Other·February 9, 2024

F000 INITIAL COMMENTS

F000 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The following reflects the findings of the California Department of Public Health during an Abbreviated Standard Survey for the investigation one complaint. Complaint Number: CA00870327. Representing the Department: Health Facilities Evaluator Nurse: 47832. The inspection was limited to the specific complaint investigated and does not represent the findings of a full inspection of the facility. Three deficiencies were identified for complaint number: CA00870327.

F684 SS=D Quality of Care CFR(s): 483.25

F684 01/25/2024 § 483.25 Quality of care Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive personcentered care plan, and the residents' choices. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to ensure skin evaluation was conducted on admission for one of three sampled residents (Resident 1). In addition, the facility failed to ensure monitoring and treatment for non-pressure skin injuries were provided to Resident 1. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients . (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: DXUS11 Facility ID: CA240000634 If continuation sheet 1 of 17 PRINTED: 05/13/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555339 (X3) DATE SURVEY COMPLETED 01/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE DESERT SPRINGS POST ACUTE 74350 Country Club Dr Palm Desert, CA 92260 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE These failures had the potential to result in delayed provision of care and treatment for the resident's skin condition, which placed the resident at risk for infection and complications. Findings: On November 30, 2023, at 8:40 a.m., an unannounced visit was conducted at the facility to investigate a quality-of-care issue. A review of Resident 1's admission record indicated Resident 1 was admitted to the facility on October 2, 2023, with diagnoses which included unspecified fracture (break in continuity) of right femur (thigh bone), lack of coordination, chronic kidney disease (long standing disease of the kidneys), thrombosis (formation of blood clot within the blood vessel) of unspecified deep veins of lower extremity (both legs from hip to the toes) and thrombocytopenia (deficiency of platelets which causes bleeding in tissues, bruising and slow blood clotting after injury). A review of Resident 1's medical records did not indicate documented skin evaluation on admission. A review of Resident 1's untitled medical record which contained body assessment diagram dated October 7, 2023, indicated discoloration on the right thigh, waist area, and an incision site covered with dressing on the right hip. A review of a document titled, "Shower Sheets," (a document used by nurses and certified nursing assistants to mark changes in skin condition on shower days) dated October 12, 2023, indicated open skin to the nose, scabs and discoloration on the right shin (front of the leg below the knee) area, and a bandage on the right lateral (side away from the body) FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: DXUS11 Facility ID: CA240000634 If continuation sheet 2 of 17 PRINTED: 05/13/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555339 (X3) DATE SURVEY COMPLETED 01/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE DESERT SPRINGS POST ACUTE 74350 Country Club Dr Palm Desert, CA 92260 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE hip. A review of Resident 1's Physician Orders dated November 30, 2023, did not indicate orders for wound treatment to the open wound on the resident's nose, and right lateral hip incision site until October 16, 2023, 14 days after Resident 1 was admitted to the facility. A review of Resident 1's medical record did not indicate the wounds on the nose, and right lateral hip incision site was assessed by a nurse after it was identified on October 12, 2023, ten days after Resident 1 was admitted. On November 30, 2023, at 12:11 p.m., during an interview with a Treatment Nurse (TN), the TN stated according to the wound care protocols, if a resident had wounds, a wound care order along with frequency of treatment and care plans should be in place. The TN further stated if a change in skin condition was identified, the licensed nurse had to notify the physician, obtain treatment orders, notify the Director of Nursing (DON) and the nurse. On November 30, 2023, at 1:59 p.m., during a concurrent interview and record review with the Registered Nurse Supervisor (RNS) stated if a change of condition of skin was noted, the floor nurse would document, would notify the physician and the wound care team via progress notes right away. The RNS acknowledged Resident 1's skin assessment was not done on admission. On January 4, 2024, at 3:40 p.m., during an interview, Licensed Vocational Nurse (LVN) 2 stated if a resident was admitted with surgical wounds, the Registered Nurse (RN) had to assess the wound or whoever admitted the resident had to assess the wounds. LVN 2 stated once the wound was assessed, the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: DXUS11 Facility ID: CA240000634 If continuation sheet 3 of 17 PRINTED: 05/13/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555339 (X3) DATE SURVEY COMPLETED 01/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE DESERT SPRINGS POST ACUTE 74350 Country Club Dr Palm Desert, CA 92260 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE licensed nurse had to inform the medical doctor (MD), obtain orders and should be documented under progress notes. On November 30, 2023, at 3:20 p.m., during an interview, the DON stated the wound team conducts a daily body audit, and once a wound was identified, the DON and the physician should be notified. The DON stated nurses had to make sure treatment and dressing orders were in place for the identified wounds. The DON stated Resident 1's skin assessment should have been done on admission within 24 hours. The DON further stated a change in skin condition should be identified and the physician, wound care team, and the DON should be notified right away. A review of the facility policy and procedure titled "Skin Management Guidelines" dated March 2022 indicated " ...the Skin Worksheet is used by the nursing assistant to document skin observations ...completed worksheets are given to the licensed nurse for validation and action planning as indicated ...In the event a patient experiences a new non-pressure injury ...notify the attending physician and obtain treatment orders ..."

