. Interviews with the Physical Therapist (PT) and the Director of Nursing (DON) revealed that the facility had several wheelchairs available for residents, and all equipment was expected to be maintained in a safe and working order. The PT stated that any wheelchair with non-functioning brakes should be tagged and a maintenance request should be submitted. The DON acknowledged that equipment should be in working order before a resident is assigned to a room and that any broken equipment should be set aside and repaired. Despite these protocols, the facility failed to ensure that Resident A's wheelchair was safe for use, as evidenced by the broken brake.
Failure to Monitor and Respond to Resident's Condition Post-Fall
Penalty
Summary
The facility failed to ensure that there were sufficient licensed nurses with the appropriate competencies and skill sets necessary to care for Resident A, as identified through resident assessments and described in the plan of care. Resident A, who was admitted with diagnoses including cerebral infarction, epilepsy, and aphasia, experienced a fall on August 6, 2024. Following the fall, Resident A exhibited symptoms such as altered level of consciousness, edema, and discoloration on the left side of the face, and abnormal vital signs, including elevated blood pressure and heart rate. Despite these symptoms, there was a lack of appropriate response from the nursing staff. Certified Nursing Assistants (CNAs) and Licensed Vocational Nurses (LVNs) failed to adequately communicate and document the changes in Resident A's condition. CNA 4 did not inform the charge nurse about Resident A's high heart rate and blood pressure, and LVN 1 did not take further action after being informed of the abnormal vital signs. LVN 2, who was responsible for monitoring Resident A during the night shift, was unaware of the irregular heart rate and high blood pressure until after Resident A was transferred to the hospital. The facility's policies and procedures, including the Fall Management Program and Change of Condition Notification, were not followed. The staff did not perform the necessary post-fall evaluations or notify the attending physician of the significant changes in Resident A's condition. This lack of adherence to established protocols contributed to the deficiency in care provided to Resident A, ultimately leading to the resident's transfer to the hospital with a diagnosis of sinus tachycardia and other cardiac issues.
Failure to Address Abnormal Vital Signs After Resident Fall
Penalty
Summary
The facility failed to consistently assess and provide treatment and care in accordance with professional standards of practice for a resident who experienced a fall and subsequent abnormal vital signs. The resident, who had a history of cerebral infarction, epilepsy, and aphasia, was found on the floor by staff with no immediate injuries noted. However, the resident's vital signs, including elevated blood pressure and pulse rate, were not adequately addressed following the fall. On multiple occasions, the resident's abnormal vital signs were recorded but not acted upon. Certified Nursing Assistants (CNAs) reported the abnormal readings to the licensed nurse, but there was no documentation of any intervention or notification to the physician. The resident's condition worsened, with altered consciousness and abnormal vital signs persisting without appropriate medical response. Interviews with staff revealed a lack of communication and failure to follow protocols for reporting changes in the resident's condition. Despite being aware of the abnormal vital signs, the CNAs and licensed nurse did not ensure that the necessary medical attention was provided. The resident was eventually transferred to the hospital, where further complications were identified, including sinus tachycardia and incomplete right bundle branch block.
Resident Safety Compromised Due to Patio Hazard
Penalty
Summary
The facility failed to ensure a safe environment for a resident when an outside patio had an open sunken area of dirt approximately two inches below the surrounding concrete pavement. This deficiency resulted in the resident becoming stuck in the dirt between a tree and the edge of the concrete pavement. The resident, who had a history of falling and severe cognitive impairment, was found unresponsive in his wheelchair with his head and shoulder leaning on a gate. The resident was later admitted to the hospital due to syncope and elevated D-dimer levels. The incident occurred after the resident had finished lunch and was wheeling around the facility. Another resident noticed the resident struggling with his wheelchair through a glass door and informed the LVN. Upon investigation, the LVN found the resident slumped in his wheelchair with all four wheels stuck in the dirt area. The resident was assessed for injuries and sent to the hospital for further evaluation. The facility did not have specific policies or procedures regarding accident prevention unless related to a specific incident, as stated by the DON.
