Below average — CMS composite of the measures below.
The next survey window likely opens around February 2027
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 Hi-desert Medical Center D/p Snf during CMS and state inspections, most recent first.
The facility did not meet its required CNA nursing hours per patient day over a three-day period, as staffing records reviewed with the DON showed CNA hours consistently below the policy and state-required minimums. A resident reported delaying use of the call light due to long response times, while CNAs and an LVN stated they had been working short-staffed. The DON acknowledged ongoing staffing problems and confirmed that required staffing levels for dozens of residents were not achieved during the identified days.
Insufficient nursing staffing led to missed restorative nursing services for 20 residents ordered to receive RNA. The WCN said she was the only wound care nurse and was sometimes reassigned to med admin because of staffing shortages. CNA and DON interviews confirmed restorative services were only completed on a few days, with no other February dates completed, and the ADON stated only two CNAs had RNA certification and RNA was not done when enough CNAs were not scheduled. Staffing records also showed multiple shifts below the facility’s minimum DHPPD.
Expired medications were found in one med cart, including Omeprazole and Docusate Sodium past their expiration dates, and two opened bottles of artificial tears were found in another cart without any open-date label. An LVN and an RN acknowledged the issues, and the DON stated the facility policy was not followed and that eyedrops should have been dated.
Inadequate administrative oversight of facility operations was identified for 90 of 90 residents. The DON could not provide a current facility assessment and stated an attempt to complete it was never finished, while Admin could not state when it was due or last completed. During a QAPI interview, surveyors identified ongoing issues including insufficient nursing staff affecting restorative nursing services, unlabeled oxygen tubing, inconsistent wound care treatment completion, care plans that were not patient-centered or regularly updated, and pharmacy recommendations that were not being followed; Admin and ACNO were unaware of several of these concerns.
Governing body oversight was ineffective because meeting minutes showed quality and safety issues were discussed, but staffing concerns and performance improvement progress for wound care compliance, updated care plans, unlabeled oxygen tubing, and pharmacy recommendations were not addressed. The Admin stated the GB was aware of staffing concerns but not these other issues, and confirmed there was a lack of transparency between the facility and the GB. The facility policy stated the GB has ultimate responsibility and legal authority for safety and quality of care.
Incomplete Annual Facility Assessment: The facility failed to complete the annual facility assessment for all residents. The DON stated the assessment was incomplete, and the Admin acknowledged it had been attempted but not finished. The DON also described assisting with day-to-day operations, including staffing, equipment, services, and department oversight, while the Admin stated she was acting as facility administrator and was unable to say when the assessment was last completed.
The facility failed to follow infection control procedures for multiple residents. Several residents receiving O2 via nasal cannula had tubing that was unlabeled, undated, or not changed per policy, and staff were unsure when the tubing had last been changed. Another resident who tested positive for influenza A did not have the required droplet precaution sign posted at the door, and staff acknowledged the sign should have been in place.
Missed Ordered Wound Treatments for Two Residents with Pressure Injuries: Two residents with pressure injuries did not receive daily wound care as ordered. One resident had a right ischium unstageable PI and the other had a left ischial stage 2 PI; record review showed multiple dates with no documented wound treatment. The DON and other nursing staff verified the missing treatments and acknowledged the facility policy was not followed.
A resident with hypertension and cerebral palsy had a right ischium unstageable PI with daily wound care orders, but the care plan was not updated to address the wound and there was no IDT meeting documented regarding the PI. The DON and ADON confirmed the LTC care plan had not been revised, and the DON acknowledged the wound care policy was not followed.
A facility failed to ensure oxygen therapy was administered per MD orders for three residents. Two residents with diagnoses including sepsis and COPD, and another resident with bilateral humerus fractures, were observed receiving O2 at 2 L/min via nasal cannula, but record review showed no physician order for oxygen therapy for any of them. The ADON confirmed the orders were missing, and the facility policy required oxygen to be administered in accordance with physician orders.
Failure to act on a consultant pharmacist’s MMR recommendation for a resident receiving Seroquel 25 mg BID. The pharmacist noted CMS guidance regarding a possible dose reduction for the psychoactive medication and asked for documentation if a reduction was not appropriate. The DON acknowledged the physician did not respond, and stated the facility’s MMR policy requiring the physician to document the rationale in the resident’s record was not followed.
A resident receiving IV vancomycin for a bone/joint infection had the infusion pump set at 20 ml/hr instead of the ordered 175 ml/hr, and the medication remained infusing for more than 3.5 hours. The RN initially hung the medication, the pump alarmed, and the ADON later confirmed the rate was incorrect. The DON stated the facility did not follow policy requiring medications to be administered as ordered.
A resident with paraplegia and multiple sclerosis, who was cognitively intact, was noted in nursing documentation to be acting impaired after returning from smoking, prompting a physician order for a UA and drug screen that later returned positive for cannabis. The resident reported occasional, non-prescribed marijuana use in the designated smoking area and stated staff were unaware of this use. Despite a corporate policy requiring investigation of illegal substance use to determine who brought the substance into the facility and whether patients used or had access to it, the facility, as confirmed by the DON, did not investigate or search the resident’s room after the positive drug test.
