Inspection visit
Inspection
18 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 18 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0578
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to
participate in experimental research, and to formulate an advance directive.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interview and record review, the facility failed to ensure information regarding formulating an Advance
Directive (AD - a written instruction, such as a living will, relating to the provision of treatment and services
when the individual is rendered unable to make decisions) was provided to two of four residents reviewed
for AD (Residents 4, and 213).
This failure had the potential to result in not determining and/or following the residents' wishes related to
the provision of medical treatment and health care services when the residents become unable to make
decisions for themselves.
Findings:
1. On November 30, 2022, Resident 4's record was reviewed. Resident 4 was admitted to the facility on
[DATE], with diagnoses which included heat stroke (irregular body temperature and loss of water).
The Social Services Assessment and Documentation, dated October 14, 2022, indicated, .advance
Directives .No .advance directive additional information .Information requested.
The Minimum Data Set (MDS - an assessment tool), dated October 21, 2022, indicated a BIMS (Brief
Interview of Mental Status) score of 14 (intact cognitive status).
There was no documented evidence information regarding formulating an advance directive was provided
to Resident 4.
On November 30, 2022, at 11:19 a.m., a concurrent interview and record review was conducted with the
Admissions Coordinator (AC). She stated residents are educated about advance directives during the
admissions interview and given the freedom to create one. If they are interested she calls social services
directly after the conversation and leaves a note about it. She claimed that it is the duty of Social Services
(SS) to get in touch with the representative or resident and offer assistance with the creation of the advance
directive. She stated SS would conduct a psychosocial assessment and indicate the resident wished to
formulate or had an advance directive. During a review of the medical record with the AC there was no
indication the psychosocial assessment was conducted.
On December 1, 2022, at 10:37 a.m., a concurrent interview and record review was conducted with the
Director of Staff Development (DSD). She stated if a resident expressed an interest in formulating an
advance directive, then the nursing staff would order a social service consult. A Social work
(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 12
Event ID:
555417
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
555417
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/01/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Desert Regional Medical Center D/P Snf
1150 North Indian Canyon Drive
Palm Springs, CA 92262
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 0578
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
note dated November 17, 2022, was reviewed in the presence of the DSD. The DSD stated the consult was
made for homelessness. The DSD stated there was no indication a consult regarding the right to formulate
an advance directive was done.
2. On May 20, 2021, Resident 213's record was reviewed. He was admitted to the facility on [DATE], with
diagnoses which included generalized weakness and atrial fibrillation (irregular heart rate).
The MDS, dated [DATE], indicated a BIMS score of 14 (intact cognitive status).
The Social Services Assessment and Documentation, dated November 18, 2022, indicated, .advance
Directives .No .advance directive additional information .Information requested.
There was no documented evidence information regarding formulating an advance directive was provided
to Resident 213.
On December 1, 2022, at 12:37 p.m., an interview was conducted with the Social Services Director (SSD).
She stated there was no social worker assigned to skilled nursing. She stated if a consult is put in by skilled
nursing for a psychosocial assessment, she would not see the request. She could not identify who was
responsible for ensuring the psychosocial assessment was performed. The SSD stated if the resident
wishes are not being followed and tracked there is a potential for the resident to not have their wishes met.
A review of the facility document titled, admission Agreements, dated November 2022, indicated .The
resident has the right to accept, request or refuse treatment including .an Advance Directive .State law
requires any new Advance Directive in a skilled nursing facility must be witnessed by the Ombudsman.
A review of the facility policy and procedure titled, Advance Directive, date January 2021, indicated .It is the
policy of the SNF (Skilled Nursing Facility) .to inform and respect the residents rights .to request, refuse,
and/or discontinue treatment, to participate in or refuse to formulate an advance directive .all residents shall
be provided written information concerning the right to accept or formulate an advance directive .on
admission .the social worker shall verify with the resident or resident representative whether he or she has
an advance directive and request a copy .the interdisciplinary team on an ongoing basis will assess and
incorporate the residents changing preferences .the right to request, refuse, discontinue treatment, the right
to establish an advance directive.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
555417
If continuation sheet
Page 2 of 12
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
555417
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/01/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Desert Regional Medical Center D/P Snf
1150 North Indian Canyon Drive
Palm Springs, CA 92262
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 0657
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed,
and revised by a team of health professionals.
