Manorcare Health Services-palm Desert

F-F725)

Findings:

1. On January 6, 2025, at 3:33 p.m., an observation and concurrent interview was conducted with Resident 95 in his room. Resident 95 was observed lying in bed, alert, and agreed to the interview. Resident 95 stated

he was frustrated that when he used the call light, no one would come, and if they did, they just turned the light off without addressing his needs. Resident 95 stated it would take hours before a staff would answer his call light, and this had been happening for more than two months.

On January 8, 2025, Resident 95's record was reviewed. Resident 95 was admitted to the facility on [DATE REDACTED], with diagnoses which included cerebral infarction (when blood flow to the brain in block), and muscle weakness.

A review of Resident 95's Care Plan, dated April 2, 2024, indicated, .ADL (Activities of Daily Living)/Mobility: Resident has actual risk for ADL/mobility decline and requires assistance related to generalized weakness .

A review of Resident 95's History and Physical, dated April 3, 2024, indicated Resident 95 had fluctuating capacity to understand and make decisions.

A review of Resident 95's Minimum Data Set (MDS-a clinical assessment tool), dated October 9, 2024, indicated Resident 95 had Brief Interview for Mental Status (BIMs- cognitive assessment tool) score of 9, indicating moderate cognitive impairment.

On January 10, 2025, at 10:23 a.m., Certified Nursing Assistant (CNA) 7 was interviewed. CNA 7 stated Resident 95 had complained to him a couple of times about staff taking a long time to answer the call light and no one answers even though the resident calls out. CNA 7 stated stated he had observed some CNAs not answering the call lighs and not doing rounds hourly. CNA 7 stated it is not right and we should at least make rounds hourly and someone should be in the hallways all the time. CNA 7 stated he had informed the scheduler but have not notice any positive change.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 8 of 93 555339 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555339 B. Wing 01/10/2025

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 0558 2. On January 6, 2024, at 4:09 p.m., an observation and concurrent interview was conducted with Resident 5

in her room. Resident 5 was observed sitting up in bed and alert. Resident 5 stated she could not get out the Level of Harm - Minimal harm or bed without help. Resident 5 stated from 11 p.m. to 7 a.m., the facility had two CNAs for the entire unit. potential for actual harm Resident 5 stated she could not get help 99 percent of the time, and staff took hours to answer her call light. Resident 5 stated she had been laying in her own urine and bowel for over an hour on more than one Residents Affected - Some occasion. Resident 5 stated they could not get any help when staff from registry agency were working. Resident 95 further stated, It is not right.

On January 8, 2025, Resident 5's record was reviewed. Resident 5 was admitted to the facility on [DATE REDACTED], with diagnoses which included paraplegia (loss of muscle function in the lower half of the body), and polyneuropathy (nerve pain).

A review of Resident 5's physician's note, dated November 15, 2023, indicated Resident 5 had normal ability to communicate and had appropriate mood and affect.

A review of Resident 5 Care Plan, dated November 17, 2024, indicated Resident 5 had urinary incontinence related to weakness, impaired mobility, obesity, and need for assistance with ADLs.

3. On January 7, 2025, at 9:49 a.m., an observation and concurrent interview with Resident 464 was conducted in his room. Resident 464 was observed alert and sitting in a chair. Resident 464 complained that

he had been waiting for staff to answer his call lights for over an hour. Resident 464 stated the facility was always shorthanded and it took too long for staff to assist him.

On January 8, 2025, Resident 464's record was reviewed. Resident 464 was admitted to the facility on [DATE REDACTED], with diagnoses which included cerebral infarction. Resident is self-responsible.

A review of Resident 464's MDS, dated [DATE REDACTED], indicated Resident 464 had a BIMS score of 15 (cognitively intact).

On January 9, 2025, at 9:28 a.m., an interview with CNA 1 was conducted. CNA 1 stated she usually worked

the day shift. CNA 1 stated the facility had been using a lot of registry license nurses and CNAs on the night shift. CNA 1 further stated, when she took over from the night shift, the residents were soiled and the residents complained that staff took too long to answer the call light.

On January 6, 2025, at 10:57 a.m., an interview with LVN 5 was conducted. LVN 5 stated the facility's process was for staff to answer the call light in five minutes, or as soon as possible. LVN 5 stated staff should not go in a resident's room, turn the light off and leave. LVN 5 stated staff should address the resident's issues. LVN 5 further stated residents should not have to wait over 30 minutes to be changed.

On January 10, 2025, at 10:48 a.m., an interview with the Director of Nursing (DON) was conducted. The DON stated her expectation was for staff to answer the call light within a maximum of five to 10 minutes. The DON further stated the residents' call lights should be answered before 30 minutes.

A review of the facility's policy and procedure titled, Answering the Call Light, dated October 2010, indicated, .

The purpose of this procedure is to respond to the resident's request and needs .Answer the resident's call light as soon as possible .Listen to the resident's request .

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 9 of 93 555339 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555339 B. Wing 01/10/2025

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 0558 Areview of the facility's policy and procedure titled, Dignity, dated 2001, indicated, .Each resident should be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with Level of Harm - Minimal harm or life and feelings of self-worth and self-esteem .Staff are expected to promote dignity and assist residents, for potential for actual harm example, promptly respond to a resident's request for toileting and assistance .

Residents Affected - Some

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 10 of 93 555339 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555339 B. Wing 01/10/2025

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 0578 Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 50204

Residents Affected - Some Based on interview and record review, the facility failed to uphold resident's rights when:

1. Formulation of an Advance Directive (AD - a written instruction, such as a living will, relating to the provision of treatment and services when the individual becomes unable to decide) was not offered to the resident and/or their resident representative , for seven of 13 residents reviewed for Advance Directives (Residents 514, 463, 116, 123, 263, 95, 38, and 81); and

2. Copies of the AD were not available in the medical records, for one of 13 residents reviewed for AD (Residents 13).

These failures had the potential to result in the residents' wishes related to the provision of medical treatment and services, to not be followed if the residents became unable to make decisions for themselves.

Findings:

1a. On January 7, 2025, Resident 514's record was reviewed. Resident 514 was admitted to the facility on [DATE REDACTED], with diagnoses which included encounter for palliative care (medical approach maximizing quality of life).

A review Resident 514's Social History Assessment, dated December 26, 2024, indicated Resident 514 did not have an AD.

A review of Resident 514's Minimum Data Set (MDS - a resident assessment tool), dated December 30, 2024, indicated Resident 514 had a BIMS score of 15 (cognitively intact).

Further review of Resident 514's medical record indicated there was no documented evidence education and information about AD was provided to Resident 514.

On January 9, 2025, at 10:25 a.m., during a concurrent interview and review of Resident 514's medical

record with the Social Service Assistant (SSA), the SSA stated Resident 514 had no AD and she did not provide resources, education, and follow up regarding formulating an AD. The SSA further stated she should have provided resources and education to Resident 514, and she should have documented in the medical records.

1b. On January 7, 2025 Resident 116's record was reviewed. Resident 116 was admitted to the facility on [DATE REDACTED], with diagnoses which included adult failure to thrive (not getting enough calories).

A review of Resident 116's Social History Review, dated October 22, 2024, indicated Resident 116 did not have an AD.

A review of Resident 116's History and Physical, dated January 8, 2025, indicated Resident 116 has the capacity to understand and make decisions.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 11 of 93 555339 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555339 B. Wing 01/10/2025

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 0578 Further review of Resident 116's medical record indicated there was no documented evidence education and information about AD was provided to Resident 116. Level of Harm - Minimal harm or potential for actual harm On January 9, 2025, at 10:25 a.m., during a concurrent interview and review of Resident 116's medical

record with the SSA, the SSA stated if a resident did not have an AD, she would provide education and Residents Affected - Some resources to formulate one. The SSA stated Resident 116 did not have an AD and she should have provided AD education or follow up to the residents and should have documented it in the resident's medical record.

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1c. On January 8, 2025, Resident 123's record was reviewed. Resident 123 was admitted to the facility on [DATE REDACTED], with diagnoses which included diabetes mellitus (abnormal blood sugars), epilepsy (brain disorder that causes seizures), and paranoid schizophrenia (a mental disorder).

A review of Resident 123's Minimum Data Set, dated dated [DATE REDACTED], indicated Resident 123 had a Brief

Interview for Mental Status (BIMS- a brief screening tool that aids in detecting cognitive status) score of 15 (cognitively intact).

A review of Resident 123's History and Physical, dated December 5, 2024, indicated Resident 123 had the capacity to understand and make decisions.

There was no documented evidence formulation of an advance directive was offered to Resident 123.

On January 9, 2025, at 9:18 a.m., a concurrent interview and record review was conducted with the Registered Nurse (RN). The RN stated Resident 123 did not have an AD in his record, and there was no documented evidence formulation of an AD was offered to Resident 123. The RN stated she was not sure what the process was regarding ADs, since this was typically done by the social workers.

On January 9, 2025, beginning at 10 a.m., a concurrent interview and record review was conducted with the SSA. The SSA stated if the resident had an AD, it should have been uploaded in the electronic record. The SSA further sated Resident 123 did not have an AD in his record.

On January 9, 2025, at 2:40 p.m., the Social Services Director (SSD) was interviewed. The SSD stated formulation of an AD should be offered to residents upon admission, as well as reviewed and re-offered quarterly. If offered and declined, this would be documented in the quarterly assessment and progress notes.

In a concurrent interview, the SSA stated Resident 123 declined the offer to formulate an AD. The SSA further stated it should have been documented in the resident's record.

1d. On January 8, 2025, at 11:06 a.m., Resident 263's record was reviewed. Resident 263 was admitted to

the facility on [DATE REDACTED], with diagnoses which included acute respiratory failure, anxiety disorder, and heart disease.

A review of Resident 263's MDS dated [DATE REDACTED], indicated a BIMS score of 12 (moderate impairment).

A review of Resident 263's History and Physical, dated December 25, 2024, indicated Resident 263 had the capacity to make health care decisions.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 12 of 93 555339 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555339 B. Wing 01/10/2025

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 0578 There was no documented evidence formulation of an advance directive was offered or information regarding formulating an AD was provided to Resident 263. Level of Harm - Minimal harm or potential for actual harm On January 9, 2025, at 9:18 a.m., a concurrent interview and record review was conducted with the RN. The RN stated Resident 263 did not have an AD in her record, and there was no documented evidence Residents Affected - Some formulation of an AD was offered to Resident 263. The RN stated she was not sure what the process was regarding ADs, since this was typically done by the social workers.

On January 9, 2025, beginning at 10 a.m., a concurrent interview and record review was conducted with the SSA. The SSA stated if the resident had an AD, it should have been uploaded in the electronic record. The SSA further sated Resident 263 did not have an AD in her record.

On January 9, 2025, at 2:40 p.m., the Social Services Director (SSD) was interviewed. The SSD stated, formulation of an AD should be offered to residents upon admission, as well as reviewed and re-offered quarterly. If offered and declined, this would be documented in the quarterly assessment and progress notes.

In a concurrent interview, the SSA stated the offer to formulate an AD should have been documented in Resident 263's record.

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1e. On January 7, 2025, Resident 38's record was reviewed. Resident 38 was admitted to the facility on [DATE REDACTED], with diagnoses which included cerebral infarction (when blood flow to the brain is blocked), and depressive disorder (mental illness causes persistent low mood).

A review of Resident 38's Physician- History & Physical, dated March 11, 2024, indicated Resident 38 had fluctuating capacity to understand and make decisions.

Further review of Resident 38's electronic medical record and hard copy records indicated there was documented evidence of education and information about AD was provided to Resident 38.

On January 9, 2025, at 10:25 a.m., during a concurrent interview and review of Resident 38's medical record with the SSA, the SSA stated Resident 38 had no AD and she did not provide resources, education, and follow up. The SSA further stated she should have provided resources and education to Resident 38, and

she should have documented in the medical records.

1f. On January 8, 2025, at 10:08 a.m., Resident 95's record was reviewed. Resident 95 was admitted to the facility on [DATE REDACTED], with diagnoses which included cerebral infarction (when blood flow to the brain is blocked), and dysphagia (difficulty swallowing).

A review of Resident 95's History and Physical, dated April 3, 2024, indicated Resident 95 had fluctuating capacity to understand and make decisions.

Further review of Resident 95's electronic medical record and hard copy records indicated there was no documented evidence education and information about AD was provided to Resident 95.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 13 of 93 555339 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555339 B. Wing 01/10/2025

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 0578 On January 9, 2025, at 10:25 a.m., during a concurrent interview and review of Resident 95's medical record with the SSA, the SSA stated if a resident did not have an AD, she would provide education and resources to Level of Harm - Minimal harm or formulate one. The SSA stated Resident 95 did not have AD's and she should have provided AD education potential for actual harm or follow up to the Residents and (RP). The SSA further stated she should have provided resources and education to Resident 95 and the RP, and she should have documented in the medical records. Residents Affected - Some 1g. On January 8, 2025, at 9:53 a.m., Resident 463's record was reviewed. Resident 463 was admitted to

the facility on [DATE REDACTED], with diagnoses which included hemiplegia (paralysis or weakness on one side of the body) and hemiparesis (muscle weakness on one side of the body).

A review of Resident 463's Physician's Progress Notes, dated December 4, 2024, indicated Resident 463 was confused, awake but did not answer questions appropriately.

Further review of Resident 463's electronic medical record and hard copy records indicated there was no documented evidence education and information about formulating an AD was provided to Resident 463's representative.

On January 9, 2025, at 10:25 a.m., during a concurrent interview and review of Resident 463's medical

record with the SSA, the SSA stated if a resident did not have an AD, she would provide education and resources to formulate one to the (RP). The SSA stated Resident 463 did not have AD's and she should have provided AD education or follow up to the resident's representative. The SSD further stated she should have provided resources and education to Resident 463's representative, and she should have documented

in the medical records.

1h. On January 7, 2025, Resident 81's record was reviewed. Resident 81 was admitted to the facility on [DATE REDACTED], with diagnoses which included cerebral infarction.

A review of Resident 81's Physician- History & Physical, dated May 23, 2024, indicated Resident 81 had the capacity to make health care decisions.

A review of Resident 81's MDS, dated [DATE REDACTED], indicated Resident 81 had a BIMS score of 14 (cognitively intact).

Further review of Resident 81's electronic medical record and hard copy records indicated there was no documented evidence review for education and information about AD was provided to Resident 81.

On January 9, 2025, at 10:25 a.m., during a concurrent interview and review of Resident 81's medical record with the SSD, the SSD stated Resident 81 had no AD and she did not provide resources, education, and follow up. The SSD further stated she should have provided resources and education to Resident 13, and

she should have documented in the medical records.

2. On January 7, 2025, at 10:25 a.m., Resident 13's record was reviewed. Resident 13 was admitted to the facility on [DATE REDACTED], with diagnoses which included multiple sclerosis (damage of the nerve fibers t the brain and spinal cord), epilepsy (brain disorder that causes seizures), and dementia (memory loss).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 14 of 93 555339 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555339 B. Wing 01/10/2025

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 0578 A review of Resident 13's Physician- History & Physical, dated August 27, 2024, indicated Resident 13 had

the capacity to make health care decisions and Resident 13 had an AD. Level of Harm - Minimal harm or potential for actual harm A review of Resident 13's MDS, dated [DATE REDACTED], indicated Resident 13 had a BIMs score of 8, which indicated (moderate cognitive impairment). Residents Affected - Some Further review indicated there was no AD located in Resident 13's record.

A review of Resident 13's electronic medical record and hard copy records indicated that there was no documented evidence a follow up to request a copy of the AD was conducted to Resident 13.

Further review of Resident 13's Social Service Note, dated January 2, 2024, indicated Resident 13 had a BIM score of 14 and was cognitively intact. There was no documentation on the social service note that a follow up was conducted by the SSA regarding obtaining a copy of the AD.

On January 9, 2025, at 10:25 a.m., during a concurrent interview and review of Resident 13's medical record with the SSA, the SSA stated Resident 13 had no AD in the resident's record and should have followed up with the resident regarding a copy of her AD.

A review of the facility's policy and procedure titled, Advanced Directives, dated 2001, indicated, .Information about whether or not the resident has executed an advance directive is displayed prominently in the medical

record in a section of the record that is retrievable by any staff .If the resident or the residents (sic) representative has executed one or more advance directive(s), or executes one upon admission, copies of

these documents are obtained and maintained in the same section of the residents (sic) medical record and are readily retrievable by any facility staff .The interdisciplinary team will review annually with the resident his or her advanced directives to ensure that such directives are still the wishes of the resident .Prior to admission of a resident, the social services director or designee inquires of the resident, his/her family members and/or his or her legal representative, about the existence of any written advance directives .The resident or representative is provided with written information converning the right to refuse or accept medical or surgical treatment and to formulate an advance directive if he or she chooses to do so .Written information about the right to accept or refuse medical or surgical treatment, and the right to formulate an advance directive is provided in a manner that is easily understood by the resident or representative .If a resident is incapacitated and unable to receive information about his or her right to formulate an advance directive, the information may be provided to the residents legal representative .The staff development coordinator is responsible for scheduling training regarding advanced directives for newly hired staff members as well as scheduling annual advanced directives in service .

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 15 of 93 555339 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555339 B. Wing 01/10/2025

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 0584 Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 50204

Residents Affected - Some Based on observation, interview, and record review, the facility failed to provide a comfortable homelike environment, for five of 165 resdients (Residents 63, 265, 28, 73, and 27), when peeled and damaged wall paper were observed inside the resident rooms 808, 212, 213, 113, and 609.

These failures had the potential to affect the comfort and psychosocial well being of the residents.

Findings:

1. On January 6, 2025, at 3:02 p.m., during a concurrent observation and interview with Resident 63 in room [ROOM NUMBER]. Resident 63 was observed looking at peeled and damaged wallpaper above her head board. Resident 63 stated she was not comfortable seeing the peeled wall paper. Resident 63 further stated I did not peel the wall paper.

On January 7, 2024, at 3:11 p.m., during an interview with the Maintenance Supervisor (MS), the MS stated when the bed was pulled up, Resident 63's head board scraped against the wall and caused it to rip off. The MS further stated, It should have been fixed and repaired.

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2. On January 7, 2025, at 3:09 p.m., peeling wall paper was observed on the wall behind Resident 265's head board in room [ROOM NUMBER]. In a concurrent interview, Resident 265 stated it may have been that way since she was admitted to the facility.

On January 7, 2025, at 4 p.m., a concurrent observation and interview was conducted with Licensed Vocational Nurse (LVN) 3 inside Resident 265's room. LVN 3 confirmed the wall paper behind Resident 265's head board was peeling. LVN 3 stated if she noticed any issues with building equipment or damage to

the room, she would notify maintenance right away or log it in the maintenance log if maintenance staff were already out of the building. The following day, maintenance would check their log and address any issues that were written down. LVN 3 stated maintenance should have been made aware of the peeling wall paper.

On January 7, 2025, at 4:19p.m., a concurrent observation and interview was conducted with the Maintenance Supervisor (MS) and Maintenance Assistant (MA) 1 inside room [ROOM NUMBER]. The MS stated the peeling of the wallpaper was due to the bed being moved up and down while the bed was pushed against the wall. The MS stated with the prior management, there was no system to check and make sure equipment and rooms in the building were regularly checked to make sure everything was in proper working order and in good condition. The MS further stated the wallpaper should have been replaced to ensure the facility had a clean, safe and homelike environment.

3. On January 7, 2025, at 4:37 p.m., peeling wall paper was observed on the wall behind Resident 27's head board in room [ROOM NUMBER]. In a concurrent interview, Resident 27 stated it had been that way since

she was transferred to the room several months before.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 16 of 93 555339 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555339 B. Wing 01/10/2025

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 0584 4. On January 8, 2025, at 8:56 a.m., peeling wall paper was observed on the wall behind Resident 73's head board in room [ROOM NUMBER]. Level of Harm - Minimal harm or potential for actual harm 49113

Residents Affected - Some 5. On January 7, 2025, at 3:05 p.m., peeling wall paper was observed on the wall behind the headboard of Resident 28's bed in Room .

On January 10, 2025, at 11:11 a.m., during an interview with the Administrator (ADM), the ADM stated he expected the maintenance staff to address any damaged materials that needed to be replaced or repaired.

The ADM further stated the peeled wall paper for resident rooms 808, 212, 213, 113, and 609, should had been repaired to provide a comfortable and homelike environment for the residents.

A review of the facility's policy and procedure titled, Homelike Environment, dated February 2021, indicated, . Residents are provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent as possible .The facility staff and management maximizes, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include .orderly environment .comfortable .

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 17 of 93 555339 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555339 B. Wing 01/10/2025

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 0640 Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.

Level of Harm - Minimal harm or 41459 potential for actual harm Based on interview and record review, the facility failed to ensure the Quarterly Minimum Data Set (MDS - a Residents Affected - Some resident assessment tool) assessments were submitted to the Centers for Medicare and Medicaid Services (CMS - provides health coverage) in a timely manner, for five of 10 residents reviewed fro Resident Assessment (Residents 20, 31, 33, 72, and 81),:

These failures resulted in the facility being out of compliance with federal regulations.

Findings:

A review of the Resident Assessment Instrument Manual (RAI guidelines for resident assessment), dated October 2024, indicated, .Transmission Date No Later Than .Quarterly Assessments .MDS completion date (14 days from ARD (Assessment Reference Date - the final day of the observation period for the MDS assessment) + (plus) 14 calendar days (total of 28 days from ARD) .

On January 9, 2025, the following MDS assessments were reviewed:

a. Resident 20's Quarterly MDS indicated the ARD was dated November 29, 2024, and was transmitted to CMS on January 9, 2025 (41 days after ARD);

b. Resident 31's Quarterly MDS indicated the ARD was dated November 27, 2024, and was transmitted to CMS on January 9, 2025, (43 days from ARD);

c. Resident 33's Quartely MDS indicated the ARD was dated November 28, 2024, and was transmitted to CMS on January 9, 2025 (41 days after the ARD);

d. Resident 72's Quartely MDS indicated the ARD was dated November 29, 2024, and was transmitted to CMS on January 9, 2025 (40 days after the ARD) and;

e. Resident 81's Quartely MDS indicated the ARD was dated November 28, 2024, and was transmitted to CMS on January 9, 2025 (41 days after the ARD).

On January 10, 2025, at 10:50 a.m., a concurrent interview and record review was conducted with MDS 1. MDS 1 was shown a printout from January 9, 2025, showing a batch of assessments that were sent to CMS with five (5) residents names. MDS 1 stated each resident assessment date was from the end of November and was sent/transmitted to CMS on January 9, 2025. MDS 1 stated The assessments were transmitted late,

we continue to work on the backlog. MDS 1 further stated we have a large backlog so two of us are trying to do the backlog and input current assessments.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 18 of 93 555339 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555339 B. Wing 01/10/2025

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 0640 On January 10, 2025, at 11:06 a.m., the Director of Nursing (DON) was interviewed. The DON stated she signed off on the completed MDS assessments before they were transmitted to CMS. The DON stated she Level of Harm - Minimal harm or was aware of the MDS assessemnts that have been transmitted late, acknowledged that they have been potential for actual harm running late in tehir submission since October 2024, and had sought assistance from corporate office to catch up on their backlog. The DON stated she expected the MDS assessments to be submitted on time, Residents Affected - Some and the MDS assessments should have been submittted timely.

A review of the policy and procedure titled, MDS Completion and Submission Timeframes, dated July 2017, indicated .the assessment coordinator or designee is responsible for ensuring that resident assessments are submitted to CMS, assessment submission and processing system in accordance with current federal and state guidelines .

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 19 of 93 555339 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555339 B. Wing 01/10/2025

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 0679 Provide activities to meet all resident's needs.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 50204 potential for actual harm Based on observation, interview, and record review, the facility failed to ensure the resident's preferred Residents Affected - Some activity was consistently provided, for three of three residents for activities (Resident 10, 48, and 128).

This failure had the potential to result in residents to have an inactive life while in the facility.

Findings:

1. On January 6, 2025, at 2:31 p.m., during concurrent observation and interview with Resident 10 in her room, Resident 10 was observed sitting at the edge of the bed and was combing her hair while watching TV. Resident 10 stated there was nothing to do but to watch TV and she would just sleep and take naps in the afternoon. Resident 10 further stated she wanted to do hair services and hair styling, I was a beautician before.