Two cognitively intact residents reported that an RN responded to a resident’s question about the timeliness of pain medication by yelling, speaking aggressively, and stating she did not have to deal with his medication at that time. One resident described withdrawing, hearing the RN bad-mouthing him in the hall, and feeling anxious and distressed, while another resident went to calm him. A third resident, about four doors away, reported clearly hearing the RN yelling, described her behavior as unprofessional and disrespectful, and later felt anxious about interacting with her. CNAs relayed these reports to the DON, and Social Services staff confirmed that residents described the RN’s tone as loud, dismissive, and lacking composure, consistent with the facility’s policy definition of verbal abuse based on tone of voice.
An allegation of psychological/mental abuse toward a resident was identified but not reported to the Ombudsman and CDPH within the required 24-hour timeframe. Instead, the concern was initially documented as a grievance by a Dietary Supervisor and handed to a social worker, who placed it in the DON’s mailbox while the DON was out of town. The DON later reviewed the grievance, recognized it as an abuse allegation, and filed the SOC 341 several days after the incident, contrary to facility policy and mandated reporter requirements.
A resident with a tracheostomy and PEG tube, documented as comatose and with a history of multiple cerebral infarctions, had a physician’s order for continuous enteral nutrition at a set rate via PEG. For approximately 48 hours, only water was infused through the PEG tube instead of the ordered tube feeding, as later identified in nursing documentation and staff interviews. Although the RN, LVN, and unit monitoring practices required verification of correct formula, labeling, infusion status, and intake at specific times each shift, these checks did not prevent or detect that the pump was continually flushing with water rather than delivering formula. Weight records showed a small weight loss over the review period, and the DON acknowledged that the facility’s enteral nutrition management policy, which required formula at goal rate when appropriate, was not followed.
A resident with multiple medical conditions, including a tracheostomy and recent fractures, was left soiled and did not receive timely assistance with activities of daily living when an RN failed to respond appropriately to the call light and did not notify a CNA or provide care, as confirmed by interviews, record review, and observation.
The facility did not promptly report suspected abuse, neglect, or theft, nor did it communicate the results of its investigation to the proper authorities as required.
A resident with a history of depression and paraplegia reported being hit by a CNA during care. The DON confirmed that, during the subsequent abuse investigation, the care plan was not updated and enhanced monitoring was not implemented, contrary to facility policy.
A resident with a history of neurological and cognitive conditions exhibited increased aggressive behaviors, but staff failed to update the care plan or document these changes as required by facility policy. Staff interviews confirmed that documentation and care plan updates were not completed despite clear changes in the resident's condition.
The facility failed to develop and implement comprehensive care plans for four residents, lacking measurable objectives and timeframes. A resident on a ventilator with a sacral wound had no re-evaluated care plan. Two residents with contractures lacked care plans for prescribed Passive Range of Motion exercises. Another resident only had a nutritional care plan, with other necessary plans discontinued. The DON confirmed these deficiencies, which contradicted the facility's care planning policy.
A long-term care facility failed to administer medications as ordered for 23 residents, with nursing staff not notifying physicians or pharmacists of missed doses. Additionally, a resident with a PEG tube received medications through the tube without verifying the route with a physician. These actions violated the facility's medication administration policies, leading to unsafe practices.
A resident with complex medical needs was transferred to a hospital for a suprapubic catheter exchange without notifying their family, as required by facility policy. The absence of documentation confirming family notification was confirmed by the DON, highlighting a lapse in communication between the healthcare team and the resident's family.
The facility failed to provide and document Passive Range of Motion (PROM) services for two residents with contractures, as ordered by their physicians. Despite orders for PROM every Monday, Wednesday, and Friday, there was no evidence of these services being performed. Interviews with staff revealed that neither the Restorative Nurse Assistant nor the Certified Nurse Assistant provided the services, with the CNA stating she was not certified to perform ROM. The Director of Nursing confirmed the lack of documentation and service provision.
The facility failed to respond to call lights in a timely manner for two residents with significant health needs. One resident with paraplegia reported delays of up to two hours, while another with metastatic lung cancer experienced variable response times. Both residents were found to be fully dependent on staff for assistance. The facility lacked a specific policy on call light response times.
The facility failed to ensure accurate controlled medication verification for 17 residents, missing a second nurse's signature on drug count records over several days. Interviews revealed that the policy required two nurses to verify controlled drugs, but records showed only one signature on some occasions.
A resident's controlled medication was improperly removed and destroyed by an LVN, violating facility policies. The LVN took Norco from the medication cart without permission, leading to a discrepancy noted during verification. The facility's policies prohibit such actions, which resulted in the unauthorized diversion of medication.
Failure to Meet Required CNA Staffing Levels Over Multiple Days
Penalty
Summary
The facility failed to provide sufficient nursing staff in accordance with its own staffing policy and state-required nursing hours per patient day (NHPPD) over a three-day period from April 10, 2026, through April 12, 2026. Review of staffing assignments and NHPPD data with the DON showed that the required 3.5 nursing hours per patient day, including a minimum of 2.4 CNA hours per patient day, were not met on these dates. Specifically, the actual CNA NHPPD was 1.79 hours on April 10 (short by 1.71), 1.87 hours on April 11 (short by 1.63), and 2.03 hours on April 12 (short by 1.47). The DON acknowledged that the facility did not meet staffing requirements on these dates and stated that the facility has problems with staffing. During interviews, one resident reported usually not using the call light because it sometimes took a long time for staff to respond. Two CNAs stated that they usually worked with not enough CNAs and that they had been working short, although one noted it was better on the day of the interview. An LVN also reported that they had been working with short nurses lately. These interviews, combined with the staffing records, demonstrated that for three consecutive days the facility did not provide the required number of CNAs to meet its staffing guidelines for 78 residents, with the DON emphasizing the necessity of adequate staffing for patient safety.
