Above average — CMS composite of the measures below.
The next survey window likely opens around October 2026
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Joshua Tree Post Acute during CMS and state inspections, most recent first.
Kitchen Refrigeration Equipment Not Maintained: The walk-in refrigerator gasket was loose and held with tape, and the walk-in freezer door had a layer of ice. The MS stated the freezer gasket did not create a tight seal, causing the door to shut improperly, and that he had to melt the ice with a blower every two to three weeks. He also stated both gaskets needed to be replaced.
Failure to Provide Written Advance Directive Information: The facility did not provide documented written information about the right to formulate an Advance Directive for four residents. Each resident had no Advance Directive in place, and several had H&P findings showing they lacked capacity to understand and make decisions. The SSD stated he was responsible for offering Advance Directive information and documenting it on the checklist, but the records reviewed showed blank or missing Advance Directive Checklist forms and no documented evidence that the residents or their representatives were informed.
A resident with diagnoses including major depressive disorder and anxiety received Ativan PRN without documented informed consent. During record review, the DON verified there was no signed informed consent before the psychotropic medication was administered, despite the facility policy requiring informed consent prior to use.
Unsanitary Shared Toilet Left Unclean After Plumbing Work: Two residents shared a restroom with a broken toilet that remained unusable, and the toilet bowl was observed with multiple brown rings and stains after plumbing work. The DON later confirmed the restroom was stained and unsanitary, and the condition did not follow the facility's housekeeping policy to promote a sanitary environment.
A resident was transferred to the hospital for a psychiatric eval due to behavioral symptoms, but the facility did not document notifying the State LTC Ombudsman of the discharge. During record review, the MRD stated she was responsible for faxing transfer and discharge notifications and verified the notification for this resident was overlooked.
A resident readmitted with schizoaffective disorder had a Level I PASRR screening that identified serious mental illness, but facility staff were unresponsive to repeated attempts to complete the Level II evaluation. The MRD could not provide evidence of follow-up on the attempted PASRR, and the Administrator confirmed the facility’s PASRR process was delegated to Medical Records and was meant to ensure all admissions had the appropriate PASRR completed.
Unsanitary wound treatment cart supplies were found when surveyors observed an expired SurePrep skin protectant wipe and a red-pink dried substance in the cart drawer, with the substance spilled onto other medications. The DON verified the expired wipe and the spill, and the IP stated that expired supplies should not be on the cart and that spills are an infection control issue.
Menu Recipe and Portion Size Not Followed: A cook did not follow the pureed starch recipe when preparing rice pilaf for residents on a pureed diet, using chicken stock instead of warm milk. Staff also served two residents one-third cup of ginger carrots instead of the one-half cup listed on the therapeutic spreadsheet. The RD and DSS verified the recipe and portion size errors.
A resident’s record was inaccurate when the resident was documented as a good candidate for a bowel and bladder retraining program despite interviews and record review showing the resident was incontinent of urine, required a Hoyer lift for transfers, and could not stand to use the bedside commode or walk to the bathroom. The DON reviewed the bowel and bladder screener and bladder continence record and confirmed the screener was incorrect.
Survey results were not readily accessible to residents, family, or visitors. During a Resident Council meeting, residents said they had not seen the state survey results and did not know where they were located. The ADM retrieved the survey binder from a locked room that required staff assistance to access and confirmed there were no signs showing its location, despite the facility policy stating residents have the right to examine survey results.
A resident with Alzheimer's, dementia, and gout was found unable to reach their call light, which was on the floor. This was confirmed by a Resource Respiratory Therapist and was against the facility's policy, as noted by the Chief Nursing Officer.
A resident with dementia and hypertension was left unattended with an uncovered breakfast tray, contrary to her care plan which required assistance during meals. The oversight was confirmed by staff, including a CNA who admitted forgetting to assist the resident, and the CNO acknowledged the facility's policy was not followed.
