F 0880
Provide and implement an infection prevention and control program.
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 infection control precautions were
implemented in accordance with the policies and procedures for two of six sampled residents (Residents 4
and 3), when: 1.Certified Nurse Assistant (CNA) 1 was observed at Resident 4's bedside wearing a face
mask, and not wearing gown, gloves, and face shield. The resident requires a droplet precaution; and 2.
CNA 2 was observed with Resident 3 at bedside wearing a face mask, and not wearing gown, gloves, and
face shield. The resident requires a droplet precaution. These failures had the potential to increase the
spread of influenza (a contagious viral infection of the respiratory tract) and cause serious illness in
high-risk individuals.Findings: 1.On December 23, 2025, at 12:34 p.m., three signage and stocked PPE
were observed outside Resident 4's room.A review of the three signage indicated the following: First
signage, .Sequence for Putting On Personal Protective Equipment (PPE).1. Gown.2. Mask or Respirator.3.
Goggles or Face Shield.4. Gloves.; Second signage, .Droplet Precautions.Everyone Must: Clean their
hands, including before entering and when leaving the room.Make sure their eyes, nose and mouth are fully
covered before room entry.or Remove face protection before room exit.; and Third signage, How to Safely
Remove Personal Protective Equipment (PPE). 1. Gown and Gloves.2. Goggles or Face Shield.3. Mask or
Respirator.4. Wash Hands or Use an Alcohol-Based Hand Sanitizer Immediately after removing all PPE. On
December 23, 2025, at 12:36 p.m., during concurrent observation and interview, CNA 1 was observed at
Resident 4's bedside wearing a face mask. CNA 1 stated the staff were required to gown up, wear face
mask, face shield and gloves prior to entering rooms with droplet precautions. CNA 1 stated Resident 4
was on droplet precautions due to influenza. CNA 1 stated she should have been wearing a gown, gloves,
and face shield while talking to Resident 4. On December 23, 2025, at 3:55 p.m., an interview was
conducted with the Infection Preventionist (IP). The IP stated that for droplet transmission-based
precautions, all staff including visitors, family members, and contractors were required to don PPE prior to
entering the resident's room. The PPE included a face shield, face mask, gown, and gloves due to the
potential exposure from residents who may be coughing or sneezing. The IP further noted that if a staff
member was answering a call light, picking up a meal tray, speaking to a resident, or providing direct
contact care, they were required to wear all PPE. On December 24, 2025, at 10:09 a.m., a concurrent
interview and record review was conducted with the IP. The IP stated that anyone entering the room must
follow transmission-based precautions by donning all PPE, including a face mask, face shield, gown, and
gloves, as directed on the droplet precautions signage outside the resident's room when communicating or
providing direct care for all residents in the room. Resident 4's record was reviewed. Resident 4 was
admitted to the facility on [DATE], with diagnoses which included immunodeficiency (failure of the immune
system to protect the body). A review of Resident 4's Minimum Data Set (MDS- an assessment tool), dated
November 3, 2025, indicated Resident 4 had a BIMS (Brief Interview of Mental Status) score of 12
(moderate cognitive impairment). A review of
Residents Affected - Few
(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 3
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
12/24/2025
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 0880
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Resident 4's Care Plan, dated December 21, 2025, indicated, .Isolation Precautions: Resident requires
contact, droplet precautions isolation.Goal: Isolation using (contact, droplet) precautions will be maintained
while medically necessary.Intervention: Follow universal precautions when working with residents in
isolation. Education of patients, families, visitors, and care providers about how infections are transmitted
and how illness can be prevented. Safe handling of potentially contaminated equipment or surfaces in the
resident environment, and respiratory hygiene/cough etiquette. Use of personal protective equipment as
recommended for type of infection. A review of Resident 4's Care Plan, dated December 21, 2025,
indicated, .Influenza: Resident has diagnosis of influenza .at risk for complications.Goal: Influenza will
resolve without signs and symptoms of complication. Will not exhibit signs of malnutrition or dehydration
secondary to influenza symptom.Intervention: Isolation precautions. Administer medication as ordered. A
review of Resident 4's physician order dated December 25, 2025, Tamiflu Oral capsule 75 mg. for Flu until
December 29, 2025. A review of the facility's policy and procedure titled, Isolation-Transmission-Based
Precautions & Enhanced Barrier Protection, revised date September 2022, indicated, .transmission-based
precautions are additional measures that protect staff, visitors and other residents from becoming
infected.droplet precautions are implemented for an individual documented or suspected to be infected.that
can be generated by the individual coughing, sneezing, talking.gloves, gown, and googles are worn if there
is a risk of spraying respiratory secretions. A review of the facility's policy and procedure titled, Infection
Prevention and Control Program, revised date October 2018, indicated, .prevention of infection.educating
staff.ensuring that they adhere to proper techniques and procedures.implementing appropriate isolation
precautions.outbreak management.preventing the spread to other residents.educating the staff and public.
