Other·June 21, 2018

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 the investigation of one facility reported incident. Facility reported incident number: CA00571446. Representing the California Department of Public Health: Surveyor 22921, HFEN The inspection was limited to the specific facility reported incident investigated and does not represent the findings of a full inspection of the facility. One deficiency was issued for entity reported incident number CA00571446.

F689 SS=D Free of Accident Hazards/Supervision/Devices F689 CFR(s): 483.25(d)(1)(2) 06/04/2018 §483.25(d) Accidents. The facility must ensure that §483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and §483.25(d)(2)Each resident receives adequate supervision and assistance devices to prevent accidents. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to provide adequate supervision to avoid accidents for one resident (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: 8L3O11 Facility ID: CA250001382 If continuation sheet 1 of 5 PRINTED: 05/14/2026 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: _______________ 555742 (X3) DATE SURVEY COMPLETED 06/04/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE DESERT MOUNTAIN CARE CENTER 47763 Monroe St Indio, CA 92201 (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 when the resident was left unattended while receiving care. This failure resulted in Resident 1 to roll out of bed on to the floor and sustain a laceration (cut or tear) to his upper lip requiring him to be transferred to the acute hospital where he received five sutures (stitches) to repair the laceration. Findings: An unannounced visit was made to the facility on February 1, 2018, at 10:30 a.m., to investigate a facility reported incident involving Resident 1. During an interview with the Director of Nursing (DON) on February 1, 2018, at 10:45 a.m., the DON stated two CNA's (Certified Nursing Assistant) pulled Resident 1's bed away from the wall and raised it up to provide care. They left Resident 1 unattended to help another resident and when they returned, Resident 1 was on the floor. A record review for Resident 1 was conducted on February 1, 2017, at 10:55 a.m. Resident 1 was admitted to the facility on January 11, 2017, with diagnoses including, chronic respiratory failure with hypoxia (lack of oxygen), persistent vegetative state (unresponsive), dependence on respirator (ventilator) status (mechanical life support), and epilepsy (a neurological disorder). A care plan for Resident 1 dated January 8, 2018, indicated, "Multiple episodes of roll out of bed-risk for injury...Goal...Will not sustain any injury from roll out...Interventions...Left side of bed against the wall...Maintain bed in lowest position..." A "Fall Risk Assessment," dated January 5, 2018, indicated Patient A had a score of six. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8L3O11 Facility ID: CA250001382 If continuation sheet 2 of 5 PRINTED: 05/14/2026 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: _______________ 555742 (X3) DATE SURVEY COMPLETED 06/04/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE DESERT MOUNTAIN CARE CENTER 47763 Monroe St Indio, CA 92201 (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 According to the assessment, a score of four or more is considered at risk for falls. A review of the "INTERDISCIPLINARY PROGRESS NOTES," indicated a post-fall review was conducted by the IDT (Interdisciplinary Team) on the following dates: a. December 8, 2017, Resident 1 was found lying face down on the floor mat on December 7, 2017; b. December 11, 2017, Resident 1 was found lying face down on the floor mat on December 9, 2017; c. December 26, 2017, Resident 1 was found on the floor mat on December 24, 2017; d. December 29, 2017, Resident 1 rolled out of bed on December 28, 2017; e. January 3, 2018, Resident 1 rolled out of bed on January 2, 2018; and f. January 8, 2018, Resident 1 was found lying on the floor mat on January 5, 2018, and on January 6, 2018. A document titled, "Initial Change of Condition V2," dated January 28, 2018, at 1:50 a.m., indicated, "...Pt (patient) was momentarily left unattended when to assist other pt when incident occurred. Pt rolled out of bed...sustained laceration...to his upper lip...MD ordered Pt to be sent out for further evaluation d/t (due to) laceration..." Resident 1 was sent to the acute hospital on January 28, 2018, at approximately 7 a.m. The final report from the acute hospital indicated Resident 1 was treated for a FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8L3O11 Facility ID: CA250001382 If continuation sheet 3 of 5 PRINTED: 05/14/2026 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: _______________ 555742 (X3) DATE SURVEY COMPLETED 06/04/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE DESERT MOUNTAIN CARE CENTER 47763 Monroe St Indio, CA 92201 (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 laceration described as 1.2 cm (centimeters, about half-inch long) in length to his right upper lip. Resident 1 received five sutures to close the laceration. A "Health Status Note," dated January 28, 2018, at 12:54 p.m., indicated..."RN (Registered Nurse) assessment...Pt has a 1.5 cm vertical closed laceration above Rt (right) upper lip-with 5 dissolvable sutures intact per (hospital initials) ER (emergency room) report. Right upper lip is slightly swollen, has small abrasion under Rt upper lip with discoloration. Discoloration noted under front incisors (teeth). Right cheeck [sic] is slightly swollen...also has small discoloration to bridge of nose." A document titled, "INTERDISCIPLINARY PROGRESS NOTES," dated January 29, 2018, at 2:36 p.m., indicated, "IDT post-fall review...Resident was left unattended by CNA when they responded appropriately to a life threatening emergency & (and) failed to use good judgement by leaving resident unattended. RCP (Resident care plan) was not followed & bed was not placed against the wall as per RCP...Res (resident) returned from acute (with) suture to laceration..." During an interview with the DON on February 1, 2018, at 1 p.m., the DON was asked if the incident was an avoidable event. The DON stated, "It happened, it shouldn't have happened." A telephone interview was conducted with CNA 1 on March 5, 2018, at 4:10 p.m. CNA 1 stated she and CNA 2 were getting ready to change Resident 1. CNA 1 stated they raised the bed to waist level. CNA 1 stated they went to help another resident across the hall and when she (CNA 1) looked over to Resident 1's room, she did not see him in the bed. CNA 1 stated when FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8L3O11 Facility ID: CA250001382 If continuation sheet 4 of 5 PRINTED: 05/14/2026 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: _______________ 555742 (X3) DATE SURVEY COMPLETED 06/04/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE DESERT MOUNTAIN CARE CENTER 47763 Monroe St Indio, CA 92201 (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 they went back into Resident 1's room, they found Resident 1 on the floor. CNA 1 stated, "One of us should have stayed with him." A telephone interview was conducted with CNA 2 on March 9, 2018, at 4 p.m. CNA 2 stated she and another CNA (CNA 1) were getting ready to change Resident 1. CNA 2 stated they had raised Resident 1's bed and pulled the bed away from the wall. CNA 2 stated they ran out to help another resident and when they returned to Resident 1's room, they found him on the floor. CNA 2 stated, "We didn't think about it at the time, we should have lowered the bed, one of us should have stayed with him, we just ran out to help." The facility policy and procedure titled, "Fall/Accident Mitigation and Intervention," revised October 2017, was reviewed. The policy indicated, "...It is the policy of this facility to minimize the risk of falls or accidents, and to minimize the risk of serious injury associated with falls or accidents..." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8L3O11 Facility ID: CA250001382 If continuation sheet 5 of 5