Failure to Provide Advance Directive Information
Penalty
Summary
The facility failed to ensure that information regarding the formulation of Advance Directives (AD) was provided to residents or their representatives, affecting three residents. Resident 29, who had severe cognitive impairment and was unable to make healthcare decisions, signed an AD Acknowledgement Form without the involvement of her resident representative (RR). Despite the resident's incapacity, there was no documented evidence that the RR was informed about the AD, as confirmed by interviews with the Activities Director (ACD) and Case Manager (CM). Resident 52, who was cognitively intact with a BIMS score of 13, did not receive information about formulating an AD upon admission. The ACD acknowledged that it was her responsibility to provide this information but failed to do so until two days into the survey. This oversight was identified during a review of the resident's record and an interview with the ACD. Resident 6, who had the capacity to make medical decisions, also did not receive information on formulating an AD. The Director of Nursing (DON) and ACD confirmed that the absence of documentation indicated a failure to follow up with the resident regarding AD formulation. The facility's policy required that residents be provided with information about ADs upon admission and during the Social Services Assessment process, but this was not adhered to in these cases.
Failure to Develop Comprehensive Care Plan for Anticoagulant Use
Penalty
Summary
The facility failed to ensure a comprehensive care plan was initiated for a resident prescribed apixaban, an anticoagulant medication, for atrial fibrillation. The resident was admitted with a diagnosis of atrial fibrillation and a telephone order for apixaban was documented. However, there was no evidence of a care plan addressing the resident's risk for bleeding due to the medication. An interview with the Director of Nursing (DON) confirmed that a care plan should have been developed within seven days of admission to monitor for signs and symptoms of bleeding. The facility's policy requires a comprehensive person-centered care plan to be developed within seven days from the completion of the comprehensive assessment. The DON acknowledged that the care plan was not completed as required.
Failure to Monitor Medication Effects and Report Irregularities
Penalty
Summary
The facility failed to ensure that the Consultant Pharmacist (CP) identified and reported irregularities during the monthly medication regimen review (MRR) for four out of five residents reviewed for unnecessary medications. Specifically, Resident 9 was administered aripiprazole, an anti-psychotic medication, without adequate behavioral monitoring for hallucinations, which was the target behavior for the medication. The Director of Nursing (DON) acknowledged that the facility did not monitor the target behavior of visual hallucinations for Resident 9 while receiving aripiprazole for approximately one year. The facility's policy and procedure on Behavior/Psychoactive Drug Management did not include guidelines for behavioral monitoring. Additionally, the facility failed to monitor three residents (Residents 6, 40, and 52) for signs and symptoms of adverse effects related to the use of anticoagulants. Resident 6, who was on apixaban for atrial fibrillation, was not monitored for signs of bleeding. Similarly, Resident 40, also on apixaban, and Resident 52, on Lovenox, were not monitored for potential adverse effects, including bleeding. The DON confirmed that there were no recommendations from the CP regarding the need for monitoring adverse effects for these residents during the use of anticoagulants. The facility lacked a policy and procedure for anticoagulant medications, and the existing policy on Medication Monitoring and Management did not mention apixaban or Lovenox. The CP's monthly MRRs for the residents did not include recommendations related to monitoring for adverse effects. The facility's policy on Consultant Pharmacist Reports required the CP to perform a comprehensive review of each resident's medication regimen monthly and to identify irregularities, including monitoring for adverse consequences, but this was not adhered to in practice.
