F 0684
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interview and record review, the facility failed to ensure an appropriate orthostatic (standing upright) blood
pressure (BP - measurement of the force of blood pushing against the blood walls) monitoring were
conducted, for one of three residents reviewed (Resident 6).
Residents Affected - Few
This failure had the potential for Resident 6 to experience complications related to orthostatic blood
pressure.
Findings:
On March 6, 2025, at 8:50 a.m., an unannounced visit was conducted at the facility to investigate a quality
care issue.
On March 6, 2025, Resident 6's record was reviewed. Resident 6 was admitted to the facility on [DATE],
with diagnoses which included Alzheimer ' s disease (memory loss) and osteoporosis (bone disease).
A review of Resident 6 ' s Minimum Data Set (MDS - a tool for assessment), dated January 18, 2025,
indicated Resident 6 had a moderately impaired and poor decisions regarding tasks of daily life.
A review of Resident 6 ' s care plan goal, dated February 3, 2025, indicated Resident 6 will be free of falls
and an intervention which included monitor orthostatic blood pressure every Thursday due to use of
Escitalopram (brand of medicine) per pharmacist recommendation.
A review of Resident 6's CNA (Certified Nursing Assistant) Task, indicated Resident 6 could stand and able
to walk at least 10 feet inside the room.
A review of Resident 6 ' s Order Summary, dated February 5, 2025, indicated Residents 6 ' s was
monitored for orthostatic blood pressure for lying and sitting every Thursday of the week.
A review of Resident 6 ' s Medication Administration Record (MAR), for the month of February 2025,
indicated the following orthostatic blood pressure for laying blood pressure (LBP) and sitting blood pressure
(SIT):
- February 13, 2025, Thursday, LBP 130/60, SIT 128/60, no standing BP was recorded;
- February 20, 2025, Thursday, LBP 128/66, SIT 124/64, no standing BP was recorded, and;
(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
03/27/2025
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)
F 0684
- February 27, 2025, Thursday, LBP 130/66, SIT 128/64, no standing BP was recorded.
Level of Harm - Minimal harm
or potential for actual harm
There was no evidence of standing blood pressure was taken from Resident 6 for orthostatic blood
pressure monitoring.
Residents Affected - Few
On March 6, 2025, at 12:10 p.m., a concurrent interview and record review was conducted with Licensed
Vocational Nurse (LVN) 1. LVN 1 stated Resident 6 had history of multiple falls and was monitored for
orthostatic blood pressure to evaluate if Resident 6 would have a sudden drop of blood pressure and would
cause a possible repeated fall. LVN 1 stated Resident 6 was ambulatory with supervision and minimal
assist in activity of daily living (ADL) and had a tendency to stand up and walk abruptly. LVN 1 stated
Resident 6 had an order to obtain blood pressure while laying on bed position and sitting position. LVN 1
further stated the licensed nurses did not obtain standing blood pressure for Resident 6. LVN 1 stated the
licensed nurses should have taken Resident 6's BP from laying to standing as the resident was ambulatory.
On March 6, 2025, at 12:25 p.m., an interview was conducted with LVN 2. LVN 2 stated Resident 6 had an
unwitnessed fall at night shift on March 5, 2025, and was sent out to the hospital for further management.
LVN 2 stated the common cause of Resident 6 ' s fall last night was probably loss of balance due to sudden
drop of blood pressure when she was laying on bed then abrupt standing to walk. LVN 2 stated the facility
identified that resident was on orthostatic blood pressure monitoring, but nurses was taking BP in sitting
blood pressure instead of standing blood pressure. LVN 2 further stated standing blood pressure should
have been taken instead of sitting position.
On March 6, 2025, at 4:30 p.m., an interview was conducted with the Director of Nursing (DON). The DON
stated she expected the nurses to follow policy and procedure in obtaining orthostatic blood pressure. The
DON stated it would be more accurate if nurses would take standing blood pressure instead of sitting
position to monitor the orthostatic blood pressure for ambulatory residents at risk for repeated fall. The DON
further stated, I admit it, facility failed to identify the appropriate position to obtain orthostatic blood
pressure.
A review of the facility ' s policy and procedure titled, Orthostatic Hypotension, dated January 1, 2012,
indicated, .To ensure that if a resident is experiencing orthostatic hypotension, there is development of an
individualized care plan to address any issues related to orthostatic hypotension .Orthostatic vital signs will
be taken and recorded when ordered by the position, and when a sudden drop in blood pressure is
suspected as the cause of residents falls .feelings of dizziness and similar occurrences .Orthostatic
hypotension is a .drop in .blood pressure within three minutes of standing up .The procedure for taking
orthostatic blood pressure is as follows .In lying down position, use the appropriate size of blood pressure
cuff of the residents arm .Have the resident stand up, taking precautions to ensure he/she does not fall .If
the resident is unable to stand, this reading may be taken while he/she is sitting .
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
555084
If continuation sheet
Page 2 of 2