Health inspection·March 27, 2025

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; Page 1 of 2 555084 555084 03/27/2025 Desert Springs Healthcare & Wellness Centre 82262 Valencia Avenue Indio, CA 92201

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 . 555084 Page 2 of 2