Insufficient Nursing Staffing Resulted in Missed Restorative Nursing Services
Penalty
Summary
The facility did not ensure sufficient nursing staff was provided to meet the needs of 20 of 20 residents who were ordered to receive restorative nursing services during February 2026. During interview, the Wound Care Nurse stated she was the only wound care nurse in the facility and that, because of staffing shortages, she would be reassigned from wound care duties to medication administration, which limited her ability to complete her assigned responsibilities. CNA1 reviewed the RNA Assignment Sheet and confirmed restorative nursing services were completed only on February 3, 4, 11, 19, and 25 for the 20 residents on the restorative nursing list, with no other February dates completed. CNA1 also stated restorative nursing services depended on staffing levels and were only implemented when sufficient CNA staffing was available. The Assistant Director of Nursing stated there were only two CNA staff members in the facility with RNA certification and that if there were not enough CNAs scheduled on a shift, no RNA would be conducted for residents, even though RNA was supposed to be done as ordered. Staffing records showed multiple day shifts below the facility’s minimum of 3.5 direct nursing hours per patient day, including 2.85 on February 7, 2.80 on February 8, 2.77 on March 6, 3.10 on March 7, and 2.45 on March 8. The DON confirmed restorative nursing services were completed only on February 3, 4, 11, 19, and 25, and stated the facility did not have enough CNAs scheduled regularly to implement restorative nursing services as ordered. The Administrator stated the facility experienced frequent call-offs and described staffing as spotty.
Expired and Unlabeled Medications Found in Medication Carts
Penalty
Summary
The facility failed to ensure that expired medications were not available for resident use in two medication carts. During a concurrent medication cart inspection and interview, Cart 100 contained Omeprazole 20 mg with an expiration date of January 2026 and Docusate Sodium 5 mg with an expiration date of October 31, 2025. The LVN stated she was unaware the medications were expired and reported that carts are checked by the pharmacist monthly, adding that there should be no expired medications in the cart. During a separate inspection at the nurse’s station in the LTC unit, the Hallway Cart contained two opened bottles of artificial tears with no label. The RN stated she thought the bottle had been opened the day before but could not confirm because there was no open date label, and stated medications should be labeled upon opening so they can be discarded when past the date. The DON later reviewed the facility policy and the manufacturer’s guidelines for the eye drops, which indicated they should be discarded 30 days after opening, and stated the policy was not followed and that expired medications should have been discarded and eyedrops should have been dated.
Inadequate Administrative Oversight of Facility Operations
Penalty
Summary
The facility did not ensure administration maintained effective oversight of facility operations for 90 of 90 residents residing in the facility. During a concurrent interview and record review, the DON stated she was unable to provide the current facility assessment report because an attempt to complete it on October 25, 2025 was never finished. The DON also stated it was Administration’s responsibility to complete the facility assessment and was unable to state when it was due or when it was last completed. During a concurrent interview and record review with the facility’s QAPI members, including the Admin, ACNO, QD, ADON, and DON, surveyors identified issues including insufficient nursing staff to provide restorative nursing services, unlabeled oxygen tubing, wound care treatment orders not being completed consistently, care plans not being patient-centered or updated regularly, and pharmacy recommendations not being followed. The Admin stated staffing concerns had been ongoing, but was not aware it affected restorative nursing services. The ACNO stated the facility was aware of inconsistent wound care completion, but not of pharmacy recommendations not being followed, care plans not being patient-centered or updated regularly, or unlabeled oxygen tubing. The Admin stated she was not aware of these issues and should have been.
Governing Body Lacked Oversight of Key Facility Issues
Penalty
Summary
The facility failed to ensure its governing body provided effective oversight of facility operations. Review of Governing Board Meeting Minutes from January 26, 2026 through March 16, 2026 showed that quality care outcomes and safety concerns were discussed at QAPI meetings, but there was no mention of staffing concerns or performance improvement progress related to wound care treatment compliance, updated care plans, unlabeled oxygen tubing, or follow-up on pharmacy recommendations. During interviews on March 19, 2026, the Administrator, Assistant Chief Nursing Officer, and Quality Director stated that performance improvement audits and facility updates were discussed in quarterly QAPI meetings, then brought to a quarterly Quality Council meeting, and later presented to the Governing Body in monthly meetings. When survey findings were reviewed with the Governing Body members, the Administrator stated the Governing Body was aware of staffing concerns, but not of wound care treatment compliance, outdated care plans, unlabeled oxygen tubing, or pharmacy recommendations not being followed. The Administrator confirmed there was a lack of transparency between the facility and the Governing Body. The facility policy stated the Governing Board has ultimate responsibility and legal authority for safety and quality of care, treatment, and services rendered in the Hospital.