A review of Resident 10's Admission Record, indicated Resident 10 was admitted to the facility on [DATE REDACTED], with diagnoses which included dementia (memory loss).

A review of Resident 10's Minimum Data Set (MDS - a resident assessment tool), dated December 17, 2024, indicated Resident 10 had a BIMS (Brief Interview of Mental Status) score of 11 (moderate cognitive impairment).

A review of Resident 10's Care Plan for Activity, date-initiated June 24, 2019, indicated, .Goal .Will participate independent leisure activities of choice daily .Provide supplies/materials for leisure activities .

A review of Resident 10's Social History Assessment, dated June 19, 2024, indicated, .Occupation .Went to cosmetology school. I cut hair, curled hair, washed hair. Did everything .

A review of Resident 10's Social History Assessment, dated September 10, 2024, indicated Resident 10 was

a beautician and she had claimed to work in a Caucasian salon and growing up doing Caucasian hair.

On January 7, 2025, at 3:10 p.m., Resident 10 was observed sleeping on the bed.

On January 8, 2025, at 3 p.m., Resident 10 was observed sleeping on the bed.

On January 9, 2025, at 8:41 a.m., an interview was conducted with Licensed Vocational Nurse (LVN) 6. LVN 6 stated Resident 10's activity should have been provided an individualized and should have been reflected from their past interest of activities. LVN 6 stated if she was a nurse like her, she expected that her activity should have been related to her past. LVN 6 further stated she would not be happy if she would receive coloring book.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 20 of 93 555339 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555339 B. Wing 01/10/2025

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 0679 2. On January 6, 2025, at 10:31 a.m., during concurrent observation and interview with Resident 48 in his room, Resident 48 was observed sitting on his bed staring at his cabinet. Resident 48 stated there was Level of Harm - Minimal harm or nothing for him to do in the facility, so he just stayed in his room. Resident 48 stated he was a former potential for actual harm bartender and he liked mixing liquors and made client happy. Resident 48 further stated, I can serve drinks if

they want. Residents Affected - Some

On January 7, 2025, at 10:20 a.m., a follow up interview was conducted with Resident 48. Resident 48 stated no one came to his room for visit and just handed him an article to read.

On January 8, 2025, at 3:21 p.m., a follow up interview was conducted with Resident 48. Resident 48 stated

he was bored and he would just walk outside and see what was going on. Resident 48 stated his room was too far from the center of the building.

On January 9, 2025, a review of Resident 48's Admission Record, indicated Resident 48 was admitted to the facility on [DATE REDACTED], with diagnoses which included major depressive disorder (low mood and feeling sad).

A review of Resident 48's History and Physical, dated June 17, 2024, indicated Resident 48 was mentally capable of understanding and make decisions.

A review of Resident 48's Social History Assessment, dated June 19, 2024, indicated, he was a former bartender and location of activity preferences in facility anywhere.

A review of Resident 48's Activities Note, dated June 19, 2024, indicated, .Activities: resident has a need for activities that are consistent with abilities and interests. Enjoyable, meaningful activities to the resident include .socializing with staff .

A review of Resident 48's Minimum Data Set (MDS - a resident assessment tool), dated December 13, 2024, indicated Resident 48 had a BIMS (Brief Interview of Mental Status) score of 12 (moderate cognitive impairment).

On January 9, 2025, at 3:35 p.m., an interview was conducted with the Activity Assistant (AA). The AA stated

she was the only activity person providing activity in Dunes Hall and she followed on what was listed in the activity schedule. The AA stated she was not aware that Resident 48 was a bartender. The AA further stated Resident 48 should have been provided activity of interest such as serving food and juice drinks to residents

during activities. The AA stated if the residents would not participate in activity because it did not fit them,

they would be sad and lonely. The AA stated residents activity preference should be honored so they would be engaged to everybody.

3. On January 6, 2025, at 10:31 a.m., during concurrent observation and interview with Resident 128 in her room, Resident 128 was observed laying on her bed looking at the TV that was turned off. There was a paper titled, Chronicles at the overbed table. Resident 128 stated she was a teacher and provide teaching to sign language class. Resident 128 stated there's nothing for her to read, they don't provide books or music in her room. Resident 128 further stated the chronicles were delivered every day, but she did not read it much,

she said, You can have it.

Resident 128 was observed in bed sleeping on multiple occasions:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 21 of 93 555339 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555339 B. Wing 01/10/2025

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 0679 - January 6, 2025, at 3:20 p.m.;

Level of Harm - Minimal harm or - January 8, 2025, at 3:50 p.m.; potential for actual harm - January 9, 2025, at 10:22 a.m.; and Residents Affected - Some - January 10, 2025, at 11:01 a.m.

A review of Resident 128's Admission Record, was reviewed. Resident 128 was admitted to the facility on [DATE REDACTED], with diagnoses which included Hypertensive heart disease (elevated blood pressure).

A review of Resident 128's Care Plan for Activity, date-initiated April 22, 2024, indicated, .Goal .Will participate in activities of choice .Provide activity materials like books, magazines .in accordance with interests .support choice of activities, both facility-sponsored group, individual activities, and independent activities designed to meet the interest of .physical, mental, and psychosocial well-being .interaction in the community .

A review of Resident 128's Activity Participation Review, dated January 3, 2025, indicated, .Will participate in activities of choice .provide activity materials like books, magazines .

On January 9, 2025, at 4:23 p.m., an interview was conducted with the Director of Nursing (DON). The DON stated she expected to all activity staff to provide activity appropriate to residents. The DON stated personalized activities would prevent inactive life and they would engage more to other people. The DON stated the AD should have been more creative and should have been reviewed social service record to determine the interest of the residents.

On January 10, 2025, at 10:21 a.m., an interview was conducted with the Activity Director (AD). The AD stated she did not review the social history of Resident 10, 48, and 128. The AD stated she should have been considered previous history of occupation and should have been provided activities that were related to their interest and preference. The AD further stated, It should have been individualized and person-centered activities.

A review of the facility's policy and procedure titled, Activity Programs, dated June 2018, indicated, .Activity programs are designed to meet the interest of and support the physical, mental and psychosocial well-being of each resident .The activities program is provided to support the well-being of residents and to encourage both independence and community interaction .Activities offered are based on the comprehensive resident-centered assessment and the preferences of each resident .Activities are considered any endeavor . that is intended to enhance his or her sense of well-being and to promote or enhance physical, cognitive or emotional health .Our activity programs consist of individual .that are designed to meet the needs and interests of each resident .that promote .Self-esteem .creativity .Independence .activities are provided that reflect the cultural .interests, hobbies, life experiences and personal preferences .

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 22 of 93 555339 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555339 B. Wing 01/10/2025

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 0679 A review of the facility's policy and procedure titled, Resident Self Determination and Participation, dated August 2022, indicated, .Our facility respects and promotes the right of each resident his or her autonomy Level of Harm - Minimal harm or regarding what the resident considers to be important of his or her life .Each resident is allowed to choose potential for actual harm activities .that are consistent with his or her interest, values, assessments and plans of care, including . activities, hobbies and interests .Residents are provided assistance as needed to engage in their preferred Residents Affected - Some activities on a routine basis. For example .if resident enjoys reading, the facility will provide access to books .

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 23 of 93 555339 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555339 B. Wing 01/10/2025

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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 50204 potential for actual harm Based on observation, interview, and record review, the facility failed to ensure necessary care and services Residents Affected - Few to achieve and maintain the highest practicable physical, mental, and psychosocial well-being were provided, for two of two residents reviewed (Residents 515 and 414), when:

1. For Resident 515, treatment orders were not initiated upon identification of a blister on the right heel. This failure had the potential to result in worsening of the wound, which could negatively affect the health status of Resident 515; and

2. For Resident 414, the following medications were not administered as ordered by the physician:

- Eliquis (medication to reduce formation of blood clots) 5 (five) mg (milligram- a unit of measuerement);

- Atorvastatin (medication used to lower cholesterol) 40 mg ; and

- Gabapentin (medication to reduce nerve pain) oral solution 250mg/5ml (milliliter- a unit of measurement).

This failure had the potential for Resident 414 to experience pain, discomfort and increased possibility of blood clots, leading to injury or death.

Findings:

1. On January 6, 2025, at 11:20 a.m., a concurrent observation and interview was conducted with Resident 515 in her room, Resident 515 was observed on the bed wearing pressure relieving boots (foam that prevent skin breakdown) on both heels. Resident 515 stated she was not sure if she received treatment for her wounds.

On January 9, 2025, Resident 515's record was reviewed. Resident 515 was admitted to the facility on [DATE REDACTED], with diagnoses which included orthopedic aftercare (care received after surgery).

A review of Resident 515's Minimum Data Set (MDS - a resident assessment tool), dated January 1, 2025, indicated Resident 515 had a BIMS (Brief Interview of Mental Status) score of 00 (severe cognitive impairment).

A review of Resident 515's Change In Condition, dated January 4, 2025, indicated, .Blister on right heel, intact with fluid build up .

A review of Resident 515's Order Summary, dated January 4, 2025, indicated, .Wound blister to right heel: clean with NS (normal saline-wound cleanser) pat dry apply honey based gel with Ca (calcium alginate-use for wound healing) cover with foam bandage every day shift .

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 24 of 93 555339 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555339 B. Wing 01/10/2025

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 0684 A review of Resident 515's Care Plan, revised January 7, 2025, indicated Resident 385 had a right heel blister, goal was to be compliant with treatments, and interventions included apply barrier cream as indicated Level of Harm - Minimal harm or and keep skin clean and dry. potential for actual harm

A review of Resident 515's Treatment Administration Record, for January 2025, indicated the treatment for Residents Affected - Few the right heel blister was initiated on January 7, 2024, three days after identification of the blister on the right heel.

There was no documented evidence the treatment ordered on January 4, 2025, for the right heel blister was implemented on January 4 to 6, 2025.

On January 9, 2025, at 2:49 p.m., a concurrent interview and record review was conducted with the Treatment Nurse (TN [NAME] Pecks). The TN stated the right heel blister was identified on January 4, 2025, and was communicated with the physician with a treatment order on the date it was identified. The TN stated

the treatment was signed in electronic treatment administration record on January 7, 2025, three days after

the right heel blister was identified. The TN stated there was no documentation that the right heel blister was treated on January 4, 5 and 6, 2025. The TN stated the right blister should been treated as soon as the wound was identified. The TN further stated if there was no documentation, or was not signed in treatment record, It never happened.

On January 9, 2025, at 4:14 p.m., an interview was conducted with the Director of Nursing (DON). The DON stated she expected all nurses to follow the standard nursing of care for wound treatment. The DON stated

the licensed nurse should have initiated the treatment of any skin issues right away, upon receiving an order from the physician. The DON further stated if there was a delay of treatment, the skin condition would worsen.

A review of the facility's policy and procedure titled, Wound Care, dated October 2010, indicated, .The purpose of this procedure is to provide guidelines for the care of wounds to promote healing .The following information should be recorded in the resident's medical record .The name and title of the individual performing the wound care .The signature and title of the person recording the data .

A review of the facility's policy and procedure titled, Administering Medications, dated April 2019, indicated, Medications are administered in a safe and timely manner, and as prescribed .Medications are administered

in accordance with prescriber orders, including any required time frame .

47374

2. On January 10, 2025, at 2:21 p.m., an interview with Resident 414's family member (FM) was conducted. Residents 414's FM stated she had concerns about the lack of medication given to the Resident 414 during

the night shift on January 9, 2025. Resident 414's FM stated there was a power failure which occurred the night of January 9, 2025 from 7:00 p.m. until approximately 05:00 a.m. and, Resident 414 did not receive any of the 9 p.m. medications including Eliquis 5 mgs. Resident 414's FM stated she had spoken to Licensed Vocational Nurse (LVN) 7 who was on duty on January 9, 2025, who explained he was unable to give any medication to residents until the computers were back active again and later on informed by LVN the medication was given late, at approximately 4 a.m. Resident 414's FM stated she had spoken to the DON to make her aware of the possible omitted medication for Resident 414 and understood outage and delay but was concerned the LVN did not know another way to verify resident's medication while the computers were down.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 25 of 93 555339 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555339 B. Wing 01/10/2025

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 0684 On January 10, 2025, at 3:15 p.m., an observation and interview and Resident 414 was conducted. Resident 414's speech was slow and slurred, stated she did not remember when she received her medication. Level of Harm - Minimal harm or potential for actual harm On January 10, 2025, at 3:20 p.m., a concurrent observation and interview was conducted with Resident 415 (Resident 414's roommate). Resident 415 stated she did not receive any medication during the night not until Residents Affected - Few 4:00 a.m., when the computers came back. Resident 415 stated LVN 7 explained he was unable to give any meds as they could not be signed out until he could verify medication with the electronic medication profile. Resident 415 stated she had not needed any medication through out that shift. However, Resident 415 stated Resident 414 did not have medications that should have been given at 9 p.m.

On January 10, 2025, at 3:45 p.m., an interview with LVN 9 was conducted. LVN 9 stated the Medication Administration Record (MAR) was printed out as soon as any computer issue becomes known. LVN 9 stated

she was on duty on the evening shift of January 9, 2025, when the EMR went down, they printed out paper MARs for all facility residents and, these were delivered to each nurses' station. LVN 9 stated this process allows medications to be given and signed on the paper MAR. LVN 9 stated once the computer becomes active the medication nurses input all medications given with the time given in the electronic MAR. LVN 9 explained and demonstrated the use of medication blister packs and reviewed each of the resident's medications that may have been given during the night shift. LVN 9 further stated it can be difficult to assess if medication was given, as some LVNs do not remove medication from blister pack using the procedure expected, which is to get it from the bubble pack on the date it was supposed to be given. LVN 9 stated after reviewing blister packs for Eliquis that medication did not appear to have been given as the amount in the pack does not match expected doses.

On January 10, 2025, at 4:15 p.m., a concurrent interview and record review with the Director of Nursing (DON) was conducted. The DON stated there had been computer failure that began during the evening shift and was resolved around 4 a.m. The DON stated all residents' MARs were printed and delivered to each nurse station, clarified the medication administration was initially signed on the paper MAR and then transferred to computer's medication administration record by licensed nurse when system is back functioning again.

A concurrent review of Resident 414's paper MAR was conducted with the DON. Resident 414's paper MAR indicated no sign off of resident's medications due at 9:00 p.m. and, signed on EMR at approximately 4:23 a. m. The DON stated medication should be signed and timed on paper MAR at the time of administration.

A review of Resident 414's blister packs for Eliqius, Gabapentin, and atorvastatin, was conducted with the DON. The DON stated Eliquis, gabapentin, and atorvastaatin medications were not taken out of the bubble pack on the date it was supposed to be given (January 9, 2025). The three medications were still observed inside the bubble pack for January 9, 2025. The DON stated the three medications were not administered to Resident 414 on January 9, 2025, at 9 p.m., as ordered by the physician.

A review of the facility's policy and procedures titled, Administering Medication, dated 2001, indicated, . medications are administered in a safe and timely manner as prescribed .administered .in the required time frame .medications are administered within (1) one hour of their prescribed time .

40988

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 26 of 93 555339 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555339 B. Wing 01/10/2025

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 0685 Assist a resident in gaining access to vision and hearing services.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 50204 potential for actual harm Based on observation, interview, and record review, the facility failed to ensure a scheduled eye appointment Residents Affected - Few was followed up, for one of one resident (Resident 50) reviewed for vision. This failure had the potential for Resident 50 to not receive the necessary treatment timely to maintain effective vision.

Findings:

On January 6, 2025, at 10 a.m., during a concurrent observation and interview with Resident 50 in her room, Resident 50 was observed laying on bed wearing a pair of eyeglasses with three clear adhesive tapes attached to the frame of the left lens. Resident 50 stated she needed eyeglasses to be able to read and see clearly. Resident 50 stated she requested to have an eye checkup to replace the glasses that she was using but the facility did not provide a schedule for eye appointment. Resident 50 further stated, It's a serious issue, I can't see without glasses.

On January 10, 2025, Resident 50's record was reviewed. Resident 50 was readmitted to the facility on [DATE REDACTED], with diagnoses which included age related cataract (clouding of the lens of the eye).

A review of Resident 50's Care Plan, dated August 4, 2024, indicated, .Vision/Eyes: Resident has impaired . visual acuity which may impact ADL self-performance secondary to Cataracts .Keep eyeglasses clean and assist as needed for placement .

A review of Resident 50's Order Summary, dated September 9, 2024, indicated, .Eye-health and vision consult exam with follow up treatment as indicated .

A review of Resident 50's History and Physical, dated September 11, 2024, indicated Resident 50 had the capacity to make decisions.

A review of Resident 50's Minimum Data Set (MDS - an assessment tool), dated December 12, 2024, indicated the following:

-Brief Interview for Mental Status (BIMS) score of 15 (cognitively intact);

- Impaired vision (sees large print, but not regular print in newspaper/books) and used corrective lenses (contacts, glasses, or magnifying glass).

On January 9, 2025, at 8:58 a.m., an interview was conducted with Licensed Vocational Nurse (LVN) 6. LVN 6 stated Resident 50 had an urgent need for eye appointment and should have been addressed right away because resident could put into danger such as fall. LVN 6 further stated she also used eyeglasses and if the lens fall off, she could not, The eye glasses should have been fixed as soon as possible.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 27 of 93 555339 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555339 B. Wing 01/10/2025

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 0685 On January 9, 2025, at 8:45 a.m., during concurrent interview and record review with Social Service Assistant (SSA) 2. SSA 2 stated Resident 50 went on eyes, nose, throat (ENT) appointment on December Level of Harm - Minimal harm or 19, 2024, for diminished hearing, nasal congestion and stuffy ears but did not provide eye consultation. SSA potential for actual harm 2 stated the eye doctor visited the facility on January 8, 2025, to review all residents that needs eye checkup but Resident 50 was not listed. SSA 2 further stated Resident 50 should have been referred to optometrist Residents Affected - Few (eye doctor).

A review of the facility's policy and procedure titled, Visually Impaired Resident, Care of, dated March 2021, indicated, .Residents with visual impairment will be assisted with activities of daily living as appropriate . Assistive devices to maintain vision include glasses, contact lenses, magnifying lens, and any other device used by the resident to assist with visual impairment .It is our responsibility to assist the resident and representatives in locating available resources .scheduling appointments and arranging transportation to obtain needed services .Residents who have lost or damaged their devices will be assisted in obtaining services to replace the devices .

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 28 of 93 555339 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555339 B. Wing 01/10/2025

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 0692 Provide enough food/fluids to maintain a resident's health.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 44504 potential for actual harm Based on observation, interview, and record review, the facility failed to provide sufficient nutrition, monitor Residents Affected - Few the effectiveness of nutritional intervention, and recommend interventions to maintain an acceptable parameters of nutritional status, for one of five sampled residents (Resident 116, when:

1. Resident 116 did not receive the requested juices on his meal tray according to the diet order and resident's food preferences;

2. Resident 116 did not receive a protein substitute in the meal tray to honor the resident's preference for a vegetarian diet. In addition, the facility did not have a menu spreadsheet for a vegetarian diet;

3. There was no alternative measures implemented for resident's refusal to be weighed;

4. There was no monitoring of Resident 116's consumption of the protein shake ordered;

5. The Registered Dietitian (RD)'s recommendation to give Resident 116 protein shake supplement five times a day was not implemented or offered to the resident since July 15, 2024; and

6. There was no additional interventions initiated to address Resident 116's poor food intake.

Thes failures resulted in Resident 116 experiencing an unhealthy, unplanned, and undesired severe weight loss of 30 pounds (lb) or 25% (percent) in 11 months, which placed Resident 116 at risk for further health status decline.

Findings: (Cross reference 806)

On January 6, 2025, at 12:12 p.m., a concurrent observation, interview, and meal ticket review was conducted with Resident 116 at the bedside. Resident 116 was lying in bed with the noon meal tray in front of him. Resident 116's meal ticket indicated a, Regular diet, yogurt, extra Veg [vegetables], 4 fluid ounce (oz) apple juice, 4 fluid oz cranberry juice, Dislikes: Meat, Fish, eggs. Resident 116 was served mashed potatoes, peas and tofu as the entree, yogurt, pudding, and water. In a concurrent interview, Resident 116 stated there was no cranberry juice and apple juice on his meal tray. Resident 116 stated, I should have apple juice and cranberry juice so I will eat more and gives me more appetite. Resident 116 finished his entree mashed potatoes, peas and tofu, and yogurt.

On January 6, 2025, at 12:35 p.m., an interview was conducted with Licensed Vocational Nurse (LVN) 17. LVN 17 stated Resident 116 did not have cranberry and apple juice on the resident's meal tray. LVN 17 stated Resident 117 should have cranberyy and apple juice. LVN 17 stated the diet order for Resident 116 should be followed so the resident would receive completed nourishment according to the dietitian's recommendations.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 29 of 93 555339 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555339 B. Wing 01/10/2025

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 0692 On January 8, 2025, at 12:10 p.m., an interview was conducted with Resident 116 at the bedside. Resident 116 stated, he is a vegetarian and had told staff he did not want meat, fish and eggs, and the staff were not Level of Harm - Minimal harm or accommodating his request to be served vegetarian food. potential for actual harm

On January 9, 2025, at 8:34 a.m., a breakfast meal observation was conducted with Resident 116 at the Residents Affected - Few bedside. Resident 116 was served one piece of waffle and one piece of hash brown as entree, 4 fluid oz apple juice, 4 fluid oz cranberry juice, one serving of oatmeal and eight (8) oz of whole milk. Observed the served meal tray, protein food item served as part of entree was missing. Resident 116 finished all served food items except waffle. The menu for breakfast included a bacon egg scramble, however Resident 116 was not offered a protein based substitution.

On January 9, 2025, at 8:52 a.m., an interview was conducted with Certified Nurse Aide (CNA) 1. CNA 1 stated Resident 116 like apple juice and orange juice and always asked for apple juice and orange juice. Resident 116 usually eat 65 % or more for his breakfast and lunch.

On January 9, 2025, at 9:02 a.m., an interview was conducted with Licensed Vocational Nurse (LVN) 10. LVN 10 stated Resident 116 liked his oral supplement and sometimes he would walk to the nurse station and asked for oral supplement, and he would not leave the nurse station unless he gets his oral supplement. LVN 10 stated it was up to the CNA to monitor how much oral supplement Resident 116 consumed, there was no monitoring of Resident 116 oral supplement intake.

On January 9, 2025, at 9:19 a.m. an interview was conducted with [NAME] (CK) 2. CK 2 stated egg was served as the protein item for breakfast, however since Resident 116 disliked eggs, she only served the waffle and harsh browns. CK 2 was unable to locate a vegetarian menu, recipes, or a Cooks Spreadsheet (the document used to guide dietary staff on food items, portions, and therapeutic diet). CK 2 stated for vegetarian diets she usually substituted tofu or cheese for the meat. CK 2 admitted she did not consult Food service director (FSD) or Registered Dietitian (RD) for meal substitution.

On January 9, 2025, at 9:23 a.m., an interview was conducted with the Restorative Nursing Assistant (RNA).

The RNA stated resident's weight were being obtained on admission, weekly for 4 weeks, then monthly thereafter. The RNA stated they would input the weights in the resident's electronic health record, including refusal to be weighed. The RNA stated Resident 116 refused to be weighed at times.

On January 10, 2025, at 8:40 a.m., a concurrent observation and interview was conducted with Resident 116. Resident 116 was served apple juice and cranberry juice. Resident 116 stated, Finally they served the apple juice and cranberry juice.

A review of Resident 116's Admission Face Sheet (a summary of important information regarding a patient which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), indicated Resident 116 was admitted to the facility on [DATE REDACTED], with diagnoses which included protein calorie malnutrition (occurs when the body doesn't have enough nutrients and energy to meet its needs leading to weight loss, muscle loss and body fat loss), anemia (a decrease in healthy red blood cells), basal cell carcinoma of skin (skin cancer), adult failure to thrive (FTT - happens when an older adult has loss of appetite which causes insufficient food intake), and fracture (broken bone) of the right femur (leg), and subsequent encounter for closed fracture with routine healing.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 30 of 93 555339 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555339 B. Wing 01/10/2025

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 0692 A review of Resident 116's Minimum Data Set (MDS- a standardized assessment and care-planning tool), dated July 22, 2024, and October 22, 2024, indicated Resident 116 had a weight loss of 5 % or more in the Level of Harm - Minimal harm or last month or loss of 10% or more in the last 6 months, and was not on physician-prescribed weight-loss potential for actual harm regimen [a program that is supervised by a medical professional that specializes primarily in weight loss for individuals that have a hard time losing weight despite their efforts]. Residents Affected - Few

A review of Resident 116's Weights and Vitals Summary, indicated the following weights:

- January 15, 2024; 120 lbs (admission weight);

- February 1, 2024; 119.4 lbs;

- No weights taken for March 2024 and April 2024;

- May 2, 2024; 90 lbs (weight loss of 29.4 lbs in three months; 24.5%);

- July 4, 2024; 89.6 lbs;

- No weights for August, September, October, and November 2024;

- December 5, 2024; 89.6 lbs (weight loss of 29.4 lbs in 11 months; 24.5%).