The facility failed to administer a prescribed medication for constipation to a resident due to unavailability from the pharmacy, and the nurse incorrectly documented its administration. Additionally, another resident's wound care was not documented on specific days, suggesting it may not have been performed as ordered. Furthermore, a change in condition evaluation and SBAR communication for a positive wound infection were not completed, contrary to facility policy.
A resident with documented food allergies to cranberries was served cranberry juice, despite clear dietary restrictions. The oversight was acknowledged by staff, including the MDSN and CNO, who confirmed the allergy information was missed during meal service. The facility's policy on food allergies was not followed, posing a risk of allergic reaction.
The facility failed to maintain complete and accurate medical records for two residents. One resident's fall was not followed by an IDT investigation or care plan update, while another resident's MAR inaccurately documented medication administration despite the medication not being available. These actions violated the facility's policies, as confirmed by the CNO.
A resident with dementia was physically abused by an Activities Staff (AS) member who grabbed and yanked her onto her bed, causing fear and distress. The incident was witnessed by a CNA, who reported the AS's rough handling and derogatory comments. The Director of Nursing confirmed the abuse and acknowledged the facility's failure to protect the resident, despite having a policy to prevent such incidents.
A resident with dementia and high fall risk was left unsupervised, resulting in a fall and subdural hematoma. Staff interviews revealed a lack of communication and coordination, with no huddles or briefings occurring. The facility's fall prevention policies were not adequately implemented, leading to the incident.
The facility failed to ensure two rooms were clean, sanitary, and homelike. One room had missing wooden trim exposing unpainted drywall, while another had a section of wall, ceiling, and windowsill with exposed drywall and chipping paint. The Infection Control Practitioner acknowledged the damage and stated a work order had been submitted.
The facility failed to provide proper treatment and assistive devices for a resident with Alzheimer's and unspecified hearing loss. Despite documented hearing difficulties and a care plan intervention to refer to audiology, no order for a hearing consult was placed, resulting in the resident being unable to appropriately express his needs.
The facility failed to date the blood glucose monitor's control solutions, leading to potential inaccuracies in blood sugar monitoring. The LVN and DON confirmed that the controls were opened without being dated, which could result in expired solutions being used.
The facility failed to ensure proper hand hygiene during medication administration and resident care tasks for two residents. An LVN did not perform hand hygiene before moving the medication cart, preparing medication, entering or exiting the resident's room, or after disposing of refused medication. Additionally, the LVN did not perform hand hygiene between caring for two residents, including before and after blood glucose monitoring and glove removal.
Kitchen Refrigeration Equipment Not Maintained
Penalty
Summary
The facility failed to ensure the walk-in refrigerator and walk-in freezer were maintained in working order. During a concurrent observation and interview on 9/15/25 at 8:05 AM in the kitchen, the Maintenance Supervisor observed that the gasket on the walk-in refrigerator was loose and held in place with tape, and the walk-in freezer door was coated in a layer of ice. The Maintenance Supervisor stated the freezer door gasket did not create a tight seal, which caused the door to shut improperly, and stated he needed to melt the ice with a blower every two to three weeks to remove the ice buildup. He also stated that both the walk-in refrigerator and walk-in freezer gaskets needed to be replaced. Review of the facility's policy and procedure titled, Physical Environment, dated 1/2025, indicated the facility's policy was to establish procedures for routine and non-routine care of equipment and to ensure it remained in good working order for resident and staff safety.