Based on interview and record review, the facility failed to develop a care plan to address and/or monitor
the low hemoglobin level (hemoglobin- blood component which carries oxygen through the blood), for one
of two residents reviewed (Resident 264).
This failure had the potential for a delay in treatment of low hemoglobin levels which may result in further
declining health of Resident 264.
Findings:
On November 30, 2022, Resident 264's record was reviewed. Resident 264 was admitted to the facility on ,
November 7, 2022, with a diagnoses of increased white blood cell count (A type of blood cell that help the
body fight infection and other diseases).
A CBC laboratory result dated November 13, 2022, indicated a hemoglobin level of 6.7 g/L (Grams per liter)
(hemoglobin normal range 12.1 to 15.1 /L). The hemoglobin level was re-drawn on the same day and the
result indicated 6.8 g/L.
A Physician's order, dated November 13, 2022, at 11:49 a.m., indicated, .Transfuse Red Blood Cells Active
Bleed-Adult/Adolescent .
On November 13, 2022, Resident 264 was transferred off the unit to receive blood transfusion (A procedure
in which whole blood or parts of blood are put into a patient's bloodstream through a vein), and returned to
the facility on November 14, 2022.
The Physician's Order dated 11/14/2022, indicated to monitor Resident 264's Complete Blood Count (CBC
- blood test used to evaluate overall health and detect a wide range of disorders) every seven days.
There was no documented evidence a care plan was initiated to address Resident 264's low hemoglobin
level.
On November 30, 2022, at 3:39 p.m., a record review with a concurrent interview was conducted with
Registered Nurse (RN 1). RN 1 stated Resident 264 did not have a care plan initiated to address his low
hemoglobin level. RN 1 stated It is not there. RN 1 further stated Resident 264's low hemoglobin levels
should have been care-planned.
The facility's policy and procedure titled, DRMC SED SNF - PATIENT CARE PLAN, dated April 4, 2021,
indicated, .It is the policy of the SNF to develop and implement an effective and person-centered care plan
that includes instructions needed to meet professional standards of quality care .The plan of care shall
include input from all disciplines involved in the care of the patient and shall outline the professional
services indicated including interventions, goals and timelines .These services shall be carried out by
qualified staff .
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
555417
If continuation sheet
Page 3 of 12
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
555417
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/01/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Desert Regional Medical Center D/P Snf
1150 North Indian Canyon Drive
Palm Springs, CA 92262
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 0685
Assist a resident in gaining access to vision and hearing services.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interview, observation and record review, the facility failed, for one of two residents (Resident 266), to
provide a follow-up and/or offer an audiology consult to address his hearing deficit.
Residents Affected - Few
This failure had the potential to result in psycho social harm related to a delay in treatment to maintain
hearing.
Findings:
On November 28, 2022, at 3:05 p.m., an interview was conducted with the Licensed Vocational Nurse (LVN
2). LVN 2 stated Resident 266, Is easily upset and frustrated with staff because, he is very hard of hearing.
On November 29, 2022, at 10:46 a.m., an observation and interview was conducted with Resident 266.
Resident 266 stated he had hearing aids and hearing assistive devices at home, but They broke. Resident
(266) denied being offered help to obtain hearing assistive devices during his stay at the facility. He stated
the facility provided him a note pad, for communication. Resident 266 stated, It's frustrating for me to keep
telling staff I can't hear them.
On November 29, 2022, a record review for resident 266 indicated he was admitted to the facility on
[DATE], with diagnosis which included diabetes (A disease which causes high blood sugar within the blood
stream) and hypertension (Elevated blood pressure).