Incomplete Annual Facility Assessment
Penalty
Summary
The facility failed to complete the annual facility assessment for 90 of 90 residents residing in the facility. The assessment, which is intended to review the resources necessary to care for residents competently during day-to-day operations, including nights and weekends, and during emergencies, was reported by the DON to be incomplete when requested during record review. During interviews, the DON stated the current Admin was the [name of facility (hospital)] CEO and that the facility assessment was the Admin's responsibility, although the DON assisted with day-to-day operational responsibilities such as ensuring nursing, dietary, and rehabilitation departments were functioning properly, ensuring adequate staff, equipment, and services, and serving as an on-call administrator during the months of November 4, 2025, through June 1, 2026. The Admin stated she had been acting as the facility administrator since March 8, 2026, acknowledged that the assessment was attempted on October 25, 2025, and was not completed, and was unable to state when it was last completed. The facility policy required an annual facility-wide assessment, and the Admin stated it was not completed per policy.
Infection Control Failures With Oxygen Tubing and Isolation Signage
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program when nursing staff did not change oxygen tubing for five residents according to the facility policy. Resident 25, Resident 90, Resident 66, and Resident 30 were observed receiving oxygen at 2 L/min via nasal cannula with tubing that was unlabeled and undated, and RN 1 stated he was not aware when the tubing had been changed. Resident 92 was also observed on oxygen at 2 L/min via nasal cannula, and the tubing was last changed on February 27, 2026. In each instance, RN 1 confirmed the tubing should have been changed but was unsure of the policy for changing it. Resident 25 had diagnoses including lactic acidosis, fever, UTI, and sepsis. Resident 92 had bilateral humerus fractures. Resident 90 had sepsis. Resident 66 had chronic renal failure and anemia. Resident 30 had COPD. During the interview, RN 1 acknowledged the oxygen tubing should have been labeled and changed, but did not know the policy requirements. The DON later reviewed the facility policy titled, CHANGING OF DISPOSABLE AND NON DISPOSABLE EQUIPMENT, which stated nasal cannulas, trach masks, and other masks would be changed every Friday, and the DON stated the policy was not followed. The facility also failed to post an isolation precaution sign for Resident 4. Resident 4 had diagnoses including type 2 diabetes mellitus with hyperglycemia and osteomyelitis, and was observed lying in bed stating he was positive for flu. The physician's orders and the Infection Prevention and Control Surveillance Data Collection Tool indicated a positive influenza A test. CNA 1 stated she was not sure why there was no sign at the door, and LVN 1 stated the droplet precautions sign should have been posted. The DON reviewed the facility's Infection Control-Transmission-based Precautions policy, which stated nursing would place the precaution sign, visitor instructions, and supply door hanger or caddy outside the resident's room, and the DON stated the policy was not followed.
Missed Ordered Wound Treatments for Two Residents with Pressure Injuries
Penalty
Summary
The facility failed to ensure that two residents with pressure injuries received wound treatment as ordered. Resident 8 was admitted with diagnoses including hypertension and cerebral palsy, and had a right ischium unstageable pressure injury documented in the record. The physician’s order dated July 22, 2025 directed daily and PRN wound care to cleanse the wound, apply skin prep to the peri-wound skin, apply nickel-thick Santyl to the wound bed, and cover with foam and border foam dressing. During observation, Resident 8 stated he had wounds on his back and thigh and said nurses sometimes did treatments but not every day. Review of the TAR showed no documented evidence that the ordered wound treatment was completed on July 3, July 9 through July 11, July 16 through July 18, 2025, and March 4, March 6, and March 17, 2026. The wound treatment LVN and the DON both verified the missing documentation, and the LVN stated she did not know why the treatments were missing. The DON acknowledged that the facility policy had not been followed and stated her expectation was for nurses to follow physician orders for treatments. Resident 10 had a left ischial stage 2 pressure injury and was observed lying on his left side with an indwelling catheter and colostomy. The order dated January 5, 2026 required daily and PRN wound care to cleanse the wound, apply skin prep to the peri-wound skin, apply [Brand] to the wound bed, and cover with border foam dressing. Review of the wound treatment flowsheet showed the treatment was not completed on January 8 through January 10, January 13 through January 17, January 28 through January 30, March 5 through March 7, and March 13 through March 15, 2026. The ADON confirmed the wound treatment was not completed daily as ordered, and the DON stated the policy was not followed and that wound care was expected to be performed daily and as needed per physician’s order.
Failure to Update Pressure Injury Care Plan and IDT Review
Penalty
Summary
The facility failed to ensure Resident 8’s care plan was reviewed, updated, and addressed by the interdisciplinary team regarding pressure injury care. Resident 8 was admitted with diagnoses including hypertension and cerebral palsy. During a record review, Resident 8’s nursing narrative documented a right ischium unstageable pressure injury, and physician orders later directed daily wound care with cleansing, skin prep, Santyl, and foam dressings. During interviews and record review with the ADON and DON, Resident 8’s Comprehensive Care Plan LTC showed no documented evidence that the care plan had been updated for the pressure injury. The DON stated there was no IDT meeting regarding the pressure injury and that the care plan had not been updated. The facility’s Wound Care Management Pressure Wounds policy stated that each wound/pressure injury should be addressed in the medical record each shift and that appropriate care plans should be initiated, but the DON acknowledged the policy had not been followed.