A review of Resident 116's Order Summary Report, included the following physician's orders for nutrition:

- Diet order: Regular diet .PATIENT IS VEGETARIAN, bite size .NO MEAT, NO FISH, NO EGGS ., dated December 2, 2024; and

- [brand name] oral supplement twice a day, per patient request ., order date May 7, 2024.

A review of Resident 116's Nutritional Assessment, dated January 17, 2024, completed by the Registered Dietitian (RD) 2, indicated, .Height: 1/15/24 (January 15, 2024): 65 inch, Weight .120 lbs .BMI (body mass index is a screening tool used to assess whether an individual's weight is within a healthy range based on their height] 20 ( BMI between 18.5 and 24.9 categories as healthy weight) .Diet: regular texture .Chewing problem, dental problems .Estimated Nutritional Needs: Calories needs 1364 -1636 calories (kcal) .Protein needs 65- 81 grams .Fluid needs 1364 -1636 cc's (a metric unit of measure) .Pt (patient) follows a lacto vegetarian diet (diet without meat, fish and egg) - dietary aware. Pt with increased nutrient needs r/t (related to) altered skin, however pt uninterested in supplements/vitamins at this time stating, no, no I don't need all that.Recent labs reviewed albumin low at 2.1 .RD attempted to provide nutrition education, Resident continues to decline. Additional food preferences obtained and reported to dietary. Will monitor and f/u (follow up) prn (as needed) .

A review of Resident 116's Nutrition Progress Note, indicated the following:

- February 29, 2024, at 12:57 p.m., .RD interviewed staff regarding Pt intakes, staff confirms pt has poor meal intakes, however requests for sandwiches at snack time .continues to decline supplements of any kind .;

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 31 of 93 555339 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555339 B. Wing 01/10/2025

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 0692 - March 4, 2024, at 3:24 p.m., .Per nursing pt continued to decline meals today. Resident consumed juice and water .Offer Protein shakes between meals .Will monitor and f/u (follow up) prn (as needed) .; Level of Harm - Minimal harm or potential for actual harm - March 6, 2024, at 4:28 p.m., .Resident continues to decline meals, snacks, supplement, weight monitoring. Supplements implemented however resident declining at this time .; Residents Affected - Few - March 13, 2024, at 11:47 a.m., .Resident continues to decline meals and supplements at this time . Resident continues to drink juice, additional juice provided with trays and between meals .;

- April 9, 2024, at 4:06 p.m., .Resident continues on Regular diet consuming 50-100% of meals meeting estimated nutritional needs. Resident continues to decline to be weighed, nursing aware .RD recommends . D/C (discontinue)supplemental shakes r/t (related to) poor acceptance/consumption .;

A review of Resident 116's Interdisciplinary team (IDT-a group of health care professionals all working toward a common goal) Weight Variance Assessment (WWA), edited by RD 1, dated May 6, 2024, indicated, .Weight 90 #, loss 24.9 # in 3 months .Diet: Regular Vegetarian (no meat, fish or egg) bite sized, Average meal intake: 25 -50 % intake, Nourishment: None, Appetite Stimulant: None, Previous wt. 119.4#, current wts. 90# .Meal Observation (Nursing/Dietary): Complaint of taste/dislikes/diet/picky eater .Summary: Pt remains on the above diet with a poor intake to refusing meals. Pt had a 29.4# wt loss in 3 months (24.6%). Pt had refused to be weighed the past few months. Pt is also refusing wound tx (treatment), vitals, meds and meals at times, despite discussing the risks and benefits. Pt is at risk for further wt loss .Spoke to pt . regarding his diet. Pt said he tries to eat what he can. He said he is a vegetarian but will eat cheese and dairy products. Pt requested some [brand name] oral supplement to drink with his breakfast and lunch. Will also do a BMP (Basic Metabolic Panel is a blood test) to access hydration status. Suggest the following: 1) BMP to access hydration status; 2) [oral supplement] BID (twice per day); 3) weekly wts and wt variance .

A review of Resident 116's IDT Weekly Weight Nutrition (WWN), edited by RD 1, dated May 12, 2024, indicated, .Current Weight: 90#; Weight Change in a week: stable; Risk Factors (diagnosis, medication, level of assist with meals, meal intake, etc.): Adult failure to thrive; refuses meals, wts, vitals and meds often poor appetite .Prior Interventions: BMP-refused; [brand name] oral supplement BID refuses; weekly wts and wt variance; Recommendations: Suggest psych eval; Continue with weekly wts and wt variance .

A review of Resident 116's IDT WWN, edited by RD 1, dated May 19, 2024, indicated, .Current Weight: Wt Refused; Weight Change in a week: Refused wt; Risk Factors (diagnosis, medication, level of assist with meals, meal intake, etc.): Pt is refusing to eat. MD is aware; MD/RESP Party Notified: previously yes; Prior Interventions: [brand name] oral supplement TID (three times per day); Recommendations: IDT to discuss goal for pt. Possible hospice eval .

A review of Resident 116's IDT WWN, edited by RD 1, dated May 26, 2024, indicated, .Date of Current Weight and Weight Change: Wt refused; New Risk Factors: Pt refuses to be weighed or measured. Updated/Changed Interventions: Will obtain updated food preferences. Continue with weekly wts (if possible) .

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 32 of 93 555339 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555339 B. Wing 01/10/2025

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 0692 A review of Resident 116's IDT WWN, edited by RD 1, dated June 4, 2024, indicated, .Date of Current Weight and Weight Change: Pt refuses to have his wt taken. New Risk Factors: previously reviewed; Level of Harm - Minimal harm or Updated/Changed Interventions .Pt is refusing to eat most of the time average meal intake is <25%. Pt is potential for actual harm also refusing nursing care. Pt has orders for hospice eval on 5/21/24 (May 21, 2024) due to pt refuses to eat. Pt will drink his fluids off his trays and occasionally [brand name] oral supplement BID. Visited pt to review Residents Affected - Few pts food preferences. Pt was not interested in talking said he will drink some liquids at times but does not want to eat. Pt needs labs done but refuses. Will increase [brand name] oral supplement to TID and suggest to follow up on hospice eval. Will continue with wt variance .

A review of Resident 116's IDT WWN, edited by RD 1, dated June 16, 2024, indicated, .Date of Current Weight and Weight Change: Pt refused. New Risk Factors: Pt refuses to eat often. MD aware. Updated/Changed Interventions: Scheduled for hospice eval. Wt loss is unavoidable. Continue with supplements continue trying to obtain pts wt .

A review of Resident 116's IDT WWN, edited by RD 1, dated June 24, 2024, indicated, .Date of Current Weight and Weight Change: Wt Pt refuses; New Risk Factors: Pt refuses hospice. Updated/Changed Interventions: Pt is refusing his meds, meals. [brand name] oral supplement and vitals. Pt also refuses hospice. Spoke with pt about his refusal of meals. Pt states he is on a hunger strike and will not eat until he gets discharged . Pt has been on hunger strikes in the past. MD is aware. Will follow up with Social Services (SS) to see if pt will be discharged . Can expect further wt loss, dehydration and skin breakdown without adequate nutrition .

A review of Resident 116's IDT WWN, edited by RD 1, dated July 7 and 14, 2024, indicated Resident 116 had been refusing meals and oral supplements, refused hospice evaluation, and desire to be discharged .

The document indicated Resident 116 refused to fo to the hospital or have a psychiatric evaluation.

A review of Resident 116's Nutrition Risk Review Quarterly, edited by RD 3, dated July 15, 2024, indicated, . Physical and Mental Functioning: Alert, Feed Self, No chewing /Swallowing Problems, Skin intact .Height: 65 1/15/24 (January 15, 2024), Most recent Weight: 89.6# (7/4/24 [July 4, 2024]), BMI: 18.5 = underweight . Ideal body weight (IBW) 136 # .Goal weight: 136 #; Underweight/malnourished -25.3 % (30.4 #) weight loss within 6 months. Clinically significant. Nutritional intake: 51 % -75% and 76 -100 % of meals. Diet order: Regular diet .RD recommendations: Recommend Ensure Plus 5 (five) times per day with meals and in between meals to promote weight gain. Nutrition Goals/Monitoring and Evaluations: Goals: weight gain to reach IBW; No significant of dehydration; PO (meal) intake: more than 75 % for all meals; Labs within normal range (WNL) .

Further review of Resident 116's record indicated there was no documented evidence RD 3's recommendation to increase the frequency of the protein shake to five times a day (with meals and in between meals) was implemented.

A review of Resident 116's Nutrition Progress Note, edited by RD 1, dated August 3, 2024, indicated, .Pt refused to be weighed .

Further review of Resident 116's indicated there were no other nutrional progress notes indicating monitoring of Resident 116's nutritional status.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 33 of 93 555339 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555339 B. Wing 01/10/2025

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 0692 On January 9, 2025, at 11:51 a.m., a concurrent interview and record review was conducted with RD 1. RD 1 stated Resident 116 had BMI 14.9 which was considered underweight with malnutrition. RD stated she Level of Harm - Minimal harm or should have continued to monitor and reassess Resident 116 since August 2024 on weekly wt. variance due potential for actual harm to underweight with malnutrition. RD 1 stated Resident 116 liked juice. He would not eat foods but drinks juices. The RD stated the missing juice for the lunch meal tray on January 6, 2025 resulted in Resident 116 Residents Affected - Few being offered fewer calories than his plan of care. RD 1 stated it was very important to honor Resident 116's food/beverage preferences in an effort to encourage Resident 116 to eat. RD 1 confirmed Resident 116 did not receive a protein substitution during the January 9, 2025 breakfast meal. RD 1 stated the [NAME] should have substituted a protein like cheese, peanut butter or cottage cheese. RD 1 acknowledged the missing juices and protein food item could lead to calories and protein deficiency for the observed meal which could contribute to the weight loss for Resident 116. RD 1 stated the bottom line was food service staff needed to follow the vegetarian menu to provide sufficient calories and nutrition and to honor the resident's food/beverage preferences.

A review of Resident 116 physician's orders, [brand name] oral supplement twice a day, per patient request order dated May 7, 2024, was conducted with RD 1. RD 1 stated there was no monitoring of the oral supplement intake, as a result RD 1 did not know the volume or calories that were consumed by Resident 116. RD 1 also acknowledged since the oral supplement was a nutritional intervention there needed to be a system to monitor so can determine the effectiveness of the interventions.

Resident 116's IDT Weight Variance Assessment (WVA),dated on May 6, 2024 was reviewed with RD 1. The document indicated Resident 116's average meal intake of 25 -50 %. RD 1 stated she could not interpret Resident 116's nutrition intake by looking at the ranges of meal % intake. RD 1 stated she did not know how many calories Resident 116 consumed, rather estimated the percentage of intake and acknowledged there was no way for her to determine whether Resident 116 obtained sufficient nutrition.

Additional review with RD 1 of the Nutrition Risk Review Quarterly, dated July 15, 2024 was reviewed with RD 1 regarding RD 3's recommendation [brand name] oral supplement 5 times per day with meals and in between meals. RD 1 could not find the recommendation implemented afer July 15, 2024. RD 1 stated RD 3 usually would give her the recommendations and completes the follow up on the recommendation. RD 1 also acknowledged there were several interventions the IDT could have done to help Resident 116 improve weight, but the IDT did not intervene, such as recommending an appetite stimulant, providing snacks, completing an evaluation of resident's actual caloric intake, or discussing Resident 116's plan of care with

the ethics committee. RD 1 acknowledged despite Resident 116's behavior issues, refusal of care and medication, the IDT still needed to provide services/interventions and care to Resident 116 to monitor and intervene for Resident 116 undesirable weight loss and document the refusals.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 34 of 93 555339 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555339 B. Wing 01/10/2025

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 0692 On January 9, 2025, at 2:39 p.m., during a concurrent interview and record review with the Director of Nursing (DON), Resident 116's weight history dated January 9, 2025 was reviewed. The DON stated Level of Harm - Minimal harm or Resident 116 lost 30 # since January 2024. The DON stated she participated in the IDT weekly weight potential for actual harm variance. The DON acknowledged the weight loss for Resident 116 was unplanned and undesired with a BMI of 14.8, which was considered as underweight and was due to insufficient oral intake. The DON Residents Affected - Few acknowledged the missing apple juice and cranberry juice on Resident 116's meal tray could contribute to

the resident's weight loss. The DON stated Resident 116 did not receive sufficient calories with the lack of substitution for the protein food item at breakfast on January 9, 2025, which could also contribute to Resident 116's unplanned weight loss. The DON stated Food and Nutrition Service staff should consult the dietitian for appropriate protein substitution. The DON stated the Food and Nutrition Service staff should follow the vegetarian menu to ensure sufficient calories and nutrition for Resident 116 was being provided. The DON stated Resident 116 who was at high nutrition risk and unplanned weight loss needed continuing monitoring, weekly weight variance and follow up after August 2024.

Resident 116 physician's orders, dated January 8, 2025, was reviewed with the DON. The DON stated nursing did not monitor the oral supplement intake and acknowledged the oral supplement needed to be documented and monitored to ensure the nutrition intervention was effective. The DON acknowledged there were several interventions the IDT could have documented and monitored to help Resident 116 improve his weight, such as ensuring recommended intervention such as snacks, providing juices between meal, and oral supplements. Additionally, the DON acknowledged the IDT could have attempted additional interventions such as an appetite stimulant, a high concentration oral supplement, evaluated Resident 116 for artificial nutrition support (liquid supplementation through a tube entering the stomach), or perform alternative methods to assess nutritional status such as meal intake, measure mid arm circumference to obtain weight. The DON stated while Resident 116 may refuse those interventions, but the IDT still needed strive to monitor, and intervene for Resident 116 undesirable weight loss and document the refusals.

A review of the facility's policy and procedure titled Weight Assessment and Intervention, revised September 2008, indicated, .The multidisciplinary team will strive to prevent, monitor, and intervene for undesirable weight loss for our residents .Negative trends will be evaluated by the treatment team . Analysis . Assessment information shall be analyzed by the multidisciplinary team and conclusions shall be made regarding .Approximate calories, protein, and other nutrient needs compared with the resident's current intake .Inadequate availability of food or fluids .Interventions for undesirable weight loss shall be based on careful consideration of the following .Resident choice and preferences .Nutrition and hydration needs of the resident .The use of supplement and/or feeding tubes .

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 35 of 93 555339 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555339 B. Wing 01/10/2025

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 0697 Provide safe, appropriate pain management for a resident who requires such services.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 40988 potential for actual harm Based on observation, interiew, and record review, the facility failed to provide pain management according Residents Affected - Few to the physician's order, for one of two residents reviewed for pain (Resident 267), when the resident was not given the pain medication Norco (a narcotic pain medication) according to the physician's order.

This failure resulted in Resident 267 experiencing inadequate pain relief.

Findings:

On January 10, 2025, at 6:30 a.m., Resident 267 was observed lying in bed, responding to name when called. In a concurrent interview, Resident 267 stated she got Norco (hydrocodone-acetaminophen- a narcotic pain medication) routinely every six (6) hours due to multiple fractures (broken bones). Resident 267 stated she had last received pain medication 14 hours ago. Resident 267 stated her pain level was 11/10 (pain scale: 1-3= mild pain, 4-7= moderate pain, 8-10= severe pain), and would not be answering any more questions until her pain was resolved. Resident 267 stated she had been asking for her pain medication since yesterday evening but has not received any. Resident 267 stated she did not have any problems with pain management until yesterday afternoon when the facility was having computer problems because of the fires and the wind or something, and the nurse could not give her pain medication because of it. Resident 267 was heard moaning on and off and no nutdr had entered the room to assess the resident.

On January 10, 2025, at 7:20 a.m., a concurrent interview and review of Resident 267's record was conducted with Licensed Vocational Nurse (LVN) 7. LVN 7 stated he was a registry staff and it was his first week working in this facility. LVN 7 stated he gave Resident 267 Tylenol (pain reliever) around 6 a.m. The electronic Medication Administration Record (e-MAR) indicated Resident 267 had an order for Tylenol 625 mg (milligram- unit of measurement) and was administered to Resident 267 at 5:57 a.m. for a pain level of 5/10. LVN 7 stated he administered Tylenol to Resident 267 as he wanted to start from the lowest dose of medication and then go up. LVN 7 further stated Resident 267 was newly admitted to the facility the previous day and did not have any medication for breakthrough pain.

On January 10, 2025, at 7:29 a.m., Resident 267 was interviewed. Resident 267 stated her pain level was 9/10, and she was still waiting for her Norco.

On January 10, 2025, at 7:33 a.m., Resident 267's record was reviewed. Resident 267 was admitted to the facility on [DATE REDACTED]. The progress notes indicated Resident 267 arrived at the facility at 3:45 p.m. from another skilled nursing facility, and had diagnoses which included fracture.

The Order Summary Report, dated January 10, 2025, included an order for Norco Oral Tablet 5-325 MG (Hydrocodone-Acetaminophen) Give 1 tablet by mouth every 6 hours as needed for Moderate to Severe Pain (4-10) .

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 36 of 93 555339 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555339 B. Wing 01/10/2025

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 0697 On January 10, 2025 , at 7:35 a.m, LVN 8 was interviewed. LVN 8 stated she was the incoming nurse for Resident 267. LVN 8 stated LVN 7 told her the computers were not working the previous day and he was Level of Harm - Minimal harm or unable to pull up Resident 267's electronic medication profile to refer to for medication administration. LVN 8 potential for actual harm stated she was also a registry staff, and did not know what the facility's protocol was for medication administration if the computer systems were down. Residents Affected - Few Resident 267's e-MAR was concurrently reviewed with LVN 8, which indicated the resident had an order for Norco 5/325 mg to be given every six hours as needed for moderate to severe pain (4-10), but none was administered to Resident 267 throughout the afternoon or night shifts. The Controlled Drug Record for Resident 267's Norco indicated LVN 7 did not sign out any of the medication. The bubble pack containing the Norco tablets showed LVN 7 did not remove any tablet for administration to Resident 267.

On January 10, 2025, at 11:20 a.m., a concurrent interview and review of Resident 167's record was conducted with the Director of Nursing (DON). The DON stated Resident 267 was given Tylenol at 5:57 a.m. and Norco at 8:31 a.m. for 9/10 pain. The DON stated Resident 267 did not receive any Norco from the time

she was admitted to the facility the prior afternoon. The DON stated LVN 7 should have given Resident 267

the Norco for her pain level of 5/10. The DON stated residents' electronic records were inaccessible to staff

the prior afternoon around 3 o'clock until about 3 o'clock this morning. The DON stated paper MARs were printed for each resident and given to the nurses to use as reference when administering medications to the residents when the computer system is down. The DON further stated after medication administration, the nurses initial on the MAR for each medication they administer. When the computers are back online, the nurses enter the administration times in the e-MAR with the paper MARs as their basis for documentation.

The DON stated LVN 7 should still have been able to give Resident 267 her Norco using the paper MAR and

the Controlled Drug Record for Norco for accountability, which would show what time the last dose of Norco was given, to determine when it could be given again.

A review of the pharmacy delivery receipts indicated Resident 267's Norco medication was delivered and received in the facility on January 9, 2025 at 00:00 (midnight).

The Case Manager (CM) was called to the DON's office and explained the same process, further stating she had printed all the paper MARs for each resident when the computer system went down around 3 p.m. When asked what time she printed the documents, the CM pointed out the information at the left bottom corner of

the stack of paper MARs on top of a desk in the DON's office indicating, .Printed on: January 9, 2025 at 18:39:39 (6:39p.m.) EST (Eastern Standard Time-3 hours ahead of the Pacific Standard Time making it 3:39 p.m. in California) ., which was just a few minutes after 3 p.m. The CM further stated she had given LVN 7

the paper MARs for his residents and explained step by step what he had to do, including submitting the paper MARs to the DON in the morning or keeping the records inside the locked medication room for collection by the DON upon her arrival to the facility.

On January 10, 2025, at 2:50 p.m., further examination with the DON of the stack of paper MARs on top of

the desk showed there was no printed paper MAR for Resident 267. The DON called the CM for assistance to locate the document, but there was none found. The CM stated since Resident 267 was admitted to the facility around the time the computers went down, her information had been entered into the system, but her medication orders/profile were not backed-up, therefore her paper MAR was not generated for use by the afternoon and night shift nurses.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 37 of 93 555339 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555339 B. Wing 01/10/2025

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 0697 A review of the facility's policy and procedure titled, Pain Assessment and Management, dated March 2020, indicated, .Pain Management is defined as the process of alleviating the resident's pain based on his or ER Level of Harm - Minimal harm or clinical conditions and established treatment goals .is a multidisciplinary care process that includes the potential for actual harm following .recognizing the presence of pain .addressing the underlying cause of pain .implementing approaches to pain management .identifying and using specific strategies for different levels and sources of Residents Affected - Few pain .monitoring the effectiveness of interventions; and .modifying approaches as necessary .acute pain . should be assessed every 30 to 60 minutes after the onset and reassessed as indicated until relief is obtained .Implementing Pain Management Approaches .Implement the medication regimen as ordered, carefully documenting the results of the interventions .

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 38 of 93 555339 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555339 B. Wing 01/10/2025

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 0725 Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 47374

Residents Affected - Some Based on observation, interview, and record review, the facility failed to ensure sufficient staff were provided to meet the needs of the residents, when:

1. For 15 of 165 residents (Residents 45, 101, 85, 88, 124, 91, 138, 20, 2, 139, 318, 265, 23, 104, and 123) complained of staff failing to aid with activities of daily living (ADLs- daily care activities) in a timely manner; and

2. Seven of eight confidentially interviewed residents from the Resident Council meeting complained of call lights not being answered timely, lost personal belongings, and meals not being delivered on time.

These deficient practices caused feelings of frustration amoung the residents, and negatively affected the quality of care for the residents.

Findings:

1a. On [DATE REDACTED], at 10:39 a.m., during an interview with Resident 45, Resident 45 stated there were not enough Certified Nursing Assistants (CNA) on the night shifts and the CNAs were worked to death. Resident 45 stated the response time was very slow during the night time, with a wait of over an hour. Resident 45 further stated he had had to call the front desk to assist with his needs on those shifts.

On [DATE REDACTED], Resident 45's record was reviewed. Resident 45's Admission Record, indicated the resident was admitted to the facility on [DATE REDACTED], with diagnoses which included left side hemiplegia (weakness on the left side of the body).

A review of Resident 45's Minimum Data Set (MDS - a resident assessment tool), dated [DATE REDACTED], indicated Resident 45 had a BIMS (Brief Interview for Mental Status) score of 15 (cognitively intact).

1b. On [DATE REDACTED], at 10:54 a.m., Resident 101 and her family members (FM) were interviewed. FM 1 stated Resident 101 had waited 45 minutes for help. FM 1 stated there were a lot of CNA travelers and they had to tell new staff each time about being careful regarding Resident 101's arm due to the fracture there. FM 1 further stated it seemed like the nurses were the only constant staff, the CNAs were always different. FM 2 stated that a lot of the call lights were out from other patient rooms. Resident 101 stated the morning time was the longest time she has had to wait for help, adding sometimes she has waited a while for her pain medication.

A review of Resident 101's record indicated Resident 101 was admitted on Decembe 8, 2024, with diagnoses which included fracture (broken bones) of the right shoulder.

