Health inspection·April 1, 2025

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 physician's orders were followed, for one out of four residents (Resident 4) when Resident 4's blood sugar of 403 mg/dl (milligram/decilitier - unit of measurement) was not reported to the physician according to Resident 4's physician's order. Residents Affected - Few This failure had the potential for Resident 4 to have abnormal blood sugar not controlled or managed and could affect the resident's overlal health condittion. Findings: On March 3, 2025, at 11 a.m., an unannounced visit was conducted at the facility to investigate a complaint regarding quality of care. On March 3, 2025, at 1 p.m., Resident 4 was observed sitting on the edge of the bed. In a concurrent interview with Resident 4, he stated he was unhappy with his care. On March 3, 2025, at 1:05 p.m., Resident 4's record was reviewed. indicated Resident 4's admission Record, indicated Resident 4 was admitted to the facility on [DATE], with diagnoses which included diabetes mellitus (abnormal blood sugar). A review of Resident 4's Medication Administration Record (MAR), for the month of January 2025, included a physician's order, dated January 11, 2025, which indicated, FSBS (finger-stick blood sugar) before meals and at bedtime .Call MD (physician) if less than 60 OR greater than 400 . A review of Resident 4 MAR, for the month of January 2025, indicated on January 22, 2025, at 8 p.m., Resident 4's bedtime blood sugar was 403. There was no documented evidence the physician was notified when Resident 4 had a blood sugar of 403 (above 400) on January 22, 2025, at 8 p.m. On March 3, 2025, at 5:30 p.m., a concurrent interview and review of Resident 4's record was conducted with the Assistant Director of Nursing (ADON). The ADON stated Resident 4 had a blood sugar level of 403 on January 22, 2025, at 8 p.m. The ADON stated there was no documentation the physician was notified when Resident 4's blood sugar was above 400 on January 22, 2025, at 8 p.m. as indicated in the resident's physician order. The ADON stated the licensed nurse should have notified the physician when Resident 4's blood sugar was 403 on January 22, 2025, at 8 p.m. A review of the facility's policy and procedure titled, Physician Services .Physician's orders, dated January 2023, indicated, .When noting orders, if the licensed staff member is not able to implement the order .then the following procedure is followed to ensure follow-up and timely implementation (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: 555742 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 555742 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/01/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Desert Mountain Care Center 47-763 Monroe Avenue Indio, CA 92201 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)