Health inspection·April 22, 2025

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure one on one (1:1) supervision was provided according to the physician's order and plan of care, for one of four residents reviewed (Resident 4) when there was no assigned sitter (staff to supervise the resident's whereabouts) to monitor Resident 4's wandering behavior. This failure had the potential to result in Resident 4 wandering out of the facility, leading to potential physical or psychosocial harm. Findings: On April 22, 2025, at 9:35 a.m., an unannounced visit to the facility was conducted to investigate complaints regarding quality of care. On April 22, 2025, at 12 p.m., during an interview with Certified Nursing Assistant (CNA) 2, CNA 2 stated there were situations where there was not a sitter for Resident 4 which was reflected as blank in the assignment sheet. CNA 2 further stated administration would ask staff to keep an eye on Resident 4 until someone was able to come in and sit with Resident 4. CNA 2 stated keep an eye on a resident meant that Resident 4 would not have a 1:1 sitter, instead, all the nurses and CNAs were responsible for monitoring the resident for any harmful behaviors while attending to their own assigned residents. CNA 2 stated it should not happen because someone should only be responsible for taking care of the one resident who required a sitter, because you do not want something to happen to the resident. On April 22, 2025, at 12:15 p.m., during an interview with CNA 3, CNA 3 stated Resident 4 had a wandering behavior due to dementia (memory loss). CNA 3 stated if the box on the staffing assignment sheet for the assigned sitter for Resident 4 was blank, it would indicate to staff that there was either no assigned sitter and it was everyone ' s job to keep an eye on the resident until they could get a CNA to come in, or a housekeeper was the assigned sitter for the resident. CNA 3 stated she found Resident 4 wandering in the hallway about three weeks ago. CNA 3 stated this incident happened when a housekeeper was assigned to Resident 4. During a concurrent record review with CNA 3 the staff assignment sheet for April 4 to April 6, 2025, indicated a blank box for the assigned sitter for Resident 4 on the staff assignment sheet for those dates. CNA 3 stated the blank on the assignment sheet indicated that either a housekeeper was the assigned sitter for Resident 4, or they were attempting to find a CNA to come in and be the sitter for Resident 4. On April 22, 2025, at 3:50 p.m., an interview and concurrent record review with the Director of (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: 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 04/22/2025 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)