Desert Haven Care Center

Inspectors wroteBased on clinical record review, staff interviews, facility documentation, policies and procedures, the facility failed to protect the rights of two residents (#87, and #37) to be free from physical abuse from each other. The deficient practice could result in further abuse of residents and appropriate action not taken.

Inspectors wroteBased on clinical record review, staff interviews, facility documentation, and review of facility policies and procedures, the facility failed to protect the rights of one (#16) of three sampled residents to be free from physical abuse by another resident (#22). The deficient practice could result in further abuse of residents.

Inspectors wroteBased on clinical record review, staff interviews, facility documentation, and review of facility policies and procedures, the facility failed to protect the rights of one (#5) of three sampled residents to be free from abuse by another resident (#19). This failure resulted in Resident #5 sustaining facial trauma, including bilateral nasal bone fractures and a laceration to the left ear after being repeatedly struck by Resident #19. The deficient practice could result in further abuse of residents.

Inspectors wroteBased on clinical record review, staff interviews, and policy review, the facility failed to ensure that one resident (#78) was free from abuse by another resident (#89). The deficient practice could result in residents being physically and emotionally harmed. Findings Include:-Regarding Resident #89:Resident #89 was admitted on [DATE], with diagnoses that included mild neurocognitive disorder, major depressive disorder, iron deficiency anemia, adjustment disorder, chronic kidney disease, anemia, dysphagia, attention-deficit hyperactivity disorder, atherosclerotic heart disease, hypertension, and type 2 diabetes mellitus. [...]

Inspectors wroteBased on clinical record review, staff interviews, and policy review, the facility failed to ensure that the abuse policy was implemented following an incident involving resident-to-resident abuse between two residents (#89 and #78). The deficient practice could result in continued abuse of residents and physical or emotional harm to residents. Findings Include:-Regarding Resident #89:Resident #89 was admitted on [DATE], with diagnoses that included mild neurocognitive disorder, major depressive disorder, iron deficiency anemia, adjustment disorder, chronic kidney disease, anemia, dysphagia, attention-deficit hyperactivity disorder, atherosclerotic heart disease, hypertension, and type 2 diabetes mellitus. [...]

Inspectors wroteBased on clinical record review, staff interviews, and policy review, the facility failed to ensure that an incident involving resident-to-resident abuse between two residents (#89 and #78) was reported. The deficient practice could result in continued abuse and physical or emotional harm to residents.-Regarding Resident #89Resident #89 was admitted on [DATE], with diagnoses that included mild neurocognitive disorder, major depressive disorder, iron deficiency anemia, adjustment disorder, chronic kidney disease, anemia, dysphagia, attention-deficit hyperactivity disorder, atherosclerotic heart disease, hypertension, and type 2 diabetes mellitus. [...]

Inspectors wroteBased on clinical record review, staff interviews, and policy review, the facility failed to ensure that an incident involving resident-to-resident abuse between two residents (#89 and #78) was investigated. The deficient practice could result in continued abuse and physical or emotional harm to residents. Findings Include:-Regarding Resident #89:Resident #89 was admitted on [DATE], with diagnoses that included mild neurocognitive disorder, major depressive disorder, iron deficiency anemia, adjustment disorder, chronic kidney disease, anemia, dysphagia, attention-deficit hyperactivity disorder, atherosclerotic heart disease, hypertension, and type 2 diabetes mellitus. [...]

Inspectors wroteBased on clinical record review, interviews and review of facility policy and procedure, the facility failed to ensure physician orders were followed regarding blood glucose monitoring; and, failed to ensure a healthcare provider was notified of abnormal blood glucose reading for one of 3 sampled resident (#44). The deficient practice led to the resident being admitted to the intensive care unit of a hospital with hyperglycemia and treatment for diabetic ketoacidosis. Findings Include: Resident #44 was admitted on [DATE], and re-admitted on [DATE], with diagnoses of type 1 diabetes mellitus, cerebral infarction, long term use of insulin, unspecified dementia, unspecified psychosis, and other sequelae of cerebral infarction. A care plan dated June 7, 2024, revealed Resident #44 had diabetes mellitus. Interventions included: [...]

Inspectors wroteBased on interviews, review of clinical record, and review of facility policy and procedure, the facility failed to ensure the medical record was complete and accurate regarding blood glucose monitoring for one resident (#44). The deficient practice could lead to incomplete and inaccurate medical record.-Findings Include:Resident #44 was admitted on [DATE], and re-admitted on [DATE], with diagnoses of type 1 diabetes mellitus, cerebral infarction, long term use of insulin, unspecified dementia, unspecified psychosis, and other sequelae of cerebral infarction. A quarterly minimum data set (MDS) assessment dated [DATE], revealed Resident #44 had a brief interview for mental status (BIMS) assessment score of 10, indicating moderate cognitive impairment. Section I revealed Resident #44 had active diagnoses of diabetes mellitus and psychotic disorder. [...]