The Minimum Data Set (MDS- an assessment tool) dated November 11, 2022, indicated Resident 266 had
a moderate hearing difficulty and .speaker has to increase volume and speak distinctly .
A review of resident 266 Care Plan dated, November 4, 2022, indicated, .Impaired Communication R/T
(Related to) HOH (Hard of Hearing) .Intervention .Allow time to process and respond .Proactively anticipate
needs .Provide communication device .Left at home and does not work anyway .
On December 1, 2022, at 1:48 p.m., an interview was conducted with the Case Manager, Registered Nurse
(CM 1). CM 1 was asked about Resident 266's hearing problem and the facility's process on providing a
hearing device. CM 1 stated he would start with an audiology consult. CM 1 stated a hearing aid would help
Resident 266, and Resident 266 was not referred to audiology.
The facility's policy titled, DES ADM 111 AUXILIARY AIDS AND SERVICES, dated, May 28, 2020,
indicated, .Purpose .sensory impaired individuals, including the blind and the hearing impaired, be provided
with auxiliary aids at no cost to allow them an equal opportunity to participate in and benefit from
healthcare services .The Facility is committed to proactively assessing communication needs as well as
providing the highest quality of services to all who use them .The term auxiliary aids and services refers to
those auxiliary aids and services that are necessary to ensure (i) effective communication between persons
with disabilities and Facility personnel, (ii) that persons with disabilities are not excluded, denied services,
segregated, or otherwise treated differently than other persons because of the absence of auxiliary aids
and services, unless it would result in an undue burden to the Facility .Auxiliary aids may include: 6.
Assistive listening devices .
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
555417
If continuation sheet
Page 4 of 12
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
555417
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/01/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Desert Regional Medical Center D/P Snf
1150 North Indian Canyon Drive
Palm Springs, CA 92262
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 0755
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a
licensed pharmacist.
Based on observation, interview, and record review the facility failed to accurately track the expiration date
of medications stored on the facility's crash cart (a cart containing medications and equipment used in an
emergency).
This failure had the potential for administration of expired medications to a vulnerable population resulting
in medication not being effective.
Findings:
On November 29, 2022, at 2:42 p.m., during a concurrent observation and interview with Registered Nurse
(RN1), of the unit's crash cart, the pharmacy label was noted to have the first drug diphenhydramine (an
antihistamine- a medication reduce the body's allergic response) documented to expire on February 2023.
The crash cart was observed to contain one bag of Lidocaine (an antiarrhythmic- a medication used to
regulate heart rhythm) 2 grams (a unit of measurement) in 400 ml (milliliters- a unit of measurement) in
D5W (a solution of water and sugar) with an expiration date of January 2023. The RN1 verified the dates on
the medications and the expiration label did not match.
A review of the medication inventory for the unit's crash cart titled Adult Crash Cart Kit: CRASH 9 dated
November 2, 2022 indicated the first medication to expire was diphenhydramine on February 1, 2023.
A review of the facility's policy and procedure titled DES RX394 Crash Cart Monitoring Exchange dated
March 24, 2022 indicated, .It is the policy of [name of the facility] to assure the readiness and availability of
emergency medications and equipment through frequent monitoring, inspection and replacement .It is the
responsibility of the pharmacy to assure that all medications are evaluated monthly for expiration .The
expiration notice appears at the top of the crash cart listing the first drug to expire and the date .
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
555417
If continuation sheet
Page 5 of 12
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
555417
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/01/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Desert Regional Medical Center D/P Snf
1150 North Indian Canyon Drive
Palm Springs, CA 92262
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 0759
Ensure medication error rates are not 5 percent or greater.
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 administer medications according physician
orders for 2 of 3 sampled residents (Resident 114 & 116).
Residents Affected - Few
These failures had the potential to cause harm to Residents 114 & 116.