A review of Resient 101's MDS, dated [DATE REDACTED], indicated a BIMS score of 12 (moderately impaired cognitive status).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 39 of 93 555339 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555339 B. Wing 01/10/2025

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 0725 1c. On [DATE REDACTED], at 11:12 a.m., Resident 85 was interviewed. Resident 85 stated there were shifts that did not have CNAs, especially at night. Resident 85 further stated the response time was very slow at night time, Level of Harm - Minimal harm or which can be over an hour for the nurse to come. Resident 85 furhter staed he had to call the front desk to potential for actual harm have them call the CNA on more than one occasion.

Residents Affected - Some A review of Resident 85's record indicated Resident 85 was admitted to the facility on [DATE REDACTED], with diagnoses which included Parkinson's diseases (chronic brain disorder that causes movement problems, stiffness, and other symptoms) and end stage renal disease (permanent condition where the kidneys can no longer function).

A review of Resident 85's MDS, dated [DATE REDACTED], indicated Resident 85 had a BIMS score of 15.

1d. On [DATE REDACTED], at 11:35 a.m., Resident 88 was interviewed. Resident 88 stated it was difficult, especially on night shift, and it was not unusual for her husband (Resident 85) to have to call the front desk to request a CNA, because it took them so long to respond.

A review of Resident 88's record indicated Resident 88 was admitted to the facility on [DATE REDACTED], with diagnoses which included peripheral neuropathy (a condition that occurs when the nerves outside of the brain and spinal cord are damaged which causes weakness, numbness, and pain from the nerve damange usually in the hands and feet).

A review of Resident 88's MDS, dated [DATE REDACTED], indicated a BIMS score of 12.

1e. On [DATE REDACTED], 11:40 a.m., Resident 124 was interviewed. Resident124 stated there had been long waits for CNAs at night for them to come, and sometimes Resident 124's neighbor (next door residents) would walk out into the hallway to find the CNAs.

A review of Resident 124's record indicated Resident 124 was admitted to the facility on [DATE REDACTED], with diagnoses which included arthritis (joint inflammation) and low back pain.

A review of Resident 124's MDS, dated [DATE REDACTED], indicated Resident 124 had a BIMS score of 14 (cognitively intact).

1f. On [DATE REDACTED], at 12:10 p.m., Resident 91was interviewed. Resident 91 stated there could be frequent long waits for CNAs, mostly at nights. Resident 91 further stated it could take an hour or more for them to come and answer the call light, and the resident would walk out into the hallway to find them herself.

A review of Resident 91's record indicated Resident 91 was admitted to the facility on [DATE REDACTED], with diagnoses which included cerebral infarction (a type of stroke that occurs when brain tissue dies due to reduced blood flow).

A review of Resident 91's MDS, dated [DATE REDACTED], indicated Resident 91, had a BIMS score of `10 (moderately impaired cognitive status).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 40 of 93 555339 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555339 B. Wing 01/10/2025

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 0725 1g. On [DATE REDACTED], Resident 138 was interviewed. Resident 138 stated the facility seemd to be permanently short staffed, which was unfair for the patients. Resident 138 stated staff seeemd to run ragged especially Level of Harm - Minimal harm or bad during the holiday, medications were not given on time, and the evenings were the worst. Resident 138 potential for actual harm stated when they used the call light and no-one came to help, she usually helped her neighbor. She stated

she herself would need help to be changed but no-one would come. Residents Affected - Some

A review of Resident 138's MDS, dated [DATE REDACTED], indicated Resident 138 had a BIMS score of 12 (moderately impaired cognitive status).

1h. On [DATE REDACTED], at 9:38 a.m., Resident 20 was interviewed. Resident 20 stated it was obvious to him the unit was often understaffed, from the length of time it took for the call lights to be answered, the lack of time staff spent with residents, and the amount of agency nurses the facility had.

A review of Resident 20's record indicated Resident 20 was admitted to the facility on [DATE REDACTED], with diagnoses which indicated compression fracture (a break in a vertebra, or bone in the spine, that causes it to collapse) of the vertebra (spine).

A review of Resident 20's MDS, dated [DATE REDACTED], indicated Resident 20 had a BIMS score of 15.

1i. On [DATE REDACTED], at 9:58 a.m., Resident 2 was interviewed. Resident 2 stated his issue with care was the long wait time for the staff to answer his call light, mostly after dark.

A review of Resident 2's record indicated Resident 2 was admitted to the facility on [DATE REDACTED], with diagnoses which included hemiplegia.

A review of Resident 2's MDS, dated [DATE REDACTED], indicated Resident 2 had a BIMS score of 3 (severely impaired).

1j. On [DATE REDACTED], at 10:39 a.m., Resident 139 was interviewed. Resident 139 stated she had been in the facility since the last week of November. Resident 139 stated she had waited two to three hours for help to arrive, depending on who was working, typically in the evening shift. Resident 139 stated Saturdays and Sundays were a bad time, it took them a while to come, and sometimes you can hear others hollering outside. Resident stated she had a bed sore and took Tramadol and Tylenol for pain. Resdient 139 stated one time

during dinner time, around 630pm, she asked for pain medication and didn't get the medication until 10 p.m. Sometimes when she fell asleep, staff would not wake her up to give the pain medication, and she would have to wake up and call staff again to ask for the pain medicine.

A review of Resident 139's record indicated Resident 139 was admitted on [DATE REDACTED].

A review of Resident 139's MDS, dated [DATE REDACTED], indicated a BIMS score of 12.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 41 of 93 555339 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555339 B. Wing 01/10/2025

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 0725 1k. On [DATE REDACTED], at 12:40 p.m., Resident 318 was observed to be soft spoken and slow when he spoke, and could relay what he wanted. Resdient 318 stated he got upset with bad manners from staff. Resient 318 Level of Harm - Minimal harm or stated staff would come into his room and when he tried to ask a question or have them reposition him, the potential for actual harm staff member often told him they didn't understand what he was saying then leave the room. Resident 318 stated it was not unusual to wait long for the CNAs at night to respond. Resdient 318 stated it could take up Residents Affected - Some to an hour or more for them to answer the call bell, and sometimes the resident or the roommate would walk out into the hallway to find them.

A review of Resident 318's record indicated Resident 318 was admitted to the facility on [DATE REDACTED], with diagnoses which included cancer.

A review of Resident 318's MDS, dated [DATE REDACTED], indicated Resident 318 had a BIMS score or 13.

1l. On [DATE REDACTED], at 3:39 p.m., Resident 265 was interviewed. Resident 265 stated staff did not respond to the call lights right away, it depended on who the nurses were, and one nurse told her they had a very heavy caseload.

A review of Resident 265's record indicated Resident 265 was admitted to the facility on [DATE REDACTED], with diagnoses which included chronic obstructive pulmonary disease (COPD - lung disease).

A review of Resident 265's MDS, dated [DATE REDACTED], indicated a BIMS score of 8 (moderately impaired cognitive status).

1m. On [DATE REDACTED], at 3:40 p.m., Resident 23 was interviewed. Resident 23 stated he has lived in the facility for four (4) years, and they were short on staff. Resident 23 stated everybody was always new, so he needed to reteach the job to the new ones because they didn't know. Resident 23 stated the CNA staff took a long time to help, sometimes it took an hour to a couple of hours for someone to come, and everybody went on break at the same time. Resident 23 stated if there was only one person for the whole wing, it was going to take time to get any help. Resident 23 further stated there was a new nurse everyday and they did not know what

the medications were, and he had to tell them how to do the job.

A review of Resident 23's record indicated Resident 23 was admitted to the facility on [DATE REDACTED], with diagnoses which included heart failure.

A review of Resident 23's MDS, dated [DATE REDACTED], indicated Resident 23 had a BIMS score of 13.

1n. On [DATE REDACTED], at 8:58 a.m., Resident 104 was interviewed. Resident 104 stated she had to go to the nurses station to get help at times. Resident 104 stated they would come into her room, turn off the light, leave and not always come back.

A review of Resident 104's record indicated Resident 104 was admitted to the facility with diagnoses which included heart failure.

A review of Resident 104's MDS, dated [DATE REDACTED], indicated Resident 104 had a BIMS score of 14.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 42 of 93 555339 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555339 B. Wing 01/10/2025

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 0725 1o. On [DATE REDACTED], at 9:42 a.m., Resident 123 was interviewed. Resident 123 stated the care at night was really bad. Resdient 123 stated he has asked for medications at 8 p.m., and did not get them until 1 a.m. Level of Harm - Minimal harm or potential for actual harm A review of Resident 123's record indicated Resident 123 was admitted to the facility on [DATE REDACTED], with diagnoses which included fracture of left hip. Residents Affected - Some

A review of Resident 123's MDS, dated [DATE REDACTED], indicated a BIMS score of 15.

On [DATE REDACTED], at 9:41 a.m., CNA 3 stated Staions O and D needed more staff, and the current number of staff were not able to give the residents the care they needed. CNA 3 stated the CNA ratio was usually one CNA to ,d+[DATE REDACTED] residents during the day shift. CNA 3 stated they had a team leader for the whole unit but the team leader did not render assistance or take any patient assignment when the CNAs were short-staffed. CNA 3 stated the CNAs have mentioned the lack of help to HR (human resources) and the DSD (Director of Staff Develeopment) they used to have, but nothing had been done to address the issues. CNA 3 stated once a registry CNA worked the morning shift sometime after Christmas, and that CNA left without providing notice to the remaining staff, resulting in the residents assigned to the registry staff having no CNA coverage for 2 hours. CNA 3 stated the registry CNAs absence only became evident when no-one was passing the lunch trays in the assigned hallway. CNA 3 stated several residents' lights were on and no one saw the registry CNA. CNA 3 stated when the DSD checked the registry app (application- computer term for an application downloaded by a user to a mobile device or computer), the DSD confirmed that the staff already clocked out of work. CNA 3 stated the residents were then reassigned to remaining staff in the unit.

On [DATE REDACTED], at 10:05 a.m., an interview with CNA 4 provided confirmation of the same issues, that CNAs were overburdened with a lot of residents and thefore could not provide the residents the care they deserve. CNA 4 stated they get ,d+[DATE REDACTED] residents, and the residents complain, You can't give us what we need. CNA 4 further stated, if the assignment goes four to five residents over, It's very heavy, overdraining for staff,

we get behind, and residents could be wet passed on to the next shift.

On [DATE REDACTED], at 11:11 a.m., LVN 2 was interviewed. LVN 2 stated the facility had been short staffed periodically. LVN 2 stated the facility had registry nurses everyday, usually for the PM or NOC shifts, and lately there has definitely been that period of staff shortage. LVN 2 stated the facility had always had registry since she started working here amost a year ago. LVN 2 stated HR had hired a lot, but the staff turnover was quick, thinking it could be because they hire new graduates and the workload was pretty hard to start, so

they got overwhelmed. LVN 2 stated the AM shift had sufficient staff to cover assignments, but PM and NOC have had a lot of registry staff. LVN 2 stated today she had received complaints from residents about NOC shift staff taking longer to answer call lights, specifically pertaining to CNAs.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 43 of 93 555339 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555339 B. Wing 01/10/2025

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 0725 On [DATE REDACTED], at 8:40 a.m., the Staffing Coordinator (SC) was interviewed. The SC stated the registry staff used at the facility were from Registry Company 1 and Registry Company 2 . The SC stated the posting of Level of Harm - Minimal harm or shifts needed to be staffed were computerized and acceptance of shift for Registry Company 2 staff was also potential for actual harm being done through the program. The SC continued Registry Company 1 staff were used on occasion, and

the scheduling with these nurses were done manually. The SC stated both registries have an orientation to Residents Affected - Some the facility and a review of abuse reporting, clinical competencies, CPR and FIT tested and registry staff cannot accept a shift until verified by the Director of Staff Development. The SC further stated the use of registry nursing staff had been high related to the high facility census and difficulty in hiring CNAs related to pay rate. The SC stated CNA Team Leader did all the CNA resident assignments and did not take any patient assignments.

On [DATE REDACTED], at 6 a.m., LVN 18 was interviewed. LVN 18 stated there were always registry nurses working in Station D. LVN 18 stated usual comlaints he received regarding registry staff was tht they were not listening to the residents, some CNAs would not change the residents, so the morning shift nurses would blame the NOC nurses for not supervising the registry staff. LVN 18 stated management should do something regarding staffing, and hire regualr staff for residents' safety and quality of care.

On [DATE REDACTED], at 6:10 a.m., CNA 10 was interviewed. CNA 10 stated she usually took care of ,d+[DATE REDACTED] residents, and staff needed more help at night.

On [DATE REDACTED], at 6:11 a.m, CNA 11 was interviewed. CNA 11 stated she usually took care of 11 residents

during PM shifts, more during NOC shift. CNA 11 stated she would usually see call lights on in rooms not in her run and woudl help out answring them. CNA 11 stated she had worked Stations O and D, and Station O's workload was heavy due to more number of beds per room, and Station D had the heaviest workload since the residents were cognitively challenged and had more physical needs. CNA 11 stated she recalled working one night shift with each CNA having ,d+[DATE REDACTED] residents each.

On [DATE REDACTED], at 6: 25 a.m., CNA 5 was interviewed. CNA 5 stated the average resident load for one CNA on night shift was between 18 - 24. CNA 5 further stated the work could be difficult with a higher patient census.

On [DATE REDACTED], at 6:45 a.m., LVN 11 was interviewed. LVN 11 stated she had noted that CNA assignments on night shift can be between 17 -21 resdients for each CNA. LVN 11 stated the current shift had only two facility CNAs and all other staff on the unit were three (3) registry licensed staff and two (2) registry CNAs.

On [DATE REDACTED], at 6:50 a.m., the Respiratory Therapist (RT) was interviewed. The RT stated there were a lot of registry CNAs and LVNs at the facility, and believes things would improve if more regular staff were hired by

the facility instead of using registry staff.

A review of the facility's Direct Care Service Hours Per Patient Day (DHPPD- measures the number of hours of direct care given to patients in skilled nursing facilities) records for [DATE REDACTED] indicated 14 of 31 days when

the actual CNA DHPPD were below the state required minimum of 2.40 hours. The hours ranged from 2.22 - 2.39 as follows:

- [DATE REDACTED] (Sunday): 2.22 hrs;

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 44 of 93 555339 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555339 B. Wing 01/10/2025

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 0725 - [DATE REDACTED] (Monday): 2.33 hrs;

Level of Harm - Minimal harm or - [DATE REDACTED] (Monday): 2.39 hrs; potential for actual harm - [DATE REDACTED] (Saturday): 2.33 hrs; Residents Affected - Some - [DATE REDACTED] (Sunday): 2.37 hrs;

- [DATE REDACTED] (Friday): 2.35 hrs;

- [DATE REDACTED] (Saturday): 2.39 hrs;

- [DATE REDACTED] (Sunday ): 2.34 hrs;

- [DATE REDACTED] (Monday): 2.29 hrs;

- [DATE REDACTED] (Christmas Day Holiday): 2.22 hrs;

- [DATE REDACTED] (Friday): 2.29 hrs;

- [DATE REDACTED] (Saturday): 2.32 hrs;

- [DATE REDACTED] (Monday): 2.39 hrs; and

- [DATE REDACTED] (New Year's Eve): 2.30 hrs.

A review of the Nursing Staffing Assignments and Sign in Sheets for the above mentioned dates indicated one CNA provided care to a number of residents that ranged as follows:

- [DATE REDACTED] (Sunday): PM shift= ,d+[DATE REDACTED] residents with showers and/or nail care, NOC shift= ,d+[DATE REDACTED] residents;

- [DATE REDACTED] (Monday): PM shift= ,d+[DATE REDACTED] residents with showers and/or nail care, NOC shift= ,d+[DATE REDACTED] residents;

- [DATE REDACTED] (Monday): PM shift= ,d+[DATE REDACTED] residents with showers and/or nail care , NOC shift= ,d+[DATE REDACTED] residents;

- [DATE REDACTED] (Saturday): PM shift= ,d+[DATE REDACTED] residents with showers and/or nail care, NOC shift= ,d+[DATE REDACTED] residents;

- [DATE REDACTED] (Sunday): PM shift= ,d+[DATE REDACTED] residents with showers and/or nail care, NOC shift= ,d+[DATE REDACTED] residents;

- [DATE REDACTED] (Friday): PM shift= ,d+[DATE REDACTED] residents with showers and/or nail care, NOC shift= ,d+[DATE REDACTED] residents;

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 45 of 93 555339 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555339 B. Wing 01/10/2025

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 0725 - [DATE REDACTED] (Saturday): PM shift= ,d+[DATE REDACTED] residents with showers and/or nail care, NOC shift= ,d+[DATE REDACTED] residents; Level of Harm - Minimal harm or potential for actual harm - [DATE REDACTED] (Sunday): PM shift= ,d+[DATE REDACTED] residents with showers and/or nail care, NOC shift= ,d+[DATE REDACTED] residents; Residents Affected - Some - [DATE REDACTED] (Monday): PM shift= ,d+[DATE REDACTED] residents with showers and/or nail care, NOC shift= ,d+[DATE REDACTED] residents;

- [DATE REDACTED] (Christmas Day Holiday): PM shift= ,d+[DATE REDACTED] residents with showers and/or nail care, NOC shift= , d+[DATE REDACTED] residents;

- [DATE REDACTED] (Friday): PM shift= ,d+[DATE REDACTED] residents with showers and/or nail care, NOC shift= ,d+[DATE REDACTED] residents;

- [DATE REDACTED] (Saturday): PM shift= ,d+[DATE REDACTED] residents with showers and/or nail care, NOC shift= ,d+[DATE REDACTED] residents;

- [DATE REDACTED] (Monday): PM shift= ,d+[DATE REDACTED] residents with showers and/or nail care, NOC shift= ,d+[DATE REDACTED] residents; and

- [DATE REDACTED] (New Year's Eve): PM shift= ,d+[DATE REDACTED] residents with showers and/or nail care, NOC shift= , d+[DATE REDACTED] residents.

A review of the [DATE REDACTED] calendar schedule for Registry Company 1 indicated the facility used multiple registry staff as follows:

- [DATE REDACTED]-7, 2024: One AM CNA, Two PM CNAs, 14 NOC CNAs (total of 17 registry staff);

- [DATE REDACTED]-14, 2024: One AM CNA, One AM LVN, Eight PM CNAs, 24 NOC CNAs, One NOC LVN (total of 35 registry staff);

- [DATE REDACTED]-21, 2024: Nine AM CNAs, 20 PM CNAs, 13 NOC CNAs, One NOC LVN (total of 43 registry staff);

- [DATE REDACTED]-28,2024: Six AM CNAs, 12 PM CNAs, 8 NOC CNAs (total of 27 registry staff); and

- [DATE REDACTED]-31, 2024: One AM CNA, Two PM CNAs, 13 NOC CNAs (total of 16 registry staff).

A review of the [DATE REDACTED] calendar schedule for Registry Company 2 indicated the facility used multiple registry staff as follows:

- [DATE REDACTED]-7, 2024: Seven AM CNAs, 10 AM LVNs, 22 PM CNAs, 14 PM LVNs, 22 NOC CNAs, Seven LVNs, and One RN (total of 83 registry staff);

- [DATE REDACTED]-14, 2024: Six AM CNAs, 10 AM LVN, One AM RN, 21 PM CNAs, 15 PM LVNs, 24 NOC CNAs, and 13 NOC LVNs (total of 90 registry staff);

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 46 of 93 555339 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555339 B. Wing 01/10/2025

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 0725 - [DATE REDACTED]-21, 2024: Eight AM CNAs, 10 AM LVNs, 22 PM CNAs, 14 PM LVNs, 19 NOC CNAs, 14 NOC LVNs, Two NOC RNs (total of 89 registry staff); Level of Harm - Minimal harm or potential for actual harm - [DATE REDACTED]-28,2024: Eight AM CNAs, Seven AM LVNs, 21 PM CNAs, 17 PM LVNs, 23 NOC CNAs, and 11 NOC LVNs (total of 87 registry staff); and Residents Affected - Some - [DATE REDACTED]-31, 2024: O23 AM CNA, 10 AM LVNs, 28 PM CNAs, 23 PM LVNs, 26 NOC CNAs, 12 NOC LVNs, and One NOC RN (total of 123 registry staff).

On [DATE REDACTED], at 1:43 p.m., an interview and record review with Director of Nursing (DON) was conducted. The DON stated the goal for CNAs on night shift was 13 - 18 residents and to maintain DHPPD at or over 2.4 hours for CNAs to maintain best quality of care for the residents and staff. The DON further stated they were currently advertising and interviewing for both licensed and CNA positions. The DON stated administration did resident rounds daily to assess care and takes any issues to the appropriate director. The DON stated

she was aware of DHPPD hours daily and each day and had worked with staffing and DSD to hire more facility staff.

2. On [DATE REDACTED] at 10:30 a.m., during a group interview, seven of eight residents stated that the facility staff answered the call light, left the room, and did not return with the needed service or item requested. The residents stated it took an extended amount of time to receive necessary care and many articles of clothing have been lost. The residents further stated the CNA's would not use laundry bags labeled for each resident which lead to multiple articles of clothing being lost.

A review of the resident council meeting minutes, dated [DATE REDACTED], residents stated the CNA's were rushing while providing care while using the Hoyer Lift, leading to a fear of falling.

A review of the resident council meeting minutes, dated [DATE REDACTED], indicated residents stated there was an ongoing issue with missing/lost articles of clothing.

A review of the resident council meeting minutes, dated [DATE REDACTED], indicated the residents stated beds were not made everyday, meals have not been delivered timely, bed controls were not put back properly, and CNAs gave negative attitude to the residents (behaving with disrespect).

A review of facility's undated policy and procedure titled, Use of Registry Staff, indicated, .appropriate use of registry staff to maintain quality care .registry staff will not be used as a substitute for maintaining adequate permanent staff levels .

A review of facility's policy and procedure titled, Answering the Call Lights, dated 2001, indicated .the purpose of the policy is to respond to the resident's requests and needs .answer the resident's call as soon as possible .

A review of facility's policy and procedure titled, Staffing, dated 2007, indicated .Our facility provides adequate staffingh to meet needed care and services for our resident population .Our facility maintains adequate staffing on each shift to ensure that our resident's needs and services are met. Licensed registered nursing and licensed nursing stafff are available to provide and monitor the delivery of resident care services . Certified Nursing Assistants are available on each shift to provide the needed care and services of each resident as outline on the resident's comprehensive care plan .

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 47 of 93 555339 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555339 B. Wing 01/10/2025

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 0755 Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 50610

Residents Affected - Some Based on observation, interview, and record review, the facility failed to ensure provision of pharmacy services met the needs of the residents when:

1. An unopened container of Controlled II (CII, Schedule II drugs with a high potential for abuse) Emergency Kit (E-kit, a sealed container of various medications for use in emergencies) contained a small, opened E-kit medication box with no medications inside and no documentation of missing medications on the outside of

the E-kit container. This failure had the potential to significantly delay treatment for pain; and

2. Three different medications lowering blood pressure were administered to Resident 103 when Systolic Blood Pressure (SBP, the top number in blood pressure reading which measures how hard the heart pumps blood into arteries) levels were below the holding parameter orders. This failure had the potential to inadequately control Resident 103's blood pressure.

Findings:

1. On January 8, 2025, at 8:30 a.m., during an inspection of the CII E-kit with the Director of Nursing (DON),

the plastic box for Norco (potent narcotic pain medication) 5/325mg (milligram, unit of measurement) was observed to have the green seal broken and four tablets of Norco (as indicated outside the box) were missing from the CII E-kit.

In a concurrent interview, the DON stated the Norco tablets were missing and could not account for the missing generic Norco tablets.

A review of the facility's policy and procedure titled, Emergency Medications, dated April 2007, indicated, .

The facility shall maintain a supply of medications typically used in emergencies .The contents of each emergency medication kit will be clearly listed .Required documentation after dispensing an emergency medications and biologicals .Any medication that is removed from the emergency kit must be documented on

the emergency medication administration log .

2. A review of Resident 103's Admission Record indicated Resident 103 was admitted to the facility on [DATE REDACTED], and readmitted to the facility on [DATE REDACTED], with diagnoses which included cerebral infarction (a medical condition where brain tissue dies due to a disruption in blood flow to the brain), hypertensive heart disease (heart condition that develop due to long-term high blood pressure) and atrial fibrillation (irregular heartbeat).