F686 Treatment/Svcs to Prevent/Heal Pressure Ulcer F686 01/25/2024 SS=G CFR(s): 483.25(b)(1)(i)(ii) §483.25(b) Skin Integrity §483.25(b)(1) Pressure ulcers. Based on the comprehensive assessment of a resident, the facility must ensure that(i) A resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable; and (ii) A resident with pressure ulcers receives FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: DXUS11 Facility ID: CA240000634 If continuation sheet 4 of 17 PRINTED: 05/13/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555339 (X3) DATE SURVEY COMPLETED 01/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE DESERT SPRINGS POST ACUTE 74350 Country Club Dr Palm Desert, CA 92260 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to provide care and services in preventing development of pressure injury (skin or soft tissue injuries that form due to prolonged pressure exerted over specific areas of the body), for one of three sampled residents (Resident 1), as evidenced by the following: 1. There was no skin evaluation conducted when Resident 1 was admitted on October 2, 2023, in accordance with the policy and procedure titled, " Skin Management Guidelines," dated March 2022. 2. There was no interventions developed to address Resident 1's risk for pressure ulcer on admission. The resident was assessed to be at risk for developing pressure injury. 3. Treatments for Resident 1's pressure injury on the right and left heel; sacrococcygeal; and right buttocks identified on October 12, 2023, was not initiated until October 17, 2023 (5 days after the pressure injuries were identified). These failures resulted in Resident 1 developing a Stage 2 pressure injury(partial thickness skin loss with exposed dermis) on the right and left heel, a Stage 2 pressure injury on the right buttock, and an unstageable pressure injury (full thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough [yellow/white material in the wound bed] or eschar [slough or piece of dead tissue that is cast off from the surface of FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: DXUS11 Facility ID: CA240000634 If continuation sheet 5 of 17 PRINTED: 05/13/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555339 (X3) DATE SURVEY COMPLETED 01/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE DESERT SPRINGS POST ACUTE 74350 Country Club Dr Palm Desert, CA 92260 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE the skin]) on the sacrococcyx area. Findings: On November 30, 2023, at 8:40 a.m., an unannounced visit was conducted at the facility to investigate a quality-of-care issue. A review of Resident 1's general acute care hospital wound documents titled, "Wound Ostomy Continence Nurse Consult Note," indicated the following: a. On September 29, 2023, skin tear (separation of skin) to left elbow. b. On September 30, 2023, skin tear to left arm. Further review of the general acute care hospital record titled, " Discharge Summary," dated October 2, 2023, at 5:05 p.m., indicated the resident has an incision site on the right hip. The discharge summary did not indicate Resident 1 has pressure injuries prior to being transferred to the skilled nursing facility on October 2, 2023. A review of Resident 1's Admission Record Report at the skilled nursing facility dated November 30, 2023, indicated Resident 1 was admitted to the facility on October 2, 2023, with diagnoses which included unspecified fracture (break in continuity) of right femur (thigh bone), lack of coordination, chronic kidney disease (long standing disease of the kidneys), thrombosis (formation of blood clot within the blood vessel) of unspecified deep veins of lower extremity (both legs from hip to the toes) and thrombocytopenia (deficiency of platelets which causes bleeding in tissues, bruising and slow blood clotting after injury). FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: DXUS11 Facility ID: CA240000634 If continuation sheet 6 of 17 PRINTED: 05/13/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555339 (X3) DATE SURVEY COMPLETED 01/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE DESERT SPRINGS POST ACUTE 74350 Country Club Dr Palm Desert, CA 92260 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE A review of Resident 1's medical record did not indicate a skin evaluation on admission was completed on October 2, 2023. A review of Resident 1's Braden Scale for Predicting Pressure Score Risk assessment dated October 2, 2023, indicated a Braden Score (consists of six subscales and the total scores range from 6-23. A lower Braden scores indicates higher level of risk for pressure ulcer development) of 15, indicating the resident was at risk for developing pressure ulcer. The risk assessment indicated the resident was occasionally moist, chairfast, has very limited mobility, adequate nutrition, and has a potential problem for friction/shear. A review of Resident 1's care plan titled, "At risk for alteration in skin integrity related to impaired mobility," initiated on October 2, 