Oxygen Therapy Given Without Physician Orders
Penalty
Summary
The facility failed to ensure that oxygen therapy was administered in accordance with physician's orders for three residents who were observed receiving oxygen by nasal cannula at 2 L/min. Resident 92, admitted with bilateral humerus fractures, was observed in bed with oxygen in place, but review of the History and Physical and current medication orders showed no physician order for oxygen therapy. The Assistant Director of Nursing confirmed that the order was missing and stated that Resident 92 should have had an order before oxygen was administered. Resident 90, admitted with sepsis, was also observed resting in bed with oxygen at 2 L/min via nasal cannula, and record review likewise showed no physician order for oxygen therapy. Resident 30, admitted with COPD, was observed sitting on the edge of the bed with oxygen at 2 L/min via nasal cannula, and review of the History and Physical and current medication orders again showed no indication that oxygen therapy had been ordered by the physician. The ADON confirmed that the orders were missing for Resident 90 and Resident 30 and stated that oxygen therapy should have had a physician's order before being administered. The facility policy titled DES SNF - OXYGEN ADMINISTRATION stated that oxygen is to be administered in accordance with physician's orders.
Failure to Act on Pharmacist Medication Review Recommendation
Penalty
Summary
The facility failed to act on recommendations made by the consultant pharmacist during the monthly medication regimen review for one sampled resident. Resident 2 was admitted with diagnoses including hypertension and dementia, and had a physician order for Seroquel 25 mg by mouth twice daily beginning July 17, 2025 and continuing through August 15, 2026. During record review, the consultant pharmacist’s medication regimen reviews dated November 1, 2025 and November 13, 2025 noted that current CMS guidelines appear to require an attempted dose reduction on psychoactive medications unless previous reductions have been unsuccessful, and asked whether a trial dose reduction would be appropriate for this resident. The pharmacist also requested that, if a reduction was not warranted, the reason be documented in the resident’s progress notes or otherwise documented to keep the center in compliance with regulations. During interview, the DON acknowledged the recommendation and stated that the physician did not respond to it. The DON further stated it is very difficult to have physicians document a sign to acknowledge pharmacy recommendations. The facility’s Medication Regimen Review policy stated that if no action is taken by the physician, the physician is requested to document the rationale in the resident’s medical record, such as a progress note, and the DON stated that this policy was not followed.
IV Vancomycin Infused at Incorrect Rate
Penalty
Summary
Resident 67, who was admitted with diagnoses including heart failure, quadriplegia, and recurrent UTI, was receiving IV vancomycin for a bone/joint infection. During observation, the vancomycin infusion bag was found programmed on the infusion pump at 20 ml/hr, while the medication label indicated the drug was to run at 175 ml/hr and infuse over 60 minutes. Resident 67 stated the bag had been hung by an RN at about 9:00 AM, and the ADON later came to reprogram the pump after it alarmed around 10:00 AM. At 12:40 PM, the ADON confirmed the pump was still set at 20 ml/hr and acknowledged the medication was not running at the correct rate. The MAR showed the vancomycin dose was administered at 9:00 AM and remained infusing for more than three and a half hours. The DON reviewed the facility policy stating medications shall be administered as ordered and stated the facility did not follow the policy.
Failure to Investigate Resident’s Positive Drug Screen for Marijuana
Penalty
Summary
Surveyors identified a deficiency related to the facility’s failure to investigate and monitor the use of illegal substances after a resident tested positive for marijuana. The resident was admitted with diagnoses including paraplegia and multiple sclerosis, and had a BIMS score of 15, indicating intact cognition. A nurse’s note documented that the resident was acting impaired after returning from smoking, and a physician ordered a urinalysis with drug screen via straight catheter. Laboratory results from that testing showed the resident was positive for cannabis. Despite the positive drug screen and the facility’s corporate policy defining illegal substances and requiring an investigation to identify who brought the substance into the facility and whether a patient used or had access to it, no investigation was conducted. In an interview, the resident stated she occasionally used non-prescribed marijuana and had smoked it in the designated smoking area without staff awareness. During a subsequent interview and record review, the DON confirmed that no search of the resident’s room or investigation for illegal substances had been performed, and acknowledged that, per policy, an investigation should have occurred after the positive drug test.
