Hi-Desert Medical Center D/P SNF

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure services to increase range of motion (measurement of how far you can move a body part) or to prevent further decrease in range of motion were provided for three of three sampled residents (Resident 1, 2 and 3), when Resident 1, 2 and 3 were assessed for but not provided the services as ordered for the Functional Maintenance Program (FMP -formally the Restorative Nursing Assistance program or RNA- a program to aim to help residents in the long-term care to maintain the highest level of functioning like bed mobility, transfer walking, dressing etc.) after discharged from Physical Therapy and (PT- a branch of rehabilitative health that uses specially designed exercise to help residents regain or improve their physical abilities) and Occupational Therapy (OT-a branch of rehabilitative health that focuses on [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide appropriate supervision and implement elopement (when a resident leaves facility without staff's permission) preventions for one of three sampled residents (Resident 1), who was assessed as having a high elopement risk. This failure resulted in Resident 1 leaving the facility unsupervised, fell, and subsequently sustained a left hip fracture (broken).

Inspectors wroteBased on interview and record review, the facility failed to provide sufficient number of nursing staff in accordance with its policy when the required number of Certified Nursing Assistant (CNAs) was not met for three consecutive days (April 10, 2026. through April 12, 2026). This failure had the potential to result in unmet resident's needs, such as psychosocial, physical needs, and safety concerns for 78 vulnerable residents.

Inspectors wroteBased on interview and record review, the facility did not ensure sufficient nursing staff was provided to meet the needs for 20 of 20 residents, who were ordered to receive restorative nursing services (a program to maintain or improve residents' physical function provided by a trained staff member such as a certified nurse assist or CNA) from February 1, 2026, through February 28, 2026. This failure resulted in missed restorative nursing services and had the potential to result in decline in residents' health and functional status.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure no expired medications were available for patients use for two of six medication carts (Cart 100 and Hallway Cart). This failure has the potential to affect all residents receiving beyond the use date (expired) medications, placing them at risk for ineffective therapy and medication errors, which could negatively affect residents' health and safety.

Inspectors wroteBased on interview and record review, the facility did not ensure administration maintained an effective oversight of facility operations for 90 of 90 residents who are residing in the facility. This failure resulted in inadequate oversight of facility operations, with the potential to negatively affect residents care needs.

Inspectors wroteBased on interview and record review, the facility failed to ensure the governing body (GB - a group of people responsible for the overall direction and management of an organization) provided effective oversight of the facility. This failure resulted in lack of oversight of facility operation, leading to unaddressed systemic issues that could negatively affect residents' care.

Inspectors wroteBased on interview and record review, the facility failed to complete the facility assessment (a review of the facility resources that are necessary to care for its residents) annually for 90 of 90 residents who are residing in the facility. This failure had the potential to result in inadequate identification and allocation of resources necessary to meet resident care needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure an effective system wide infection control program for the prevention and control of disease for six of seven sampled residents (Resident 25, 92, 90, 66, 30, and 4) when: 1. For five residents (Resident 25, 92, 90, 66 and 30), the nursing staff did not change the oxygen tubing (a thin, flexible tube that delivers oxygen to a patient) according to the facility's policy and procedure (P&P). 2. For one resident (Resident 4), the isolation precaution (infection control methods that involve wearing appropriate cover to protect staff and residents from spreading germs or infection) sign was not posted in front of resident's room. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two of two sampled residents (Resident 8 and Resident 10) received necessary pressure injury (PI-injury to skin and underlying tissues that develop because of prolonged pressure, shear, or friction) treatment when the facility staff did not provide daily wound treatment. This failure had the potential to contribute to worsening of residents' wound or skin condition that could negatively affect residents' health status from delayed wound healing.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the facility staff reviewed and updated care plan (an individualize plan that is create based on each resident's need) and interdisciplinary team (IDT-a meeting where different professionals come together to discuss a patient's care need) regarding pressure injury (PI-injury to skin and underlying tissues that develop because of prolonged pressure, shear, or friction) for one of two sampled residents (Resident 8). This failure had the potential to contribute to worsening of Resident 8's wounds or skin condition from not reviewing intervention and evaluating the effectiveness of the treatment plan.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that oxygen therapy was administered in accordance with physician's order for three of six residents (Resident 92, Resident 90 and Resident 30) while receiving oxygen. This failure had the potential for placing Resident 30, Resident 92 and Resident 25 at risk for inappropriate treatment and altered oxygen saturation (how well oxygen is being delivered to the body) levels.

