Joshua Tree Post Acute

In the surveyor’s words

From the most serious findings on record at Joshua Tree Post Acute, in the surveyor’s own words.

• Actual harm, isolatedF684Oct 6, 2023

  Based on observation, interview, and record review, the facility failed to ensure one of 24 sampled residents (Resident 21) received care and treatment for Resident 21's left contracted foot (preventing proper expansion of the foot parts producing pressure on the soft structures), when Resident 21 was found to have multiple skin tissue injuries to her contracted left foot which was not identified by the facility. This failure resulted in a delay in the treatment for skin injuries to Resident 21's contracted left foot. […]

• No harm, potential for more than minimal, widespreadF908Nov 13, 2025

  Based 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. […]

• No harm, potential for more than minimal, widespreadF802Apr 13, 2023

  Based on observation, interview, and record review, the facility failed to ensure their dietary staff had the appropriate competencies and skill sets to carry out the functions of the Food and Nutrition Services, when the dishwashing machine was tested incorrectly. This failure had the potential to cause foodborne illness (an illness caused by eating contaminated foods) or food contamination for 57 residents in the facility, who received foods from the kitchen. Findings: During an observation and concurrent interview on April 12, 2023, at 9:05 AM, in the kitchen, with a Dietary Aide (DA 1) and the Director of Dietary Services (DDS), DA 1 was observed testing the dish washing machine sanitation levels. […]

• No harm, potential for more than minimal, widespreadF727Feb 22, 2022

  Based on interview, and record review, the facility failed to provide 8 hours of Registered Nurse (RN) coverage for the facility's 37 residents. This failure had the potential to jeopardize the health and safety of the facility's 37 clinically compromised residents. Findings: During an interview with Licensed Vocational Nurse (LVN) 1 on July 16, 2021, at 1:25 PM, he stated the facility has RNs from the company's other facility come to work at the facility. During an interview with the Administrator (ADM) on July 16, 2021, at 1:30 PM, he stated the facility's previous Director of Nursing (DON) resigned on July 9, 2021, and the facility's interim DON has not assumed the position at this time. He further stated the facility's policy is to provide daily RN coverage. […]

• No harm, potential for more than minimal, widespreadF801Apr 9, 2021

  Based on observation, interview, facility document review, and Policy and Procedure review, the facility failed to ensure that a full time, qualified Dietary Manager (DM) was hired to oversee the daily operations of the kitchen and food preparation. The facility had a cook who was unqualified by education and experience functioning as the dietary supervisor which resulted in: 1. Food products being removed from their original containers and stored in another container without having the expiration dates listed. 2. Two opened food products found in the walk-in refrigerator did not have the date opened listed. 3.a. Four of eight containers of spices were available for use after their six month use-by date per facility policy and procedure. b. […]