Failure to Protect Residents From Verbal Abuse by RN
Penalty
Summary
The deficiency involves the facility’s failure to protect cognitively intact residents from verbal abuse by a registered nurse (RN 1). One resident with multiple sclerosis and chronic pain due to trigeminal neuralgia, and another resident admitted after an accident with bone fractures, both had Brief Interview for Mental Status (BIMS) scores of 15, indicating normal cognition. According to interviews, when the resident with multiple sclerosis questioned RN 1 about the timeliness of his medications for chronic pain, RN 1 began yelling and “freaking out.” The resident reported withdrawing from the area, hearing RN 1 “bad mouthing” him in the hallway, and then blocking it out by putting on headphones. He stated that the interaction made him feel “like shit,” “crazy,” and anxious because he needed his pain medication. Another resident reported that RN 1 was yelling at the first resident, saying she did not have to deal with administering his medication at that time and that she was already late, and described RN 1 as aggressive and yelling, which upset the first resident enough that the second resident went to calm him down. A third resident, located approximately 40 feet and four doors down from the first resident’s room, reported overhearing the incident and stated that RN 1 was yelling at the first resident about the timing of his pain medication, describing RN 1 as very unprofessional and disrespectful. This resident emphasized that RN 1’s yelling was audible from his room and reported feeling anxiety about any potential interactions with her afterward. Social Services staff, after meeting with the involved residents, stated that the residents reported RN 1’s tone as loud, that she may not have maintained her composure in a stressful situation, and that she was loud talking and dismissive toward the first resident. The DON reported that CNAs 1 and 2 had brought forward the incident, and the DON characterized the behavior as verbal abuse based on yelling that could be heard down the hallway. CNAs 1 and 2 confirmed that the third resident reported RN 1 was irritated and yelling at the first resident about medication, and one CNA noted having previously heard RN 1 talk “a little loud” toward others. The facility’s abuse policy defines verbal abuse to include use of a tone of voice that causes a resident to feel frightened or threatened, and notes behavioral indicators such as fear, withdrawal, anger, and anxiety.
Failure to Timely Report Allegation of Psychological Abuse
Penalty
Summary
The facility failed to timely report an allegation of psychological/mental abuse toward one resident within the required 24-hour timeframe. Review of a Report of Suspected Dependent Adult/Elder Abuse (SOC 341) dated January 21, 2026, showed that the allegation of psychological/mental abuse was identified on January 13, 2026, but was not reported to the Ombudsman and the California Department of Public Health (CDPH) until January 21, 2026, eight days after the incident. The SOC 341 documented that the allegation involved psychological/mental (mind, emotion, and behavior) abuse toward the resident. During an interview, the DON stated they had been out of town when the incident was initially documented. The DON explained that the Dietary Supervisor wrote the concern as a grievance and gave it to the Social Worker, who then placed it in the DON’s mailbox. The DON reported that on January 21, 2026, they read the grievance, recognized it should have been treated as an allegation of abuse, and then filed the SOC 341. The DON acknowledged there was a delay in reporting and stated that the facility’s policy, "Resident Abuse, Neglect Prevention, Investigation and reporting," requires all mandated reporters to report any allegation of abuse, and that all allegations of abuse not resulting in serious bodily injury must be reported within 24 hours to the facility administrator, CDPH, and the Ombudsman. The DON stated the policy was not followed because mandated reporters did not report the suspected abuse within 24 hours as required.
Failure to Administer Ordered PEG Tube Feeding for 48 Hours
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident receiving enteral nutrition via PEG tube was provided tube feeding according to the physician’s order. The resident was admitted with a tracheostomy and PEG tube and had a history of hypertension, hyperlipidemia, and multiple cerebral infarctions. The MDS documented the resident as comatose with no discernible consciousness. Physician orders dated January 19, 2026, directed continuous tube feeding at 60 ml/hr via PEG tube. However, the resident did not receive the ordered enteral formula for approximately 48 hours, during which only water was infused through the PEG tube instead of the prescribed tube feeding. Interviews with staff described how tube feedings were expected to be managed and monitored. RN 1 stated that RNs and LVNs were responsible for managing tube feedings, including checking them at the start of each shift, during designated shut-off times, and at the end of the shift to document intake. The Clinical Coordinator reported that tube feedings were to be monitored during rounds to verify the correct formula, proper labeling, and that the feeding was infusing, and that feeding and water were to be changed every 24 hours. Despite these stated practices, the nursing narrative documented that when the resident was reconnected to enteral feeding, it was discovered that only water had been running through the system and that the pump appeared to be continually flushing with water instead of delivering the ordered formula. Further record review showed that the resident’s weights decreased from 87.2 kg to 85.4 kg over an 11-day period. The nursing narrative documented that the physician was notified that the resident’s tube feeding had not been administered for 48 hours and that only water had been infused via the PEG tube during that time. RN 1 acknowledged that nursing staff should have checked the feeding to ensure it was being administered as ordered and stated that it was important for residents to receive needed nutrition. Review of the facility’s policy, “Guidelines for Management of Enteral and Parenteral Nutrition,” indicated that enteral formula should be initiated at full strength at goal rate if there was no GI compromise. The DON stated that this policy was not followed and confirmed that it was important to meet each resident’s nutritional needs.
Failure to Provide Timely Assistance with Activities of Daily Living
Penalty
Summary
A resident with a complex medical history, including blunt abdominal trauma, non-displaced C5 and C7 fractures, anxiety, a right upper arm partial thrombus, and a tracheostomy, was admitted to the facility. The resident was left soiled and their activities of daily living were not met in a timely manner. The incident occurred when a registered nurse failed to respond to the resident's call light and did not provide assistance when the resident attempted to communicate her needs. The nurse initially believed the call light was for another patient and, upon realizing it was for this resident, asked her to write down her request when she could not speak clearly. When the resident did not write down her needs, the nurse did not pursue further assistance and continued with other tasks until a respiratory therapist informed him that the resident needed to be changed. Interviews and record reviews confirmed that the nurse did not notify a CNA or provide timely care, resulting in the resident remaining soiled. The facility's policy requires that residents receive good personal hygiene and timely care to prevent bedsores and incontinence. The Director of Nursing acknowledged that there was no justification for the nurse's failure to assist or communicate the resident's needs to other staff. This lapse in care was identified through interviews, record reviews, and direct observation.
