Desert Cove Nursing Center

Inspectors wroteBased on clinical record review, staff and resident interviews, facility documentation and review of facility policies and procedures, the facility failed to protect the rights of one resident (Resident #46) to be free from physical abuse from another resident (Resident #27). The deficient practice could place residents at risk for resident to resident abuse and potential physical harm.

Inspectors wroteBased on clinical record review, interviews, the State Agency's (SA) complaint portal, and review of the facility's policies and procedures, the facility failed to ensure 5 out of 5 residents' (#7, #10, #40, #90, and #100) medications administration were accurately documented in the Medication Administration Record (MAR). The sample size was 5. The deficient practice could cause an unclear indication of whether medication was administered to the right resident.

Inspectors wroteBased on clinical record review, staff and resident interviews, and review of facility documentation and policies, the facility failed to ensure that professional standards of care were followed regarding the implementation of Physician-ordered speech services for Resident #2. The deficient practice could result in speech issues not identified and treated as appropriate.

Inspectors wroteBased on clinical record review, staff and resident interviews, and facility documentation, policies and procedures, the facility failed to ensure that adequate supervision and monitoring was provided for one resident (#76) who was left unattended in the shower room for an extended period of time. The deficient practice could result in avoidable accidents and/or decline in function.

Inspectors wroteBased on a review of clinical records, observation, and staff interviews, the facility failed to ensure that appropriate infection control practices were implemented and followed for one resident (#33). The deficient practice could result in a spread of preventable illness to residents and staff.

Inspectors wroteThe facility failed to wear Personal Protective Equipment (PPE) and properly sanitize hands during resident care and interaction. The deficient practice could spread infection to other residents. -Regarding not wearing Personal Protective Equipment (PPE) Resident #2 was admitted to the facility on [DATE], with diagnoses that included neuromuscular dysfunction of the bladder, cellulitis of the right lower limb, Type 2 Diabetes Mellitus, and acquired absence of the left leg above the knee. During initial pool screening on September 22, 2025, at 7:41 AM, Resident #2 was observed to have a Foley catheter bag hanging on her bed rails. Upon entering the room, a Certified Nurse Assistant (CNA/Staff #89) was observed emptying the contents of the Foley bag into a plastic container. The CNA was observed to be wearing gloves, but was not observed to be wearing a gown. [...]

Inspectors wroteNumber of residents sampled: 2Number of residents cited: 2Based on clinical record review, resident and staff interviews, and policy review, the facility failed to ensure advance directives were completed and maintained for two residents (#9 and #58). The deficient practice could result in residents not receiving proper care according to their preferences or potential harm to the resident's life.-Regarding Resident #58 Resident #58 was admitted to the facility on [DATE], with diagnoses that included paraplegia, hypertension, major depressive disorder, chronic pain, anxiety disorder, and heart failure. During an initial pool record review on [DATE], evidence of Resident #58's advance directive wishes could not be located in the physician's orders or in the miscellaneous tab of his electronic record. [...]

Inspectors wroteBased on clinical record review, facility documents, staff interviews and facility policy, the facility failed to ensure that 2 residents (#6, 66) were not abused.

Inspectors wroteBased on personnel file review, staff interview, and facility policy review, the facility failed to ensure that 2 of 3 sampled direct-care staff (#87 and #118) maintained valid Cardiopulmonary Resuscitation (CPR) and first aid certifications as per their job descriptions. The deficient practice could result in potential harm to residents due to staff not being knowledgeable about how to provide emergency care to residents.

Inspectors wroteBased on observation, staff interviews, and policy review, the facility failed to ensure current nurse staffing information was accurate for actual hours worked by licensed direct care nursing staff. The deficient practice could result in residents and visitors not being informed of accurate and current staffing information.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure that medications were accurately acquired and administered to meet the needs of one resident (#58). This deficient practice could lead to mismanagement of the residents' symptoms. Resident #58 was initially admitted to the facility on [DATE], and most recently admitted on [DATE], with diagnoses that included paraplegia, hypertension, chronic pain, heart failure, major depressive disorder, and anxiety disorder. During initial pool screening, on September 21, 2025, at 11:58 AM, Resident #58 explained that the facility oftentimes runs out of his scheduled pain medication, leaving the resident to experience extreme pain. Resident #58's initial care plan indicated he was at risk for pain related to neuropathy, chronic pain, and generalized pain. [...]

Inspectors wroteBased on observations, record review, and staff interviews, the facility failed to ensure that one resident (#8) was free from significant medication errors. This deficient practice could lead to adverse outcomes for residents.

Inspectors wroteNumber of residents sampled: Number of residents cited: Based on observations, staff interviews, and a review of facility policies, the facility failed to ensure that expired medications were properly discarded and not available for use. These deficient practices could result in residents receiving expired medications, and could result in resident injury, medication overdose, or contradictions. The facility census was 69. An observation was conducted of the Central medication room on September 22, 2025, at 02:46 PM with the Assistant Director of Nursing (ADON/staff #104). The following expired medications were identified: Five boxes of unopened one-daily Multivitamin dietary supplement, with an expiration date of April 2025. One unopened box of zinc 50mg, with an expiration date of March 2025. Four unopened boxes of vitamin B-12 100mcs, with an expiration date of July 2025. [...]

Inspectors wroteBased on observations, record review, and staff interviews, the facility failed to ensure that the medication administration record (MAR) was accurately documented for one resident (#8). This deficient practice could lead to adverse outcomes for residents.

Inspectors wroteBased on interview, review of clinical record, and review of facility policy and procedure, the facility failed to ensure a resident (#5) was provided assistance with bathing or showering according to the resident's preference and to meet the resident' needs. The deficient practice could lead to a breakdown in skin integrity and/or psychosocial harm of a resident.