Inspectors wroteBased on interview and record review, the facility failed to act on recommendations made by the pharmacist for one of two sampled residents. (Resident 2). This failure had the potential for unnecessary medication to cause harm to Resident 2.

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure medications were administered in accordance with physician orders for one of 23 sampled residents (Resident 67), when Resident 67 received an antibiotic (medication that treats bacterial infections) intravenous (IV - administered through the vein) at an incorrect rate. This failure resulted in medication error and had the potential to result in ineffective treatment and adverse clinical outcomes such as antibiotic resistance (a condition that bacteria have evolved and difficult to kill).

Inspectors wroteBased on interview and record review, the facility failed to investigate and monitor the use of illegal substances (drug or chemical that the government has made against the law to have, use, or sell) for one of three sampled residents (Resident 1), when Resident 1 tested positive for marijuana (most common name of the cannabis plant, widely used either for its mind-altering effect or for medical purposes). This failure had the potential to pose a safety hazard to Resident 1 and other residents in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect two of three sampled residents (Resident 1 and 3) from verbal abuse (suing negative words and language that cause harm) from Registered Nurse (RN 1). This failure had the potential to contribute to Resident 1 and 3 distrust in the healthcare team which could negatively affect Resident 1 and 3 participating in their care that could lead to actual harm and worsen their condition.

Inspectors wroteBased on interview, and record review, the facility failed to report an allegation of abuse within 24 hours for one of three sampled residents (Resident 1). This failure prevented the appropriate state agencies from ensuring that the facility was taking the necessary actions to protect Resident 1 and other residents from actual or potential harm.

Inspectors wroteBased on interview and record review the facility failed to ensure one of three sampled residents (Resident 1) received enteral nutrition (tube feeding - a delivery of liquid nutrition directly into the stomach through a percutaneous endoscopic gastrostomy (PEG - a feeding tube that is place through the stomach used for a person who cannot eat or swallow safely)) according to the physician's order, when Resident 1 did not receive the calculated amount of feeding for approximately two days. This failure had the potential to compromise Resident 1's nutritional status placing him at risk for weight loss, dehydration, and decline in condition.

Inspectors wroteBased on interviews, Record Review and observation, the facility failed to follow policy and procedure to provide services in a timely manner to 1 out of 4 residents to avoid physical harm, pain, mental anguish and emotional distress. This failure had the potential to compromise the residents' health, safety, psychosocial wellbeing and overall quality of care, when the resident was left soiled, and their activities of daily living were not met in a timely manner. Based on interviews, Record Review and observation, the facility failed to follow its policy and procedure to provide services in a timely manner to 1 out of 4 residents to avoid physical harm, pain, mental anguish and emotional distress. [...]

Inspectors wroteBased on interview, and record review, the facility failed in response to safety concerns with suspected abuse for one of three sampled Residents (Resident 1) when the facility reported the suspected abuse to the California Department of Public Health (CDPH) on August 20, 2025, or five (5) days after the suspected abuse incident. This failure had the potential to result in a delay of an investigation to determine abuse which could continue or become more severe, other vulnerable Residents to be put at risk for abuse, worsen long-term psychological and physical effects, delay timely access to medical, psychological, and other services for healing for Resident 1.

Inspectors wroteBased on interview and record review, the facility failed to follow their policy and procedure (P&P) for resident abuse for one of three sampled residents (Resident 1) when Resident 1's care plan (an individualize treatment plan) was not updated or revised and enhanced monitoring was not implemented. This failure had the potential to result in Resident 1 having psychosocial (affecting person's feelings, emotions, relationships, and sense of well-being) harm to residents such as fear, anxiety and loss of trust in staff.

Inspectors wroteBased on interview and record review, the facility failed to follow their policy and procedure (P&P) for resident documentation of care plan for one of three sampled residents (Resident 2) when Resident 2's care plan (an individualize treatment plan) was not updated with description of changes in Resident 2's condition and behaviors. This failure had the potential to result in Resident 2 deterioration, emotional distress and an increase in the risk of injury to self, other residents, and staff.