Failure to Timely Report Suspected Abuse, Neglect, or Theft
Penalty
Summary
The facility failed to timely report suspected abuse, neglect, or theft and did not report the results of the investigation to the proper authorities. This deficiency was identified based on the facility's actions or inactions regarding the required reporting process for such incidents. The report indicates that when an event involving suspected abuse, neglect, or theft occurred, the facility did not fulfill its obligation to promptly notify the appropriate authorities or provide the outcomes of its internal investigation as required.
Failure to Update Care Plan and Implement Monitoring During Abuse Investigation
Penalty
Summary
The facility failed to follow its policy and procedure for resident abuse in the case of one resident. After an allegation was made that a Certified Nurse Assistant (CNA) hit the resident on the buttocks and thighs while assisting with dressing, the resident expressed concern that the incident could recur if not reported. The Director of Nursing (DON) confirmed that, during the investigation, no interventions were added to the resident's care plan, and enhanced monitoring was not implemented as required by facility policy. Record review showed that the resident had a history of depression, paraplegia due to a self-inflicted gunshot wound, and left-sided weakness. The facility's policy stated that during an abuse investigation, actions such as assessment, care planning, supervision, staff assignment, and monitoring should be taken to ensure the resident's health and safety. The DON acknowledged that the care plan was not updated or revised following the incident, and the required monitoring was not put in place during the investigation process.
Failure to Update and Document Changes in Resident's Care Plan
Penalty
Summary
The facility failed to follow its policy and procedure for care plan documentation for one resident when the care plan was not updated to reflect changes in the resident's condition and behaviors. Specifically, a resident with a history of subdural hemorrhage, aphasia, and dementia exhibited increased aggressive behaviors, including yelling, slamming doors, and inappropriate interactions with another resident. Despite these changes, the care plan was not updated, and nursing staff did not document the resident's outbursts or aggressive behaviors as required by the facility's policy. The last documented update in the care plan was several weeks prior to the observed incidents. Interviews with staff confirmed that the resident's care plan should have been updated to reflect the recent behavioral changes, and that documentation of each outburst or aggressive behavior was not completed as per policy. The Director of Nursing acknowledged that the policy regarding care plan documentation was not followed, emphasizing the importance of timely updates and documentation to ensure effective communication among staff.
Failure to Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for four of five sampled residents, which included measurable objectives and timeframes to meet their medical, nursing, mental, and psychosocial needs. For Resident 24, who was on a ventilator and had a sacral wound, the care plan lacked measurable goals and timeframes, and there was no re-evaluation of the care plan since its initiation. The Director of Nursing confirmed that the care plan should have been initiated and re-evaluated as needed. Resident 61, who had anoxic brain injury and contractures, did not have a care plan developed for the prescribed Passive Range of Motion exercises. The Director of Nursing verified that a care plan should have been initiated the same day the physician order was received. Similarly, Resident 67, who also had contractures and required Passive Range of Motion exercises, did not have a care plan developed and implemented, as confirmed by the Director of Nursing. Resident 50, with a history of cerebral vascular accident and other conditions, only had an active care plan for nutritional status, while other necessary care plans were discontinued. The Director of Nursing was unable to provide documented evidence of the required care plans for Resident 50, confirming that the nursing staff should have documented the care plan. The facility's policy and procedure on care planning emphasized the need for documentation and consideration of individualized patient needs, which was not adhered to in these cases.
Medication Administration Failures in LTC Facility
Penalty
Summary
The facility failed to ensure that nursing staff administered medications as ordered for 23 out of 41 sampled residents. On December 1, 2024, medications were not administered to 22 residents, and the responsible physician or pharmacist was not notified of the missed doses. This included critical medications such as levetiracetam and apixaban, which are essential for managing conditions like seizures and preventing blood clots. The Director of Nursing confirmed that the facility's policy and procedure for medication administration were not followed, as the nursing staff did not report the medication omissions or notify the appropriate medical personnel. In a separate incident, a resident with a PEG tube was administered medications through the tube without verifying the route of administration with a physician. The resident had orders for oral medications, but due to their inability to swallow, the medications were given via the G tube. The registered nurse responsible for administering these medications did not notice the discrepancy in the route of administration, and the physician was not informed of the change in administration method. The Interim Director of Nursing acknowledged that the nursing staff failed to adhere to the facility's policy, which requires validation of the six rights of medication administration, including the right route. These failures in medication administration resulted in unsafe practices that could potentially lead to adverse health outcomes for the residents involved. The facility's policy and procedure for medication administration were not followed, leading to a lack of communication with physicians and pharmacists regarding missed doses and changes in medication administration routes. This oversight highlights significant deficiencies in the facility's medication management processes.