Failure to Monitor Anticoagulant Adverse Effects
Penalty
Summary
The facility failed to ensure that three residents were free from unnecessary medications due to inadequate monitoring for adverse effects associated with anticoagulant medications. Resident 6, who was admitted with atrial fibrillation, received apixaban without being monitored for signs and symptoms of bleeding from June 25, 2024, to July 15, 2024. The Director of Nursing (DON) acknowledged this oversight during an interview and record review. Similarly, Resident 40, also diagnosed with atrial fibrillation, was not monitored for bleeding while on apixaban from April 13, 2024, to July 17, 2024, as confirmed by the DON. Resident 52, with a history of diabetes, hypertension, and falls, received enoxaparin without monitoring for bleeding or other adverse effects. The DON verified the lack of monitoring during an interview and record review. Additionally, the facility's Administrator confirmed that there was no specific policy and procedure for anticoagulant medications, and the existing Medication Monitoring and Management policy, dated October 2012, did not address apixaban or Lovenox. This lack of monitoring had the potential for side effects to go undetected, as indicated by the drug information from DailyMed.
Failure to Follow Prescribed Menu and Portion Sizes
Penalty
Summary
The facility failed to adhere to the prescribed menu during a tray line observation, impacting three residents who consumed food in the facility. On July 17, 2024, the facility's Summer Menu for Week 3, Wednesday, was reviewed, which included Taco Casserole, Seasoned Fresh Zucchini, Fiesta Salad, and Tangy Glazed Fresh Fruit. However, during the tray line observation, discrepancies were noted in the portion sizes and food items served to Residents 9, 45, and 35, which did not align with the menu or dietary requirements. Resident 9, who was on a renal diet with an 80-gram protein restriction, was served only one taco with one ounce of ground meat instead of the prescribed two tacos with one and a half ounces of meat each. This was due to the use of an incorrect measuring scoop. Resident 45, also on a renal diet with a large portion requirement, received a regular portion instead of a large portion, as the dietary staff was unsure of the correct portion size for a large renal diet. Resident 35, on a regular large portion diet with pureed texture, was served a smaller portion of pureed taco casserole than required, again due to the use of an incorrect scoop. The Registered Dietitian (RD) confirmed that serving less than the required portions could lead to weight loss and emphasized the importance of following the menu. The facility's policy, dated April 14, 2014, mandates adherence to the written menu to meet nutritional requirements. The failure to follow the menu as prescribed had the potential to negatively impact the residents' nutritional status, especially given their medical conditions, which included end-stage renal disease, diabetes mellitus, protein-calorie malnutrition, dementia, and dysphagia.
Inadequate Implementation of Infection Control Practices
Penalty
Summary
The facility failed to properly implement Infection Prevention and Control practices, as evidenced by several observations and interviews. Direct care staff were not aware of which residents were on Enhanced Barrier Precautions (EBP), a measure requiring the use of gowns and gloves during high-contact resident care. For instance, CNA 1 was observed practicing EBP while feeding Resident 40, who was not on the EBP list. Additionally, there was confusion among staff regarding the reasons for EBP for Residents 6 and 117, with inconsistent explanations provided by different staff members. The facility also failed to adhere to cohorting guidelines for EBP. Residents 6 and 117 were placed in the same room despite Resident 6 being colonized with C. diff, a highly contagious bacteria. The Director of Nursing (DON) and Infection Preventionist (IP) were unable to provide a rationale for this decision. The IP acknowledged that Resident 117, who was at high risk due to end-stage renal disease and the presence of a dialysis catheter, should not have been roomed with Resident 6. The facility's policy on Enhanced Barrier Precautions, revised in June 2024, was not followed. The policy requires a risk assessment to determine the need for EBP and advises against cohorting residents with multidrug-resistant organisms (MDRO) with those at high risk of acquiring infections. The IP admitted to not reviewing hospital documentation thoroughly, which led to the inappropriate room assignment for Resident 117.