A review of Resident 103's Order Summary Report, included the following physician's orders for hypertension (HTN, high blood pressure):

- Carvedilol oral tablet 6.25 mg, give 1 tablet by mouth two times a day for HTN, hold if SBP< (less than 110 or HR (Heart Rate) < 60, dated January 19, 2024;

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 48 of 93 555339 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555339 B. Wing 01/10/2025

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 0755 -Losartan potassium oral tablet 50 mg, give 1 tablet by mouth one time a day for HTN, hold if SBP<110 or HR<60, dated October 20, 2024; and Level of Harm - Minimal harm or potential for actual harm - Hydralazine HCl oral tablet 50 mg, give 1 tablet by mouth four times a day for HTN, hold for SBP <110 and/or pulse <60, dated October 26, 2024. Residents Affected - Some

A review of Resident 103's Medication Administration Record (MAR), for December 2024 and January 2025 indicated carvedilol was administered to the Resident 103 when the SBP was lower than 110 on the following dates and times:

- December 27, 2024, at 9 a.m., SBP 107;

- January 1, 2025, at 9 a.m., SBP 103;

- January 3, 2025, at 9 a.m., SBP 103; and

- January 5, 2025, at 9 a.m., SBP 105.

A review of Resident 103's Medication Administration Record (MAR), for December 2024 and January 2025 indicated hydralazine was administered to the Resident 103 when the SBP was lower than 110 on the following dates and times:

- December 5, 2024, at 5 p.m., SBP 97;

- December 14, 2024, at 5 p.m., SBP 109;

- December 19, 2024, at 5 p.m., SBP 97;

- December 19, 2024, at 9 p.m., SBP 97;

- December 27, 2024, at 9 a.m., SBP 107;

- January 2, 2025, at 9 p.m., SBP 108;

- January 3, 2025, at 9 a.m., SBP 103; and

- January 5, 2025, at 9 a.m., SBP 105.

A review of Resident 103's Medication Administration Record (MAR), for December 2024 and January 2025 indicated losartan potassium was administered to the Resident 103 when the SBP was lower than 110 on

the following dates and times:

- December 27, 2024, at 9 a.m., SBP 107;

- January 3, 2025, at 9 a.m., SBP 103; and

- January 5, 2025, at 9 a.m., SBP 105.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 49 of 93 555339 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555339 B. Wing 01/10/2025

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 0755 On January 9, 2025, at 11:08 a.m., during a concurrent interview and record review with the DON, the DON stated carvedilol, hydralazine, and losartan potassium was administered to Resident 103 when the SBP was Level of Harm - Minimal harm or outside the holding parameters according to the physician's orders. The DON stated the staff should have potential for actual harm followed the holding parameters prior to administering blood pressure medications to Resident 103.

Residents Affected - Some A review of the facility's policy and procedure titled Administering Medications, revised April 2019, indicated, . Medications are administered in accordance with prescriber orders .

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 50 of 93 555339 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555339 B. Wing 01/10/2025

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 0756 Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 50610

Residents Affected - Few Based on interview and record review, the facility failed to ensure the consultant pharmacist (CP)'s Medication Regimen Review (MRR) recommendation for one of five residents reviewed for unnecessary medications (Resident 50) was carried out in a timely manner. In addition, the facility's MRR policies did not include the time frames for the physician to act upon the CP's MRR recommendation.

These failures resulted in inadequate monitoring and had the potential to result in ineffective medication management and to compromise the Resident 50's health.

Findings:

On January 9, 2025, the Resident 50's medical record was reviewed. Resident 50's Admission Record, indicated was readmitted to the facility on [DATE REDACTED], with the diagnoses that included hypertensive heart disease with heart failure (elevated blood pressure).

A review of Resident 50's physician's order indicated furosemide (medication to reduce fluid retention and to treat high blood pressure) 20 mg (milligram - unit of measurement), 1 tablet by mouth one time a day for fluid retention (an accumulation of fluid in body tissues and cavities), dated September 10, 2024;

A review of the Resident 50's laboratory results indicated the latest Basic Metabolic Panel (BMP, a blood test that measures the body's fluid balance and levels of electrolytes) was obtained on September 10, 2024 (4 months ago);

A review of the CP's MRR recommendation, dated December 11, 2024 (a month ago), indicated the CP requested for a BMP along with Complete Blood Count (CBC, a blood test that measures the number and types of cells in the blood) laboratory levels to be drawn on the next convenient lab draw date and every 2 weeks thereafter;

There was no documented evidence in Resident 50's clinical records the facility conducted any recent BMP laboratory test to monitor the blood electrolytes including but not limited to potassium, magnesium, sodium, calcium, serum creatinine (a blood test that measure the level of creatinine in the blood, which indicates how well the kidneys are working) and serum blood urea nitrogen (BUN, a blood test that measures the amount of urea nitrogen in the blood which measures the function of kidney) levels.

On January 9, 2025, at 11:08 a.m., during a concurrent record review and interview with the Director of Nursing (DON), the DON stated the physician has not acted upon the CP' s recommendation to obtain BM for Resident 50 and no BMP laboratory testing had been ordered by the physician.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 51 of 93 555339 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555339 B. Wing 01/10/2025

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 0756 A review of the National Institute of Health (NIH)'s National Library of Medicine (NLM, a nationally recognized source of medical information), indicated, .According to Beers Criteria, caution is necessary when Level of Harm - Minimal harm or administering diuretics to patients [AGE] years and older to avoid potent adverse effects of inducing potential for actual harm hyponatremia .close monitoring of serum sodium is advisable at initiation or during the dose adjustment in older adults .Careful monitoring of the patient's clinical condition .electrolytes, i.e., potassium and Residents Affected - Few magnesium, kidney function monitoring with serum creatinine and serum blood urea nitrogen level is vital to monitor the response of furosemide. For example, if indicated for diuresis with furosemide, replete electrolytes lead to electrolyte depletion, and adjust the dose or even hold off on furosemide if laboratory work shows signs of kidney dysfunction .

A review of the facility's policy and procedure titled Medication Regimen Reviews, revised May 2019, indicated, .If the Physician does not provide a timely or adequate response, or the Consultant Pharmacist identifies that no action has been taken, he/she contacts the Medical Director or (if the Medical Director is the physician of record) the Administrator .The attending physician documents in the medical record that the irregularity has been reviewed and what (if any) action was taken to address it .Copies of medication regimen review reports, including physician responses, are maintained as part of the permanent medial

record .

A review of the facility's policy and procedure titled Consultant Pharmacist Services Provider Requirements, dated January 2023, indicated, .The consultant pharmacist .provides pharmaceutical care services, including .Review and follow-up to previous month's pharmacy recommendations with nursing care center staff .

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 52 of 93 555339 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555339 B. Wing 01/10/2025

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 0758 Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic Level of Harm - Minimal harm or medications are only used when the medication is necessary and PRN use is limited. potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 50610 Residents Affected - Few Based on interview and record review, the facility failed to ensure antipsychotic medications (medications to treat psychotic disorders with symptoms of altered sense of reality) were ordered and used for residents with proper diagnoses and evaluations to meet residents' needs, for one of five residents reviewed for unnecessary medications (Resident 157).

An antipsychotic medication for sleep received while Resident 157 was admitted in the hospital was ordered to continue with a new indication of psychosis (symptoms of psychotic disorders) without prior history of psychotic disorders and thorough psychiatric evaluation by a qualified medical professional.

This failure had the potential for residents to receive an unnecessary medication with serious long term adverse effects including permanent movement disorder, seizure, and uneven heart rate.

Findings:

On January 8, 2025, Resident 157's medical record was reviewed. Resident 157's Admission Record, indicated Resident 157 was admitted on [DATE REDACTED], with diagnoses which included anxiety disorder and unspecified psychotic disorder with hallucinations due to known physiological condition.

A review of Resident 157's physician's order indicated quetiapine (Brand Name: Seroquel, an antipsychotic medication) 25 mg (milligram - unit of measurement) be given to the resident by mouth once at bedtime for psychosis manifested by physical aggression, dated December 4, 2024.

A review of Resident 157's Medication Administration Record (MAR), indicated Seroquel 25 mg dose was given to Resident 157 daily, consistently, from December 6, 2024, until present;

A review of Resident 157's hospital initial admission documents and the history and physical (H&P) during

the hospital stay prior to transfer to the facility, from November 14, 2024 to December 5, 2025, indicated Resident 157 had diagnoses that did not include psychotic disorders. The hospital H&P indicated the home medications list obtained on November 14, 2024, Resident 157 was not on any antipsychotic medication.

The hospital record indicated Resident 157 had an order on November 19, 2024, for Seroquel 25 mg to be given by mouth once at bedtime as needed for sleep; and

On January 9, 2025, Resident 157's MDS (Minimum Data Set - a care planning and assessment process used in nursing homes to identify a resident's needs, monitor changes in a resident's status, guide care planning), dated December 9, 2024, was reviewed, and it indicated the following:

- Resident 157's BIMS (brief interview for mental status) test score was 15 out of 15, meaning there was no impairment in mental ability; and

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 53 of 93 555339 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555339 B. Wing 01/10/2025

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 0758 - The assessment did not indicate Resident 157 had hallucination, delusions, physical, verbal, and other behavioral symptoms towards others, rejection of care, and no schizophrenia. Level of Harm - Minimal harm or potential for actual harm On January 9, 2025, at 2:45 p.m., during an interview and record review with the Director of Nursing (DON),

the DON stated the physician continued all medications from the hospital and the new order for Seroquel Residents Affected - Few was signed by the physician. The DON stated there was only depression and anxiety as diagnoses from the hospital. The DON stated she did not know how the new diagnosis of psychosis was started. The DON stated there was no psychiatric evaluation of Resident 157 by the facility psychiatrist because Resident 157 was a patient of another medical group and the facility psychiatrist was not allowed to evaluate residents belonging to this medical group.

On January 9, 2025, at 3 p.m., during an interview with the physician (MD) 1, MD 1 agreed the diagnosis of psychosis was not valid based on what Seroquel was used for. MD 1 stated because patients in a hospital usually would get Seroquel for agitation.

On January 9, 2025, at 3:06 p.m., during an interview with physician (MD) 2, MD 2 stated he authorized to continue all hospital medications as instructed. MD 2 stated he never gave the diagnosis of psychosis for Seroquel to be taken routinely and would not have continued Seroquel if he knew Seroquel was used for sleep as needed in the hospital. MD 2 stated Resident 157 did not show symptoms of psychosis.

On January 9, 2024, at 4:30 p.m., during an interview with the Consultant Pharmacist (CP), the CP stated

she would not recommend continuing Seroquel for psychosis if there was no psychosis diagnosis to begin with from the hospital. The CP stated she did not know how the psychosis diagnosis was made and that she was not able to review Resident 157's hospital admission record completely.

A review of the facility's policy and procedure titled, Psychotropic Medication Use, dated, 2001, indicated, . Drugs in the following categories are considered psychotropic medications and are subject to prescribing, monitoring, and review requirements specific to psychotropic medications .Anti-psychotics .Residents, families and/or representative are involved in the medication management process. Psychotropic medication management includes .indication for use .Residents who have not used psychotropic medications are not prescribed or given these medications unless the medication is determined to be necessary to treat a specific condition that is diagnosed and documented in the medical record .Consideration of the use of any psychotropic medication is based on comprehensive review of the resident. This includes evaluation of the resident's signs and symptoms in order to identify underlying causes .Situations which may prompt an evaluation or re-evaluation of the resident include .admission or re-admission .The evaluation may include . resident status .goals and preferences .history of medication use .

A review of the facility's policy and procedure titled, Non-Controlled Medication Orders, dated, 2007, indicated, .order that appears inappropriate, considering the resident's .condition .or diagnosis, is verified by nursing with the prescriber .

A review of the facility's policy and procedure titled, Consultant Pharmacist Services Provider Requirements, dated, 2007, indicated, .Communicate to the responsible prescriber, the facility's medical director and the director of nursing potential or actual problems detected and other findings related to medication therapy orders at least monthly .

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 54 of 93 555339 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555339 B. Wing 01/10/2025

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 0758 A review of DSM-5, Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, published by American Psychiatric Association, a diagnostic tool served in the United States as the authority for Level of Harm - Minimal harm or psychiatric diagnoses, was referenced in the government website article, Impact of the DSM-IV to DSM-5 potential for actual harm Changes on the National Survey on Drug Use and Health, by Substance Abuse and Mental Health Services Administration, June 2016, as below .In DSM-5, the psychotic disorders class includes: schizophrenia; Residents Affected - Few schizophreniform disorder; schizoaffective disorder; delusional disorder; brief psychotic disorder; psychotic disorder due to another medical condition; substance/medication-induced psychotic disorder; unspecified schizophrenia spectrum and other psychotic disorder; and other specified schizophrenia spectrum and other psychotic disorder. These disorders share a common set of characteristic symptoms or key features that include delusions (fixed beliefs that are not amenable to change in light of conflicting evidence); hallucinations (perception-like experiences that occur without an external stimulus); disorganized thinking/speech (e.g., frequent derailment or incoherence); grossly disorganized (e.g., childlike silliness or unpredictable agitation) or catatonic behavior (a marked decrease in reactivity to the environment, or purposeless and excessive motor activity without obvious cause); and negative symptoms such as affective flattening (diminished emotional expression), avolition (lack of motivation to achieve meaningful goals), or alogia (diminished speech output) .

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 55 of 93 555339 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555339 B. Wing 01/10/2025

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 0759 Ensure medication error rates are not 5 percent or greater.

Level of Harm - Minimal harm or 50610 potential for actual harm Based on observation, interview and record review, the facility had a medication error rate of 7.14% when Residents Affected - Few two medication errors occurred out of 28 opportunities during the medication administration, for two out of six residents (Resident 465 and 314).

The deficient practice resulted in medications not given in accordance with the prescriber's orders and had

the potential for residents not receiving the full therapeutic effects of medications with the potential for worsening of residents' medical conditions.

Findings:

1. On January 7, 2025, at 9:10 a.m., during a medication administration observation with the Licensed Vocational Nurse (LVN ) 12, LVN 12 was observed preparing and administering four medications for Resident 465. One of the observed medications was Lidocaine 4% patch (topical patch medication for pain relief).

A review of the Resident 465's physician's order, dated 2022, indicated, Lidoderm Patch (Lidocaine), Apply to Lt (left) shoulder/neck topically every 24 hours for neck pain and remove per schedule. The physician's order did not indicate strength of the lidocaine patch.

On January 7, 2025, at 2:40 p.m., during a concurrent interview and record review with the LVN 12, LVN 12 verified the order for Lidoderm patch did not indicate the strength of the patch. LVN 12 confirmed he applied Lidocaine 4% patch instead of Lidoderm patch 5%. LVN 12 stated, the order did not have strength, I thought lidocaine 4% and Lidoderm were the same strength.

2. On January 7, 2025, at 10:00 a.m., during a medication administration observation with LVN 13, LVN 13 was observed preparing and administering five medications for Resident 314 including Lidocaine 4% patch. LVN 13 was observed to apply the patch to the Resident 314's right mid back.

A review of the Resident 314's physician's order, dated December 21, 2024, indicated:

- Lidocaine External Patch 4% (Lidocaine), Apply to Left lower back topically one time a day for pain management and remove per schedule.

On January 7, 2025, at 2;45 p.m., during a concurrent interview and record review with LVN 13, LVN 13 confirmed she applied Lidocaine 4% patch to Resident 314's left side of the back, and not on the right side of

the back. LVN 13 stated Resident 314 needed Lidocaine 4% patch on the left lower back due to pain caused by coughing. However, Resident 314 complaint of pain on the right side of the back since January 6, 2025, and LVN 13 had obtained physician's order on January 6, 2025, which changed the location of patch to be applied from the left side of the back to the right side of the back. LVN 13 also stated she did not had a chance to update the order in esident 314's medical record yet. LVN 13 acknowledged the medication should have been administered following the physician's current order in the Resident 314's medical record.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 56 of 93 555339 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555339 B. Wing 01/10/2025

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 0759 On January 7, 2025, a review of the Resident 314's January 2025 medication administration record (MAR) indicated the nursing staff documented most of the entries for location of administration with Back-lower Level of Harm - Minimal harm or without specifying the side of back whether the patch was applied to the resident's left side or the right side potential for actual harm of the back.

Residents Affected - Few On January 8, 2025, a review of the Resident 314's January 2025 MAR still indicated Lidocaine 4% patch for

the Resident 314's left lower back as a current active order in the Resident 314's medical records. There was no discontinued order or the change of order for Lidocaine 4% patch as of January 8, 2025.

On January 9, 2025, at 11:58 a.m., during an interview with the Director of Nursing (DON), the DON stated staff should have administered the medications according to the physician's order.

A review of the facility's policy and procedure titled Administering Medications, revised April 2019, indicated, . Medications are administered in accordance with prescriber orders, including any required time frame .The individual administering the medication checks the label THREE (3) times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication .

According to the webarticle titled DailyMed, published by the National Library of Medicine, indicated, Lidoderm is supplied in 5% dosage only.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 57 of 93 555339 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555339 B. Wing 01/10/2025

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 0761 Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately Level of Harm - Minimal harm or locked, compartments for controlled drugs. potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 50610 Residents Affected - Some Based on observation, interview and record review, the facility failed to store and label medications in accordance with the manufacturer's instructions and the facility policy and procedures when:

1. Total of three expired medications were identified in the medication refrigerator, IV/IM (intravenous/intramuscular, routes of administrations, methods of injecting medication into body) E-kit (Emergency Kit, a sealed container of various medications for use in emergencies) and the oral E-kit;

2. Total of six different medications without the open dates were stored in the medication room, the medication refrigerator, and the medication carts;

3. A discontinued order of controlled medication was stored in the medication cart; and

4. A box of ointment was stored in the treatment cart with no pharmacy-applied labels.

These deficient practices had the potential for residents to receive unsafe and less potent medications, and

the potential for medication errors from improperly labeled medications and the discontinued medications mixed with active stocks.

Findings:

1a. On January 6, 2025, at 11:13 a.m., an inspection of the MedBridge Medication Room was conducted with the Director of Nursing (DON). An expired IV bag of compounded Daptomycin (medication to treat certain blood infections or serious skin infections) 400 mg (milligram - unit of measurement)/50 mL (milliliter - unit of measurement) NS (normal saline, a sterile solution made up of water and salt, specifically sodium chloride) containing a pharmacy label with compounded date 1/2/25 (January 2, 2025), use by 1/4/25 (January 4, 2025).

On January 6, 2025, at 11:33 a.m., during a concurrent observation and interview with the DON, the DON stated the Daptomycin bag should have been removed from the refrigerator since it was expired. The DON was observed to place the Daptomycin bag into an unlabeled blue bin located on the countertop of medication cabinets and stated the blue bin was a designated location for expired and discontinued medications for further disposition procedure.

1b. On January 6, 2025, at 12:08 p.m., an inspection of an unopened IM E-kit in the MedBridge medication room with the DON was conducted. An unopened small clear plastic container labeled with Zofran (medication to prevent nausea and vomiting) 2mg/mL #1 vial 2mL, Expiration Date 12/24 (December 2024). Inside the small plastic container, there was one expired vial of Zofran 2mg/mL with the expiration date of December 2024 on the vial's manufacture label.

During a concurrent observation and interview with the DON, the DON confirmed the expired Zofran vial stored in the IM E-kit.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 58 of 93 555339 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555339 B. Wing 01/10/2025

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 0761 1c. On January 6, 2025, at 4:02 p.m., during an inspection of the medication room in the Oasis Nursing Station with Registered Nurse (RN)/Infection Preventionist (IP) IPRN, an unopened PO E-kit (E-kit containing Level of Harm - Minimal harm or oral medications for emergency use) was inspected. After opening the PO E-kit, five tablets of unit-dose potential for actual harm warfarin (blood thinner medication) with an expiration date of 10/16/24 (October 16, 2024) in a small clear plastic container. The container was labeled as Coumadin (generic name: Warfarin, medication to prevent Residents Affected - Some blood clot) 1mg #8 tabs, Expiration date 2/25. The expiration date of the three remaining tablets of unit-dose Warfarin was 2/12/2025.

On January 6, 2025, at 4:02 p.m., during a concurrent observation and interview with the IPRN the IPRN verified the five tablets of unit-dose warfarin 1mg were expired.

On January 9, 2025, at 11:58 a.m., during an interview with the DON, the DON stated the facility staff was unable to find out if the unopened E-kit container contains any expired medications inside until the E-kit is opened for emergency use and the staff checks for any outdated medications.

A review of the facility's policy and procedure titled Medication Labeling and Storage, dated 2001 MED-PASS, indicated, .If the facility has discontinued, outdated or deteriorated medications for biologicals,

the dispensing pharmacy is contacted for instructions regarding returning or destroying these items .

2a. On January 6, 2025, at 11:13 a.m., during an inspection of cabinet drawers in the MedBridge medication room with the DON, nine bags of D5 1/2NS (dextrose 5% in 0.45% sodium chloride, a sterile fluid for IV administration) 1000 mL were unlabeled and an unlabeled bag of Lactated Ringer's (a sterile IV solution that replaces water and electrolytes in the body) 1000mL in Excel IV containers manufactured by B. [NAME].

These ten bags were out-of-overwrap (removed from manufacture's overwrap package) and stored in a same drawer below the cabinet countertop. The manufacturer's instruction on the bag indicated .Do not remove overwrap until ready to use . Also, there were no labels attached to these bags, no documentation of opened date when the bags were first removed from the manufacturer's overwrap and/or the expiration date for the out-of-overwrap bags.

On January 6, 2025, at 11:13 a.m., during a concurrent observation and interview with the DON, the DON stated these IV bags were ordered for a resident who was discharged but the facility decided to keep the bags because of the IV fluid shortages. The DON confirmed the medications were stored without pharmacy-applied labels and acknowledged the medications without labels should not be stored in drawers, cabinets, medication rooms, refrigerators, and carts. The DON also stated different types of medications that look-alike should not be stored in the same compartment due to potential mix-up errors.

A review of B. [NAME] manufacturer's document titled FAQ: EXCEL(R) IV Container indicated .The EXCEL 250mL, 500mL, and 1000mL IV containers, without any additions, can be stored at 25 C for one (1) month without plastic overwrap (or until its expiration date, whichever is sooner) .

A review of the facility's policy and procedure titled Medication Labeling and Storage, dated 2001 MED-PASS, indicated, .if medication containers have missing, incomplete, improper or incorrect labels, contact the dispensing pharmacy for instructions regarding returning or destroying these items .Medications are stored in an orderly manner in cabinets, drawers .to prevent the possibility of mixing medications of several residents .

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 59 of 93 555339 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555339 B. Wing 01/10/2025

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 0761 2b. On January 6, 2025, at 11:13 a.m., during an inspection of IV E-kit in the MedBridge medication room with the DON, two bags of D5W (Dextrose 5% in water, sterile fluid for IV administration) in 100mL VIAFLEX Level of Harm - Minimal harm or (a type of plastic container) was observed removed from the manufacturer's overwrap. The bags were stored potential for actual harm in a regular zip lock bag inside the IV E-kit. The manufacturer's expiration dates on the bags indicated 7/25 (July 2025). However, there were no labels on the bags indicating the open date when the bags were first Residents Affected - Some removed from the manufacturer's overwrap, the duration of storage for how long the out-of-overwrap bags can maintain its stability at the room temperature, or the expiration date when the bags should be discarded.

On January 9, 2025, at 11:58 a.m., during an interview with the DON, the DON stated the pharmacy had provided the facility with supporting documents regarding the storage duration for Baxter's small volume IV fluid bags.

A record review of the documents received from the pharmacy titled Persisting Shortage and Supply Disruption of SVP (small volume parenteral) and LVP (large volume parenteral) fluids continue, dated on January 7, 2025, indicated .The American System of Health Care Pharmacists (ASHP) has provided guidance that these (Baxter's) VIAFLEX bags after removal from protective overwrap are good for 30 days at room temperature .

2c. On January 6, 2025, at 4:02 p.m., during an inspection of medication refrigerator in the Oasis medication room with the IPRN, two bottles of Lorazepam (a controlled medication to treat anxiety or agitation) oral concentrate 2mg/mL solution were observed without the open dates. One bottle of Lorazepam was 30mL size manufacture's bottle kept in a manufacture's box. The other bottle of Lorazepam was a small amber bottle containing 15mL solution with pharmacy label attached on the bottle indicating the manufacturer as Pharmaceutical Association Inc. The manufacturer of both Lorazepam oral solution bottles found in the refrigerator was Pharmaceutical Association Inc.