Failure to Notify Family of Resident Transfer
Penalty
Summary
The facility failed to notify the family or emergency contact of a resident before transferring them to an acute care hospital for a suprapubic catheter exchange. This deficiency was identified during a review of the resident's emergency department physician note and interviews with facility staff. The resident, a male with a history of quadriplegia, tracheostomy, ventilator dependency, neurogenic bladder, and suprapubic catheter dependency, was transferred from the long-term care facility without documented evidence of family notification. Interviews with a Licensed Vocational Nurse and the Director of Nursing revealed that the facility's policy requires family notification upon any transfer, which was not adhered to in this case. The Director of Nursing confirmed the absence of documentation regarding family notification in the resident's medical record. The facility's policy and procedure for transferring residents requiring emergency or acute care also mandates notifying the resident's primary contact, which was not followed, leading to a lack of communication between the resident's family and the healthcare team.
Failure to Provide and Document PROM Services
Penalty
Summary
The facility failed to provide Passive Range of Motion (PROM) services as ordered for two residents, leading to a deficiency in care. Resident 61, who was observed on the sub-acute unit, had bilateral upper extremities contractures and was supposed to receive PROM services every Monday, Wednesday, and Friday. However, there was no documented evidence that these services were provided on the specified dates. Interviews with the Restorative Nurse Assistant (RNA) and Certified Nurse Assistant (CNA) revealed that neither provided the PROM services, with the CNA stating she was not certified to perform ROM. Similarly, Resident 67, who also had contracted upper extremities and was breathing via tracheostomy, was not provided with the ordered PROM services. The physician's order for Resident 67 also indicated PROM every Monday, Wednesday, and Friday, but there was no documentation of these services being performed. The RNA and CNA both confirmed they did not provide the services, and the Director of Nursing (DON) verified the lack of documentation and service provision. The facility's policy and procedure on Wound Care Management Pressure Wounds required turning with range of motion every two hours and as needed, along with appropriate documentation. However, the failure to provide and document PROM services for Residents 61 and 67 indicates a lapse in following these procedures, as confirmed by the DON during the review of the residents' records.
Delayed Call Light Response for Clinically Compromised Residents
Penalty
Summary
The facility failed to ensure that call lights were answered in a timely manner, affecting two residents who were clinically compromised. Resident 1, who has paraplegia and is totally dependent on staff for transfers, reported that it sometimes took up to two hours for staff to respond to calls for help. This was observed during an interview where Resident 1 was found seated in a wheelchair, indicating reliance on the wheelchair for mobility. Resident 1's clinical records confirmed a diagnosis of paraplegia and a Brief Interview for Mental Status (BIMS) score indicating no mental impairment. Similarly, Resident 2, who has lung cancer that has metastasized to the bone and is totally dependent on staff for assistance with activities such as using the commode, reported variable response times to call lights, ranging from prompt to delays of up to 45 minutes. During an interview, Resident 2 was found lying in her room, indicating reliance on staff for commode use. Resident 2's clinical records also showed a BIMS score indicating no mental impairment. Interviews with the Director of Nursing and the Administrator revealed that the facility lacked a specific policy on call light response times.
Controlled Medication Verification Deficiency
Penalty
Summary
The facility failed to maintain an accurate controlled medication verification process for 17 residents, as evidenced by missing signatures from two licensed nurses on the controlled drug count records. This deficiency was observed on seven out of 20 days between August 1, 2024, and August 20, 2024. The absence of a second nurse's signature was noted on specific shifts, including both AM and PM shifts on certain days. This lapse in procedure was identified during a review of the facility's control drug count records. Interviews conducted with the Director of Staff Development, the Pharmacist Consultant, and the Administrator revealed that the facility's policy required two nurses to verify controlled drugs at the beginning and end of each shift. However, the drug count sheets for August 2024 showed instances where only one nurse's signature was present. The Administrator acknowledged being recently informed of this issue. The facility's policy, dated March 15, 2017, mandates that high alert medications be checked by two licensed nurses, with both required to document the verification process in the Medication Administration Record (MAR).
Unauthorized Removal of Controlled Medication by LVN
Penalty
Summary
The facility failed to ensure the secure storage of controlled medications for a resident, leading to the wrongful use of the resident's belongings. A Licensed Vocational Nurse (LVN) took acetaminophen and hydrocodone (Norco) from the medication cart without permission, resulting in the diversion of controlled medication. This incident involved a resident who was admitted with a diagnosis of unspecified focal traumatic brain injury and had orders for Norco to be administered as needed for pain management. During a controlled medication verification, discrepancies were noted, and it was discovered that 18 tablets of Norco were missing. Interviews revealed that the LVN took the pill card and remaining medication home and destroyed them, admitting to the action but unable to explain the discrepancy. The facility's policies and procedures clearly state that controlled medications should not be surrendered to anyone other than specified parties, highlighting a breach in protocol. The incident was reported by a Registered Nurse (RN) who noticed the discrepancy and informed the facility's management. The LVN's actions resulted in the unauthorized removal and destruction of the resident's medication, violating the facility's medication storage policies.
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What surveyors actually found near you
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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.
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Nursing homes near Joshua Tree
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Indian Canyon Post Acute | 7.2 mi | ★★★★★ | 12 | 0 |
| Joshua Tree Post Acute | 8.9 mi | ★★★★★ | 24 | 0 |
| California Nursing & Rehabilitation Center | 24.8 mi | ★★★★★ | 4 | 0 |
| Premier Care Center For Palm Springs | 25.5 mi | ★★★★★ | 35 | 1 |
| Desert Regional Medical Center D/p Snf | 25.5 mi | ★★★★★ | 20 | 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.