Desert Mountain Care Center

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure care and treatment with the use of indwelling catheter (a tubing that is inserted through the urethra [the tube that carries urine from the bladder out of the body] which drains urine from the bladder into a bag outside the body) was provided timely, for one of three residents reviewed (Resident A), when the resident had low and/or no urine output for eight hours. This failure had a potential for a delay in the care and treatment to address Resident A's low or no urine output.

Inspectors wroteBased on interview and record review the facility failed to ensure, for one of three residents reviewed (Resident 1):1. A complete skin assessment was conducted and documented upon the resident's admission; and2. Physician's order was obtained for treatment of sacrococcyx (tailbone) pressure ulcer (PU - skin damage due to prolonged pressure). These failures resulted in a delay in the care and treatment of Resident 1's sacrococcyx PU and had the potential for complications of delay wound care such as infection and delayed wound healing, which could compromised the resident's overall health condition.

Inspectors wroteBased on interview and record review the facility failed to ensure appropriate treatment and services to restore continence (voluntary control to retain urine or feces until an appropriate time) was provided, for one of five residents (Resident B). This failure resulted in Resident B not receiving the appropriate toileting program to restore or maintain as much normal function of her bladder as possible, and prevent accidents and injuries.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure care and treatment to manage pain was provided, for one of five residents (Resident A), when:1. Resident A received a pain medication ordered by the physician for pain scale of 4 to 10 for a pain scale of 0/10 (no pain); and2. The physician's order for pain management consult was not scheduled since it was ordered on October 26, 2025. These failures could delay the care and treatment needed to manage Resident A's pain effectively.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure patient care equipment was maintained in a safe operating condition, when two of the mechanical lifts (also referred to as Hoyer lifts - devices used to safely transfer mobility impaired patients between beds, chairs, and toilets) remained in use on the floor despite identified problems. This failure could have put residents at risk by allowing the use of unsafe equipment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe, functional, and sanitary environment for the residents, staff, and the visitors, when:1. The floors in Hallway 100 were deformed with multiple raised areas; and2. The ceiling in room [ROOM NUMBER] had a crack due to water damage. These failures had the potential for residents, staff, and visitors to be harmed from the unsafe environment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure provision of pharmacy services to meet the needs of the residents, when: 1. Four discontinued bags of large volume fluid for injections containing normal saline (electrolyte supplement in water) 0.45% remained stored in the medication room available for use; 2. One discontinued bag for IV (intravenous, into vein) infusion containing vancomycin (antibiotic for infection) 1 gram in 250 ml (milliliter, unit of measurement) remained stored in the medication refrigerator available for use; 3. One discontinued blister card containing ondansetron (medication for nausea and/or vomiting [N/V]) 4 mg (milligram, a unit of measurement) tablets remained in the medication cart available for use for Resident 55; 4. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe, sanitary food preparation and storage practices were followed in the kitchen when wooden storage shelves in the dry supply area were observed to be chipped, splintered and the lacquered varnish peeled off. This failure had the potential to cause food-borne illness in a highly susceptible resident population.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure an assessment for safe self-administration of medication was conducted, for one of one resident reviewed (Resident 44), when two open white plastic containers of topical ointment was found on the overbed table. This facility failure increased the potential for unsafe self-administration of medication.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure medications were labeled with the name of the resident for whom they were intended to be administered. This failure had the potential for medications to be shared by multiple residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow up the dental needs of a resident, for one resident reviewed for dental services (Residents 15) . This failure has the potential to place Resident 15 at high risk for complications related to dental and nutritional needs due to the delay in providing dental services.

Inspectors wrote2. On June 23, 2025, at 12:10 p.m., Resident 64 was observed eating lunch in his room. Resident 64 was eating one of two burritos served on a separate plate from the main entree, which contained a piece of meat, parslied rice, and braised cabbage. When asked if he did not like the main dish served for lunch, Resident 64 stated, I don't like pork, so he asked for burritos instead. Resident 64 further stated he disliked pork, but I get it always. Resident 64's meal ticket was reviewed, which indicated, LCS (low calorie sweeteners) Diet .Regular Consistency .GARLIC HERB PORK CHOP 1-EACH .Dislikes: PORK . On June 23, 2025, at 12:30 p.m., Licensed Vocational Nurse (LVN) 2 was interviewed. LVN 2 stated Resident 64 should not have been served pork since that was his dislike, and kitchen staff should follow what it says on the diet slip. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure infection control practices were implemented, when: 1. For Resident 47, a black stand fan in the resident's room was observed with dust accumulated on the front and back guard covers; and 2. For Resident 287, one used plastic urinal was found inside the resident's personal belonging's storage closet. These failures had the potential to increase the spread of pathogens (germs) and infections to residents which could lead to serious illness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure resident's wheelchairs were maintained in a safe operating condition, for two of 15 residents (Residents 45 and 70). These failures had the potential to result in injury to the residents.

Inspectors wroteBased an observation, interview, and record review, the facility failed to ensure trained staff were utilized to provide one on one (1:1) supervision of a resident with wandering behavior, for one of four sampled residents (Resident 4). This failure resulted to untrained staff providing 1:1 supervision to Resident 4 and had the potential for wandering residents to experience physical and psychosocial harm due to lack of training to handle residents with wandering behavior.

