Hi-Desert Medical Center D/P SNF

In the surveyor’s words

From the most serious findings on record at Hi-Desert Medical Center D/P SNF, in the surveyor’s own words.

• Actual harm, isolatedF689May 6, 2026

  Based 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).Findings: A review of Resident 1's face sheet (contains demographic and medical information), undated, indicated, Resident 1 was admitted on [DATE], with diagnoses including sepsis (serious body-wide reaction to an infection that can damage organs) and dementia (condition that causes memory loss and trouble thinking, severe enough to affect daily life). […]

• Actual harm, isolatedF692Oct 10, 2022

  Based on interview and record review, the facility failed to ensure one out of three sampled residents (Resident 1) received adequate fluid intake and nutrition, as ordered, to maintain their optimal hydration, nutrition, and well-being. This failure contributed in harm to Resident 1, when he was not provided his tube feeding from July 12 to July 15, 2021, as ordered by the physician upon readmission to the facility. This led to Resident 1's second hospitalization where he was diagnosed with indications of significant dehydration (Loss of over 10% of total body water causes mental and physical deterioration. […]

• No harm, potential for more than minimal, widespreadF725Mar 19, 2026

  Based 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.Findings: During an interview on March 17, 2026, at 9:10 AM, with the Wound Care Nurse (WCN), the WCN stated she is the only wound care nurse in the facility. […]

• No harm, potential for more than minimal, widespreadF761Mar 19, 2026

  Based 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.Findings: During a concurrent medication cart inspection and interview on March 18, 2026, at 7:44 AM, with Licensed Vocational Nurse (LVN 1), the medication cart (Cart 100) was observed as follows: Omeprazole (medication that use to reduce stomach acid) 20 milligrams (mg-unit of dosing medication) with the expiration date of January 2026 (expired 46 days). […]

• No harm, potential for more than minimal, widespreadF835Mar 19, 2026

  Based 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.Findings: During a concurrent interview and record review on March 18, 2026, at 8:53 AM, with the Director of Nursing (DON), the DON stated she was unable to give the current facility assessment report (report that determines what resources are necessary to care for the facility's residents competently and outline an education and competency plan for staff) because it was attempted on October 25, 2025 but was never completed. […]