Findings:
1. A review of Resident 116's record indicated the resident was admitted to the facility on [DATE] with
diagnoses which included post CVA (cerebral vascular accident- impairment of blood flow to the brain) and
right hemiplegia (right-sided weakness).
A review of Resident 116's physician's order dated October 29, 2022 indicated an order for Prednisone (an
anti-inflammatory drug) 2.5 mg (milligram- a unit of measurement) oral tablet every other day. The order
comments indicated to give with food/meals.
On November 28, 2022, at 8:13 a.m., Registered Nurse (RN1) stated breakfast trays are delivered prior to
day shift's arrival. She stated residents are served breakfast between 6 a.m. and 7 a.m.
On November 29, 2022, at 9:20 a.m., during a concurrent observation and interview with Licensed
Vocational Nurse (LVN1), she stated Resident 116's prednisone dose was not available for administration.
On November 29, 2022, at 1:35 p.m., during a concurrent interview and record review with LVN1, she
stated medications given with food means while eating or within 15 minutes of eating. She reviewed
Resident 116's record. LVN1 verified Resident 116 consumed her meal at 8:00 a.m.
On November 29, 2022, at 1:35 p.m., during a concurrent interview and record review with Certified Nuring
Assistant (CNA1), she stated the resident's breakfast trays are distributed by the night shift prior to the day
shift's arrival. She stated she collected the breakfast trays and documented the amount eaten in the
electronic health record under the section labeled ADL (Activities of Daily Living). Resident 116 record was
reviewed indicating the resident ate her breakfast at 8:00 a.m.
On November 29, 2022, at 2:42 p.m., during an interview with RN1, she stated with meal means while
consuming the meal or with a snack. She stated a resident who ate at 8 AM and received the medication at
10 AM is not in accordance with the physician's order.
A review of the facility's policy and procedure titled DES SNF-Medication Administration Times dated April
23, 2021 indicated, .Medications shall be administered within one hour of the prescribed time, unless
otherwise indicated by the physician's order . Before meals (AC) .Approximately 30-60 min (minutes) before
meals .After meals (PC) .Approximately 30-60 min (minutes) after meals
The policy did not define medication administration with meals.
A review of the facility's policy and procedure titled DES RX 183 Medication Administration dated
September 22, 2022 indicated, All medications .shall be prepared and administered in accordance with
Federal and State Laws, under the orders of a licensed practitioner, as per accepted standards of
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
555417
If continuation sheet
Page 6 of 12
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
555417
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/01/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Desert Regional Medical Center D/P Snf
1150 North Indian Canyon Drive
Palm Springs, CA 92262
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 0759
practice.
Level of Harm - Minimal harm
or potential for actual harm
According to Lexicomp (a nationally recognized pharmaceutical drug reference) updated December 3,
2022, indicated prednisone for oral administration is to be administered after meals or with food or milk to
decrease stomach upset.
Residents Affected - Few
2. A review of Resident 114's record indicated the resident was admitted to the facility on [DATE] with
diagnoses which included femur (thigh bone) fracture.
A review of Resident 114's physician's orders dated November 21, 2022 indicated an order to start
amlodipine (a medication that lowers blood pressure) 5 mg oral tablet daily. The order further indicated
under order comments to hold for SBP (systolic blood pressure) less than 100 and heart rate less than 90 (
bpm-beats per minute).
During medication administration observation on November 29, 2022 at 9:00 a.m., LVN1, reviewed
Resident 114's heart rate was documented at 80 bpm and administered amlodipine 5 mg orally to the
resident.
On November 29, 2022 at 1:00 p.m., during a concurrent interview and record review with LVN1, she stated
the procedure for administering medications included reviewing vital signs as indicated. She further stated
she reviewed physician parameters for medications. She reviewed the physician order for Resident 114's
amlodipine 5 mg indicating to hold the medication for a heart rate lower than 90 bpm. She reviewed
Resident 114's vital signs indicating a heart rate of 84 beats per minute during the administration of the
medication amlodipine 5 mg. She stated she should not have given the medication and should have called
the physician.