Failure to Provide Written Advance Directive Information
Penalty
Summary
The facility failed to provide written information concerning the right to formulate an Advance Directive for four sampled residents. Resident 2 was admitted to the facility and had an Advance Directives Checklist dated 4/18/25 that showed the resident did not possess an Advance Directive, but the section indicating the resident was offered and received referral tools to formulate one was left blank. Resident 2's History and Physical dated 4/21/25 indicated the resident did not have the capacity to understand and make decisions. Resident 5 was readmitted to the facility and had a POLST dated 10/13/24 indicating the resident did not have an Advance Directive. Resident 5's History and Physical dated 8/22/25 indicated the resident did not have the capacity to understand and make decisions. During interview and record review, the Social Services Director stated he was responsible for ensuring Advance Directives were available in the clinical record or offered to residents, but Resident 5's record contained no documented evidence that the resident or representative was offered the right to formulate an Advance Directive, and no Advance Directive Checklist form was completed. Resident 7 had been admitted to the facility since 3/19/22 and had a POLST dated 3/19/22 indicating no Advance Directive. Resident 7's History and Physical dated 6/11/25 indicated the resident did not have the capacity to understand and make decisions, and the clinical record contained no documented evidence that the resident or representative was provided written information concerning the right to formulate an Advance Directive. Resident 9 was readmitted to the facility and had a POLST dated 7/6/24 indicating no Advance Directive. Resident 9's History and Physical dated 11/26/24 indicated the resident did not have the capacity to understand and make decisions, and the clinical record also lacked documented evidence that the resident or representative was provided written information concerning the right to formulate an Advance Directive. The Social Services Director verified there was no Advance Directive Checklist form completed for Resident 9 and stated the facility had a difficult time contacting the family, with no Advance Directive in place since admission.
Failure to Obtain Informed Consent Before Ativan Administration
Penalty
Summary
The facility failed to obtain informed consent before administering Ativan (lorazepam) to one resident. Resident 1 was readmitted to the facility with diagnoses including major depressive disorder and anxiety, and the physician’s order summary showed an order for Ativan 0.5 mg by mouth every 8 hours as needed for anxiety. During a concurrent interview and record review, the DON verified there was no documentation that Resident 1 received informed consent before Ativan was given and confirmed the resident received Ativan without a signed informed consent. The DON also reviewed the facility’s Psychotropic Drug Use policy, which stated that informed consent was to be obtained prior to use, and verified the facility did not follow that policy.
Unsanitary Shared Toilet Left Unclean After Plumbing Work
Penalty
Summary
The facility failed to clean and disinfect the shared toilet used by two residents after plumbing work was completed, leaving the restroom in an unsanitary condition. On 9/15/25, during an observation and interview with one resident, the restroom door had a red banner stating, "Stop do not enter," and the resident stated the toilet was broken. Later that day, another resident stated the toilet in their room was still broken and was not usable. During observation of the shared restroom, the top ring of the toilet bowl had multiple brown rings and stains. The Maintenance Work Order Log showed an entry dated 8/16/25 indicating the shared toilet was clogged. On 9/17/25, the DON observed the shared restroom and confirmed the toilet was stained and unsanitary for resident use. On 9/18/25, the DON reviewed the facility's Housekeeping Services policy, which states the facility's policy is to promote a sanitary environment, and confirmed the toilet had been left in an unsanitary condition and did not follow that policy.
Failure to Notify Ombudsman of Resident Hospital Transfer
Penalty
Summary
The facility failed to notify the Office of the State Long-Term Care Ombudsman prior to, or as soon as practicable after, the discharge of one sampled resident to the hospital. Resident 3’s record showed admission to the facility, a physician order on 6/4/25 to transfer the resident to the hospital for a psychiatric evaluation, and an eINTERACT Transfer Form indicating a planned hospital transfer on 6/4/25 due to behavioral symptoms. Progress notes later showed the resident was readmitted to the facility on 6/27/25. Review of the clinical record found no documented evidence that the Ombudsman was notified of the resident’s discharge to the hospital. During interview and record review, the Medical Records Director stated that she was responsible for faxing Ombudsman notifications for resident transfers and discharges, kept a copy of the fax transmittal, and verified that the notification for this resident’s discharge was overlooked and should have been sent.
