Health inspection·April 24, 2025

F 0607 Develop and implement policies and procedures to prevent abuse, neglect, and theft. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to implement the facility's policy and procedure on abuse on investigating an allegation of abuse, for one of seven residents reviewed (Resident 2) when Resident 2 reported an allegation of abuse by Physical Therapy Assistant (PTA). In addition, the facility did not suspend the PTA after Resident 2 reported an allegation of abuse. Residents Affected - Few This failure had the potential to result in further abuse to Resident 2 and other vulnerable residents. Findings: On April 4, 2025, at 9:15 a.m., an unannounced visit was conducted at the facility to investigate a complaint regarding resident abuse. On April 4, 2025, at 12:45 p.m., Resident 2 was observed sitting up in bed. In a concurrent interview, Resident 2 stated the PTA was assisting her out of her bed into a wheelchair when she roughly squeezed her and caused a skin tear to her right arm last March 2025. Resident 2 further stated the Director of Rehabilitation (DOR) was aware of the allegation because Resident 2 requested for a different PTA to work with her during therapy. On April 4, 2025, at 3:10 p.m., the Physical Therapist (PT) was interviewed. The PT stated the Occupational Therapist (OT) reported to her that Resident 2 alleged the PTA to have bruised her arm. The PT stated the abuse allegation was reported around March 20, 2025 and the PTA was not assigned to Resident 2 after the report was made. On April 4, 2025, at 3:30 p.m., the OT was interviewed. The OT stated Resident 2 and her family member reported to him that the PTA bruised her right wrist area about two weeks ago. The OT stated when he received the report of abuse from Resident 2, he reported it immediately to the PT and was advised to report the allegation to the Director of Rehabilitation (DOR). The OT stated he reported the allegation to the DOR. The OT stated he believed the DOR reported to the Director of Nursing (DON). On April 4, 2025, at 4:15 p.m., an interview was conducted with PTA. The PTA stated she was aware of the allegation that she bruised and tore Resident 2's skin. The PTA stated she was not suspended after the abuse allegation was reported. On April 4, 2025, at 5:23 p.m., an interview was conducted with the DON. The DON stated she and the DOR checked on Resident 2 after hearing about the allegation on March 28, 2025. The DON stated she did not conduct an investigation of the allegation, or report the allegation because she did not see Page 1 of 6 555339 555339 04/24/2025 Desert Springs Post Acute 74-350 Country Club Drive Palm Desert, CA 92260

F 0607 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few a bruise on Resident 2's right wrist or forearm area. The DON stated she should have reported the allegation and PTA should have been suspended pending an investigation. On April 4, 2025, Resident 2's record was reviewed. Resident 2 was admitted to the facility on [DATE], with diagnoses which included abnormalities of gait and mobility. A review of Resident 2's Minimum Data Set (MDS - a resident assessment tool), dated March 3, 2025, indicated Resident 2 had a Brief Interview for Mental Status (BIMS) score of 15 (cognitively intact). Further review of Resident 2's record did not indicate an abuse allegation reported by Resident 2 towards the PTA. A review of facility's policy and procedure titled, Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating, revised September 2022, indicated, . All allegations are thoroughly investigated. The administrator initiates investigations .Any employee who has been accused of resident abuse is placed on leave with no resident contact until the investigation is complete .Within five (5) business days of the incident, the administrator will provide a follow-up investigation report . 555339 Page 2 of 6 555339 04/24/2025 Desert Springs Post Acute 74-350 Country Club Drive Palm Desert, CA 92260

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 observation, interview, and record review, the facility failed to report an allegation of abuse to California Department of Public Health (CDPH), immediately or within two hours after an allegation of abuse was reported, for one of seven residents (Resident 2), when Resident 2 reported an allegation of abuse by the Physical Therapy Assistant (PTA). This failure had the potential to result in delayed investigation of abuse and further exposed Resident 2 and other vulnerable residents to abuse by the PTA. Findings: On April 4, 2025, at 9:15 a.m., an unannounced visit was conducted at the facility to investigate a complaint regarding resident abuse. On April 4, 2025, at 12:45 p.m., Resident 2 was observed sitting up in bed. In a concurrent interview, Resident 2 stated the PTA was assisting her out of her bed into a wheelchair when she roughly squeezed her and caused a skin tear to her right arm last March 2025. Resident 2 further stated the Director of Rehabilitation (DOR) was aware of the allegation because Resident 2 requested for a different PTA to work with her during therapy. On April 4, 2025, at 3:10 p.m., the Physical Therapist (PT) was interviewed. The PT stated the Occupational Therapist (OT) reported to her that Resident 2 alleged the PTA to have bruised her arm. The PT stated the abuse allegation was reported around March 20, 2025 and the PTA was not assigned to Resident 2 after the report was made. On April 4, 2025, at 3:30 p.m., the OT was interviewed. The OT stated Resident 2 and her family member reported to him that the PTA bruised her right wrist area about two weeks ago. The OT stated when he received the report of abuse from Resident 2, he reported it immediately to the PT and was advised to report the allegation to the Director of Rehabilitation (DOR). The OT stated he reported the allegation to the DOR. The OT stated he believed the DOR reported to the Director of Nursing (DON). On April 4, 2025, at 4:15 p.m., an interview was conducted with PTA. The PTA stated she was aware of the allegation that she bruised and tore Resident 2's skin. The PTA stated she was not suspended after the abuse allegation was reported. On April 4, 2025, at 5:23 p.m., an interview was conducted with the DON. The DON stated she and the DOR checked on Resident 2 after hearing about the allegation on March 28, 2025. The DON stated she did not report the abuse allegation to CDPH because she did not see a bruise on Resident 2's right wrist or forearm area. The DON stated she should have reported the abuse allegation. On April 4, 2025, Resident 2's record was reviewed. Resident 2 was admitted to the facility on [DATE], with diagnoses which included abnormalities of gait and mobility. A review of Resident 2's Minimum Data Set (MDS - a resident assessment tool), dated March 3, 2025, indicated Resident 2 had a Brief Interview for Mental Status (BIMS) score of 15 (cognitively intact). Further review of Resident 2's record did not indicate an abuse allegation reported by Resident 2 towards the PTA. 555339 Page 3 of 6 555339 04/24/2025 Desert Springs Post Acute 74-350 Country Club Drive Palm Desert, CA 92260