Failure to Maintain Resident Dignity During Feeding
Penalty
Summary
The facility failed to uphold the dignity and respect of two residents during meal times, as observed by surveyors. Certified Nursing Assistants (CNAs) were seen feeding Residents 40 and 43 while standing, rather than sitting at eye level, which is necessary for promoting social interaction and communication. CNA 1 was observed feeding Resident 40 while standing, and acknowledged in an interview that he should have been sitting. Similarly, the Restorative Nurse Assistant (RNA) was seen feeding Resident 43 while standing and admitted that sitting would have facilitated better eye contact and communication. Resident 40, who was admitted with a fracture, abnormal gait, and metabolic encephalopathy, was assessed as severely impaired and requiring extensive assistance with feeding. Resident 43, admitted with hemiplegia, hemiparesis, cerebral infarction, and dysphagia, had a BIMS score indicating severe cognitive impairment and needed limited assistance during meals. The facility's policy on Resident Rights emphasizes care that promotes dignity and respect, and their competency validation document specifies that staff should be seated at eye level when assisting with meals. These observations and interviews highlight a failure to adhere to these standards, impacting the residents' quality of life.
Failure to Assist Residents with Meal Setup
Penalty
Summary
The facility failed to provide necessary assistance to two residents during mealtime, leading to deficiencies in their care. Resident 30 was observed with an incomplete lunch meal tray setup, with plastic coverings on food items and an unopened milk carton. The resident, who has severe cognitive impairment, chronic obstructive pulmonary disease, dysphagia, muscle weakness, and dementia, was unable to remove the plastic coverings or open the milk carton. The Director of Staff Development confirmed that it was the responsibility of the CNA to open the food and set it up for the residents. Similarly, Resident 29 was observed with a meal tray that was not properly set up, with plastic coverings on plated food items and a drink placed out of reach. The resident, who has end-stage heart failure, dysphagia, dementia, muscular dystrophy, and severe arthritis of the wrist, stated she needed help to access her drink. Interviews with CNAs revealed that the facility's process was to prepare the food and remove the plastic seal for the residents, which was not done in this case. The facility's policies indicated that residents should be properly prepared to eat before a meal and receive adequate supervision and assistance during mealtime.
Delay in Addressing Abnormal Chest X-Ray Results
Penalty
Summary
The facility failed to ensure timely medical intervention for a resident, identified as Resident 22, who had abnormal chest x-ray results indicating bilateral infiltrates, suggestive of a lung infection. The resident was admitted with diagnoses including aftercare for a right femur fracture and malnutrition. On May 10, 2024, the resident exhibited altered levels of consciousness and other concerning symptoms, prompting the ordering of a chest x-ray and laboratory tests. The chest x-ray, conducted on May 13, 2024, revealed bilateral infiltrates, but the results were not addressed by the physician until May 15, 2024. The physician's notes from May 13, 2024, indicated a plan to discontinue Macrobid, an antibiotic for a urinary tract infection, and start Avelox for the lung infection. However, this order was not communicated to the licensed nurse or the Director of Nursing (DON) at the time. The physician uploaded his notes on May 15, 2024, and the order for Avelox was not placed until that morning. The medication was not administered until May 17, 2024, due to a lack of communication and follow-up, resulting in a delay in treatment. Interviews with the DON and the Infection Preventionist revealed that the facility's process for notifying physicians of abnormal results was not followed. The physician typically communicated orders to the DON, who was not informed of the Avelox order on May 13, 2024. The physician admitted to uploading his notes late and not ensuring the order was communicated. The facility's policy required immediate notification of significant changes in a resident's condition, which was not adhered to in this case.
Failure to Implement Fall Prevention Interventions
Penalty
Summary
The facility failed to implement necessary interventions to prevent falls for a resident with a history of impulsive behavior and falls. The resident, who was blind and had severely impaired cognitive status, was observed with bumps on her forehead, indicating recent falls. Despite being at high risk for falls due to confusion, gait problems, and Alzheimer's dementia, the resident was not provided with a 1:1 sitter or frequent monitoring, as noted in her care plan. The resident's medical history included a fracture of the left radius, abnormal gait, and metabolic encephalopathy. Observations revealed that the resident was often left alone, attempting to get up from her wheelchair, which posed a significant fall risk. The care plan had identified the need for a 1:1 sitter due to the resident's impulsive behavior, but this intervention was not implemented, leading to multiple falls and injuries. Interviews with facility staff, including an LVN and the DON, confirmed that the resident was not on frequent checks and did not have a bed alarm, despite being visually impaired and having a history of falls. The DON acknowledged that the resident's care plan was ineffective and should have been re-evaluated to meet her needs. The facility's policy on fall management was not adequately followed, as the resident's environment was not free from fall hazards, and necessary interventions were not in place.