PASRR Follow-Up Not Completed for Resident With Serious Mental Illness
Penalty
Summary
The facility failed to follow up on one resident’s Level II PASRR after a Level I screening identified a serious mental illness. Resident 6 was readmitted with diagnoses including schizoaffective disorder, and the Level I PASRR screening dated 8/13/24 marked “Yes” for serious mental illness, listing schizoaffective disorder, depressive type, and major depressive disorder. The resident’s Notice of Attempted Evaluation dated 8/13/24 stated facility staff were unresponsive to two or more separate attempts of communication within 48 hours of the Level I screening, and the California Department of Health Care Services was unable to complete the Level II evaluation for serious mental illness. During interview and record review, the Medical Records Director stated she was responsible for completing and following up on PASRRs for residents in the facility and that PASRR determines whether residents require special services or are appropriate to remain in the facility. She was unable to provide documented evidence that the facility followed up on the attempted Level II PASRR and stated it must have been missed. The Administrator reviewed the facility’s PASSR Completion Policy and confirmed that the center was to ensure PASRRs were completed for all admissions and that the Administrator was accountable for monitoring the process, while stating the PASRR responsibility had been delegated to Medical Records.
Unsanitary Wound Treatment Cart Supplies
Penalty
Summary
Drugs and biologicals used in the facility were not maintained in accordance with accepted professional principles when wound treatment supplies in the Wound Treatment Cart were found in an unsanitary condition. During a concurrent inspection and interview with the DON, surveyors found an expired SurePrep skin protectant wipe inside the treatment cart drawer and a red-pink colored dried substance in the top drawer of the cart that had spilled onto other medications. The DON verified that the SurePrep had expired and confirmed the presence of the dried substance. The IP stated that expired supplies should not be on the cart and that spills are an infection control issue that should have been cleaned up immediately. The DON also stated that expired wipes should not be on the cart and that spills in the treatment cart should be cleaned up immediately.
Menu Recipe and Portion Size Not Followed
Penalty
Summary
The facility failed to follow the lunch menu and recipe for a pureed starch when preparing rice pilaf for 12 residents ordered a pureed diet. During a concurrent observation, interview, and record review, the cook measured 12 servings, placed them in a blender, and blended them before adding approximately one cup of chicken stock to reach the desired consistency. The facility’s recipe for Pureed (IDDSI Level 4) Starch required the regular recipe to be completed, the total number of portions to be measured out, the food to be pureed on low speed to a paste consistency before adding any liquid, and warm milk to be added gradually. The RD and DSS verified that chicken stock was used instead of warm milk, and the RD stated the nutritional value could be changed by not following the recipe. The facility also failed to serve the correct portion size for ginger carrots during tray line. The therapeutic spreadsheet for the lunch menu listed ginger carrots with a regular serving size of one-half cup, but the staff member plated one-third cup scoops for Resident 23 and Resident 53. During observation, the DSS verified that the serving size listed on the therapeutic spreadsheet was one-half cup and confirmed the residents were incorrectly served one-third cup. The RD stated staff should use the serving sizes listed on the therapeutic spreadsheet and acknowledged that using the wrong size scoop meant the residents received a smaller serving than they were supposed to get.
Inaccurate bowel and bladder retraining assessment
Penalty
Summary
The facility failed to ensure the medical record was accurate for one of 14 sampled residents when Resident 12 was incorrectly assessed and documented as a good candidate for a bowel and bladder retraining program. Resident 12’s admission record dated 9/17/25 showed the resident was admitted to the facility on [DATE]. During an interview on 9/17/25 at 2:39 PM, Resident 12 stated that using a bedpan to urinate was difficult and that incontinence briefs were preferred because of loss of bladder control. Resident 12 also stated that using the bedside commode and walking to the bathroom was not feasible because the resident could not stand. During an interview on 9/17/25 at 2:41 PM, CNA 1 stated that Resident 12 required a Hoyer lift for transfers, was incontinent of urine, and received urinary incontinence care after incontinence episodes. During a concurrent interview and record review on 9/17/25 at 3:22 PM, the DON reviewed Resident 12’s SSL-Bowel and Bladder Program Screener dated 9/5/25, which indicated the resident voided appropriately without incontinence at least daily and was alert and oriented. The DON also reviewed Resident 12’s Tasks - Bladder Continence dated 8/19/25 through 9/17/25 and verified the resident had only one episode of bladder continence in the prior 30 days. The DON stated the SSL-Bowel and Bladder Program Screener was incorrect.