Inspectors wroteBased on observation, clinical record review, staff interviews, and review of facility policy, the facility failed to ensure one resident (#3) was provided wound care in accordance with physician orders and professional standards. The deficient practice could result in wounds worsening or becoming infected.

Inspectors wroteBased on observations, staff interview, and policy review, the facility failed to ensure staff were maintaining proper sanitary conditions by not wearing hair nets and facial hair guards during food preparation. The deficient practice could result in infection and or contamination of food.

Inspectors wroteBased on observation, staff interviews, and review of facility documentation, the facility failed to ensure call light was within reach for one resident (#27). The deficient practice could result in a preventable accident and resident not able to meet the resident's needs.

Inspectors wroteBased on clinical record review, staff interviews, and facility documentation and policy review, the facility failed to ensure adequate supervision was provided to one resident (#1) to prevent elopement. The deficient practice could result in injury or harm to the resident.

Inspectors wroteBased on observations, staff and resident interviews, the facility failed to ensure that residents were were treated with dignity while dining by using disposable cutlery and dishware. The deficient practice could result in residents not able to exercise their right to be treated with respect and dignity.

Inspectors wrote-An observation of the bathroom of a room (#30) conducted on April 16, 2024 at 3:28 p.m. with the maintenance director who stated that housekeeping was expected to clean bathrooms, including the walls, sink, and vents. He then poked a white substance on the bathroom vent and there was a puff of white and brown substance that came out from the vent. The maintenance director said that the white and brown substance that came out of the vent was dust and should have been cleaned. Another observation of bathroom between two different rooms was conducted with the maintenance director. The bathroom wall was stained with brown substance; and, the maintenance director stated that he would call a pest control company and have them assess the stain because he does not know what the brown stain was. He then grabbed a paper towel and touched the substance, and it crumbled under his touch. [...]

Inspectors wroteBased on clinical record reviews, staff interviews and review of facility policy, the facility failed to ensure that Preadmission Screening and Resident Review (PASRR) was updated for two residents (#73 and #22); and failed to ensure level II determination was submitted for one resident (#22). The deficient practice could result in residents not receiving the care and services they needed.

Inspectors wroteBased on observations, staff interviews and review of facility policy and procedure, the facility failed to ensure food items were labeled and dated when opened; and, failed to ensure that open food item was stored to maintain freshness and prevent contamination.

Inspectors wroteBased on observations, clinical record review, staff interviews, review of facility documentation and policy, the CDC (Centers for Disease Control and Prevention) and CMS (Centers for Medicare and Medicaid Services) guidance, the facility failed to ensure enhanced barrier precautions (EBP) were implemented for one resident (#72). The deficient practice could result in transmission of multi-drug resistant organisms.

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

Inspectors wroteBased on clinical record review, facility documentation, resident and staff interviews, and facility policy and procedure, the facility failed to assist one resident (#4) with a request to transfer to another facility within a timely manner. The sample size was 3. The deficient practice could result in residents being denied the right to make their own choices.

Inspectors wroteBased on clinical record review, staff interviews, and review of policy, the facility failed to ensure that one out of two sampled residents (#44) was accurately assessed and referred for Level II Pre-admission and Resident Review (PASRR) services. The deficient practice increases the occurrence of improper placement into a nursing home and/or may fail to provide residents with necessary services.

Inspectors wroteBased on clinical record review, staff interviews, and review of policy, the facility failed to ensure a care plan intervention and policy was implemented for one sampled resident (#89) regarding a transfer to a wheelchair. The deficient practice could result in potential harm to residents.

Inspectors wroteBased on clinical record review, staff interviews, and policy reviews, the facility failed to ensure that the necessary behavioral health care and services were provided to sampled one resident (#90). The deficient practice could result in residents not receiving the necessary behavioral health care and services they require to prevent self-harm.

Inspectors wroteBased on clinical record review, staff interviews, and policy review, the facility failed to ensure one resident (#84) drug regimen was free of unnecessary drugs, by administering a medication outside of the physician ordered parameters. 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 review of policies and procedures, the facility failed to ensure identification and monitoring of target behaviors for one resident (#32) receiving psychotropic medications. The sample size was 5. The deficient practice could result in residents receiving medications that may not be necessary.

Inspectors wroteBased on observation, clinical record review, staff interviews, and review of policy and procedure, the facility failed to ensure the medication error rate was less than 5% by failing to ensure medications were not crushed without a physician's order for one resident (#37). The medication error rate was 8%. The deficient practice could result in further medication errors.

Inspectors wroteBased on review of facility documentation, staff interview, and facility policy and procedure, the facility failed to ensure that nurse staffing information was posted on a daily basis that included the number of each type of licensed and unlicensed nursing staff working on each shift and the actual hours worked. The deficient practice resulted in information not being readily available to residents and visitors.