A review of the manufacturer's instructions on the package inserts and the lorazepam manufacturer's box container indicated, .Dispense only in the bottle and only with the calibrated dropper provided .Discard opened bottle after 90 days .do NOT repackaging the contents of the bottle. To dispense as a child-resistant package, replace bottle closure only with the calibrated dropper provided .

2d. On January 7, 2025, at 2:55 p.m., an inspection of medication cart at the Oasis nursing station with Licensed Vocational Nurse (LVN) 14 identified Latanoprost (medication to treat high pressure inside the eye due to glaucoma) eye drop container without an open date.

During a concurrent observation and interview with LVN 14, LVN 14 verified there was no open date written

on the auxiliary label attached on the manufacturer's box and the medication bottle for the Latanoprost. LVN 14 read the manufacturer's package inserts that was inside the medication box, and stated the medication bottle can be stored at room temperature up to 6 weeks.

A review of the facility's policy and procedure titled Medications and Medication Labels, dated January 2023, indicated, .Nursing staff should document the date opened on multi-dose vials on the attached auxiliary label .

2e. On January 7, 2025, at 3:38 p.m., an inspection of medication cart at the [NAME] nursing station was conducted with LVN 15 identified Lantus Solostar 3mL insulin pen without an open date.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 60 of 93 555339 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555339 B. Wing 01/10/2025

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 0761 During a concurrent observation and interview with LVN 15, LVN 15 verified the Lantus Solostar insulin pen was stored at the room temperature inside the medication cart and there was no open date written on the Level of Harm - Minimal harm or pen. potential for actual harm

On January 9, 2025, at 11:08 a.m., during an interview with the DON, the DON stated staff was expected to Residents Affected - Some write the open date on the medication or the medication label for proper storage and disposition procedures.

A review of the facility's policy and procedure titled, Storage of Medication, dated January 2023, indicated, . Insulin products should be stored in the refrigerator until opened. Note the date on the label for insulin vials and pens when first used .Opened insulin pens can be stored at room temperature .

3. On January 7, 2025, at 3:40 p.m., during an inspection of medication cart in the [NAME] nursing station with LVN 15, a discontinued order of Lorazepam blister card was observed stored in the active stock. The label on the blister card indicated the order was for Resident 11 with the direction of Lorazepam 0.5mg tablet, give 1 tablet by mouth every evening as needed for 14 days for anxiety, and the pharmacy fill date was 9/27/24 (November 27, 2024). There were two tablets of Lorazepam remaining in the blister card.

On January 7, 2025, at 3:40 p.m., during a concurrent observation, interview and record review with the LVN 15, LVN 15 verified the order was discontinued on November 19, 2024. LVN 15 acknowledged the discontinued medications were not to be stored in the medication cart and the medication should have been removed from the medication cart and placed to the designated location. LVN 15 also stated the discontinued controlled medications should have been given to the DON for further disposition procedures.

A review of the facility's policy and procedure titled, Discontinued Medications, dated January 2023, indicated, .If a prescriber discontinues a medication, the medication container is removed from the medication cart according to state/federal regulations in a timely manner .

A review of the facility's policy and procedure titled, Discarding and Destroying Medications, revised April 2019, indicated, .All unused controlled substances shall be retained in a securely locked area with restricted access until disposed of .

4a. On January 8, 2025 at 9:22 a.m., during an inspection of the treatment cart with LVN 16, it was noted Santyl Collagenase ointment (topical enzyme prescription medication to remove damaged or burned skin, aiding in wound care and the growth of healthy skin) 30g (gram - unit of measurement) did not contain pharmacy-applied labels (one containing information such as patient name, medication name, direction for use, prescription number) on the ointment tube and the outside of its manufacturer's box.

During a concurrent observation and interview with the LVN 16, LVN 16 confirmed the Santyl ointment tube and the manufacturer's box did not contain any labels. LVN 16 stated the Santyl ointment should have been properly labeled to be stored in the treatment cart.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 61 of 93 555339 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555339 B. Wing 01/10/2025

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 0761 On January 9, 2025, at 11:08 a.m., during an interview with the DON, the DON acknowledged the prescription medications should have been labeled for safe use in the facility. The DON also stated that with Level of Harm - Minimal harm or help of a RN consultant who comes to the facility on ce a month, the DON checks the expiration dates of potential for actual harm medications within the facility and dispose any expired medications identified.

Residents Affected - Some A review of the facility's policy and procedure titled, Medications and Medication Labels, dated January 2023, indicated, .Medications are labeled in accordance with currently accepted professional principles including appropriate auxiliary and cautionary instructions to promote safe medication use following state and federal laws .The provider pharmacy permanently affixes label to the outside of prescription containers .

A review of the facility's policy and procedure titled, Medication Labeling and Storage, dated 2001 MED-PASS, indicated, .if medication containers have missing, incomplete, improper or incorrect labels, contact the dispensing pharmacy for instructions regarding returning or destroying these items .

A review of the facility's policy and procedure titled Consultant Pharmacist Services Provider Requirements, dated January 2023, indicated .Quality assurance (random) inspections of mediation storage areas, carts and rooms at appropriate intervals to check for proper storage, cleanliness and dating of medications .This includes checking of emergency medications supplies (kits) to ascertain that they are properly maintained, and that the contents are not outdates .

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 62 of 93 555339 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555339 B. Wing 01/10/2025

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 0791 Provide or obtain dental services for each resident.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 50204 potential for actual harm Based on observation, interview, and record review, the facility failed to identify, refer, and follow up the Residents Affected - Few dental needs for the resident, for one of one resident reviewed for dental (Resident 22).

These failures have the potential to place the resident at high risk for complications related to dental and psychosocial needs due to the possible delay in providing dental devices.

Findings:

On January 6, 2025, at 3:52 p.m., during a concurrent observation and interview with Resident 22 in her room, resident was observed with missing upper and lower teeth and unable to speak words clearly. Resident 22 stated she requested the staff and social worker she wanted to see the dentist so she can have recommendation to have dentures, but she had not been seen by a dentist since admission. Resident 22 further stated, I am embarrassed to smile and it's hard to chew a food.

On January 9, 2025, Resident 22's record was reviewed. Resident 22 was admitted to the facility on [DATE REDACTED], with diagnoses that included depression and gastro esophageal reflux disease (stomach contents flow back to tube connecting the mouth and stomach).

A review of Resident 22's Minimum Data Set (MDS - an assessment tool), dated September 30, 2024, indicated Resident 22 had .No natural teeth or tooth fragment(s) (edentulous) .

A review of Resident 22's Order Summary Report, dated November 1, 2024, indicated, .Dental consult and treatment .

A review of Resident 22's Social History Assessment, dated November 4, 2024, indicated Resident 22 had dentures as not applicable and had no dental needs.

On January 7, 2025, at 10:41 a.m., an interview was conducted with Licensed Vocational Nurse (LVN) 6. LVN 6 stated Resident 22 had missing dentition when she was admitted to the facility. LVN 6 stated Resident 22 had not been referred to the dentist for the missing teeth. LVN 6 stated if Resident 22 did not have teeth,

it would be hard for her to eat, socialize and would be embarrassed to smile when she communicates. LVN 6 further stated, It's embarrassing to smile if I don't have teeth. LVN 6 stated Resident 22 should have been referred to the dentist to evaluate dental condition and take necessary actions for the resident to have a set of teeth.

On January 9, 2025, at 10:06 a.m., an interview was conducted with the Social Service Director (SSD). The SSD stated the dental issues of Resident 22 was not addressed and not seen by a dentist of the facility. The SSD stated there was a standing order for dental consultation and treatment but there was no appointment for Resident 22 to visit a dentist. The SSD further stated Resident 22 should have been identified the dental issues and referred to a dentist.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 63 of 93 555339 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555339 B. Wing 01/10/2025

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 0791 On January 9, 2025, at 10:13 a.m., an interview was conducted with the Facility Dentist (FD). The FD stated dental checkup should have been regular and should have not been taken for granted, he added teeth were Level of Harm - Minimal harm or vital and it was connected to nutrition and psychosocial wellbeing. The FD stated if resident requested to see potential for actual harm a facility dentist, social service staff should have been made an appointment to addressed dental issues. The FD further stated, Facility should have been called me and I'm available anytime. Residents Affected - Few

On January 9, 2025, at 4:24 p.m., an interview was conducted with the Director of Nursing (DON). The DON stated she expected all licensed nurses and social service staff to follow policy and procedure regarding dental management. The DON further stated dental issues should have been identified, referred, and followed up to accommodate the request of the residents.

A review of the facility's policy and procedure titled, Dental Services, dated December 2013, indicated, . Routine and the emergency dental services are available to meet the residents oral health services in accordance with the resident's assessment and plan of care .Routine and 24-hour emergency dental services are provided to our residents through .a contract agreement with a licensed dentist that comes to facility .referral to the residents personal dentist .referral to community dentist; or referral to other health care organizations that provide dental services .Social services representatives will assist residents with appointments, transportation arrangements .

A review of the facility's policy and procedure titled, Dental Examination/ Assessment, dated December 2013, indicated, .Each resident shall undergo a dental assessment prior to or within ninety (90) days of admission .Resident shall be offered dental services as needed .Upon conducting a dental examination, a resident needing dental services will be promptly referred to a dentist .

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 64 of 93 555339 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555339 B. Wing 01/10/2025

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 0801 Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. Level of Harm - Minimal harm or potential for actual harm 44504

Residents Affected - Few Based on interviews and record review, the facility failed to ensure the Food Service Director (FSD - the position responsible for the day-to-day operation of the dietary department), met the educational requirements as outlined in the facility's policy, Federal Regulation, and California Health and Safety Code.

Findings:

According to California Code of Regulations, Title 22: Dietetic services are defined as the provision of safe, satisfying, and nutritionally adequate food for residents with appropriate staff, space, equipment, and supplies. Staffing requirements of dietetic services are such that if the position responsible for the day-to-day management of the department is not a registered dietitian there must be a full-time person who meets specific training requirements to be the dietetic services supervisor, responsible for the operation of the food service.

According to the California, Health, and Safety Code - HSC S 1265.4: Qualifications of Dietary Supervisor:

(b) The dietetic services supervisor shall have completed at least one of the following educational requirements:

(1) A baccalaureate degree with major studies in food and nutrition, dietetics, or food management and has one year of experience in the dietetic service of a licensed health facility.

(2) A graduate of a dietetic technician training program approved by the American Dietetic Association, accredited by the Commission on Accreditation for Dietetics Education, or currently registered by the Commission on Dietetic Registration.

(3) A graduate of a dietetic assistant training program approved by the American Dietetic Association.

(4) Is a graduate of a dietetic services training program approved by the Dietary Managers Association and is

a certified dietary manager credentialed by the Certifying Board of the Dietary Managers Association, maintains this certification, and has received at least six hours of in-service training on the specific California dietary service requirements contained in Title 22 of the California Code of Regulations prior to assuming full-time duties as a dietetic services supervisor at the health facility.

(5) Is a graduate of a college degree program with major studies in food and nutrition, dietetics, food management, culinary arts, or hotel and restaurant management and is a certified dietary manager credentialed by the Certifying Board of the Dietary Managers Association, maintains this certification, and has received at least six hours of in-service training on the specific California dietary service requirements contained in Title 22 of the California Code of Regulations prior to assuming full-time duties as a dietetic services supervisor at the health facility.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 65 of 93 555339 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555339 B. Wing 01/10/2025

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 0801 (6) A graduate of a state approved program that provides 90 or more hours of classroom instruction in dietetic service supervision, or 90 hours or more of combined classroom instruction and instructor led Level of Harm - Minimal harm or interactive Web-based instruction in dietetic service supervision. potential for actual harm (7) Received training experience in food service supervision and management in the military equivalent in Residents Affected - Few content to paragraph (2), (3), or (6).

On January 6, 2025, at 10:09 a.m., an interview was conducted with the Food Service Director (FSD). The FSD stated he had been working in this facility for seven (7) years. The FSD stated he started as a [NAME] and Diet Aide and was promoted to Food Service Director there (3) years ago. The FSD stated, I am currently at my 1st semester to obtained my Certified Dietary Manager.

On January 8, 2025, at 3:03 p.m., a concurrent interview and record review was conducted with the Administrator (ADM) and the Regional Director of Clinical Services (RDCS). Explained to the facility, since

the facility did not have a qualified dietetic services supervisor, the facility should have a full-time person either qualified as a Dietary Service Supervisor or a full time dietitian acting as a dietetic services supervisor for compliance with both Federal and State regulations. The facility document titled Agreement to Provide Dietetic Consultations Services and Registered Dietitian Nutritionist Long-Term Care Job Description was reviewed with the ADM and the RDCS. Both records were not aligned with the Food Service Director position. It was noted that neither the contract for the Registered Dietitian (RD) or the RD position description included the responsibility of the day to day operational or staff supervision of the dietetic services.

On January 9, 2025, at 10:02 a.m., an interview was conducted with RD 1. RD 1 stated she was aware the FDS did not possess the required certification for his job position. RD 1 stated she worked on Monday, Tuesday, Thursday and remotely on Sundays. RD 1 stated she usually worked 24 -28 hours per week. RD 1 stated she spend at least two times per week, usually 20 -30 minutes each time, approximately one to two hours per week overseeing the dietetic services by checking temperature log, labeling, and dating food in walk in refrigerator, sanitation bucket concentration, ensuring cooks are following menus and providing in-service training per the FDS request. RD 1 stated she would spend 90 percent of her working hours focus

on residents' clinical nutrition.

A review of RD 1's weekly hours from June 2, 2024 to December 28, 2024 indicated RD 1 was consistently limited to 28 hours, except for the week ending July 25, 2024 where 31 hours of consultative services were provided.

A review of the facility's Job Description titled, Dietary Supervisor, undated, indicated, .Education: Must be a graduate of an approval dietary manager's course that meet the state and federal care regulations .

A review of the facility's policy and procedure titled, Personnel Management, dated 2015, indicated, . POLICY: A qualified Dietary Service Supervisor, chosen by the Administrator, is responsible for the total operation of the Dietary Department. All Dietetic service is performed under their direction. Procedure: If a person is not a Registered Dietitian, he must be a graduate of a state approved course that provided ninety or more hours of classroom instruction in Dietetic Service Supervision .or have met equivalent requirements .

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 66 of 93 555339 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555339 B. Wing 01/10/2025

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 0802 Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. Level of Harm - Minimal harm or potential for actual harm 44504

Residents Affected - Some Based on observation, interview, and record review, the facility failed to ensure the Food service staff were able to carry out the functions of food and nutrition services safely and effectively when:

1. [NAME] 1 and Food Service Director (FSD) did not follow the recipes to prepare pureed foods items (bread, chicken, and vegetable) during dinner meal on January 6, 2025; (Cross reference 803)

2. [NAME] 1 and Diet Aide 3 used water as sanitizer to clean used kitchen equipment;

3. [NAME] 1, [NAME] 2, and Diet Aide 3 did not follow manufacturer guideline instruction time length for submerging washed kitchenware in sanitizer sink; and

4. [NAME] 1, [NAME] 2, and Diet Aide 4 did not follow facility's sanitization policy and procedure to clean the used prep counter and equipment.

These failures had the potential to cause foodborne illness for 161 out of 165 sampled residents who received foods from the kitchen and aspiration (accidentally inhaling food or liquid into the lungs) and providing insufficient nutrients for twelve out of twelve sample residents who had physician order for pureed diet (the food texture should be smooth for residents who have difficulty chewing and/ or swallowing ability).

Findings:

On January 6, 2025, at 3:25 p.m., a concurrent observation and interview was conducted with [NAME] (CK) 1 inside the kitchen. There was a pan of cooked bread, a pan of cooked chicken which half of the pan was filled with liquid and a pan of vegetable (green bean and carrot) which half of the pan was filled with liquid inside the steamer table. In a concurrent interview with CK 1, CK1 1 stated he was going to used the cooked bread, chicken and vegetable inside the steamer as pureed food items for tonight's dinner.

On January 6, 2025, at 3:47 p.m., a concurrent pureed bread preparation observation and interview was conducted with CK 1. CK 1 stated he used half load of wheat bread with 240 milliliter (a unit of measurement) two percent milk and 2 tablespoons butter to make the cooked bread. Instead using blender to make pureed bread. CK 1 was observed to use a whisk to puree the cooked bread. The end product of pureed bread appeared lumpy. CK 1 did not follow any recipe while preparing the pureed bread.

On January 6, 2025, at 4:14 p.m., a preparation of pureed vegetable observation and interview was conducted with CK 1. CK 1 took the pan of vegetable out from the steamer and directly pour into blender then blended the vegetable. The end product of pureed vegetable turned out watery. CK 1 stated he needed to add three cups of thickener (powder used to make liquid thicker) to form the pureed vegetable pudding consistency. CK 1 did not follow any recipe while preparing the pureed vegetable.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 67 of 93 555339 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555339 B. Wing 01/10/2025

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 0802 On January 6, 2025, at 4:23 p.m., a preparation of pureed chicken observation and interview was conducted with CK 1. CK 1 stated he forgot how many pieces baked chicken he put inside the pan. CK 1 took out the Level of Harm - Minimal harm or pan of chicken from the steamer and directly pour into blender and then blended it. The end product of potential for actual harm pureed chicken turned out watery. CK 1 stated he needed to add one and half cup thickener to form the pureed chicken pudding consistency. CK 1 did not follow any recipe while preparing the pureed chicken. Residents Affected - Some

On January 6, 2025, at 4:33 p.m., an interview was conducted with the Food Service Director (FSD). He was asked to demonstrate how to prepare pureed foods. The FSD stated the proper way to make pureed chicken or vegetable was to blend the chicken or vegetable in a blender with gradually adding water until a smooth consistency is achieved.

On January 8, 2025, at 10:02 a.m., an interview was conducted with Registered Dietitian (RD) 1. RD 1 stated pureed food items need to be smooth to prevent residents from aspirating or spitting it out which could result

in insufficient calorie intake, weight loss, vitamin, and mineral deficiency. RD 1 stated the bread should be placed in the blender when making pureed bread. RD 1 stated food service employee should use broth, juice or milk instead of water when adding into pureed foods becuase water lacks nutrients. RD 1 explained excess liquid should be removed from the meat and vegetables before blending as excess liquid dilutes nutrients, which affects the taste. RD 1 stated Food service staff should follow the recipes when they prepare

the pureed foods.

A review of the job description Dietary Supervisor, indicated, .The Dietary Supervisor will direct and assist

the preparation and service of regular meals and therapeutic diets .Essential Duties: Direct and participate in food preparation and service of food that is safe and appetizing and is the quality and quantity to meet each resident's needs in accordance with physicians order in compliance with approved menus .

A review of the job description Cook, indicated, .Essential Duties .Prepare pureed foods .

2. On January 6, 2025, at 3:03 p.m., a concurrent observation and interview was conducted with [NAME] (CK) 1. CK 1 was asked to check the red bucket sanitizer before he used to clean the prep table. CK 1 dipped the test strip into the sanitizer, the test strip turned become orange color. CK 1 attempted two more times, the test strip still remained orange color. CK 1 stated orange color on the test strip meant the sanitizer was not in the right concentration for sanitation.

On January 6, 2025, at 3:13 p.m., a concurrent observation and interview was conducted with Diet Aide (DA) 3. DA 3 was asked to check the red bucket sanitizer after she used to clean the meal cart. DA 3 dipped the test strip into the sanitizer, the test strip turned orange color. DA 3 stated orange color on the test strip indicated the sanitizer was not in right concentration for sanitation.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 68 of 93 555339 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555339 B. Wing 01/10/2025

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 0802 On January 6, 2025, at 3:36 p.m., a concurrent observation and interview was conducted with the FSD and CK 1 in front of three compartment sinks [three sinks (one for wash, one for rinse and another one for Level of Harm - Minimal harm or sanitizer) use for cleaning used kitchenware]. The FSD explained sanitizer dispenser which was located potential for actual harm above the 3-compartment sinks had 2 pipe line, one for water and another one for sanitizer. The FSD stated

after pressing sanitizer dispenser, water come out first, then the Food service staff had to wait for a while for Residents Affected - Some the sanitizing solution to come out. The FSD stated when Food service staff see the bubble come out from

the line that means the water is already mixing with the sanitizer, then they could collect the solution into the red bucket and checked for the sanitizer concentration. CK 1 stated he was not aware he needed to wait water mixing with the sanitizer.

On January 9, 2025, at 10:02 a.m., an interview was conducted with RD 1. RD 1 stated when the sanitizer test strip showed orange color that meant there was no sanitizer, it was just water. RD 1 stated Food service staff needed to wait for the sanitizer to mix with the water to check the red bucket sanitizer. RD 1 stated the test strip had to show green peas color to indicate the right concentration of sanitizer. RD 1 stated the potential risk to use water as sanitizer was the prep counter and equipment was not properly sanitized which could cause cross contamination and bacteria to grow in the kitchen.

A review of the job description Cook, indicated, .Essential Duties .Maintain quaternary (sanitizer) solution in sanitizer buckets (red bucket) .

A review of the facility's policy and procedure titled, DEMONSTRATING FOOD SAFETY AND JOB COMPETENCY FOR FOOD AND NUTRITION SERVICES EMPLOYEES, dated 2023, indicated, .POLICY: Each Food and Nutrition Services employee must be able to demonstrate competency in the food safety principles and job skills the facility requires .

3. A review of the manufacturer guideline directions for Scout Pot and Pan Wash Procedure, poster which was posted above the 3-compartment sinks indicated, .5. Submerge in sanitizer sink for one minute .

On January 7, 2025, at 3:07 p.m., an interview was conducted with CK 2. CK 2 was asked how long she needed to submerge washed kitchenware into the sanitizer sink. CK 2 stated she needed to submerge washed kitchenware into the sanitizer for five (5) seconds.

On January 7, 2025, at 3:26 p.m., an interview was conducted with DA 3. DA 3 was asked how long she needed to submerge washed kitchenware into the sanitizer sink. DA 3 stated she needed to submerge washed kitchenware into the sanitizer for 15 - 20 seconds.

On January 7, 2025, at 3:33 p.m., an interview was conducted with CK 1. CK 1 was asked how long he needed to submerge washed kitchenware into the sanitizer sink. CK 1 stated he usually just dipped the washed kitchen ware into sanitizer like three (3) seconds.

On January 9, 2025, at 10:02 a.m., an interview was conducted with RD 1. RD 1 stated Food service staff needed to submerge washed kitchenware into the sanitizer sink for one (1) minute per manufacturer guideline. RD 1 stated washed kitchenware which was not sanitized properly if submerge in the sanitizer sink less than 1 minute could lead to cross contamination and bacterial growth.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 69 of 93 555339 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555339 B. Wing 01/10/2025

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 0802 4. On January 7, 2025, at 11:32 a.m., a concurrent observation and interview was conducted with DA 4. DA 4 used sanitizer to clean the two meal carts. DA 4 confirmed she only used sanitizer to clean the meal carts. Level of Harm - Minimal harm or potential for actual harm On January 7, 2025, at 3:43 p.m., a concurrent observation and interview was conducted with CK 1. CK 1 cleaned the soiled stove with soap and sanitizer. CK 1 stated he used the green bucket (soap and water) to Residents Affected - Some wash the stove and then sanitized it with the sanitizer (red bucket).

On January 7, 2025, at 3:45 p.m., a concurrent observation and interview was conducted with CK 2 at the Prep cook area. CK 2 cleaned the prep counter by using soap and sanitizer after preparing dessert. CK 2 confirmed she cleaned the prep counter by using soap and sanitizer.

January 9, 2025, at 10:02 a.m., an interview was conducted with RD 1. RD 1 stated Food service staff should follow the steps wash, rinse, and sanitizer to clean the used prep counter and equipment. RD 1 explained not following wash, rinse, sanitizer steps could lead to not properly sanitizing the used prep counter and equipment which could lead to cross contamination and bacterial growth.

A review of the facility's policy and procedure titled, Sanitization, indicated, .The food service area shall be maintained in a clean and sanitary manner .Manual washing and sanitizing will employ a three-step process for washing, rinsing and sanitizing .Scrape food particles and wash using hot water and detergent .Rinse with hot water to remove soap residue .Sanitize with .chemical sanitizing solution .For fixed equipment or utensils that do not fit in the dishwashing machine, washing shall consist of the following steps .washed according to manual or dishwashing procedures .