Survey Results Not Readily Accessible
Penalty
Summary
The facility failed to ensure that the most recent survey results and the corresponding plan of corrections were readily accessible to residents, family, and visitors. During a Resident Council meeting, four residents stated they had not seen the state survey results and did not know where they were located. In a concurrent interview, the Administrator retrieved the survey binder from a locked room that required staff assistance to access. The Administrator confirmed there were no signs posted to show where the survey binder was kept and explained that the binder had previously been in the lobby but was moved to the locked room because it was often removed and misplaced. A review of the facility's Resident Rights policy dated 1/25/25 stated that residents have the right to examine survey results.
Call Light Accessibility Deficiency
Penalty
Summary
The facility failed to ensure the call light was accessible for Resident 9, as observed during a survey. Resident 9, who was admitted with Alzheimer's disease, dementia, and gout, was found unable to reach the call light, which was on the floor next to the bed. This observation was confirmed during an interview with the Resource Respiratory Therapist, who acknowledged that the call light should not be on the floor. The facility's policy and procedure for answering call lights, which requires ensuring the call light is accessible to residents when in bed, was not followed, as confirmed by the Chief Nursing Officer during a review of the policy.
Failure to Assist Resident During Mealtime
Penalty
Summary
The facility failed to provide necessary assistance during mealtime for a resident, identified as Resident 50, who was unable to perform activities of daily living independently. Resident 50, a female with dementia and hypertension, was at risk for malnutrition according to her care plan, which required staff to set up her meal tray and provide assistance and verbal cues during meals. On the morning of September 18, 2024, Resident 50 was observed lying in bed asleep with an uncovered and untouched breakfast tray left on her bedside table for over twelve minutes, compromising the quality and temperature of the meal. Interviews with facility staff revealed that the breakfast tray was delivered by CNA 2, who admitted to leaving it uncovered and unattended, forgetting to return to assist Resident 50. The Procurement Director confirmed the tray was left unattended, and CNA 1, who was not assigned to Resident 50, acknowledged the oversight and offered assistance. The Chief Nursing Officer confirmed that the facility's policy and procedure for activities of daily living, which mandates providing necessary services to maintain good nutrition, was not followed by the staff.
Medication and Wound Care Documentation Deficiencies
Penalty
Summary
The facility failed to provide appropriate treatment and care for two residents, resulting in deficiencies. For one resident, the medication Linzess, prescribed for constipation, was not available from the pharmacy and was not administered as ordered by the physician. This oversight occurred over a period of four days, during which the medication was not delivered, and the nurse mistakenly documented that it had been given. The facility's policy requires that medications be administered as prescribed, but this was not adhered to, placing the resident's health and safety at risk. Another resident did not receive proper wound care treatment as documented in the Treatment Administration Record (TAR). The TAR lacked documentation for wound care on specific days, indicating that the treatment may not have been performed as ordered by the physician. The facility's policy mandates that wound care be documented in the resident's clinical record at the time of administration, but this was not followed. The Chief Nursing Officer acknowledged the missing documentation and stated that the nurses are expected to carry out and document treatments as per physician's orders. Additionally, the facility failed to complete a Change in Condition Evaluation and an SBAR communication form for a positive wound infection in the same resident. The facility's policy requires documentation of any change in condition and the use of SBAR for communication, but these were not completed. The Chief Nursing Officer admitted that a change of condition should have been initiated for the wound infection, and the lack of documentation was an oversight. This failure to document and communicate changes in the resident's condition could lead to unidentified complications.