2023, did not indicate interventions addressing the risk for alteration in skin integrity. A review of Resident 1's medical record untitled which contained body assessment diagram for October 7, 2023, indicated a surgery site on the right hip, generalized discoloration on the right lower extremity, and discoloration on the waist area. The body assessment did not indicate pressure injuries on the sacro coccyx area, left and right heel, and right buttock. A review of Resident 1's Skin worksheet, dated October 12, 2023, indicated, an open skin to the sacro coccyx area. A review of Resident 1's Progress Notes dated October 12, 2023, (ten days after admission), by the Registered Nursing Supervisor (RNS) indicated, " CNA reported patient was displaying skin breakdown at the coccygeal region as well as bilateral heels. RN Supervisor examined lesions and established that coccygeal lesion is unstageable decubitus with FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: DXUS11 Facility ID: CA240000634 If continuation sheet 7 of 17 PRINTED: 05/13/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555339 (X3) DATE SURVEY COMPLETED 01/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE DESERT SPRINGS POST ACUTE 74350 Country Club Dr Palm Desert, CA 92260 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE eschar with no bone or tendon visible. No undermining or tunneling visualized. Patient reports no pain felt at site. Sacral dressing applied. Heel lesions are stage 2 with island dressings applied, heels elevated on pillow. Patient reports no pain at either heel." A review of Resident 1's Shower Sheet dated October 13, 2023, 11 days after admission, indicated on the posterior (back) side of the body map a cross mark on the coccyx (small triangular bone at the base of the spine) and right and left heels. The worksheet did not indicate a description of the marked areas. A review of Resident 1's Progress Notes dated October 13, 2023, indicated the RNS and the wound nurse visited Resident 1 "to assess and treat decubiti." There was no documented physician order for treatments for the open wounds on the coccyx and bilateral heels. A review of the Physician Orders dated October 16, 2023, (4 days after the pressure injuries were documented as identified) indicated treatments for the following: 1. "Right heel pressure injury open wound, clean with NS or wound cleanser, pat dry, apply Medihoney (used to clean and debride acute and chronic wounds) , cover with silicone foam dressing. every day shift every 2 day(s) for 21 Days until finished. and as needed for when saturated/soiled/dislodged." 2. "Right buttocks pressure injury partial thickness open wound, clean with NS or wound cleanser, pat dry, apply medihoney, cover with silicone foam dressing. every day shift every 2 day(s) for 21 Days until finished." 3. "left heel pressure injury open wound, clean FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: DXUS11 Facility ID: CA240000634 If continuation sheet 8 of 17 PRINTED: 05/13/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555339 (X3) DATE SURVEY COMPLETED 01/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE DESERT SPRINGS POST ACUTE 74350 Country Club Dr Palm Desert, CA 92260 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE with NS or wound cleanser, pat dry, apply medihoney, cover with silicone foam dressing. every day shift every 2 day(s) for 21 Days until finished and as needed for when saturated/soiled/dislodged." 4. "sacrococcygeal pressure injury unstageable eschar, clean with NS or wound cleanser, pat dry, apply medhoney, cover with silicone foam dressing. every day shift every 2 day(s) for 21 Days until finished and as needed for when saturated/soiled/dislodged." A review of Resident 1's Care Plan titled, "Pressure Ulcers," developed on October 16, 2023, indicated the following: Focus: "Resident has pressure ulcers at sacrococcygeal region and bilateral heels related to limited mobility." Goal: "Debridement of necrotic tissue; Free from odor; Free from signs and symptoms of infection (such as increased drainage/pain/peri wound erythema)" Interventions: "Administer treatment per physician orders; Daily body audit; Dietary consult; Friction reducing transfer surface." Further review of Resident 1's Progress notes dated October 17, 2023, (15 days after admission) by Registered Nurse (RN) 1 indicated, " Patient was admitted with unstageable pressure ulcer on sacrococcygeal and Pressure injury open wound on right and left heel stage 2...Wound # 1 Sacrococcygeal unstageable, wound bed 100 % covered with dark non-viable necrotic tissue, soft to touch, patient denies any sensitivity at time of inspection. Measures 8 x 4.5 cm., no depth...Wound # 2 Rt. buttocks stage 2, partial thickness open wound, shallow, pink wound bed, small amount of serosanguinous drainage...wound size 3 x 2 cm shallow, peri FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: DXUS11 Facility ID: CA240000634 If continuation sheet 9 of 17 PRINTED: 