A review of the facility's policy and procedure titled DES RX 183 Medication Administration dated
September 22, 2022 indicated, All medications .shall be prepared and administered in accordance with
Federal and State Laws, under the orders of a licensed practitioner, as per accepted standards of practice.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
555417
If continuation sheet
Page 7 of 12
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
555417
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/01/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Desert Regional Medical Center D/P Snf
1150 North Indian Canyon Drive
Palm Springs, CA 92262
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 0761
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted
professional principles; and all drugs and biologicals must be stored in locked compartments, separately
locked, compartments for controlled drugs.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview, and record review, facility failed to store a medication according to manufacturer's
specifications for 1 of 3 sampled residents (Resident 217) when the facility failed to date an opened
medication with a limited best use date.
This failure had the potential to cause the resident to receive an expired medication.
Findings:
A review of Resident 217's record indicated the resident was admitted to the facility on [DATE] with
diagnoses which included sepsis (the body's response to an infection).
On [DATE] at 2:52 p.m., during a medication storage observation, observed opened eye drops latanoprost
ophthalmic solution .0005% for Resident 217 stored in facility's medication refrigerator. The medication's
label indicated good for 6 weeks, no open date noted on the medication.
On [DATE], at 2:53 p.m., during a concurrent observation and interview with Registered Nurse (RN1), she
stated the facility only dates insulin. No other medications are dated when opened. She reviewed the
pharmacy label for Resident 217's latanoprost solution ophthalmic eye drops and acknowledged the use by
6 weeks instructions. The RN could not state when the medication was opened
A review of Resident 217's physician order dated [DATE], indicated latanoprost ophthalmic (Xalatan
ophthalmic 0.005% solution) 1 drop each eye daily at bedtime with an indication for treatment of glaucoma
(a condition resulting from damage to nerves of the eyes).
A review of the Medication Administration Record Note dated [DATE] at 12:46 p.m. by Registered
Pharmacist (RPh) indicated, Once opened, may be stored at Room Temp for 6 weeks, BUD (best use
date): [Blank].
According to Lexicomp (a nationally recognized pharmaceutical drug reference utilized by the facility),
Latanoprost ophthalmic solution once opened the container may be stored at room temperature up to 25
degrees Celsius (a unit of measurement) for 6 weeks.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
555417
If continuation sheet
Page 8 of 12
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
555417
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/01/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Desert Regional Medical Center D/P Snf
1150 North Indian Canyon Drive
Palm Springs, CA 92262
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 0804
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Level of Harm - Minimal harm
or potential for actual harm
Based on observation, interview, and record review, the facility failed to the ensure lunch meal was served
at an appetizing temperature. The hot food items (Garlic Herb Pork Loin, Roasted Corn, and Mashed Sweet
Potato) were not served hot.
Residents Affected - Many
These failures had the potential for residents not to consume their meals (15 of 16 vulnerable residents on
an oral diet).
Findings:
On November 28, 2022, at 3:45 p.m., during individual resident interviews, one resident (Resident 113)
complained of the food's temperature not being appetizing (not hot enough).
On November 30, 2022, at 10:15 a.m., the lunch meal preparation was observed. The food items were kept
inside the warm box (food cooked early were kept inside the equipment to keep the food warm) prior to
placement on the steam table.The food items' temperature on the steam table were checked by the Patient
Service Manager (PSM).
On November 30, 2022, at 10:45 a.m., the following food items' temperature were as follows:
1. Garlic herb pork loin- 155 ºF (degrees Fahrenheit);
2. Roasted corn- 156 ºF; and
3. Mashed sweet potato- 142 ºF.
On November 30, 2022, at 11:27 a.m., the Patient Dining Associate (PDA 1) started putting the residents'
meal trays on the cart.