Inspectors wroteBased on observation, interview, record review the facility failed to develop and implement a comprehensive person-center care plan (a document that outlines a patient's care, including their diagnosis, treatment goals, and nursing orders) that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental, and psychosocial needs for four of five sampled residents (Resident 24, 61, 67, and 50). This failure had the potential to result in person-centered care not being provided which may lead to negative physical, mental, and psychosocial impact upon the resident's function, mood, and cognition.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the nursing staff administered medication as ordered for 23 residents of 41 sampled residents (Residents 2, 4, 8, 9, 20, 28, 41, 42, 45, 49, 53, 55, 56, 57, 58, 59, 60, 64, 65, 71, 74, 147 and 295) when: 1.) The nursing staff did not give medications to 22 residents (Residents 2, 4, 8, 9, 20, 28, 41, 42, 45, 49, 53, 55, 56, 57, 58, 59, 60, 64, 65, 71, 74 and 295) on December 1, 2024, as ordered and did not notify a responsible physician or a pharmacist for not giving the medications. 2.) The nursing staff did not administer Resident 147's medication by mouth as ordered and did not verify with a physician for using a percutaneous endoscopic gastrostomy (PEG-a feeding tube surgically inserted directly to the stomach wall to use for food and medication) tube for medication administration. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure family or emergency contact person were notified appropriately of resident transfer for one of 22 sampled residents (Resident 1) when there was no documented evidence that Resident 1's family was notified before Resident 1 was transferred to the acute care hospital for suprapubic catheter (a surgically created tube that drains urine from the bladder when other methods are not possible) exchange. This failure resulted in no communication between Resident 1's family and the healthcare team and had the potential to interfere with Resident 1's family ability to follow and participate in Resident 1's transfer process and care.

Inspectors wroteBased on observation, interview, record review, the facility failed to ensure Passive Range of Motion (PROM - the movement of a joint from staff or therapist with no effort from the resident) services were provided for two of five sampled residents (Resident 61 and 67) when there was no documented evidence that the Range of Motion (ROM-extent or limit to which joint can be moved around) was completed as ordered. This failure has the potential to result in further decline in physical, mental, and/or psychosocial aspects of the resident's ability to maintain and improve range of motion and mobility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure call lights were answered in a timely manner to provide care and services for two of three residents (Resident 1 and Resident 2). This failure has the potential to jeopardize the health and safety of clinically compromised Residents (Resident 1 and Resident 2) when their requests for assistance with activities of daily living were not responded to promptly.

Inspectors wroteBased on interviews, and record review, the facility failed to maintain an accurate controlled medication (medications that can cause physical and mental dependence) verification process for a universe of 17 residents when the controlled medication verification was not accurately completed with two (2) licensed nurses for seven (7) of 20 days from August 1, 2024, through August 20, 2024. This failure had the potential in delaying the recognition of any discrepancy to the controlled medication which can negatively affect residents ' health from misuse of medication or diversion (medication illegally going to someone without a prescription) of medication to unauthorized people.

Inspectors wroteBased on interviews, and record review, the facility failed to ensure the controlled medication (medications that can cause physical and mental dependence) was kept securely within the facility for one resident (Resident 1) when License Vocational Nurse (LVN 1) took Resident 1 ' s acetaminophen and hydrocodone (Norco-one of controlled medications that combine two types of medications together for pain control) from the medication cart without permission. This failure had resulted in diversion (medication illegally going to someone without a prescription) of controlled medication, which had the potential formisuse of drugs and stealing of Resident 1 ' s medication that could put Resident 1 at risk for inadequate relief of pain.

Inspectors wroteBased on interview, and record review, the facility failed to ensure 2 of 3 sampled residents (Resident 1 and Resident 2) Schedule II medication narcotic (medication which is controlled by law due to the potential for misuse/abuse), to be unlawfully diverted (medication illegally going to someone without a prescription) from the facility The facility failed to ensure strict controls for persons authorized to access controlled substances in preventing the diversion of medication, leading to potential misuse and theft of the medications for clinically compromised Residents (Residents 1 and 2) health and safety.

