Joshua Tree Post Acute

Inspectors wroteBased on observation and interview, the facility failed to ensure the walk-in refrigerator and walk-in freezer were maintained. This failure had the potential for temperatures to fluctuate, putting an already vulnerable population at risk for foodborne illness. During a concurrent observation and interview on 9/15/25 at 8:05 AM, with the Maintenance Supervisor (MS) in the facility's kitchen, the gasket (an airtight seal around the door to keep cold air inside and warm, moist air out, maintaining consistent temperatures for food safety and energy efficiency) for the walk-in refrigerator was loose and held in place with tape. The walk-in freezer door was coated in a layer of ice. The MS stated the freezer door gasket did not create a tight seal which caused the door to shut improperly. The MS stated he needed to melt the ice with a blower every two to three weeks to remove the ice buildup. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide written information concerning the right to formulate an Advance Directive for four of 10 sampled residents (Residents 2, 5, 7, and 9). This failure had the potential for the residents' decisions regarding their healthcare and treatment options not being honored. 1. A review of Resident 2's admission Record, (a document showing a summary of the resident's information) dated 9/17/25, indicated Resident 2 was admitted to the facility on [DATE]. A review of Resident 2's Advance Directives Checklist, dated 4/18/25, indicated Resident 2 did not possess an Advance Directive (a written document specifying an individual's end- of -life care). The section indicating I was offered and received referral tools to formulate Advance Directive was left blank. [...]

Inspectors wroteBased on interview and record review the facility failed to obtain informed consent (a process in which a healthcare professional educates a resident/patient about the risks, benefits, and alternatives of a given procedure or intervention so the resident/patient can make an educated decision) before administration of Ativan ([lorazepam] a psychotropic medication that affects a person's mental state and used to treat anxiety) for one of five sampled residents (Resident 1). This failure resulted in Resident 1 being administered Ativan without Resident 1 understanding or agreeing to the risks and benefits of the medication. A review of Resident 1's admission Record, (a document showing a summary of the resident's information) dated 9/18/25, indicated Resident 1 was readmitted to the facility on [DATE] with diagnoses including major depressive disorder and anxiety. [...]

Inspectors wroteBased on observation and interview, the facility failed to clean and disinfect the shared toilet of two sampled residents (Resident 32 and Resident 53) after completing plumbing work. This failure violated the residents' right to a safe and sanitary living environment. During a concurrent observation and interview on 9/15/25, at 9:25 AM with Resident 53, in the resident's room, the door to the restroom had a red banner that read, Stop do not enter. Resident 53 stated the toilet was broken. During an interview on 9/15/25, at 4:19 PM with Resident 32, Resident 32 stated the toilet in their room was still broken and was not usable. During an observation on 9/15/25, at 11:13 AM in Residents 32 and 53 shared restroom, the top ring of the toilet bowl had multiple brown rings and stains. [...]

Inspectors wroteBased on interview and record review, the facility failed to notify the Office of the State Long-Term Care Ombudsman (an advocate for residents in nursing homes) prior to the transfer or as soon as practicable when one of three sampled residents (Resident 3) was discharged to the hospital. This failure had the potential to leave Resident 3 unprotected from improper discharge and limit Resident 3's rights to advocacy and representation. 1. A review of Resident 3's admission Record, (a document showing a summary of the resident's information) dated 9/18/25, indicated Resident 3 was admitted to the facility on [DATE]. A review of Resident 3's Order Details, dated 6/4/25, indicated a physician's order to transfer the resident to the hospital for a psychiatric evaluation. [...]

Inspectors wroteBased on interview and record review, the facility failed to follow up on one of four residents (Resident 6) Level II (two) Preadmission Screening and Resident Review ([PASRR] a mandatory screening process to ensure that individuals with a serious mental illness or an intellectual disability are not improperly placed in a nursing home) to determine the resident's need for specialized services and appropriate placement. This failure placed Resident 6 at risk for unmet behavioral health needs and inappropriate care planning. [...]

Inspectors wroteBased on observation and interview, the facility failed to ensure that wound treatment supplies were maintained in a sanitary manner when a red-pink colored dried substance and an expired treatment wipe were found inside the facility's Wound Treatment Cart. This failure had the potential to result in unsafe or ineffective resident treatments. During a concurrent Wound Treatment Cart inspection and interview on [DATE], at 11:33 AM with Director of Nursing (DON), an expired (passed the use by date printed on the package and can no longer be clean or effective) SurePrep (skin protectant wipe that prevents irritation) and red-pink dried substance were found inside the treatment cart drawer. The DON verified that the SurePrep expired on [DATE] and that there was a red-pink colored dried substance in the top drawer of the treatment cart that had spilled onto other medications. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the lunch menu was followed when: The recipe was not followed during preparation of the pureed starch 2. The portion size for the ginger carrots was not followed during tray line These failures had the potential to put the residents at risk for choking hazards and malnutrition. 1. A review of the Fall Menus, dated 9/16/25, indicated that rice pilaf was on the menu for lunch. During a concurrent observation, interview, and record review on 9/16/25 at 11:01 AM, with the Cook, in the presence of the Registered Dietician (RD) and Dietary Services Supervisor (DSS), the [NAME] began to make the [NAME] Pilaf for 12 residents who were ordered a pureed diet. The [NAME] measured out 12 servings, placed them into the blender, and blended. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the medical record was accurate for one of 14 sampled residents (Resident 12) when the facility incorrectly assessed and documented Resident 12 as a good candidate for a bowel and bladder retraining program. This failure had the potential for Resident 12 to receive a delay in incontinence (involuntary loss and control of urine from the bladder and/or stool from the rectum) care, have an increased risk of skin breakdown and urinary tract infections (an infection in any part of the urinary system, such as the bladder, kidneys, or urethra). A review of Resident 12's admission Record, (a document showing a summary of the resident's information) dated 9/17/25, indicated Resident 12 was admitted to the facility on [DATE]. [...]