On November 30, 2022, at 11:45 a.m., the test tray (regular diet) was placed inside the meal cart.
On November 30, 2022, at 11:50 a.m., the meal cart delivered to the skilled nursing unit on the fourth floor
of the building at 11:53 a.m.
On November 30, 2022, at 11:53 a.m., facility staff distributed the meal trays from the meal cart.
On November 30, 2022, at 12:05 p.m., the PSM checked the temperature of the following food items on the
test tray:
1. Garlic Herb Pork loin- 123 ºF;
2. Roasted Corn- 132 ºF; and
3. Mashed Sweet Potato- 135 ºF.
On November 30, 2022, at 12:08 p.m., a tasting of all the food items were conducted with the PSM. The 3
food items were not appetizing according to measured temperature.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
555417
If continuation sheet
Page 9 of 12
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
555417
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/01/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Desert Regional Medical Center D/P Snf
1150 North Indian Canyon Drive
Palm Springs, CA 92262
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 0804
Level of Harm - Minimal harm
or potential for actual harm
On December 1, 2022, at 9:45 a.m., in an interview with the Director of Food Service (DFS), the DFS
stated, food served hot should be above 140 ºF.
On December 1, 2022, at 10 a.m., in an interview with the Clinical Nutrition Manager (CNM), the CNM
stated if the food served falls below 140 ºF, the food should be warmed again.
Residents Affected - Many
A review of the facility's undated policy and procedure titled HOT HOLDING TEMPERATURES, indicated,
.Foods should be held hot for service at a temperature of 140ºF or higher .
A review of the facility's undated policy and procedure titled REHEATING, indicated, .If a food that is being
held for service falls below 140ºF, corrective action is taken .
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
555417
If continuation sheet
Page 10 of 12
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
555417
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/01/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Desert Regional Medical Center D/P Snf
1150 North Indian Canyon Drive
Palm Springs, CA 92262
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 0812
Level of Harm - Minimal harm
or potential for actual harm
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve
food in accordance with professional standards.
Based on observation, interview, and record review, the facility failed to store, prepare, serve and distribute
resident's food under sanitary conditions when:
Residents Affected - Many
Five bags of pancakes were found to be not in the original packaging and not labeled according to the
facility policy.
This failure had the potential to result in food borne illness in a medically vulnerable resident population (15
of 16).
Findings:
On November 28, 2022, at 9:25 a.m., a kitchen tour was conducted with the Director of Food Services
(DFS). Observed inside the walk-in freezer were five plastic bags-of pancakes (eight pieces pancakes /
bag) were not in their original packaging, were not labeled, and were warm (as checked reads a
temperature of 90 ºF (degrees Fahrenheit) and were soft.
On November 28, 2022, at 9:30 a.m., the Clinical Nutrition Manager (CNM) verified the pancakes found
inside the freezer were not in their original packaging and were not labeled.
On December 1, 2022, at 9:27 a.m., in an interview with the DFS, she stated the pancakes should have
been discarded and not returned to the freezer.
On December 1, 2022, at 10 a.m., in an interview with the CNM regarding the pancakes found in the
freezer, she stated items found outside of its original packaging, should have been labeled to know when
the food item are still good for consumption.
A review of the facility document titled, FROZEN STORAGE LIFE OF FOODS, indicated, . Pancakes
unopened + 3 months .re-label when product is opened, to use within 3 months .
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
555417
If continuation sheet
Page 11 of 12
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
555417
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/01/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Desert Regional Medical Center D/P Snf
1150 North Indian Canyon Drive
Palm Springs, CA 92262
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 0908
Keep all essential equipment working safely.
Level of Harm - Minimal harm
or potential for actual harm
Based on observation, interview and record review, the facility failed to ensure the food warm box (food
cooked early were kept inside the equipment to keep the food warm) was not maintained regularly
according to facility policy.