05/13/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555339 (X3) DATE SURVEY COMPLETED 01/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE DESERT SPRINGS POST ACUTE 74350 Country Club Dr Palm Desert, CA 92260 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE wound slightly pink 1 cm. blanchable...Wound # 3 stage 2, rt. heel pressure injury stage 2, pink wound bed, shallow, small amt. of serosanguinous drainage, size 4 x 4 cm. Wound # 4 left heel pressure injury stage 2, pink wound bed, shallow, small amt. of serosanguinous drainage, size 4 x 4 cm..." A review of Resident 1's medical record which included: the physician's progress notes on October 4, 2023; the skin worksheet dated October 7, 12, and 13, 2023; the care plan developed on October 2, 2023; did not reflect Resident 1 had the pressure injuries on admission as documented in RN 1's progress notes dated October 17, 2023. The order summary report dated November 30, 2023, did not include physician orders for treatment on Resident 1's pressure injury on sacrococcyx area, right and left heel, and right buttocks, initiated on October 2, 2023, contrary to what was indicated in the progress notes dated October 17, 2023. On November 30, 2023, at 1:59 p.m., during a concurrent interview and record review with the RNS, the RNS stated a skin assessment should be done as soon as a resident was admitted, and the assessment should be documented in the progress notes. The RNS stated skin assessment for a newly admitted resident should be conducted weekly for four weeks. The RNS stated if a change in skin condition was noted, the floor nurse should document in the progress notes, notify the physician and the wound care team right away. The RNS stated Resident 1 was admitted to the facility with no pressure injuries. The RNS verified Resident 1's skin assessment was not done on admission. On November 30, 2023, at 2:41 p.m., during a concurrent interview and record review, RN 1 stated once a pressure injury was identified, a FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: DXUS11 Facility ID: CA240000634 If continuation sheet 10 of 17 PRINTED: 05/13/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555339 (X3) DATE SURVEY COMPLETED 01/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE DESERT SPRINGS POST ACUTE 74350 Country Club Dr Palm Desert, CA 92260 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE low air loss mattress (a mattress designed to prevent and treat pressure wounds) should be ordered by the nurse after obtaining orders from the physician. RN 1 further stated the physician, the wound care team, the Director of Nursing (DON), and the Registered Dietician (RD) should be informed right away, along with the resident's family and rest of the team that a pressure injury was identified. RN 1 verified Resident 1 was admitted to the facility with no pressure injury and RN 1 stated he should have not indicated on the progress notes dated October 17, 2023, that Resident 1 was admitted with pressure injuries. On November 30, 2023, at 3:20 p.m., during an interview with the DON, the DON stated the policy and procedure in managing pressure injuries indicated if a resident was admitted with a pressure injury or developed a facility acquired pressure injury; a daily body audit, a care plan, wound treatment should be provided to the residents. She added, the physician and the resident's family should be notified of the status of the pressure injury. The DON stated the interventions for pressure injury included the following: to provide a low air loss mattress, scheduled turning /repositioning, float heels to relieve pressure and conducting daily rounds by the wound care team. The DON stated Resident 1's skin assessment should have been done within 24 hours of admission. The DON further stated a change in the skin condition should be noted and reported to the physician, the wound nurse, the DON, and the resident's responsible party. On January 4, 2024, at 9:30 a.m., during an interview with Minimum Data Set nurse (MDS nurse), the MDS nurse stated if a wound was present on admission, it should be reflected under Section M (title Skin Conditions) of the MDS and from the documentation by the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: DXUS11 Facility ID: CA240000634 If continuation sheet 11 of 17 PRINTED: 05/13/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555339 (X3) DATE SURVEY COMPLETED 01/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE DESERT SPRINGS POST ACUTE 74350 Country Club Dr Palm Desert, CA 92260 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE wound nurse. On January 4, 2024, at 3:40 p.m., during an interview, LVN 2 stated Body Audits (skin worksheet) was checked and signed by the nurses after every shower. LVN 2 stated the result of the body audit was documented in the computer under the resident's medical record. LVN 2 stated if there was a change in the resident's skin condition, it would be the responsibility of the charge nurse to notify the physician, the