Inspectors wroteBased on interview and record review, the facility failed to request permission, to remove a Resident ' s beard from the Responsible Person (RP, ensures the residents wishes are carried out and enforced) for one of three residents (Resident 1). This failure resulted in the nursing staff not respecting Resident 1's right to have the RP exercise his wishes.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Dietary Supervisor (DS - plans and supervises employees in the food and nutrition services at a health care facility) was qualified and hired full-time (working 35 or more hours a week). This failure had the potential to harm 80 residents by not monitoring or managing food services to promote, maintain or restore the residents' health.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food ingredients were stored to conserve nutritive value (vitamins and minerals in food), flavor, and appearance when bulk food (food items offered in large quantities) storage was not labeled with the name of the product and initial date of storage. These failures had the potential to harm 80 highly vulnerable residents by not providing food with the full nutritive value, or food palatability (taste and/or flavor of the food).

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain professional standards for food service safety when: 1. There were crumbs and dust buildup on the right side of the staff refrigerator in the kitchen. 2. Food spill stains and crumbs were found in six of six food warming drawers. 3. There were trash, crumbs, and dirt buildup under the nourishment station (an area designed for storage for food and beverages) in the resident dining room area. 4. A total of four open rodent snap traps (a trap that snaps shut when the bait or trigger is disturbed) were found in the kitchen, under the metal racks for storing clean cooking supplies and nourishment station in the resident dining room area. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed follow their own policy and procedure, and the standards of care for medication administration and reporting to physician for one of three residents reviewed for omitted (absent) medications (Resident 438) when: 1. Resident 438 had an order to receive routine Albuterol (respiratory medication) for Chronic Obstructive Pulmonary Disorder (COPD - is a chronic inflammatory lung disease that causes obstructed airflow from the lungs). The Albuterol was ordered on October 26, 2023, at 11:52 AM and did not receive the medication until October 27, 2023, at 1:00 AM. Documentation indicated the licensed nurses and RTs did not notify the physician of the omitted medication. 2. Resident 438 had an order to receive routine Umeclidinium (respiratory medication) for COPD. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a comprehensive care plan was developed and implemented for one of three residents reviewed for rehabilitative and restorative care (Resident 6) when an individualized care plan for functional maintenance program was not initiated for Resident 6. This failure had the potential for inadequate treatment and management of the resident's medical conditions and had a potential to not meet the residents' personal goals, choices and preferences that could negatively impact Residents 6.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the care plan (a summary of a resident's health conditions, specific care needs, and current treatments) was revised for one of five residents reviewed for nutrition (Resident 32), when Resident 32's nutrition care plan was not revised or updated from June 15, 2023, to December 6, 2023, and visual function care plan was not revised or updated since March 23, 2023. Resident 32 went from 139.5 pounds in May 2023 to 129.4 pounds in December 2023. This failure had the potential to cause Resident 32 to continue to lose weight and negatively affect her nutrition status.

Inspectors wroteBased on observation, interview, and record review, the facility failed to establish a safe resident smoking practice for one of two residents reviewed for accidents (Resident 439) when Resident 439's smoking assessment was not completed accurately. This failure had the potential for Resident 439's safety needs to be unmet, which could place him at risk for accidents and life-threatening injuries.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow the facility's policy and procedure for enteral nutrition (a form of nutrition delivered to the digestive system in the form of a liquid usually through a feeding tube) for one of five residents reviewed for tube feeding (Resident 81), when Resident 81's enteral nutrition feeding container was not dated. This failure had the potential for the enteral nutrition container and tubing set to exceed the manufacturer's prescribed hang-time (amount of time a feeding is safe to use after opening), and for Resident 81 to not receive the prescribed amount of nutritional calories resulting in weight loss.

Inspectors wrote2. During a review of Resident 588's clinical record, the face sheet indicated Resident 588 was admitted to the facility on [DATE], with diagnosis of diabetes mellitus (long lasting health condition that affects how the body turns food into energy). During a review of Resident 588's POLST, dated on December 1, 2023, under Section D of Information and Signatures, it indicated the Advanced Directive information was not documented. The POLST items indicating if the Advance Directive was available or not, or if the education was provided with the patient and legal representative were left blank and incomplete. During a concurrent interview and record review, on December 5, 2023, at 2:30 PM, with Licensed Vocational Nurse (LVN) 1, LVN 1 reviewed Resident 588's POLST and stated it was not filled out completely. LVN 1 acknowledged that all parts of the form should be documented in its entirety. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a safe, comfortable, homelike environment, when the facility's main dining room was not maintained at the appropriate temperature on August 24, 2023. This failure had the potential to affect the health and wellness of 74 residents residing in the facility.