Failure to Adhere to Dietary Restrictions for Resident with Food Allergies
Penalty
Summary
The facility failed to adhere to dietary restrictions for a resident with documented food allergies, specifically to cranberries. The resident, who was admitted with conditions including paroxysmal atrial fibrillation, asthma, and gastroesophageal reflux disease, was served cranberry juice despite having a known allergy to it. This incident was observed when the resident complained about her breakfast tray containing cranberry juice, which was confirmed by the Medical Data Set Nurse (MDSN) who promptly removed the juice and acknowledged the oversight. Interviews with various staff members, including the Chief Nursing Officer (CNO) and Licensed Vocational Nurses (LVNs), revealed that the dietary restrictions were clearly stated on the resident's diet card, yet were overlooked during meal service. The facility's policy and procedure on food allergies, which mandates the identification and substitution of allergens, was not followed. Staff members admitted to missing the allergy information while focusing on other dietary aspects, leading to the potential risk of a serious allergic reaction for the resident.
Incomplete and Inaccurate Documentation for Two Residents
Penalty
Summary
The facility failed to ensure complete and accurate documentation of medical records for two residents, leading to potential risks. Resident 48 experienced a fall on August 21, 2024, which was not followed by an interdisciplinary team (IDT) investigation or recommendations, as required by the facility's policy. The resident's care plan, which should have been updated to reflect the fall and any new risk factors, remained unchanged since June 4, 2024. Interviews with the Minimum Data Set Nurse and the Chief Nursing Officer confirmed the absence of IDT meeting notes and the failure to adhere to the facility's fall prevention and management policies. Resident 49's medication administration record (MAR) contained inaccuracies, as it documented the administration of Linzess on September 17 and 18, 2024, despite the medication not being available from the pharmacy. During a medication cart inspection, the medication was not found, and the Licensed Vocational Nurse admitted to mistakenly documenting the administration. The facility's policies on documentation and medication administration, which require accurate and chronological recording of care and reasons for withheld medications, were not followed, as confirmed by the Chief Nursing Officer. These documentation failures for Residents 48 and 49 had the potential to result in missed interventions, inaccurate medication counts, and unaddressed adverse side effects. The facility's policies and procedures, reviewed in December 2023, were not adhered to, as acknowledged by the Chief Nursing Officer during interviews and record reviews.
Failure to Protect Resident from Physical Abuse by Staff
Penalty
Summary
The facility failed to protect a resident from physical abuse by an Activities Staff (AS) member. During an unannounced visit, it was found that the AS grabbed the resident's right arm and yanked her down onto her bed, causing the resident to experience fear and abuse. The incident was witnessed by a Certified Nursing Assistant (CNA), who reported that the resident, diagnosed with dementia, was not supposed to walk without assistance. The CNA observed the AS enter the room, grab the resident roughly, and pull her towards the bed, leading to the resident stumbling onto it. The AS then left the room after making derogatory comments about the resident. The Director of Nursing (DON) confirmed that the AS acted abusively towards the resident and acknowledged the facility's failure to protect the resident from abuse. The AS resigned from her position via text message and was unavailable for an interview. The facility's policy on abuse prevention and prohibition, dated January 2024, states that residents have the right to be free from abuse and that the facility will provide oversight to ensure staff deliver care that respects residents' rights. However, this policy was not adhered to in this instance, resulting in the deficiency.
Failure to Implement Fall Prevention Policies
Penalty
Summary
The facility failed to implement their fall prevention policies and procedures for a resident, resulting in a fall and subsequent injury. The resident, who had dementia, lack of coordination, and muscle weakness, was admitted to the facility with a high risk for falls. Despite this, the resident was left unsupervised and was found on the floor with both wheelchair locks in the unlocked position, leading to a subdural hematoma and necessitating admission to the ICU for a higher level of care. Interviews with staff revealed a lack of communication and coordination regarding the resident's care. Certified Nurse Assistants (CNAs) reported that no huddles or briefings occurred on the day of the incident or on other days, which contributed to the lack of supervision. The facility's policies required high fall risk residents to be mentioned in every huddle for reinforcement, but this was not followed. The facility's policies and procedures for fall prevention and safety were not adequately implemented. The resident's care plan indicated the need for frequent visual checks and supervision, but these interventions were not effectively communicated or executed. The failure to adhere to these protocols directly led to the resident's fall and subsequent injury.