Inspectors wroteBased 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.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure infection prevention and control practices were implemented when Certified Nursing Assistant (CNA) 1 did not perform hand hygiene after provision of care to a resident and after touching the linen cart. These failures had the potential to spread infection among the vulnerable residents of the facility.

Inspectors wroteBased 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. 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.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure proper infection prevention and control standards were followed, when three direct care staff members were noted to have artificial nails. This failure had the potential to result in the transmission of healthcare-associated infections to the vulnerable immunocompromised residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure an environment free of accident hazard was provided, for one of three residents (Resident 1) reviewed for elopement (resident leaves the facility without authorization or supervision necessary for his safety) when the door alarm was not activated. This failure had the potential for Resident 1 to be able to leave the facility undetected, which could lead to repeated elopement and have subsequently result in accidents, injuries or even death to the resident.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a comfortable and home like environment was provided when: 1. The room and hallway temperatures exceeded 81degrees Fahrenheit (F), for five of seven sampled resident (Resident 1, 2, 3, 4, and 7). In addition, the facility failed to report an unusual occurrence of disruption of services when the facility's airconditioning unit was not working. This failure resulted in discomfort and had the potential to for the resident to experience dehydration (loss of body fluids), heat stress (condition where the body is under stress from overheating), and heat stroke (when the body cannot control its temperature); and 2. The carpets in the resident's hallways and through-out the facility were observed to be dirty with multiple areas of dark black circular stains. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide incontinent care, for two of twelve residents reviewed, (Residents 11 and 12), when the residents was left in their soiled diaper for a long period of time. This failure resulted in a delay of care needs and had the potential of a negative impact on their self-esteem.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain environmental conditions that could keep insects from entering the building, as evidenced by one window screen was missing, other screens were observed to have tears and gaps, and the entrance and exit doors also had gaps large enough for a fly or other insect to enter the facility. This failure could result in insects coming in to the resident's rooms and other areas of the facility frequented by the residents which could potentially cause health problems to vulnerable residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure treatments were provided upon admission for one of three sampled residents' (Resident 1) wounds located on the right lower extremity (back of the right leg) and left achilles. This failure has the potential to result in worsening of the wounds, which could negatively affect the health status of Resident 1.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the following: 1. A multidose bottle of oxycodone (controlled narcotic medication) was dispensed in a readily accountable container. This failure increased the risk for diversion of a controlled medication. 2. A routine fentanyl patch (medication used in the management and treatment of chronic pain) was made available for one of three sampled residents (Resident 2). This failure has the potential to negatively affect the resident's pain management.

Inspectors wroteBased on interview and record review, the facility failed to ensure medications to treat scabies (contagious skin infestation caused by an itch mite) were administered according to the physician's orders, for two of eight residents (Residents 1 and 2), when: 1. The oral medication Ivermectin (medication given by mouth to treat scabies) was not administered to Resident 1 on December 18 and 19, 2023; and 2. The medication Elimite topical cream (brand name for permethrin- medication applied to the skin to treat scabies) was not administered timely for Resident 2. These failures had the potential to result in insufficient and/or ineffective treatment of scabies for Residents 1 and 2.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure an allegation of abuse was reported to the State Survey Agency (CDPH-California Department of Public Health) within two hours or immediately after the facility was aware of the abuse allegation, for one of three sampled residents (Resident 1). This failure had the potential to delay the identification and implementation of appropriate actions and place Resident 1 at risk for further injury.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a final report for investigation of an injury of an unknown origin was provided to the California Department of Public Health (CDPH), within five working days from the time injury was identified, for one of three residents (Resident A) reviewed for abuse. This failure had the potential to result in a delay of the implementation of the appropriate action and the provision of protection to the residents of the facility and placed Resident A at risk for further abuse.

Inspectors wrote3. On August 23, 2021, at 3:37 p.m., Resident 1 was observed lying in bed, not verbally responsive. Resident 1 was observed to have contractures on his right hand. On August 26, 2021, the record of Resident 1 was reviewed. Resident 1 was readmitted to the facility on [DATE], with diagnoses which included quadriplegia (weakness of arms and legs). The MDS, dated March 15, 2021, indicated, .Functional Limitation in Range of Motion .Impairment of both sides .Upper extremity (shoulder, elbow, wrist, hand) .Lower extremity (hip, knee, ankle, foot) . The quarterly MDS, dated [DATE], indicated, .Functional Limitation in Range of Motion .Impairment on both sides . A physician's order dated, August 28, 2020, indicated, .Continue gentle ROM . [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure medications were properly stored and disposed when: 1. One licensed nurse (LN) was observed disposing the sorbitol liquid medication (medicine to treat constipation) in a regular trash bin inside the resident's room. 2. Multiple non-controlled medications were observed not properly disposed or placed in authorized collection receptacles for proper destruction. These failures had the potential for accidental poisoning or possible environmental contamination to occur. 3. Expired medications were stored in the treatment cart and medication storage room readily available for use. This failure had the potential for residents to receive expired medication with less potency and efficacy.