treatment nurse, the DON, the RNS and the resident's family and should be documented under the progress notes and skin assessment. LVN 2 stated Resident 1 did not have pressure injury on admission. She stated the skin assessment should be done within two hours of admission. LVN 2 stated if the resident needed dietary consult, it would be the responsibility of the charge nurse to call the physician to obtain an order for the consult. A review of Resident 1's medical record did not indicate a dietary consult was completed as indicated in the care plan developed on October 16, 2023. A review of the facility's policy and procedure titled "Skin Management Guidelines" dated March 20, 2022, indicated, "...Purpose ...To describe the process steps required for identification of patients at risk for the development of skin alterations, identify prevention techniques and interventions to assist with management of pressure injuries and skin alterations...Guidelines...Skin alterations and pressure injuries are evaluated and documented by the licensed nurse: using the Admission/Readmission Evaluation upon admission with a head-to-toe skin evaluation ...using the Braden Scale, weekly x 3 after admission for a total of 4 weekly evaluations ...Body audits are completed: by the licensed FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: DXUS11 Facility ID: CA240000634 If continuation sheet 12 of 17 PRINTED: 05/13/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555339 (X3) DATE SURVEY COMPLETED 01/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE DESERT SPRINGS POST ACUTE 74350 Country Club Dr Palm Desert, CA 92260 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE nurse daily with pressure injuries ...weekly for patients without pressure injuries ...by the nursing assistant during scheduled baths/showers ...Wound rounds are completed weekly... Skin prevention strategies that can be implemented upon admission for any patient ...repositioning and off-loading pressure ...pressure reducing support system, skin evaluations ...Registered dietician referral...The individualized comprehensive care plan addresses the skin management program, the goal for prevention and treatment, individualized interventions to address the patient's specific risk factors and the plan for reduction of risk. Care plan interventions to consider based upon the Braden risk categories include: ...At risk (15-18) potential intervention to consider: Repositioning/offloading/ heel protection * Manage moisture * Manage nutrition/hydration needs * Manage friction/shear * Pressure reduction support surface...In the event a patient experiences a new pressure injury complete Braden Scale ...complete the comprehensive evaluation ...notify the attending physician and obtain treatment orders, notify the patient/family/responsible party ..."

F692 SS=D Nutrition/Hydration Status Maintenance CFR(s): 483.25(g)(1)-(3)

F692 01/25/2024 §483.25(g) Assisted nutrition and hydration. (Includes naso-gastric and gastrostomy tubes, both percutaneous endoscopic gastrostomy and percutaneous endoscopic jejunostomy, and enteral fluids). Based on a resident's comprehensive assessment, the facility must ensure that a resident§483.25(g)(1) Maintains acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that this is not possible or FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: DXUS11 Facility ID: CA240000634 If continuation sheet 13 of 17 PRINTED: 05/13/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555339 (X3) DATE SURVEY COMPLETED 01/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE DESERT SPRINGS POST ACUTE 74350 Country Club Dr Palm Desert, CA 92260 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE resident preferences indicate otherwise; §483.25(g)(2) Is offered sufficient fluid intake to maintain proper hydration and health; §483.25(g)(3) Is offered a therapeutic diet when there is a nutritional problem and the health care provider orders a therapeutic diet. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to ensure nutritional assessment were completed on admission for one of three sampled residents (Resident 1). In addition, weekly weights were not completed in accordance with the policy and procedure. These failures placed Resident 1 at risk for compromised nutrition, a delay in necessary treatment and services, which has the potential to result in further decline of the resident's health status. Findings: On November 30, 2023, at 8:40 a.m., an unannounced visit was conducted at the facility to investigate a quality-of-care issue. A review of Resident 1's admission record indicated Resident 1 was admitted to the facility on October 2, 2023, with diagnoses which included unspecified fracture (break in continuity) of right femur (thigh bone), lack of coordination, chronic kidney disease (long standing disease of the kidneys), thrombosis (formation of blood clot within the blood vessel) of unspecified deep veins of lower extremity (both legs from hip to the toes) and thrombocytopenia (deficiency of platelets which causes bleeding in tissues, bruising and slow blood clotting after injury). FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: DXUS11 Facility ID: CA240000634 If continuation sheet 14 of 17 PRINTED: 05/13/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555339 (X3) DATE SURVEY COMPLETED 01/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE DESERT SPRINGS POST ACUTE 74350 Country Club Dr Palm Desert, CA 92260 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE A review of Resident 1's medical record did not indicate a nutritional assesment was completed for the resident during the 16 days stay at the facilty. A review of Resident 1's medical record indicated the resident's weight was taken on October 4, 2023, two days after Resident 1 was admitted to the facility. The record indicated Resident 1's weight on Ocotber 4, 2023, was 135.2 lbs. (pounds). Further review of record did not indicate Resident 1's weight was taken after October 4, 2023. A review of the facility document titled "Amount Meal Taken" by Resident 1 from October 3, 2023, to October 17, 2023, indicated on most days' intake was between 25 to 50% of the total meal. On November 30, 2023, at 10:00 a.m., during an interview with Certified Nursing Assistant (CNA) 1, CNA 1 stated CNAs were responsible for taking residents' weights. CNA 1 stated residents were weighed monthly, some weekly and some others if needed to be reassessed again. CNA 1 further stated, once residents were weighed, weights sheet was handed over to the Director of Nursing (DON). CNA 1 stated if a resident refused the meal, she informed the nurses. CNA 1 also stated the meal intake was documented in the residents medical record under the Tasks in Amount Meal Taken. On November 30, 2023, at 10:38 a.m., during an interview with Licensed Vocational Nurse (LVN) 1, LVN 1 stated residents were weighed weekly and monthly. LVN 1 stated the DON and the Registered Dietician (RD) informed the nurses on resident weight change. LVN 1 stated if a resident refused the meal, she provided alternatives, offered snacks and tried FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: DXUS11 Facility ID: CA240000634 If continuation sheet 15 of 17 PRINTED: 05/13/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555339 (X3) DATE SURVEY COMPLETED 01/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE DESERT SPRINGS POST ACUTE 74350 Country Club Dr Palm Desert, CA 92260 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE to find out the reason for refusing the meal. LVN 1 further stated she would inform the physician and the DON right away if a resident refused or ate 50% or less of the meal. On November 30, 2023, at 12:30 p.m., during an interview with the Registered Dietitian (RD), she stated a nutrition assessment was done on admission, quarterly and as needed. The RD stated nutritional assessment was primarily done by an RD. The RD also stated residents were weighed on admit for four weeks weekly and then monthly. She further stated the residents were also weighed as needed. The RD stated recommendations would be documented in the residents' medical record under the progress notes. The RD stated she was off during Resident 1's stay at the facility. She stated a nutritional assessment should have been completed for Resident 1. On November 30, 2023, at 3:20 p.m., during an interview, the DON stated resident weights were taken weekly and monthly. The DON stated Resident 1's weight should have been documented weekly and she verified Resident 1's weekly weights after October 4, 2023, were not in the medical record. The DON stated not monitoring weight and not completing a nutritional assessment could delay wound healing and could lead to infection of the wound. A review of the facility's policy titled "Weight Management Guidelines" revised January 1, 2022, indicated under Guidelines, "Newly admitted patients are weighed upon admission and then weekly for a total of four (4) consecutive weeks, then monthly ...weights are recorded I the Weights/Vitals tab of Point Click Care. The Registered Dietitian completes nutrition assessment upon admission of the patient ...". FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: DXUS11 Facility ID: CA240000634 If continuation sheet 16 of 17 PRINTED: 05/13/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555339 (X3) DATE SURVEY COMPLETED 01/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE DESERT SPRINGS POST ACUTE 74350 Country Club Dr Palm Desert, CA 92260 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE A review of facility's policy titled "Medical Nutrition Therapy and Documentation" dated November 2020 indicated under Assessment of Nutritional Status " ...the assessment may include ...risk factors-does the patient have risk factors identified in the Investigative Protocols for ...Pressure Ulcer and Unintended Weight Loss ...". FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: DXUS11 Facility ID: CA240000634 If continuation sheet 17 of 17