Facility Failed to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to ensure two of 25 rooms were clean, sanitary, and homelike. In one room, an entire section of wooden trim was missing along the back wall and headboard wall, exposing unpainted drywall. In another room, a 2-foot by 4-foot section of wall, ceiling, and windowsill was unpainted with exposed drywall and chipping paint. During an observation and interview, the facility's Infection Control Practitioner acknowledged the damage and stated that a work order had been put in to fix it. The facility's policy on maintaining a homelike environment was not adhered to, as evidenced by the observed damage and lack of timely repair.
Failure to Provide Hearing Assistive Devices
Penalty
Summary
The facility failed to provide proper treatment and assistive devices to maintain hearing ability for Resident 10. Resident 10, who was admitted with Alzheimer's disease, dementia, and unspecified hearing loss, was observed without hearing aids and expressed difficulty in hearing. The Minimum Data Set (MDS) indicated moderate hearing difficulty and no hearing aid, and the care plan noted a communication problem related to hearing deficit with an intervention to refer to audiology for a hearing consult. However, no order for an audiology consult was ever placed, as confirmed by the Licensed Vocational Nurse (LVN) and the Medical Records Director (MRD). During interviews and record reviews, it was revealed that Resident 10's hearing difficulties had worsened over time, yet no action was taken to address this issue. The lack of an audiology consult order and the absence of hearing aids resulted in Resident 10 being unable to appropriately express his needs. This oversight highlights a significant deficiency in the facility's care for Resident 10's hearing needs.
Failure to Date Blood Glucose Monitor Control Solutions
Penalty
Summary
The facility failed to ensure that the blood glucose monitor's control solutions were dated with an open date. During an observation and interview at 06:00 AM, it was noted that the glucometer controls on medication cart #2 had been opened and used but did not have an open date written on the bottles or the box. The Licensed Vocational Nurse (LVN) stated that the controls were opened about a week ago and should have been dated but were not. The LVN further mentioned that registry personnel and other staff would not be able to identify when these controls were opened, and the control solution would be discarded after 90 days of opening. During a subsequent interview and record review at 10:00 AM, the Director of Nursing (DON) confirmed that the glucose controls are only good for three months after opening and should be labeled with the date opened and the date expired. The [name of brand] Glucose Monitoring System User's Guide also indicated that control solutions should be discarded three months after opening or by the expiration date on the bottle, whichever comes first. The failure to label the control solutions with the open date could lead to inaccurate blood glucose results for residents requiring blood sugar monitoring.
Failure to Perform Hand Hygiene During Medication Administration and Resident Care
Penalty
Summary
The facility failed to ensure proper hand hygiene was performed during medication administration and resident care tasks for two residents. During an observation, a Licensed Vocational Nurse (LVN) did not perform hand hygiene before moving the medication cart, preparing medication, entering or exiting the resident's room, or after disposing of refused medication. Additionally, the LVN did not perform hand hygiene between caring for two residents, including before and after blood glucose monitoring and glove removal. In an interview, the LVN admitted to not recalling if hand hygiene was performed during these tasks and acknowledged that hand washing should be done to prevent infection spread. The facility's policy on hand hygiene, reviewed with the Director of Nursing (DON), indicated that hand hygiene is essential before and after resident contact, performing aseptic tasks, and glove removal. The DON confirmed that hand hygiene should be performed upon entering and exiting a resident's room and when administering medication or performing resident care.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 123 citations issued within 25 miles in the last 12 months — including the 1 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Yucca Valley
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Indian Canyon Post Acute | 1.7 mi | ★★★★★ | 12 | 0 |
| Hi-desert Medical Center D/p Snf | 8.9 mi | ★★★★★ | 23 | 0 |
| California Nursing & Rehabilitation Center | 18.4 mi | ★★★★★ | 22 | 0 |
| Desert Regional Medical Center D/p Snf | 19.2 mi | ★★★★★ | 10 | 0 |
| Premier Care Center For Palm Springs | 20 mi | ★★★★★ | 32 | 1 |
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