Inspectors wrote2a. On August 23, 2021, at 9:36 a.m., Resident 6 was observed to be awake, lying in bed and not verbally responsive. Resident 6 was observed to have a tracheostomy (surgical opening created at the front of neck to help a person breathe). Resident 6 was observed to be connected to a ventilator (a machine that provides ventilation by moving breathable air into and out of the lungs) through the tracheostomy. A [NAME] tubing of approximately one and a half feet long was observed to be connected to the tracheostomy tube. The bottom end of the suction valve of the [NAME] tubing was observed to not have a protective cap. On August 25, 2021, the record of Resident 6 was reviewed. Resident 6 was admitted to the facility on [DATE], with diagnoses which included respiratory failure (lung failure). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the call light was within reach, for one of 23 residents reviewed (Resident 8). This failure had the potential for Resident 8 to not receive timely care and assistance from staff.

Inspectors wroteBased on interview and record review, for three of six residents reviewed for Advance Directives (AD - a written instruction regarding the provision of health care when the individual is incapacitated) (Residents 6, 43, and 48), the facility failed ensure: 1. For Resident's 6 and 43, written information regarding formulating an AD were provided to the resident and/or the resident's representative (RR); and 2. For Resident 48, a follow up with the RR was conducted regarding obtaining a copy of the resident's AD. These failures 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.

Inspectors wroteBased on interview, and record review, the facility failed to ensure timely coordination with the resident and/or the family member (FM) to obtain the list of home medications upon admission, for one of one resident reviewed (Resident 273). This failure resulted in the delay of Resident 273's administration of her home medications necessary for the continuity of care in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop a plan of care (POC) when the resident (Resident 1) was assessed to have limitations of his lower and upper extremities, for one of six residents reviewed for range of motion (ROM- movement of joints) and restorative nursing care. This failure had the potential for Resident 1 to not receive timely treatment and interventions which could result in further decline with mobility and range of motion.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the plan of care (POC) was updated or revised, for one of 23 residents reviewed (Resident 58), when the resident had a physician's order perform range of motion exercises. This failure had the potential to result in a delay of the implementation of appropriate interventions to address the care and treatment for Resident 58.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the medication was administered as ordered by the physician, for one of four residents reviewed during medication administration observation (Resident 19). This failure had the potential for Resident 19 to not receive the intended therapeutic effect of the medication.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide care and treatment per professional standards of practice, for two of 23 residents reviewed (Residents 22 and Resident 5) when: 1. For Resident 22, the multiple discolorations on both hands and forearms were not assessed and monitored. This failure had the potential for a delay in the necessary care and treatment for Resident 22; and 2. For resident 5, there was no consistent blood sugar monitoring when the resident was receiving diabetic medications and had frequent episodes of refusing meals. This failure had the potential for a delay in the identification of abnormal blood sugar levels which could lead to a compromised health condition.

Inspectors wroteBased on interview and record review, the facility failed to ensure the emergency kits (e-kit- an emergency storage box containing a small quantity of critical medications used in emergent situations) were replaced within seventy-two hours according to the facility's policy and procedure. This failure had the potential to result in a delay in the administration of medications.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Medication Regimen Review (MRR - process by which a consultant pharmacist reviews all medications the resident is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy) recommendations were acted upon timely, for one of five residents reviewed for unnecessary medications (Resident 58), when the recommendation to recheck the potassium (electrolyte which helps the nerves to function and muscles to contract) level was not referred to the physician. This failure had the potential to result in the delay with the provision of treatment and the monitoring of the potassium level for Resident 58.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure psychotropic medications (medications to manage mood disorders) were necessary in managing mental and mood disorders, for two of five residents reviewed for unnecessary medications (Residents 60 and 8) when: 1. For Resident 60, the physician or psychiatrist (specializes on mental illness) did not evaluate the resident prior to the use of duloxetine (a medication to treat mood disorder). There was no behavior monitoring for the use of duloxetine. In addition, the facility did not follow through with the physician's recommendation for psychiatric evaluation for Resident 60; and 2. For Resident 8, a periodic evaluation for the continued use of sertraline (medication to treat mood disorder) was not completed by a physician or health care practitioner. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the physician was notified of the abnormal laboratory test results for potassium (electrolyte which helps the nerves to function and muscles to contract) and platelets (blood cells which help form clots to stop bleeding), for one of 23 residents reviewed (Resident 58). This failure had the potential for a delay in the care and treatment for Resident 58.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a diagnostic procedure was provided in a timely manner, for one of 23 residents reviewed (Resident 48), when a CT (computer tomography - a radiologic procedure to get detailed images of the body) scan was not completed as ordered by the physician. This failure had the potential for the delay in the treatment and management of Resident 48's pain.

Inspectors wroteBased on interview and record review, the facility failed to ensure the result of an electrocardiogram (EKG/ECG - a test to check the electrical activity of the heart) was reported to the physician, for one of 23 residents reviewed (Resident 48). This failure resulted in the delay in the identification and notification to the physician of an abnormal EKG result. In addition, this failure had the potential for a delay in the initiation of appropriate treatment for Resident 48.