Desert Springs Post Acute

F 0558

Reasonably accommodate the needs and preferences of each resident.

Level of Harm - Minimal harm or potential for actual harm

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

interview and record review, the facility failed to ensure call lights were answered as soon as possible, for one of five residents (Resident 2).This failure had the potential to cause delay of care, and to cause Resident 2's needs to not be met in a timely manner.Findings:On August 4, 2025, at 9:50 a.m., an unannounced visit was conducted at the facility for investigation of a facility reported incident involving Resident 2.A review of the facility's census indicated Resident 2 was no longer residing in the facility.A

review of Resident 2's admission Record, indicated Resident 2 was admitted to the facility on [DATE REDACTED], with diagnoses which included fracture of the left humerus. Resident 2 was discharged from the facility on August 2, 2025.A review of Resident 2's (Name of facility) Room History, which contained information regarding how long Resident 2's call light remained on after it was turned on, indicated Resident 2's call light was turned on on July 20, 2025, at 11:24 a.m., and remained on for 58 minutes and 16 seconds. On August 11, 2025, at 4:48 p.m., a concurrent interview and review of Resident 2's record was conducted with

the Director of Staff Development (DSD). The DSD stated regarding call lights, the goal was for the call lights to be answered within 10 minutes. Regarding Resident 2, the documented 58 minutes could mean two things, the Certified Nursing Assistant (CNA) was instructed to not turn it off, but would tell whoever was responsible for the resident's issue so it can be addressed, then when the issue was addressed, the call light would be turned off; or the call light was not really answered. Either way, that was not acceptable.

The call light should have been answered as soon as possible.Further review of the (Name of facility) Room History for Resident 2, indicated the following durations for when the call lights remained on: -7/18/2025 8:44- 16 min (minutes)15 secs (seconds);-7/18/2025 11:08 - 18 min 38 secs;-7/18/2025 21:03- 19 min 30 secs;-7/19/25 07:12- 11 min 9 secs;-7/19/2025 11:23- 14 min 55 secs;-7/19/2025 15:39- 15 min 1 sec;-7/19/2025 00:02 12 min 33 secs;-7/20/2025 11:24- 58 min, 16 secs;-7/20/2025 16:08- 19 min 53 secs;-7/21/2025 09:13- 17 min 36 secs;-7/22/2025 07:51 16 min 9 secs;-7/22/2025 15:25- 18 min 42 secs;-7/22/2025 20:29- 33 min 8 secs; and-7/22/2025 21:49 12 min 10 secs.A review of the facility's undated policy and procedure titled, Answering the Call Light, indicated, .The purpose of this procedure is to respond to the resident's requests and needs.Answer the resident's call as soon as possible.

Residents Affected - Few

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date

these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE

TITLE

(X6) DATE

FORM CMS-2567 (02/99) Previous Versions Obsolete

Facility ID:

If continuation sheet

Event ID:

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/27/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Desert Springs Post Acute

74-350 Country Club Drive Palm Desert, CA 92260

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

observation, interview, and record review, the facility failed to ensure the plan of care was implemented to have another staff present while care was being provided, for one of three residents (Resident 3). This resulted in Resident 3's care plan to not be followed.Findings:On August 4, 2025, at 9:50 a.m., an unannounced visit was conducted at the facility for investigation of a facility reported incident regarding an allegation of abuse.On August 5, 2025, at 11:36 a.m., Resident 3 was observed lying on the first bed (bed A), awake and answering questions. Posted on the door of Resident 3's room was a sign indicating A Bed Cares in Pairs.Certified Nursing Assistant (CNA) 1 was observed to enter the room after putting on a disposable gown and a pair of gloves, and proceeded to change Resident 3's soiled disposable underwear, as well as clean the resident. CNA 1 stated Resident 3 was supposed to be Cares in Pairs, which meant It should be two persons all the time, but could not find anybody to assist her. A review of Resident 3's record indicated Resident 3 was admitted to the facility on [DATE REDACTED], with diagnoses which included diabetes and muscle weakness.A review of Resident 3's History and Physical, dated May 11, 2025, indicated Resident had the capacity to understand and make decisions.A review of Resident 3's care plan included a care plan initiated on May 28, 2025 for the focus area Fabrication of stories m/b (manifested by) accusing staff of not taking care of him, and saying staff is intentionally hurting him, with interventions including .Care in Pairs.A

review of Resident 3's Minimum Data set (MDS - a clinical assessment tool), dated July 11, 2025, indicated Resident 3 had a Brief Interview for Mental Status (BIMS) score of 10 (moderately impaired cognition).A

review of Resident 3's Progress Notes, dated July 29, 2025, at 7:46 a.m., indicate, .LVN (Licensed Vocational Nurse) reported to me that pt (patient) was being changed at 0410 (4:10 a.m.) hrs (hours) , pt was turned and cleaning his bottom, pt pulled her arm and she pulled his arm away from her and made a skin tear .Pt stated to LVN that CNA was rough in handling him .On August 22, 2025, during a follow up telephone interview, CNA 2 was interviewed. CNA 2 stated when she provided care to Resident 3 on July 22, 2025, at 4:10 a.m., she was aware Resident 3 was Cares in Pairs, but provided care to the resident by herself since all the other staff were on their break. On August 26, 2025, at 11:42 a.m., the Director of Staff Development (DSD) was interviewed. The DSD stated anytime there was a Cares in Pairs resident, When

they go in, there should always two staff to protect themselves and the resident .they should always have a witness when they go in for whatever activity .A review of the facility's document titled, In-service Training Report, dated August 5, 2025, indicated the topic, Pairs and Cares Abuse prevention Lesson Plan for Nursing Homes.To protect nursing home residents from abuse allegations-and actual abuse- facilities often implement structured systems like pairs and cares as part of broader safety and accountability strategies.it generally refers to staff pairing and care protocols designed to reduce risk and enhance oversight.Staff pairing.Two-person care teams: Assigning two caregivers to assist residents during high-risk activities (e.g., bathing, transferring, toileting) reduces the chance of abuse and protects staff from false allegations.Witness accountability: Having a second staff member present can serve as a witness in case of disputes or complaints.

Event ID:

Facility ID:

If continuation sheet