Inspection visit
Health inspection
4 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 4 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
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
(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 6
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
04/24/2025
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 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 .
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
555339
If continuation sheet
Page 2 of 6
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
04/24/2025
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
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.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
555339
If continuation sheet
Page 3 of 6
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
04/24/2025
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
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
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 .
Event ID:
Facility ID:
555339
If continuation sheet
Page 4 of 6
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
04/24/2025
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 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 .
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
555339
If continuation sheet
Page 5 of 6
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
04/24/2025
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 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 .
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
555339
If continuation sheet
Page 6 of 6
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Back to topCitations
4 citations 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.
F607 - The facility must develop and implement written policies and procedures that:
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
F609 - The facility must develop and implement written policies and procedures that:
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
F684 - Quality of care
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
F921 - Other Environmental Conditions
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
FAQ · About this visit
Common questions about this visit
What happened during the April 24, 2025 survey of DESERT SPRINGS POST ACUTE?
This was a inspection survey of DESERT SPRINGS POST ACUTE on April 24, 2025. The surveyor cited 4 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at DESERT SPRINGS POST ACUTE on April 24, 2025?
Yes, 4 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Develop and implement policies and procedures to prevent abuse, neglect, and theft."
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.
SourceView on CMS Care Compare
Next steps
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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.