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 70 of 93 555339 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555339 B. Wing 01/10/2025

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 0803 Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. Level of Harm - Minimal harm or potential for actual harm 48240

Residents Affected - Some Based on observation, interview, and record review, the facility failed to ensure:

1. Recipes were followed to prepare pureed food items (bread, chicken, and vegetables) during dinner meal

on January 6, 2025. This failure had the potential for 15 out of 15 residents receiving pureed food prepared

in the kitchen to not meet their nutritional needs which may lead to nutritional related health complications; and

2. Recipes for seasoning broccoli was followed during lunch meal on January 7, 2025 (Cross reference

F-F804). This failure had the potential for 161 out of 165 residents receiving food prepared in the kitchen to not meet their nutritional needs which may lead to nutritional related health complications.

Findings:

1. On January 6, 2025, at 3:25 p.m., during an observation in the kitchen, there were pureed chicken and vegetables (carrots and green beans) in separate deep pans inside the steamer. Both half of the deep pans were filled with liquid.

On January 6, 2025, at 3:47 p.m., during a concurrent observation and interview with [NAME] (CK) 1, CK 1 was observed preparing pureed bread. CK 1 stated he used a half loaf of wheat bread, 240 milliliters (a unit of measurement) of 2% milk and two tablespoons of butter to cook the bread in steamer. CK 1 used a whisk to puree the cooked bread. The finished pureed bread appeared lumpy. CK 1 was observed not follow any recipe when preparing pureed bread.

On January 6, 2025, at 4:14 p.m., during a concurrent observation and interview with CK 1, CK 1 was observed to puree the vegetables. CK 1 took out the vegetables (carrots and green beans), half of the deep pan was liquid, from steamer and directly poured into blender and then blended the vegetables. The end product of the pureed vegetable was observed to be watery. CK 1 stated he needed to add three cups of thickener (a substance used to make a liquid thicker) into the pureed vegetables to form a pudding consistency. CK 1 was observed not to follow any recipe when preparing the pureed vegetables.

On January 6, 2025, at 4:23 p.m., during a concurrent observation and interview with CK 1, CK 1 was observed preparing pureed chicken. CK 1 took out the chicken from steamer and directly poured into blender and then blended the chicken with a lot of water. CK 1 could not remember how may pieces of baked chickens were placed in the blender. The end product of pureed chicken was observed watery. CK 1 stated

he needed to add one and half cups of thickener into the pureed chicken to form pudding consistency. CK 1 was observed not to follow any recipe when preparing the pureed chicken.

On January 6, 2025, at 4:33 p.m., a concurrent interview and test tray (to evaluate the quality of a meal

during a meal service and identify any areas for improvement) for pureed food items was conducted with the Food Service Director (FSD). The FSD stated the following:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 71 of 93 555339 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555339 B. Wing 01/10/2025

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 0803 a. The pureed bread was grainy and was not smooth. The FSD stated the residents who recived pureed bread could choke, spit out the food and lose interest in eating, potentially leading to decreased food intake Level of Harm - Minimal harm or and weight loss. The FSD stated the proper way to puree bread is to blend bread mix, hot water and potential for actual harm margarine until a smooth texture is achieved;

Residents Affected - Some b. The proper way to puree chicken is to blend the total amount of chicken per servings needed and add water gradually until a smooth consistency is achieved, then add thickener to ensure a pudding thick texture is achieved; and

c. The food service employee need to follow the recipes because the recipe served as their guidance.

On January 9, 2025, at 10:18 a.m., during an interview with Registered Dietitian (RD) 1, RD 1 stated the following:

a. Pureed food needs to be smooth to prevent residents from aspirating or spitting it out which could result in insufficient calorie intake, weight loss, vitamin, and mineral deficiency;

b. When making pureed bread, the bread should be placed in the blender and the recipe should be followed. RD 1 stated milk or something nutrient should have been added instead of water as it lack nutritional value;

c. Water should be removed from meat and vegetables before blending as water dilutes nutrients, affects the taste and may lead to poor nutrition and weight loss. RD 1 stated adding more thickener does not taste good and it dilutes the nutrional value of the food which could lead to weight loss.

A review of the facility's document titled (name of facility) Diet Type Report dated January 6, 2025, indicated 12 residents, Residents 18, 38, 44, 58, 96, 109, 126, 463, 513, 663, 664 and 665 were on a pureed diet.

A review of the facility's policy and procedure titled FOOD PREPARATION, dated 2023, indicated, . the facility will use approved recipes, standardized to meet the resident census .

A review of the facility's policy and procedure titled, MENU PLANNING, dated 2023, indicated, .Standardized recipes adjusted to appropriate yield shall be maintained and used in food preparation .

A review of the facility document procedure titled, RECIPE: PUREED .VEGETABLES, dated 2024, indicated, .Complete regular recipe .Puree on low speed to a paste consistency before adding any liquid .Gradually add warm liquid (low sodium broth or milk) if needed .start with smaller amount and adding more as needed to achieve desired consistency .The finished pureed item should be smooth and free of lumps, hold its shape, while not being too firm or sticky, and should not weep .

A review of the facility document titled RECIPE: PUREED .MEATS, dated 2024, indicated, .Complete regular recipe .Puree on low speed to a paste consistency before adding any liquid .Gradually add warm liquid (low sodium broth or gravy) .starting with smaller amount and adding in more as needed to achieve desired consistency .The finished pureed item should be smooth and free of lumps, hold its shape, while not being too firm or sticky, and should not weep .

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 72 of 93 555339 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555339 B. Wing 01/10/2025

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 0803 A review of the facility document titled, RECIPE: PUREED .BREAD And Other BREAD PRODUCTS, dated 2025, indicated, .Measure out the total number of portions needed for pureed diet .Puree on low speed Level of Harm - Minimal harm or adding milk gradually .The finished pureed item should be smooth and free of lumps, hold its shape, while potential for actual harm not being too firm or sticky, and should not weep .

Residents Affected - Some 2. On January 7, 2025, at 10:34 a.m., during a concurrent observation and interview with CK 3, CK 3 placed five packages of broccoli (each package was two pounds), and placed it into the streamer. CK 3 did not add any seasoning to the broccoli.

A review of the facility document titled RECIPE: SEASONED BROCOLLI dated 2024, indicated .Directions . Boil or steam broccoli until tender .Melt margarine and salt. Pour over broccoli and mix gently to combine .

On January 7, 2025, at 11:00 a.m., during an observation, CK 3 took out broccoli from steamer and directly placed in the steam table (a food-holding equipment designed to keep hot foods at a safe holding temperature) and did not add any seasoning prior serving.

On January 7, 2025, at 12:18 p.m., a concurrent interview and test tray of broccoli was performed with the FSD. The FSD stated the broccoli lacked of salt.

On January 9, 2024, at 10:02 a.m., during an interview with RD 1, RD 1 stated that not following the recipe affects the taste of food which can lead to residents' poor oral intake, inadequate nutrient intake and more weight loss.

A review of the facility document titled (name of facility) Diet Type Report, dated January 6, 2025, indicated there were 162 residents on regular, mechanical soft and pureed diets.

A review of the facility's policy and procedure titled, MENU PLANNING dated 2023, indicated, .Standardized recipes adjusted to appropriate yield shall be maintained and used in food preparation .

A review of the facility's policy and procedure titled FOOD PREPARATION, dated 2023, indicated, . the facility will use approved recipes, standardized to meet the resident census .Add a variety of seasonings to

the vegetables to vary their taste and appeal .

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 73 of 93 555339 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555339 B. Wing 01/10/2025

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 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Level of Harm - Minimal harm or 48240 potential for actual harm Based on observation, interview, and record review, the facility failed to follow its policy and procedure to Residents Affected - Some provide appetizing and palatable (refers to the taste and/or flavor of the food) food at appropriate temperatures according to residents' preferences, for nine out of 161 sample residents, Residents 2, 3, 20, 34, 45, 87, 103, 145, and 264.

This failure placed residents at potential risk to decrease nutritional intake and affect the resident's nutrition status.

Findings: (Cross reference 804)

On January 6, 2025, at 10:39 a.m., during an interview, Resident 45 stated the egg salad did not have any real egg cut up in it and is like baby food, the cheese enchiladas are hard and brittle. Resident 45 stated he had spoken to the manager, but nothing changed.

On January 6, 2025, at 11:58 a.m., during an interview, Resident 264 stated her food was lukewarm and a little on the cold side.

On January 6, 2025, at 12:05 p.m., during an interview, Resident 34 stated the food is often served cold for all meals.

On January 6, 2025, at 12:10 p.m., during an interview, Resident 103 stated the food was always very bland.

On January 7, 2025, at 8:56 a.m., during an interview, Resident 145 stated the food is not good and tasteless, so he does not eat it. Resident 145 stated he spoke to dietary staff, and nothing changed.

On January 7, 205, at 9:38 a.m., during an interview, Resident 20 stated the food does not taste good and came warm, almost cold.

On January 7, 2025, at 9:58 a.m. during an interview, Resident 2 stated the menu is not very tasty and gets tiresome after time.

On January 7, 2025, at 11:46 a.m., during an interview, Resident 87 stated served soup sometimes is cold .

On January 7, 2025, at 12:18 p.m., a concurrent interview and test tray (to evaluate the quality of a meal

during a meal service and identify any areas for improvement) for mechanical soft diet was performed with

the Food Service Director (FSD). The FSD confirmed the broccoli lacked of seasoning.

On January 7, 2025, at 4:27 p.m., during an interview, Resident 3 stated he did not like the food and the alternative choices are not any better, that is why he does not eat.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 74 of 93 555339 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555339 B. Wing 01/10/2025

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 0804 On January 9, 2024, at 10:02 a.m., during an interview with Registered Dietitian (RD) 1, RD 1 stated food service employee should follow the recipes to prepare tasty meals otherwise residents would not eat the Level of Harm - Minimal harm or served meals which can lead to inadequate nutrient intake, and weight loss. potential for actual harm

A review of the facility's policy and procedure titled, MEAL SERVICE, dated 2023, indicated, .Meals that Residents Affected - Some meet the nutritional needs of the resident will be served in an accurate and efficient manner, and served at

the appropriate temperatures .Temperature of the food when the resident receives it is based on palatability .

A review of the facility's policy and procedure titled FOOD PREPARATION dated 2023, indicated .The food & Nutrition Services employee who prepares the food will sample it to be sure the food has a satisfactory flavor and consistency .

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 75 of 93 555339 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555339 B. Wing 01/10/2025

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 0805 Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. Level of Harm - Minimal harm or potential for actual harm 48240

Residents Affected - Some Based on observation, interview, and record review, the facility failed to ensure pureed bread was prepared following the recipe, for 12 of 12 residents (Residents 18, 38, 44, 58, 96, 126, 109, 463, 513, 663, 664 and 665) who had physician prescribed order for pureed diet texture.

This failure had the potential to place the residents at risk of aspiration (accidentally inhaling food or liquid into the lungs), choking and decreased meal intake.

Findings:

On January 6, 2025, at 3:47 p.m., during a concurrent observation and interview with [NAME] (CK) 1, CK 1 was preparing pureed bread. CK 1 stated he used a half loaf of wheat bread, 240 milliliters (a unit of measurement) of 2% milk and two tablespoons of butter to cook the bread in the steamer. CK 1 used a whisk to puree the cooked bread. The finished pureed bread appeared lumpy. CK 1 was observed not to follow any recipe when preparing pureed bread.

On January 6, 2025, at 4:33 p.m., a concurrent interview and taste test (to evaluate the quality of a meal

during a normal meal service and identify any areas of improvement) for pureed food items was conducted with the Food Service Director (FSD). The pureed bread had grainy texture. The FSD stated the pureed bread was grainy and was not smooth. The FSD stated the residents who recived pureed bread could choke, spit out the food and lose interest in eating, potentially leading to decreased food intake and weight loss. The FSD stated food servie employee need to follow the recipes because the recipe served as their guidance to prepare meals.

On January 8, 2025, at 10:02 a.m., during an interview with Registered Dietitian (RD) 1, RD 1 stated pureed food needs to be smooth to prevent residents from aspirating or spitting it out which could result in insufficient calorie intake, weight loss, vitamin, and mineral deficiency. RD 1 explained when making pureed bread, the bread should be pureed in a blender, not mixed with the whisk, and the recipe should be followed.

A review of the facility document titled Diet type Report, dated January 6, 2025, indicated there were 12 residents on pureed texture diet, Residents 18, 38, 44, 58, 96, 126, 109, 463, 513, 663, 664 and 665.

A review of the facility's policy and procedure titled REGULAR PUREED DIET, dated 2023, indicated, .The pureed diet is a regular diet that has been designed for residents who have difficulty chewing an/or swallowing. The texture of the food should be of a smooth and moist consistency and able to hold its shape . All foods are prepared in a food processor or blender .

A review of the facility's policy and procedure titled MENU PLANNING, dated 2023, indicated, .The menus are planned to meet nutritional guidelines, Physician's orders and, to the extent medically possible

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 76 of 93 555339 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555339 B. Wing 01/10/2025

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 0805 A review of the facility's recipe titled RECIPE: PUREED .BREAD And Other BREAD PRODUCTS, dated 2025, indicated, .Measure out the total number of portions needed for pureed diet .Puree on low speed Level of Harm - Minimal harm or adding milk gradually .The finished pureed item should be smooth and free of lumps, hold its shape, while potential for actual harm not being too firm or sticky, and should not weep .

Residents Affected - Some

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 77 of 93 555339 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555339 B. Wing 01/10/2025

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 0806 Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. Level of Harm - Minimal harm or potential for actual harm 44504

Residents Affected - Few Based on observation, interview, and record review, the facility failed to ensure resident's beverage preference was honored on January 6, 2025 lunch and protein substitution was given on January 9, 2025 breakfast for one of one sampled resident (Resident 116).

This failure resulted in Resident 116 not to receive sufficient calories and protein which could contribute to

the unplanned weight loss, further compromising Resident 116's nutritional and medical status.

Finding: (Cross reference 692)

On January 6, 2025, at 11:37 a.m., Resident 116 was interviewed. Resident 116 stated he was a vegetarian and the vegetable that he was eating was always canned food and was not fresh.

On January 6, 2025, at 12:12 p.m., a concurrent observation, interview and meal ticket review was conducted with Resident 116 at the bedside. Resident 116 was lying in bed with the noon meal tray in front of him. Resident 116's meal ticket indicated a, Regular diet, yogurt, extra Veg [vegetables], 4 fluid ounce (oz) apple juice, 4 fluid oz cranberry juice, Dislikes: Meat, Fish, eggs. Resident 116 was served mashed potatoes, peas and tofu as the entree, yogurt, pudding, and water. Resident 116 stated, there was no cranberry juice and apple juice on his meal tray. Resident 116 stated, I should have apple juice and cranberry juice so I will eat more and gives me more appetite. Resident 116 finished his entree mashed potatoes, peas and tofu, and yogurt.

On January 6, 2025, at 12:35 p.m., an interview was conducted with Licensed Vocational Nurse (LVN) 17. LVN 17 confirmed Resident 116 did not receive cranberry juice and apple juice on his meal tray. LVN 17 stated Food and Nutrition service employee should followed the meal ticket served 4 oz apple juice and 4 oz cranberry juice to Resident 116. LVN 17 stated without apple juice and cranberry juice Resident 116 would not receive sufficient calories as meal plan recommended by the Registered dietitian.

On January 9, 2025, at 8:34 a.m., a breakfast meal observation was conducted with Resident 116 at the bedside. Resident 116 was served 1 piece of waffle and 1 piece of hash brown as entree, 4 fluid oz apple juice, 4 fluid oz cranberry juice, 1 serving oatmeal and 8 oz of whole milk. Observed the served meal tray, protein food item served as part of entree missing. Resident 116 finished all served food items except waffle.

The menu for breakfast included a bacon egg scramble, however Resident 116 was not offered a protein based substitution.

On January 9, 2025, at 9:19 a.m., an interview was conducted with [NAME] (CK) 2. CK 2 stated egg was served as the protein item for breakfast, however since Resident 116 disliked eggs, she only served the waffle and harsh browns. CK 2 was unable to locate a vegetarian menu, recipes, or a Cooks Spreadsheet (the document used to guide dietary staff on food items, portions, and therapeutic diet). CK 2 stated for vegetarian diets she usually substituted tofu or cheese for the meat. CK 2 admitted she did not consult Food service director (FSD) or Registered Dietitian (RD) for meal substitution.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 78 of 93 555339 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555339 B. Wing 01/10/2025

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 0806 On January 9, 2025, at 11:51 a.m. an interview was conducted with Registered Dietitian (RD) 1. RD 1 stated, Resident 116 like juice. He would not eat foods but drinks juices. RD 1 stated, the missing juices for the Level of Harm - Minimal harm or lunch meal tray on January 6, 2025 resulted in Resident 116 being offered fewer calories than his plan of potential for actual harm care. RD 1 stated it was very important to honor Resident 116's beverage preferences in an effort to encourage Resident 116 to eat. RD 1 confirmed Resident 116 did not receive a protein substitution during Residents Affected - Few the January 9, 2025 breakfast meal. RD 1 stated the [NAME] should have substituted a protein like cheese, peanut butter or cottage cheese. RD 1 acknowledged the missing juices and protein food item lead to calories and protein deficiency for the observed meal which could contribute the weight loss for Resident 116. RD 1 stated the bottom line was food service employees need to follow the vegetarian menu to provide sufficient calories and nutrition and to honor Resident food or beverage preferences.

On January 9, 2025, at 2:39 p.m., an interview was conducted with the Director of Nursing (DON). The DON acknowledged the missing apple juice and cranberry juice on Resident 116's meal tray could contribute weight loss. The DON stated Resident 116 did not receive sufficient calories with the lack of substitution for

the protein food item at breakfast on January 9, 2025, which could also contribute to Resident 116's unplanned weight loss. The DON stated Food and Nutrition Service employee should consult dietitian for appropriate protein substitution on January 9, 2025 breakfast. The DON stated the Food and Nutrition Service employee should follow the vegetarian menu to ensure provide sufficient calories and nutrition for Resident 116.

A review of the facility policy and procedure titled FOOD PREFERENCES, dated 2023, indicated, .Resident's food preference will be adhered to within reason. Substitutes for all foods disliked will be given from the appropriate food group .

A review of the facility policy and procedure titled Therapeutic Diets, dated 2001, indicated, .Therapeutic diets are prescribed by the attending physician to support the resident's treatment and plan of care and in accordance with his or her goals and preferences. 1. Diet will be determined in accordance with the resident's informed choices, preferences .

A review of the facility policy and procedure titled Menus, revised October 2017, indicated, .Menus are developed and prepared to meet resident choices .while following established national guidelines for nutritional adequacy. Policy Interpretation and Implementation .Menus meet the nutritional needs of residents

in accordance with the recommended dietary allowances of the Food and Nutritional Board (National Research Council and National Academy Sciences) .If a food group is missing from a resident's daily diet (e. g. dairy products), the resident is provided an alternative means of meeting his or her nutritional needs .

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 79 of 93 555339 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555339 B. Wing 01/10/2025

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 0809 Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to Level of Harm - Minimal harm or eat at non-traditional times or outside of scheduled meal times. potential for actual harm 44504 Residents Affected - Some Based on observations, interviews, and record reviews, the facility failed to ensure evening snacks were offered to eight of nine residents (Residents 3, 124, 464, 50, 67, 76, 11, and 13).

This failure had the potential to affect the nutritional and wellbeing of the residents.

Findings:

On January 7, 2025, at 10:30 a.m., during the resident council meeting, Residents 3, 124, and 464 stated

they were not offered evening snacks. Resident 124 stated when she asked for evening snack it took a long time for nursing to get the snack for her.

On January 7, 2025, at 8:03 p.m., an observation was conducted at Nurse station Dunes area. Diet Aide (DA) 1 delivered a black container consist of evening snacks to Nurse station. Each food item inside the black container was labeled with resident's name and room number, there was no extra snacks available.

On January 7, 2025, at 8:09 p.m., an interview was conducted with Certified Nurse Aide (CNA) 6. CNA 6 stated he only passed evening snacks with resident's name on the food items. He never offered evening snacks for residents. CNA 6 stated if a resident wanted an evening snack, then the resident had to request evening snack from him. CNA 6 stated he had go to kitchen to ask for evening snack if resident request, because there was no extra snacks available.

On January 7, 2025, at 8:18 p.m., an interview was conducted with Resident 50. Resident 50 stated she had been staying in this facility for six years and she had never been offered evening snacks. She stated it would be nice nursing staff would offer him evening snacks.

On January 7, 2025, at 8:20 p.m., an interview was conducted with Resident 67. Resident 67 stated she had to ask for evening snack, and nobody offered to her.

On January 7, 2025, at 8:24 p.m., an interview was conducted with CNA 7. CNA 7 stated he did offer snacks for residents but there was no extra snacks available for other residents. CNA 7 stated he needed to go to

the kitchen to ask for snacks. CNA 7 stated it would be more efficient if the kitchen could provide extra snacks.

On January 7, 2025, at 8:38 p.m., an interview was conducted with Resident 76. Resident 76 stated once in

a while nursing offered him evening snack. Resident 76 stated it would be very nice if nursing staff would offer him evening snack daily. Resident 76 stated sometimes he had go to nurse station to ask for evening snack.

On January 7, 2025, at 8:41 p.m., an interview was conducted with Resident 11. Resident 11 stated nursing never offer her evening snack.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 80 of 93 555339 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555339 B. Wing 01/10/2025

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 0809 On January 7, 2025, at 8:43 p.m., an interview was conducted with Resident 13. Resident 13 stated nursing never offer her evening snack and she had to ask for the evening snack. Level of Harm - Minimal harm or potential for actual harm On January 8, 2025, at 10:50 a.m., an interview was conducted with the Food Service Director (FSD). The FSD stated Dietary staff would make enough evening snacks for the residents who had a physician order for Residents Affected - Some bedtime snacks and those residents who request evening snacks per his interview. The FSD confirmed there were no extra evening snacks available for nursing to offer to residents. The FSD acknowledged he should put extra evening snacks, so nursing could offer to residents.

On January 9, 2025, at 10:02 a.m., an interview was conducted with Registered Dietitian (RD) 1. RD 1 stated evening snacks should be offered to all residents. RD 1 explained staying in this facility should be like staying at home like environment. RD 1 stated residents could excess evening snacks and enjoy snacks while watching television while at home. RD 1 stated the residents should be offered evening snacks like at home environment to make residents happy and maintain wellbeing. RD 1 further stated sometimes residents get hungry at night and offered evening snacks would satisfy them.

A review of the facility's policy and procedure titled, Snacks (Between Meal and Bedtime), Serving, revised dated September 2010, indicated, .The purpose of this procedure is to provide the residents with adequate nutrition .

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 81 of 93 555339 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555339 B. Wing 01/10/2025

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 0812 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food

in accordance with professional standards. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 48240

Residents Affected - Some Based on observations, interview, and record review, the facility failed to ensure safe and sanitary food preparation and storage practices in the kitchen when:

1. Thawed, uncooked meat (chicken and bacon) was stored in the walk-in refrigerator past their use-by dates;

2. A coffee cart was stored next to an uncovered trash bin;

3. Trash was found on the kitchen floor in multiple areas;

4. Worn-out cutting boards were still in use by dietary staff;

5. Buildup was found on different kitchen equipment;

6. Moldy, bruised, wilted, and wrinkled produce (tomatoes, cucumber, zucchini, red bell peppers and strawberries) were found in the walk-in refrigerator;

7. A rolling cart used to store soup bowls and dessert cups had chipping white coating;

8. Food residue was on the condiment tray underneath the prep area;

9. Dust accumulation in several areas of the kitchen was found;

10. An opened cheese enchilada stored in the walk-in freezer exposed to the air; and

11. An expired cranberry cocktail was stored inside the nourishment room refrigerator.

These failures had the potential to cause foodborne illnesses (stomach illness acquired from ingesting contaminated food) in a medically vulnerable population of 162 of 165 residents who received food prepared

in the kitchen.

Findings:

1. On [DATE REDACTED], at 10:37 a.m., a concurrent observation in the walk-in refrigerator and an interview with the Food Service Director (FSD) was conducted. There were meat (chicken and bacon), in separate containers, stored at the bottom shelf and each were labeled with a preparation date of [DATE REDACTED], and a use by date of [DATE REDACTED]. The chicken was observed completely thawed with pink, bloody juice. The FSD confirmed chicken and bacon were labeled with a preparation date of [DATE REDACTED], and a use by date of [DATE REDACTED].