Inspectors wroteBased on observation and interview, the facility failed to ensure the most recent survey results, and the corresponding plan of corrections were readily accessible to the residents, family, and visitors. This failure had the potential to limit the residents' and the public's ability to stay informed about the facility's quality of care and efforts to address the identified deficiencies.1. During an interview on 9/16/25 at 10:05 AM at the Resident Council meeting, the residents were asked if they were able to review the results of the state survey without having to ask a staff. All four residents (Residents 4, 35, 52, and 57) who attended the meeting stated they had not seen the survey results and did not know where they were located. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the call light was accessible for one of six sampled Residents (Resident 9) when Resident 9's call light was found on the floor. This failure had the potential to result in Resident 9 unable to use the call light system to call for any assistance Resident 9 may require.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide assistance during mealtime as required by the care plan for 1 of 6 sampled residents (Resident 50) which resulted in Resident 50 being left with an uncovered and unattended breakfast tray which compromise the quality and temperature of the meal. This failure had the potential to lead to inadequate nutrition and placed Resident 50 at risk for malnutrition.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of two sampled Residents (Resident 49 and 9) received treatment and care when the facility did not follow their policy and Procedures (P&P): 1. For Resident 49, the medication Linzess (a medication used to treat constipation) was not available from the pharmacy to be administered as ordered by the physician. This failure resulted in Resident 49 not receiving the medication and placing Resident 49's health and safety at risk. 2. For Resident 9, the treatment Administration Record (TAR) was not documented as being done on May 27, 2024, May 31, 2024, August 5, 2024, and August 10, 2024 to Resident 9's right hip wound. This failure had the potential to result in worsening of skin condition placing Resident 9 at risk for further injuries. 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the dietary restrictions as indicated on the allergy diet card was followed for 1 of 6 sampled Residents (Resident 14) when Resident 14's diet card indicated Resident 14 had food allergies to cranberry. This failure had the potential for Resident 14 to develop serious and fatal allergic reactions.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medical records were complete and accurately documented for two of six sampled Residents (Resident 48 and 49) when: 1. Resident 48 had missing interdisciplinary team (IDT- interdisciplinary team- a mix of different disciplines in medicine that meet to discuss patient's care) investigation and recommendation from a fall Resident 48 sustained on August 21, 2024. 2. Resident 49 had inaccurate documentation on the medication administration record for a medication documented as given but the medication had not arrived from pharmacy. These failures had the potential to place Resident 48 and 49 at risk for missed interventions being updated in the plan of care, inaccurate count of medications, further falls, and missed adverse side effects from medications.

Inspectors wroteBased on interview and record review, the facility failed to protect against physical abuse for one of three sampled residents (Resident 1) when an Activities Staff (AS) person grabbed Resident 1 ' s right arm and yanked Resident 1 down onto her bed. This failure caused Resident 1 to suffer fear and abuse.

Inspectors wroteBased on interview and record review, the facility failed to ensure their fall prevention policies and procedures were implemented for one of three sampled residents (Resident 1). This failure resulted in Resident 1 to fall on March 27, 2024, sustained an injury (subdural hematoma-occurs after a head injury such as a fall) necessitating admission to the acute hospital to intensive Care Unit (ICU) trauma for a higher level of care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two of 25 rooms were clean, sanitary, and homelike when damage was observed on walls and ceiling of rooms [ROOM NUMBERS]. These failures created an environment that was not clean, sanitary, and homelike for residents who reside in room [ROOM NUMBER] and 107.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide proper treatment and assistive devices to maintain hearing ability for one of 12 Sampled Residents (Resident 10). This failure resulted in Resident 10 not being assessed for hearing ability and unable to appropriately express his needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the blood glucose monitor's (a device used to test a person's blood sugar level) control solutions (a pair of sugar solution, each set with a specific amount of sugar, used to ensure the glucometer and strips are accurate) were dated with an open date. This failure had the potential for the glucometer control testing to be inaccurate and potential for residents that require blood sugar monitoring to have inaccurate results.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure hand hygiene (cleaning hands with hand sanitizer or soap and water) was performed during medication administration and resident's care tasks for two of seven sampled residents (Resident 41 and Resident 49). This failure had the potential to cause infectious diseases (germs) to be spread from one resident to another by contaminated hands .

Inspectors wroteBased on interview, and record review, the facility failed to promptly report an injury of unknown origin to the California Department of Public Health (CDPH) in accordance with the facility's policy, for one of three residents (Resident 1). This failure had the potential for an injury of unknown origin to go uninvestigated and unreported thereby increasing the chances of harm to Resident 1.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Minimum Data Set Assessment (MDS- a computerized resident assessment instrument) was completed and certified for three of three sampled residents (Residents' 9, 29 and 41) per the facility's policy and procedure when: 1) Resident 9's MDS assessment was not coordinated or conducted by a Registered Nurse (RN), the MDS assessment was not signed by each staff member who contributed to sections to certify accuracy of that portion of the assessment, and the MDS was not signed and completed by an RN. 2) Resident 29's MDS assessment was not coordinated or conducted by a Registered Nurse (RN), the MDS assessment was not signed by each staff member who contributed to sections to certify accuracy of that portion of the assessment, and the MDS was not signed and completed by an RN. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure portable air conditioning (AC) units in 16 of 57 resident rooms (Rooms 100-112, and 114-116), were setup for use according to manufacturer's instructions. All 16 AC units were placed on top of plastic storage totes and were not on a stable, flat, and level surface. This failure had the potential to increase the risk of injury to the residents within the facility in the event that an AC unit were to fall.