2.On December 23, 2025, at 2:52 p.m., three signage and stocked PPE were observed outside Resident
3's room. A review of the three signage indicated the following: First signage, .Sequence for Putting On
Personal Protective Equipment (PPE).1. Gown.2. Mask or Respirator.3. Goggles or Face Shield.4. Gloves.;
Second signage, .Droplet Precautions.Everyone Must: Clean their hands, including before entering and
when leaving the room.Make sure their eyes, nose and mouth are fully covered before room entry.or
Remove face protection before room exit.; and Third signage, How to Safely Remove Personal Protective
Equipment (PPE). 1. Gown and Gloves.2. Goggles or Face Shield.3. Mask or Respirator.4. Wash Hands or
Use an Alcohol-Based Hand Sanitizer Immediately after removing all PPE. On December 23, 2025, at 3:04
p.m., a concurrent observation and interview was conducted with Resident 3. Resident 3 was observed
resting in bed, alert, and well groomed. Resident 3 stated she was aware that she had the flu and was in
isolation. Resident 3 stated the staff did not always wear a gown and a face shield when providing care.
Resident 3's record was reviewed. Resident 3 was admitted to the facility on [DATE], with diagnoses which
included bronchitis (inflammation of the bronchial tubes (airways to your lungs). A review of Resident 3's
MDS, dated [DATE], indicated Resident 3 had a BIMS (Brief Interview of Mental Status) score of 12
(moderate cognitive impairment). A review of Resident 3's Care Plan, dated December 17, 2025, indicated,
.Isolation Precautions: Resident requires contact, droplet precautions isolation.Goal: Isolation using
(contact, droplet) precautions will be maintained while medically necessary.Intervention: Follow universal
precautions when working with residents in isolation. Education of patients, families, visitors, and care
providers about how infections are transmitted and how illness can be prevented. Safe handling of
potentially contaminated equipment or surfaces in the resident environment, and respiratory hygiene/cough
etiquette. Use of personal protective equipment as recommended for type of infection. A review of Resident
3's physician orders indicated the following: On December 18, 2025, Isolation with contact and droplet
precautions d/t (due to)
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
555339
If continuation sheet
Page 2 of 3
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
12/24/2025
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 0880
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
exposure to the flu. Special Instructions: All nursing care and Therapy to be completed in room. Private
room if possible or cohort with other flu-positive residences every shift for 7 Days; and On December 18,
2025, Tamiflu Oral Capsule 75 MG (Oseltamivir Phosphate) Give 1 capsule by mouth two times a day for
FLU for 5 days. On December 23, 2025, at 3:14 p.m., a concurrent observation and interview was
conducted with CNA 2. CNA 2 was observed entering Resident 3's room wearing a face mask. CNA 2 was
observed speaking to Resident 3. CNA 2 stated the staff were required to gown up, wear face masks, face
shield and gloves prior to entering rooms with droplet precautions. CNA 2 stated Resident 3 was on droplet
precautions due to influenza. CNA 2 stated she should have been wearing a gown, gloves, and face shield
while talking to Resident 3. On December 23, 2025, at 3:55 p.m., an interview was conducted with the
Infection Preventionist (IP). The IP stated the process for droplet transmission-based precautions are all
staff including visitors, family, contractors were required to don PPEs prior to entering the resident's room; a
face shield, face mask, gown, gloves due to exposure from residents in room that may be coughing and
sneezing. The IP stated if a staff member was answering the call light, picking up a meal tray, speaking to a
resident, or providing direct contact, the staff member was required to wear all PPEs. On December 24,
2025, at 10:09 a.m., a concurrent interview and record review was conducted with the IP. The IP stated that
anyone entering the room will follow transmission-based precautions by donning all PPE face masks, face
shields, gown, gloves as indicated on the droplet precaution signage outside of resident's room, when
communicating or providing direct care for all residents in the room. A review of the facility's policy and
procedure titled, Isolation-Transmission-Based Precautions & Enhanced Barrier Protection, revised date
September 2022, indicated, .transmission-based precautions are additional measures that protect staff,
visitors and other residents from becoming infected.droplet precautions are implemented for an individual
documented or suspected to be infected.that can be generated by the individual coughing, sneezing,
talking.gloves, gown, and googles are worn if there is a risk of spraying respiratory secretions. A review of
the facility's policy and procedure titled, Infection Prevention and Control Program, revised date October
2018, indicated, .prevention of infection.educating staff.ensuring that they adhere to proper techniques and
procedures.implementing appropriate isolation precautions.outbreak management.preventing the spread to
other residents.educating the staff and public.
Event ID:
Facility ID:
555339
If continuation sheet
Page 3 of 3