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Inspection visit

Health inspection

DESERT SPRINGS HEALTHCARE & WELLNESS CENTRECMS #5550841 citation on this visit
1 citation recorded

Inspector’s narrative

What the inspector wrote

This survey cited 1 deficiency. The full statement and the facility’s plan of correction follow, verbatim from the federal record.

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

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Citations

1 citation recorded*CMS

What do CMS severity letters mean?

Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.

General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.

Each letter combines severity with scope: how many residents the deficiency affected.

  • 0684GeneralS&S Dpotential for harm

    F684 - Quality of care

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

FAQ · About this visit

Common questions about this visit

What happened during the March 27, 2025 survey of DESERT SPRINGS HEALTHCARE & WELLNESS CENTRE?

This was a inspection survey of DESERT SPRINGS HEALTHCARE & WELLNESS CENTRE on March 27, 2025. The surveyor cited 1 deficiency, recorded on the federal Form 2567 statement of deficiencies.

Were any deficiencies cited at DESERT SPRINGS HEALTHCARE & WELLNESS CENTRE on March 27, 2025?

Yes, 1 deficiency was cited, each with a CMS Scope and Severity grade. The first was: "Provide appropriate treatment and care according to orders, resident’s preferences and goals."

What type of survey was this?

This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.

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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.