Inaccurate Accountability of Controlled Medications
Penalty
Summary
The facility failed to ensure accurate accountability of controlled medications for a resident when a random controlled medication audit did not reconcile. Specifically, the Individual Narcotic Record for a resident indicated that Norco, a potent controlled medication for pain, was signed out on two occasions but was not documented on the Medication Administration Records (MAR) to indicate it was administered. This discrepancy was identified during a survey when the records for four random residents receiving controlled medications were reviewed. The resident in question had a physician's order for Norco to be administered as needed for pain. During interviews, the Licensed Vocational Nurse (LVN) acknowledged that the Norco tablets were unaccounted for in the MAR for the specified dates. The Director of Nursing (DON) confirmed the facility's process for controlled medication administration, which includes logging the medication, assessing the resident's pain, administering the medication, and documenting it in the MAR immediately. The facility's policy and procedure for medication administration and storage were reviewed, highlighting the requirement for accurate documentation of controlled substances. The failure to document the administration of Norco resulted in inaccurate accountability of controlled medications, with potential for misuse or diversion.
Failure to Monitor Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure a resident was free from unnecessary psychotropic medications. Specifically, a resident diagnosed with schizoaffective disorder was administered aripiprazole, an antipsychotic medication, without adequate behavioral monitoring. The resident's medical records showed a physician's order for aripiprazole to manage hallucinations, but there was no documented monitoring of the target behavior of visual hallucinations during the medication's use from July 2023 to July 2024. During interviews and record reviews, the Director of Nursing acknowledged the lack of monitoring for the resident's target behavior while on aripiprazole. The facility's policy on Behavior/Psychoactive Drug Management, dated November 2018, was reviewed and found not to include guidelines for behavioral monitoring. This oversight had the potential to result in unnecessary medication use, increasing the risk of medication interactions and adverse reactions.
Inappropriate Antibiotic Use Due to Non-compliance with Stewardship Program
Penalty
Summary
The facility failed to ensure antibiotics were prescribed and administered under the guidance of their antibiotic stewardship program for a resident. The resident's condition did not meet the McGeer's criteria for the use of antibiotics for a urinary tract infection (UTI). Despite this, the resident was prescribed and administered Macrobid, an antibiotic for UTI, from May 11 to May 17, 2024. The resident's urinalysis and urine culture results indicated the presence of Escherichia coli, but the resident did not exhibit symptoms of a UTI, as confirmed by the facility's Surveillance Data Collection Form. Additionally, the physician's order to discontinue Macrobid and switch to Avelox, an antibiotic for lung infection, was not carried out as ordered. The Infection Preventionist (IP) acknowledged that the resident's condition did not meet the criteria for a UTI and that the physician should have been notified to reevaluate the use of Macrobid. The facility's policy on antibiotic stewardship, which includes the use of McGeer's criteria and antibiotic time-outs, was not followed, leading to inappropriate antibiotic use.
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What surveyors actually found near you
We read the 113 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
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Illustrative
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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 Mountain Care Center | 0.9 mi | ★★★★★ | 5 | 0 |
| The Springs Healthcare Center At The Carlotta | 6.5 mi | ★★★★★ | 3 | 0 |
| Monterey Palms Health Care Center | 9.2 mi | ★★★★★ | 1 | 0 |
| Rancho Mirage Health And Rehabilitation Center | 10 mi | ★★★★★ | 3 | 0 |
| Desert Springs Post Acute | 10.7 mi | ★★★★★ | 39 | 0 |
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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 June 2026) and official state health department websites.