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 82 of 93 555339 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555339 B. Wing 01/10/2025

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 0812 On [DATE REDACTED], at 10:02 a.m., during an interview with Registered Dietitian (RD) 1, RD 1 stated according to their policy, chicken should be used in two days after thawed and bacon should be used in five days. The RD Level of Harm - Minimal harm or stated if the meat (chicken and bacon) was used beyond what was indicated in their policy, it can potentially potential for actual harm cause the residents to get sick.

Residents Affected - Some A review of the facility's policy and procedure titled PROCEDURE FOR REFRIGERATED STORAGE, dated 2023, indicated, .Frozen food should be left in a refrigerator to thaw .Once thawed, uncooked meat is to be use within 2 days . The policy further indicated a maximum refrigeration time .for bacon was five days .

2. On [DATE REDACTED], at 8:40 a.m., during an observation in the kitchen, a coffee cart with a box of opened packets cocoa powder was stored next to an uncovered trash bin.

On [DATE REDACTED], at 9:12 a.m., during an interview with the FSD, the FSD stated the coffee cart should not be stored next to a trash bin and the packets of cocoa should be thrown away because of cross contamination.

On [DATE REDACTED], at 10:02 a.m., during an interview with RD 1, RD 1 stated the coffee cart was stored next to a trash bin in the dishwashing area, where dietary staff scraped left over foods from the meal cart. RD 1 stated

it was not a good spot to place the coffee cart because the dietary staff can accidentally splash left over foods to the coffee urn/cart, and it can cause cross contamination.

A review of the U.S Food and Drug Administration's (FDA) Food Code 2022, indicated, .Cleanliness of the food establishment is important to .aid in preventing the contamination of food and equipment .

3. On [DATE REDACTED], at 8:56 a.m., during a concurrent observation in the dry storage room and an interview with

the FSD, there was trash on the floor, under the shelves. The FSD stated trash should not be on the floor.

On [DATE REDACTED], at 10:08 a.m., during an observation of an area outside the kitchen that leads to the dining room, there was a prep table with sink and was used as storage. There was trash under the prep table.

On [DATE REDACTED], at 3:57 p.m., during an interview with the FSD, the FSD stated the area outside the kitchen that leads to the dining room was called the cove area. The FSD was asked to go to the cove area. The FSD stated there was trash under the prep table. The FSD stated trash should not be there.

On [DATE REDACTED], at 10:02 a.m., during an interview with RD 1, RD 1 stated the floor should be cleaned as it can cause cross contamination, and they did not want to get the residents sick.

A review of the U.S. Food and Drug Administration's (FDA) Food Code 2022, Section ,d+[DATE REDACTED].13 Nonfood-Contact Surfaces, the Food Code, indicated, .The presence of food debris or dirt on nonfood contact surfaces may provide a suitable environment for the growth of microorganisms which employees may inadvertently transfer to food. If these areas are not kept clean, they may also provide harborage for insects, rodents, and other pests .

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 83 of 93 555339 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555339 B. Wing 01/10/2025

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 0812 A review of the facility's policy and procedure titled, Sanitation, revised [DATE REDACTED], indicated, .Kitchen and dining room surgaces not in contact with food shall be cleaned on a regular schedule and frequently enough Level of Harm - Minimal harm or to prevent accumulation of grime . potential for actual harm 4. On [DATE REDACTED], at 2:51 p.m., during a concurrent observation in the kitchen and an interview with [NAME] Residents Affected - Some (CK) 1, a green cutting board was on the prep table, and it did not have a smooth surface. CK 1 stated he used the green cutting board to chop the zucchinis and he used it a lot. CK 1 stated the cutting board did not have a smooth surface and had stain on it. CK 1 further stated it needs to be replaced.

On [DATE REDACTED], at 4:09 p.m., during a concurrent observation of the kitchen's cutting boards and an interview with the FSD, there were three cutting boards in the kitchen. The cutting boards did not have smooth surfaces and have stain on them. The FSD stated when cutting boards have rough surfaces, they could hold bacteria and will not be cleaned properly.

On [DATE REDACTED], at 10:02 a.m., during an interview with RD 1, RD 1 stated when cutting boards are not smooth, it could catch food particles and cause cross contamination.

A review of the U.S FDA (Food and Drug Administration) Food Code 2022, Section ,d+[DATE REDACTED].12 Cutting Surfaces, the FDA Food Code, indicated, .Cutting surfaces such as cutting boards and blocks that become scratched and scored may be difficult to clean and sanitize. As a result, pathogenic microorganisms transmissible through food may build up or accumulate. These microorganisms may be transferred to foods that are prepared on such surfaces .

5. On [DATE REDACTED], at 11:15 a.m., during a concurrent observation in the kitchen and an interview with the FSD,

the blender base had food buildup on it. The FSD stated they should keep the blender base clean.

On [DATE REDACTED], at 9:07 a.m., during a concurrent observation of two coffee dispensers and an interview with the FSD, the two coffee dispensers' spouts had black buildup around it, there was also a hot waterspout with white buildup around it. The FSD stated the dietary staff oversaw cleaning of the coffee dispensers. The FSD stated the coffee dispensers' spout had backsplash of coffee around it and the hot waterspout had calcium buildup around it. The FSD stated the buildup of coffee backsplash and calcium should not be there because

it could get into the water and bacteria can grow in it.

On [DATE REDACTED], at 10:02 a.m., during an interview with RD 1, RD 1 stated the blender base, coffee and hot waterspouts need to be kept clean because it can cause cross contamination.

A review of the U.S Food and Drug Administration's (FDA) Food Code 2022, ,d+[DATE REDACTED].13 Nonfood-Contact Surfaces , indicated, .The presence of food debris or dirt on nonfood contact surfaces may provide a suitable environment for the growth of microorganisms which employees may inadvertently transfer to food. If these areas are not kept clean, they may also provide harborage for insects, rodents, and other pests .

A review of the U.S Food and Drug Administration's (FDA) Food Code 2022, indicated, .Cleanliness of the food establishment is important to minimize attractants for insects and rodents, aid in preventing the contamination of food and equipment, and prevent nuisance conditions .

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 84 of 93 555339 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555339 B. Wing 01/10/2025

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 0812 6. On [DATE REDACTED], at 10:37 a.m., during a concurrent observation in the walk-in refrigerator and an interview with

the FSD, the following produce was found: Level of Harm - Minimal harm or potential for actual harm - Five tomatoes with soft and black spots;

Residents Affected - Some - One wrinkled cucumber;

- One wrinkled zucchini;

- Three red bell peppers, with soft spots and wrinkles;

- Two-16-ounce containers of strawberries with white mold.

The FSD stated the produce had soft spots, were bruised, wilted and moldy. The FSD stated the food service workers were supposed to throw them away. The FSD stated he did not want to serve food in bad quality to the residents.

On [DATE REDACTED], at 10:02 a.m., during an interview with RD 1, RD 1 stated produce that have soft spots, were bruised, wilted, wrinkled and moldy should be thrown out. RD 1 stated mold could cause residents to get sick. RD 1 stated they did not want to serve residents produce that was not fresh as it can cause them to get sick.

A review of the facility's policy and procedure titled PROCEDURE FOR REFRIGERATED STORAGE, dated 2023, indicated, .fresh produce is used, free of any wilting or spoilage .

7. On [DATE REDACTED], at 3:31 p.m., during an observation in the kitchen, the white coating of the rolling cart used to store soup bowls and dessert cups, was chipped.

On [DATE REDACTED], at 4:02 p.m., during a concurrent observation of the rolling cart and an interview with the FSD,

the FSD stated the rolling cart did not have a smooth surface and the white coating was chipped. The FSD stated food service employee were unable to properly sanitize equipment that did not have a smooth surface which could harbor bacteria.

On [DATE REDACTED], at 10:02 a.m., during an interview with RD 1, RD 1 stated the rolling cart needs to be replaced because chipped paint could fall into the food. In addition, RD 1 stated any equipment that was not in good shape needed to be repaired or replaced.

A review of the facility's policy and procedure titled Sanitization, Revised [DATE REDACTED], indicated, .All .equipment shall be kept clean, maintained in a good repair and shall be free from .chipped areas that may affect their use or proper cleaning .

8. On [DATE REDACTED], at 2:52 p.m., during an observation in the kitchen, there was food residue on the condiment tray under the cook's prep table.

On [DATE REDACTED], at 2:52 p.m., during an interview with the FSD, the FSD stated the condiment tray had food residue. The FSD stated food residue should not be in the condiment tray. The FSD stated the morning cook was responsible for keeping his work area clean.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 85 of 93 555339 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555339 B. Wing 01/10/2025

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 0812 On [DATE REDACTED], at 10:02 a.m. during an interview with RD 1, RD 1 stated the dietary staff should find a better place to store the condiments and they should keep that area clean because it can cause cross Level of Harm - Minimal harm or contamination. potential for actual harm

A review of the U.S. Federal and Drug Administration (FDA) Food Code 2022, ,d+[DATE REDACTED].13 Residents Affected - Some Nonfood-Contact Surfaces , indicated, .The presence of food debris or dirt on nonfood contact surfaces may provide a suitable environment for the growth of microorganisms which employees may inadvertently transfer to food. If these areas are not kept clean, they may also provide harborage for insects, rodents, and other pests .

9. On [DATE REDACTED], at 10:37 a.m., during a concurrent observation in the walk-in refrigerator and an interview with

the FSD, there was buildup of dust on the door frame and on the food cart. The FSD confirmed there was dust on the door frame and on the food cart. The FSD stated equipment used in the kitchen needs to be clean.

On [DATE REDACTED], at 3:03 p.m., during a concurrent observation of the cook's area and interview with CK 1, there was buildup of dust and grease on the hood and vent above the stove. CK 1 admitted there was buildup of dust and grease on the hood and vent above the stove. CK 1 stated it should not be like that because dust and grease could fall while preparing food at the stove.

On [DATE REDACTED], at 3:25 p.m., during a concurrent observation of the cook's area and an interview with the FSD,

the FSD stated there was dust on the hood and it should not be there because dust can fall on the food and

the food can get contaminated.

On [DATE REDACTED], at 10:08 a.m., during an observation of the cove area, there was buildup of dust on the shelves used to store cleaned, clear plastic storage bins.

On [DATE REDACTED], at 4:01 p.m., during a concurrent observation in the cove area and an interview with the FSD, the FSD stated the shelves need to be wiped down to avoid cross contamination.

On [DATE REDACTED], at 10:02 a.m., during an interview with RD 1, RD 1 stated dust could fall into the food and cause cross contamination. RD 1 stated the door frame of the walk-in refrigerator, the hood and vents above the stove and the shelves in the cove area should be clean.

A review of the facility's policy and procedure titled Sanitization, revised [DATE REDACTED], indicated, The food service area shall be maintained in a clean and sanitary manner .All .equipment shall be kept clean .

10. On [DATE REDACTED], at 11:07 a.m., during a concurrent observation in the walk-in freezer and an interview with

the FSD, an opened box of cheese enchiladas was exposed to air. The FSD stated food items in the walk-in freezer are supposed to be sealed, otherwise the food will get freezer burn.

On [DATE REDACTED], at 10:02 a.m., during an interview with RD 1, RD 1 stated opened food items in the walk-in freezer should not be exposed to air due to freezer burn. RD 1 stated freezer burn affects the quality of food. RD 1 further explained food stored in the walk-in freezer should be sealed to prevent other things falling into

the opened unsealed food items.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 86 of 93 555339 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555339 B. Wing 01/10/2025

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 0812 A review of the facility's policy and procdure titled PROCEDURE FOR FREEZER STORAGE, dated 2023, indicated, .Store frozen foods in an airtight moisture-resistant wrapper such as a plastic bag or freezer paper Level of Harm - Minimal harm or to prevent freezer burn . potential for actual harm 11. On [DATE REDACTED], at 9:55 a.m., during an observation of the refrigerator in the nourishment room of (name of Residents Affected - Some unit), an opened carton of thickened cranberry cocktail was observed with an open date of [DATE REDACTED] (12 days since it was opened). A review of the thickened cranberry cocktail carton indicated .Thickened Cranberry Cocktail from Concentrate .Directions .After opening, may be kept up to 7 days under refrigeration .

On [DATE REDACTED], at 9:58 a.m., during an interview with Licensed Vocational Nurse (LVN) 1, LVN 1 stated the thickened cranberry cocktail was opened on [DATE REDACTED], and it can be used up to the expiration date. LVN 1 was asked to read the directions at the back of the carton. LVN 1 stated the directions indicated it can be used up to seven days after it was opened. LVN 1 stated it should not be given to the residents because it was beyond the expired date indicated in the instructions.

On [DATE REDACTED], at 10:02 a.m., during an interview with RD 1, RD 1 stated thickened cranberry cocktail stored beyond the manufacturer's recommended expiration date should be discarded, otherwise it can get residents sick.

A review of the facility's policy and procedure titled PROCEDURE FOR REFRIGERATGED STORAGE, indicated, .REFRIGERATED STORAGE GUIDE .THICKENED LIQUIDS: Follow manufacturer's instructions .

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 87 of 93 555339 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555339 B. Wing 01/10/2025

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 0814 Dispose of garbage and refuse properly.

Level of Harm - Minimal harm or 48240 potential for actual harm Based on observation, interview, and record review, the facility failed to ensure garbage bins were not Residents Affected - Many overflowing and properly closed, for two of five garbage bins. In addition, trash was found on the ground beneath the dumpsters.

This failure had the potential to attract pests and rodents.

Findings:

On January 6, 2025, at 4:50 p.m., the loading dock was observed with the Food Service Director (FSD). Two of five dumpsters were observed overflowing with boxes, the lids were not fully closed, and trash was found

on the ground beneath the dumpsters. In a concurrent interview with the FSD, he stated the lids should be properly closed and trash should not be on the ground, as this could attract pests and rodents.

On January 9, 2025, at 10:02 a.m., during an interview with Registered Dietitian (RD) 1, RD 1 stated the dumpster lids should be properly closed, as it attracts pests and flies, which could go the kitchen when the door is open. RD 1 further stated it would be also an infection control issue.

A review of the facility's policy and procedure titled MISCELANEOUS AREAS, dated 2023, indicated, . Garbage and trashcans must be inspected daily that no debris is on the ground or surrounding area, and that

the lids are closed . The trash collection area is a potential feeding ground for vermin and rodents and must be kept clean .The area must be swept and washed down by maintenance with a detergent on a regular basis .

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 88 of 93 555339 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555339 B. Wing 01/10/2025

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 0880 Provide and implement an infection prevention and control program.

Level of Harm - Minimal harm or 49113 potential for actual harm Based on observation, interview and record review, facility failed to ensure infection control practices were Residents Affected - Few implemented when Certified Nursing Assistants (CNA) did not wear personal protective equipment (PPE - equipment used to protect against infection or illness) when providing care to a resident with enhanced barrier precautions (EBP- infection control intervention to reduce transmission of multi-drug resistant organism [MDRO- bacteria that have become resistant to multiple antibiotics]).

This failure had the potential spread infections throughout the facility, which is transferred through direct close contact of skin to skin or sharing of bedding or clothing.

Findings:

On January 7, 2025, at 9:37 a.m., Resident 463's door was observed to have a sign posted indicating Enhanced Barrier Precaution (EBP). Resident 463 was observed lying in bed with eyes open and the call light was on. Observed CNAs 8 and 9 to enter Resident 463's room, cleaned and changed Resident 463 without wearing a PPE.

On January 7, 2025, at 9:48 a.m., during an interview with CNA 8, she stated there was no available PPE inside or outside Resident 463's room. CNA 8 stated she was aware Resident 463 was on EBP for wounds. CNA 8 stated she was rushing and forgot to put on her PPE. CNA 8 further stated she should have put on PPE to prevent spreading bacteria to other residents.

On January 7, 2025, at 9:57 a.m. an interview with CNA 9 was conducted. CNA 9 stated she was aware Resident 463 was on EBP because of her wounds. CNA 9 stated she forgot to use PPE and should have used it to prevent spreading germs to others.

On January 8, 2025, Resident 463 record was reviewed. Resident 463 was admitted to the facility December 1, 2024, with diagnoses which included hemiplegia (partial paralysis on one side of the body).

A review of Resident 463's Order Summary, included a physician's order, dated December 2, 2024, which indicated, .Enhanced barrier precautions during high contact resident care activities secondary to pressure ulcers every shift .

A review of Resident 463's Physician's Progress Notes, dated December 4, 2024, indicated, . bed bound with and urine incontinence .continue wound care to left knee and left heel .

A review of Resident 463's Care Specialist Log - (weekly skin treatment log), dated January 2, 2025, indicated Resident 463 had multiple wounds at the abdomen, sacrococcyx (tail bone) extending to the right buttocks, and the side of the ankle.

On January 10, 2025, at 6:40 p.m., during an interview with Licensed Vocational Nurse (LVN) 6, she stated

the facility staff was to wear gown and gloves when providing care to resident with pressure ulcers. LVN 6 stated there is a sign outside the resident's door for EBP and the reason for the EBP at the back of the card.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 89 of 93 555339 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555339 B. Wing 01/10/2025

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 0880 On January 10, 2025, at 6:44 p.m. during an interview was conducted with the DON, the DON stated the staff was made aware of residents who were on EBP during staff morning huddles, infection prevention Level of Harm - Minimal harm or in-service and by EBP signs placed at the designated resident's door. The DON further stated staff were potential for actual harm expected to wear all necessary PPE to avoid spreading infections. The DON stated the staff should have had

on PPE when administering high contact care for Resident 463. Residents Affected - Few

A review of the facility's policy and procedure titled, Personal Protective Equipment, dated October 2018, indicated, .Personnel who perform tasks that may involve exposure to blood/body fluids are provided appropriate personal protective equipment (PPE) .A supply of protective clothing and equipment is maintained at each nurses' station. PPE required for transmission-based precaution is maintained outside and inside the residence room as needed .

A review of the facility's policy and procedure titled, Isolation - Transmission-Based Precautions & Enhancement Barrier Precautions, dated September 2022, indicated, .Enhanced barrier precautions are indicated for residents with any of the following .Wounds, even if the resident is not known to be infected or colonized with the MDRO .Wear gowns and gloves while performing the following high contact tasks associated with the greatest risk for MDRO contamination of staff hands, clothes, and the environments such as .Any care activity where close contact with the resident is expected to occur, such as bathing, peri-care, assisting with toileting, changing incontinence brief, respiratory care, changing bed linens .

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 90 of 93 555339 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555339 B. Wing 01/10/2025

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 0908 Keep all essential equipment working safely.

Level of Harm - Minimal harm or 50204 potential for actual harm Based on observation, interview, and record review, the facility failed to ensure bed equipment in the Residents Affected - Few residents' rooms were maintained in a safe operating condition, when the bed controls were observed to have damaged and exposed wirings, for two of seven residents reviewed (Residents 8 and 318).

This failure to maintain a functional environment had the potential to compromise resident safety.

1. On January 6, 2025, at 9:38 a.m., a concurrent observation and interview was conducted with Resident 8 inside her room. The bed control to the left of Resident 8's bed was observed damaged, and the inner wire was exposed. Resident 8 stated she reported it a long time ago, but was never repaired. Resident 8 further stated every time she used the bed control, It makes me nervous.

On January 7, 2025, at 3:08 p.m., an interview was conducted with the Maintenance Supervisor (MS). The MS stated the bed control cord was torn and the inner wires were exposed. The MS stated the bed control cord should have been fixed and replaced to prevent further damage, that led to malfunction of the device.

The MS further stated, It should have been repaired or replaced as soon as possible.

On January 10, 2025, at 10:56 a.m., an interview was conducted with the Administrator (ADM). The ADM stated he expected the maintenance staff to repair any damaged devices and make sure it worked properly.

The ADM further stated the broken device should have been replaced or repaired to provide a safe and functional environment for the resident.

2. On January 7, 2025, at 12:40 p.m., a concurrent observation and interview was conducted with Resident 318 inside the room. Resident 318's bed control was found to be damaged, with the wiring exposed through

the thick, black protective covering. Resident 318 stated, It worries me with the wiring on the bed control showing, so I keep it toward the end of the bed.

On January 7, 2025, at 12:52 p.m., an interview was conducted with the Maintanence Assistant (MA) 2. MA 2 stated the wiring for the bed control should not be showing through the black covering.

A review of the facility's policy and procedure titled, Maintenance Service, dated December 2009, indicated, . Maintenance service shall be provided to all areas of the building, grounds, and equipment .The Maintenance department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times .Functions of maintenance personnel include .maintaining the building in compliance with current federal, state, and local laws, regulations, and guidelines .maintaining the building in good repair and free from hazards .

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 91 of 93 555339 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555339 B. Wing 01/10/2025

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 0921 Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 50204

Residents Affected - Some Based on observation, interview, and record review, the facility failed to provide a sanitary and comfortable environment, for two of seven residents reviewed for environment (Residents 22 and 63), when:

1. For Resident 22, appropriate window covering to block the light per resident's preference was not provided; and

2. For Resident 63, multiple black stained patches of bathroom floors were observed inside the resident's room. In addition, rooms [ROOM NUMBERS] were also observed to have black stained patches on the bathroom floors.

These failures resulted in the resident feeling uncomfortable and disrupted the resident's daily living needs and environment.

Findings:

1. On January 6, 2025, at 3:52 p.m., during a concurrent observation and interview with Resident 22 in her room, a multi-colored bath towel was observed hanging over a brown vertical window blind. Resident 22 stated she had asked the nurses to replace the window blinds with darker shades to block the light that came through the window. Resident 22 stated the nurse hung the bath towel to cover the brightness of the sun light. Resident 22 further stated the bath towel cannot cover the entire blind, and stated It was still bright, and

it strikes on my face.

On January 7, 2025, at 8:24 a.m., during an interview with the Maintenance Supervisor (MS), the MS stated

the towel should not have used to block the brightness and it was not good to see a bath towel hanging in

the window. The MS further stated the blinds should have been replaced with darker shades to block the brightness of the sun.

On January 10, 2025, at 10:50 a.m., during an interview with the Administrator (ADM), the ADM stated the staff should have been treated the facility as resident's second home. The ADM stated, the blinds should have been replaced to provide Resident 22's comfort. The ADM further stated, The blinds should have been replaced as resident requested.

2. On January 6, 2025, at 3:02 p.m., a concurrent observation and interview was conducted with Resident 63

in her room, multiple black stained patches were observed in bathroom floor. Resident 63 stated she don't remember the color of the bathroom floor, but it should be clean. Resident 63 further stated, I don't want to use stained floor.

On January 7, 2025, at 2:25 p.m., rooms [ROOM NUMBERS]'s bathroom were observed with the Maintenance Supervisor (MS). The bathroom floors in rooms [ROOM NUMBERS] were observed to have the black stain patches. The MS stated the house keeper used a bleach cleaning solution that stained the bathroom floor. The MS further stated the old stained floor should be replaced, and It's about time to change it.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 92 of 93 555339 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555339 B. Wing 01/10/2025

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 0921 On January 10, 2025, at 11:09 a.m., during an interview with the Administrator (ADM), the ADM stated he expected to maintenance staff to make rounds and should have been checked all the corners of the room of Level of Harm - Minimal harm or the residents. The ADM further stated he agreed to MS that resident should have been provided sanitary and potential for actual harm comfortable bathroom, the ADM stated, Bathroom floor should have been changed.

Residents Affected - Some A review of the facility's policy and procedure titled, Maintenance Service, dated December 2009, indicated, . Maintenance service shall be provided to all areas of the building, grounds and equipment .Functions of maintenance personnel include .maintaining the building in compliance with current federal state, and local laws, regulations and guideline .maintaining lighting level that are comfortable .maintaining the grounds .in good order .

A review of the facility's policy and procedure titled, Homelike Environment, dated February 2021, indicated, . Residents are provided with a safe, clean, comfortable and homelike environment .The facility staff and management maximizes, to the extent as possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include .comfortable (minimum glare) yet adequate (suitable to the task) lighting .Comfortable and adequate lighting is provided in all areas of the facility to promote safe, comfortable and homelike environment. The lightning design emphasizes .reduction in glare (through the use of light filters) .maximum use of daylight .

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 93 of 93 555339