F 0609
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper
authorities.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interview and record review, the facility failed to ensure an allegation of abuse by the Restorative Nursing
Assistant (RNA) towards a resident, for one of six residents (Resident 3), was reported to the California
Department of Health (CDPH - State Agency) immediately or within two hours after the facility was made
aware of the alleged abuse.
This failure resulted in a delayed investigation by CDPH and had the potential to expose the patient to
further abuse.
Findings:
On December 23, 2024, at 9:24 a.m., an unannounced visit was conducted at the facility to investigate
facility reported incident and complaint intake.
On December 23, 2024, at 1:10 p.m., Resident 3 was observed lying in bed. In a concurrent interview with
Resident 3, he stated he was standing on his walker and Restorative Nursing Assistant (RNA) 1 grabbed
his buttocks and squeezed it more than twice. Resident 3 stated he told his family member (FM) about the
incident.
On December 23, 2024, Resident 3 ' s medical record was reviewed. Resident 3 was admitted to the facility
on [DATE], with diagnoses which include cerebral infarction (dead tissue in the brain), chronic kidney
disease (renal failure), depressive disorder (mental illness that causes severe mood changes), anxiety
disorder (mental health disorder characterized by excessive feelings of worry), type 2 diabetes mellitus
(problems regulating sugar in the blood), legal blindness (loss of vision), and congestive heart failure
(condition where the heart doesn ' t pump well).
A review of Resident 3 ' s Minimum Data Set (MDs – an assessment tool), dated October 9, 2024,
indicated the patient had a Brief Interview for Mental Status (BIMS – assessment to monitor
cognitive status) score of 11, which indicated mild cognitive impairment.
On December 23, 2024, at 1:53 p.m., during an interview with CNA 2, she stated three to four weeks ago,
she took Resident 3 to shower, and the resident informed her that the resident's FM was calling the state to
report the RNA 1 who touch his buttocks. The CNA stated she reported to the Director of Nursing (DON).
CNA 1 further stated the facility ' s process was to report allegations of abuse immediately to the charge
nurse, the DON, and the state within two (2) hours.
On December 23, 2024, at 4:18 p.m., during an interview with Resident 3's FM, Resident 3 informed
(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:
555339
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
555339
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
01/21/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Desert Springs Post Acute
74-350 Country Club Drive
Palm Desert, CA 92260
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 0609
Level of Harm - Minimal harm
or potential for actual harm
her on Deember 3, 2024, that RNA 1 squeezed his buttocks. Resident3's FM stated she first reported the
allegation of abuse to the DON on December 3, 2024, verbally and then via text. Resident 3's FM stated
she told the DON to follow the facility ' s process of reporting abuse. Resident 3's FM further stated she
contacted the DON again on December 4, 2024, to see if she had spoken with Resident 3 about the
allegation.
Residents Affected - Few
On December 23, 2024, at 5:06 p.m., an interview with the DON was conducted. The DON stated she was
first made aware of the allegation on December 3, 2024, by Resident 3's FM, after verifying her phone text.
The DON stated she did not initiate an investigation at that time. The DON further stated she did not report
the incident not until December 7, 2024 (four days after the abuse allegation was reported to the DON). The
DON stated she did not follow the facility ' s process and should have reported the alleged incident with the
two hours of being informed.
A review of the facility ' s policy and procedure titled, Abuse, Neglect, Exploitation or MisappropriationReporting and Investigation, dated September 2022, indicated .All reports of resident abuse .are reported
to local, state, and federal agencies (as required b current regulations) and thoroughly investigated by
facility management. If resident abuse, neglect, exploitation, misappropriation of resident property, or injury.
Is suspected. This suspicion must be reported immediately to the administrator and to other officials,
according to the state law. Immediately is defined as within two hours of an allegation involving abuse or
result in serious bodily injury, or within 24 hours of an allegation that does not involve abuse or result in
serious bodily injury .
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
555339
If continuation sheet
Page 2 of 2