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few A review of facility's policy and procedure titled Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating, revised September, 2022, indicated, .All reports of resident abuse (including injuries of unknown origin) .are reported to local, state and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigations are documented and reported .All allegations are thoroughly investigated. The administrator initiates investigations .Within five (5) business days of the incident, the administrator will provide a follow-up investigation report . 555339 Page 4 of 6 555339 04/24/2025 Desert Springs Post Acute 74-350 Country Club Drive Palm Desert, CA 92260

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 observation, interview, and record review, the facility failed to ensure care and treatment was provided, for one of seven residents (Resident 2), when Resident 2 sustained a skin tear on the right wrist. Residents Affected - Few This failure had the potential for a delay in the care and treatment of Resident 2 skin tear on the right wrist. Findings: On April 4, 2025, at 12:45 p.m., Resident 2 was observed to be sitting in bed with a beige wound dressing on the right wrist. In a concurrent interview with Resident 2, she stated she sustained a skin tear on the right wrist due to the blood pressure cuff being used to get her blood pressure. On April 4, 2025, Resident 2's record was reviewed. Resident 2 was admitted to the facility on [DATE], with diagnoses which included abnormalities of gait and mobility and long term use of anticoagulants (medication to prevent blood clots). A review of Resident 2's Minimum Data Set (MDS - a resident assessment tool), dated March 3, 2025, indicated Resident 2 had a Brief Interview for Mental Status (BIMS) score of 15 (cognitively intact). Further review of Resident 2's record did not indicate an abuse allegation reported by Resident 2 towards the PTA. A review of Resident 2's care plan, dated February 25, 2025, indicated, .Skin: Resident has impaired skin integrity present on admission as evidenced by bruises easily, other, skin discolorations .Interventions .Check skin during daily care provisions. Notify physician of abnormal findings . Further review of Resident 2's record indicated there was no documented evidence the skin tear on the right wrist was identified, monitored, and addressed for care and treatment. On April 4, 2025, at 5:05 p.m., a concurrent observation, interview, and record review was conducted with Licensed Vocational Nurse (LVN) 2. LVN 2 was observed to remove the dressing on the right wrist and a skin tear was observed. Resident 2's medical record was concurrently reviewed with LVN 2. LVN 2 stated there was no change in condition notes, physician's order, or care plan addressing Resident 2's right wrist skin tear. LVN 2 stated there should be an order and a change in condition note for Resident 2's skintear. LVN 2 stated the wound is at risk for getting worse without a physician's order for treatment and ongoing assessment and management of the skin tear. On April 4, 2025, at 5:23 p.m. a concurrent interview and record review was conducted with the Director of Nursing (DON). The DON stated the doctor should have been notified to obtain treatment order of Resident 2's skin tear. A review of the facility's policy and procedure titled Wound Care, revised October, 2010, indicated, .Purpose .The purpose of this procedure is to provide guidelines for the care of wounds to promote healing .Preparation .Verify that there is a physician's order for this procedure . 555339 Page 5 of 6 555339 04/24/2025 Desert Springs Post Acute 74-350 Country Club Drive Palm Desert, CA 92260

F 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide a sanitary environment, for one out of seven residents (Resident 7), when black mold was observed in Resident 7's shower. This failure had the potential to result in physical and psychosocial effect to Resident 7. Findings: On April 7, 2025, at 1:55 p.m., a concurrent interview and observation was conducted with Resident 7. Resident 7 stated there was a black mold in her shower. Resident 7's shower room was observed to have black grimy substance. On April 7, 2025, at 3:52 p.m., an interview and concurrent observation was conducted with the Housekeeper (HK) in Resident 7's bathroom. Black grimy substance was observed in the shower area at the corner of the bathroom. In a concurrent interview with HK, she stated the black substance looks like mold. The HK stated that it should not be there. On April 7, 2025, at 3:56 p.m., an interview and concurrent observation was conducted with the Housekeeping Supervisor (HS) in Resident 7's bathroom. Black substance was observed in Resident 7's shower room. The HS stated the substance appeared to be black mold. The HS further stated black mold should not be in the resident's shower, or anywhere in the facility. The HS stated black mold could cause respiratory issues to the residents. The HS further stated housekeeping should have used bleach when cleaning to get rid of the black mold. On April 7, 2025, at 4:30 p.m., an interview was conducted with the Administrator (Admin). The Admin stated black mold should not be in the facility. On April 7, 2025, a review of Resident 7's record was conducted. Resident 7 was admitted to the facility on [DATE], with diagnoses which included chronic obstructive pulmonary disease (COPD - a chronic lung disease). A review of Resident 7's Minimum Data Set (MDS - a resident assessment tool), dated March 25, 2025, indicated Resident 7 had a Brief Interview of Mental Status (BIMS) score of 14 (cognitively intact). A review of the facility's policy and procedure titled, Cleaning and Disinfection of Environmental Surfaces, revised August 2019, indicated, .Housekeeping surfaces (e.g., floors, tabletops) will be cleaned on a regular basis, when spills occur, and when these surfaces are visibly soiled . 555339 Page 6 of 6