Residents Affected - Many
This failure had the potential for the food warm box not to be in safe operating condition and had the
potential to result in food borne illness in a medically vulnerable resident population (15 of 16).
Findings:
On November 30, 2022, at 10:15 a.m., during tray line observation with the Patient Service Manager
(PSM), the PSM stated the foods were cooked earlier and were placed inside a warm box, to maintain
temperature prior to being transferred to the steam table during tray line. Food items inside the warm box
were checked and the following food items were below 140ºF:
1. Garlic herb pork loin- 135 ºF and
2. Garlic herb pork loin- puree-122 ºF.
On November 30, 2022, at 10:55 a.m., the PSM ordered [NAME] 1 to re-heat using the steamer (equipment
used to re-heat).
On December 1, 2022, at 9:45 a.m., in an interview with the Director of Food Services (DFS), the DFS
stated food served hot should be above 140 ºF. The DFS further stated there had been known issue
with the warm box and is still unresolved.
On December 1, 2022, at 10 a.m., in an interview with the Clinical Nutrition Manager (CNM), the CNM,
verified there had been known issue with the warm box and is still unresolved. Copies of the repair order
were requested.
Repair orders were as follows:
On October 21, 2020, indicated, .Hot box for holding food door will not stay closed and door seal needs to
be fixed .
On December 11, 2020, indicated, .door seals falling apart hot box warmer needs replace .
A review of the facility's document do not show evidence of monthly check list of the warm box.
A review of the facility policy and procedure titled, EQUIPMENT INSPECTION PROGRAM,
Indicated, .To ensure that all equipment is in safe operating condition, an equipment inspection program is
followed . PROCEDURES .Director/Designee .Complete the Inspection checklist monthly .
According to the 2017 FDA Food Code .Equipment .Good Repair and Proper Adjustment. Equipment shall
be maintained in a state of repair and condition that meets the requirement .
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
555417
If continuation sheet
Page 12 of 12
Reading this as a family member? Your long-term care ombudsman is a free advocate for residents and families.
Back to topCitations
18 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.
F755 - Pharmacy Services
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
F761 - Labeling of Drugs and Biologicals
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
F804 - Food and drink
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
F812 - Food safety requirements
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
F908 - Maintain all mechanical, electrical, and patient care equipment in safe
Keep all essential equipment working safely.
F578 - The right to request, refuse, and/or discontinue treatment, to participate in or
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
F657 - Comprehensive Care Plans
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
F685 - Vision and hearing
Assist a resident in gaining access to vision and hearing services.
F759 - Medication Errors
Ensure medication error rates are not 5 percent or greater.
- 0004GeneralS&S Dpotential for harm
Develop and maintain an Emergency Preparedness Program (EP).
- 0006GeneralS&S Dpotential for harm
Conduct risk assessment and an All-Hazards approach.
- 0161GeneralS&S Dpotential for harm
Use approved construction type or materials.
- 0324GeneralS&S Epotential for harm
Provide properly protected cooking facilities.
- 0345GeneralS&S Dpotential for harm
Have approved installation, maintenance and testing program for fire alarm systems.
- 0351GeneralS&S Fpotential for harm
Install an approved automatic sprinkler system.
- 0353GeneralS&S Epotential for harm
Inspect, test, and maintain automatic sprinkler systems.
- 0363GeneralS&S Epotential for harm
Install corridor and hallway doors that block smoke.
F918 - Bathroom Facilities
Have generator or other power source capable of supplying service within 10 seconds.
FAQ · About this visit
Common questions about this visit
What happened during the December 1, 2022 survey of DESERT REGIONAL MEDICAL CENTER D/P SNF?
This was a inspection survey of DESERT REGIONAL MEDICAL CENTER D/P SNF on December 1, 2022. The surveyor cited 18 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at DESERT REGIONAL MEDICAL CENTER D/P SNF on December 1, 2022?
Yes, 18 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharm..."
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
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.
Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.