Inspectors wroteBased on interview, review of clinical record, and review of facility policy and procedure, the facility failed to ensure a resident (#5) was provided care and services for a urinary catheter according to physician orders. The deficient practice could lead to infection.

Inspectors wroteBased on interviews, review of clinical record, and review of facility policy, the facility failed to ensure an allegation of abuse was reported to mandated entities within 2 hours for one resident (#2). The deficient practice could lead to an allegation of abuse not being investigated by all mandated entities timely, resulting in possible ongoing abuse to a resident.-

Inspectors wroteBased on clinical record review, interviews, and facility documentation and policy, the facility failed to ensure that one resident (# 23) received wound care in accordance with physician orders. This deficient practice can result in diminished quality of life, and suboptimal clinical outcomes.

Inspectors wroteBased on clinical record review, staff interviews, and facility policy review, the facility failed to ensure one resident (#26) was free from sexual abuse. The deficient practice resulted in a resident being inappropriately touched by another resident.

Inspectors wroteBased on clinical record review, facility documentation, and staff interviews, the facility failed to ensure three residents (#1, #2 and #3) were provided adequate supervision to prevent resident abuse. The deficient practice could result in residents being at risk for abuse.

Inspectors wroteBased on clinical record review, observations, staff interviews, and review of policy, the facility failed to provide necessary services to maintain good grooming and personal hygiene for one resident (#39) and that assistance with meals was provided for one resident (#10). The sample size was 16. The deficient practice had the potential for not providing services and assistance to residents.

Inspectors wroteBased on review of clinical records and policy, observations, and staff interviews, the facility failed to ensure the environment remained free of accident hazards by not leaving medications unattended. The deficient practice had the potential to cause an accident and may result in undesirable medication-induced harm.

Inspectors wroteBased on review of facility documentation, staff interviews and facility policy, the facility failed to use the services of a registered nurse (RN) for at least 8 consecutive hours a day, 7 days a week. The census was 63. The deficient practice has the potential to affect resident care.

Inspectors wroteBased on clinical review, staff interviews, and facility policy and procedures, the facility failed to administer pain medication within the pain scale parameters for two resident (#39, #17). The deficient practice could result in residents being overmedicated.

Inspectors wroteBased on observations, staff interviews, and review of policies and procedures, the failed to ensure staff conducted appropriate hand hygiene during kitchen food preparation and dining services, as well as donning beard guards/ nets in the presence of facial hair. The deficient practice could result in infection and or contamination of food.

Inspectors wroteBased on observation, interviews, and review of policy, the facility failed to ensure infection control practices were observed. The deficiency in practice can lead to the spread of infections. Regarding failure to ensure transmission-based precautions: Resident # 60 was admitted on [DATE] with diagnoses of unspecified hydronephrosis, malignant neoplasm of endometrium, and Type 2 Diabetes Mellitus. Review of a Minimum Data Set (MDS) assessment revealed a Brief Interview for Mental Status (BIMS) score of 15 indicatING the resident was cognitively intact. Review of a care plan initiated on June 27, 2018 by Infection Preventionist (IP)/Registered Nurse (RN) (Staff # 26), revealed Resident # 60 had a foley catheter. Interventions included to place resident in enhanced barrier precautions in order to prevent signs or symptoms of urinary infection. [...]

Inspectors wroteBased on observation, interviews, and record and policy review, the facility failed to ensure one resident (#6) was assessed to self-administration medication. The deficient practice could result in residents self-administering medications without assessment.

Inspectors wroteBased on clinical record review, interviews, and facility policy, the facility failed to ensure one resident (#123) received safe monitoring of vital signs. Vital signs were obtained using the arm with the shunt contrary to the facility policy and care plan. The deficient practice could result in the potential for complications and the resident not receiving appropriate care and treatment.

Inspectors wroteBased on review of clinical records and policy, observations, and staff interviews the facility failed to ensure unused medication were disposed of according to accepted professional standards. The deficient practice of erroneous medication disposal may result in undesirable medication-induced harm.

Inspectors wroteBased on clinical record review, staff interviews, and review of facility policy, the facility failed to ensure that one resident (#208) and/or their representative were informed of the risks and benefits of psychotropic medications prior to the administration of the medications. The sample size was 8. The deficient practice could result in residents and/or resident representatives not being aware of the benefits and the potential adverse side effects of psychoactive medications.

Inspectors wroteBased on clinical record review, resident and staff interviews, and policy reviews, the facility failed to ensure one resident (#212) was assessed to self-administer medications. The sample size was 18. The deficient practice could result in medications not being administered as ordered.

Inspectors wroteBased on observation, clinical record review, resident and staff interviews, and policy review, the facility failed to ensure that one resident (#26) had an order for a multi-podus boot. The sample size was 3. The deficient practice could result in residents having multi-podus boots without an order.

Inspectors wroteBased on clinical record review, resident and staff interviews, and review of policy and procedure, the facility failed to ensure necessary services were consistently provided to maintain good personal hygiene for one resident (#25). The sample size was 5. The deficient practice could result in personal hygiene needs not being met for residents.

Inspectors wroteBased on clinical record review, staff interviews, and policy review, the facility failed to ensure one resident (#212) was free of unnecessary drugs, by failing to ensure pain medication was administered as ordered by the physician. The sample size was 5. The deficient practice could result in residents receiving medications that may not be necessary.

Inspectors wroteBased on clinical record review, staff interviews, and policy review, the facility failed to ensure a PRN (as needed) psychotropic medication had a stop date within the required time frame for one resident (#212). The sample size was 5. The deficient practice could result in residents receiving medication that is not necessary.