Health inspection·August 9, 2024

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a safe environment was provided, for one of three resients reviewed (Resident 1), when the otuside patio had an open sunken area of dirt, approximately 2 inches below the level of surrounding concrete pavement. This failure resulted in Resident 1 being stuck in the dirt between a tree and the edge of the concrete pavement. Findings: On August 7, 2024, at 1:37 p.m. an unannounced visit was conducted at the facility to investigate two complaints. A request for facility policies and procedures, including those regarding Accidents and/or Accident Prevention was made. The Director of Nursing (DON) stated per her consultant, the facility did not have any, unless it pertained to a specific incident or condition that involved an accident. Resident 1' s record was reviewed. The resident was admitted to the facility on [DATE], with diagnoses which included right femur fracture, history of falling, high blood pressure, and muscle wasting and atrophy (decrease in muscle mass and strength). A review of Resident 1's History and Physical Examination, dated April 9, 2024, indicated Resident 1 had the capacity to understand and make decisions. A review of Resident 1's Minimum Data Set (MDS- an assessment tool), dated July 12, 2024, indicated Resident 1 had a BIMS score of six (Brief Interview for Mental Status- a score of zero to seven meant severe cognitive impairment); but had the ability to wheel at least 50 feet and make two turns using a manual wheelchair, as well as wheel at least 150 feet in a corridor or similar space using the same. A review of Resident 1's Progress Notes, dated July 20, 2024, at 2 p.m., written by the Licensed Vocational Nurse (LVN), included a change in condition report indicating unresponsiveness but with stable vital signs (clinical measures including pulse, respiratory rate, blood pressure, and temperature). The narrative notes indicated, .resident was found unresponsive outside on patio. resident sitting on w/c (wheelchair) with right side of head and right shoulder leaning on gate .had eyes closed and not responding to verbal or painful stimuli. resident was wheeled inside therapy room, while this nurse called 911 another nurse was at bedside. resident stared (sic) talking and answering (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 555084 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555084 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/09/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Desert Springs Healthcare & Wellness Centre 82262 Valencia Avenue Indio, CA 92201 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)