Desert Springs Health Care LLC

Inspectors wroteBased on record review and interview, the facility failed to prevent an accident for 1 (R #81) of 3 (R #4, R #37, and R #81) residents reviewed for falls when staff failed to provide the required assistance during personal care resulting in R #81 falling from her bed. This deficient practice resulted in R #81 sustaining a fractured (broke) femur (thigh bone) and a fractured finger.

Inspectors wroteBased on observation, record review, and interview, the facility failed to provide respiratory care in accordance with professional standards for 3 (R #3, R #39, and R #91) of 4 (R #1, R #3, R #39, and R #91) residents reviewed for respiratory care when staff failed to:1. Ensure medical orders indicated when to administer supplemental oxygen (extra oxygen required to support the body's vital functions) needed to R #3 and R #39.2. Ensure a medical order was in place for R #91's supplemental oxygen use. These deficient practices are likely to result in residents receiving too much or not enough oxygen and can lead to worsening of their conditions.

Inspectors wroteBased on record review and interview, the facility failed to ensure each resident's drug regimen was free from unnecessary drugs by ensuring medications have an adequate indication of use and ensuring indication of use is based off of the residents' current diagnosis for 2 (R #7 and R #11) of 5 (R #2, R #3, R #6, R #7, and R #11) residents reviewed for unnecessary medications. This deficient practice could likely lead to adverse drug effects and poor patient outcomes.

Inspectors wroteBased on observation, record review, and interview, the facility failed to implement an ongoing infection prevention and control program (a program that is used to prevent, recognize, and control the onset and spread of infections) by not ensuring Enhanced Barrier (EBP) signs are posted outside of rooms with Personal Protective equipment (PPE; protective clothing, face masks, goggles, or other garments or equipment designed to protect the wearer's body from injury or infection) readily available for 2 (R #37 and R #91) of 7 (R #2, R #5, R #8, R #9, R #10, R #37 and R #91) residents reviewed. These deficiencies place residents at risk of contracting infections, hospitalization, and death.

Inspectors wroteBased on record review, observation and interview, the facility failed to ensure residents were provided with a choice about aspects of his/her life that are significant to the residents for 1 (R #27) of 3 (R #3, R #27 and R #91) residents by not having a choice to refuse dietician orders. If the facility does not honor residents' choices, then residents are likely to experience a loss of independence and self-worth leading to feelings of frustration and depression.

Inspectors wroteBased on record review and interview, the facility failed to ensure the resident's current advance directive (a written instruction, such as a living will or durable power of attorney for health care, recognized under State law and relating to the provision of health care when the individual is incapacitated) and New Mexico Orders for Scope of Treatment (MOST) form (a document which provides an individual's wishes for emergency and lifesaving care) matched the order in the electronic health record (EHR) for 2 (R #5 and R #39) of 7(R #5, R #6, R #8, R #9, R #10, R #12, and R #39) residents reviewed for advance directives when staff failed to update the resident's code status. This deficient practice is likely to result in confusion, delay, and residents not having their wishes honored if a life-threatening event occurred.

Inspectors wroteBased on record review and interview, the facility failed to complete an accurate Minimum Data Set (MDS; a federally mandated assessment instrument completed by facility staff) assessment for 1 (R #42) of 3 (R #2, R #3, and R #42) residents reviewed for assessments. This deficient practice could likely result in the residents' preferences and care needs not being met.

Inspectors wroteBased on record review and interview, the facility failed to develop and implement a baseline care plan (minimum healthcare information necessary to properly care for a resident immediately upon their admission to the facility) within 48 hours for 1 (R #11) of 6 (R #1, R #2, R #7, R #8, R #9, and R #11) residents reviewed for baseline care plans. If the facility fails to develop and implement a baseline care plan, then residents might not get the care and services they need.

Inspectors wroteBased on observation, record review, and interview, the facility failed to develop and implement an accurate, comprehensive care plan for 1 (R #91) of 4 (R #2, R #3, R #42, and R #91) residents reviewed for care plans when staff failed to: 1. Develop a care plan to include interventions for R #91's use of oxygen.2. Develop a care plan to include interventions for R #91's use of floor mat. This deficient practice could likely result in proper care not being provided to residents.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure staff revised the care plan for 1 (R #3) of 5 (R #2, R #3, R #27, R #34 and R #55) residents reviewed when staff failed to revise the care plan to include the current use of oxygen interventions. These deficient practices are likely to result in residents' care and needs not being addressed if care plans are not updated.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide adequate foot care services for 1 (R #77) of 1 (R #77) resident reviewed for toenail care. This deficient practice could likely result in functional decline, pain, and infections.

Inspectors wroteBased on record review and interview, the facility failed to ensure medical records were updated and accurate for 1 (R #6) of 5 (R #1, R #3, R #6, R #27, and R #55) residents reviewed, when the facility failed to document an updated consent ordered by physician. This deficient practice is likely to result in residents having an inaccurate medical record, which could result in the residents receiving less than optimal care and treatment.

Inspectors wroteBased on record reviews and interview, the facility failed to ensure staff assessed residents who utilized bed rails for 5 (R #21, R #25, R #27, R #31, and R #39) residents review for risk of entrapment (an event in which a resident is caught, trapped, or entangled in the space in or about the bed rail) for bedrails. If the facility fails to assess the resident's risk for entrapment, then residents are likely to experience injury by becoming trapped between the mattress and the bedrail.

Inspectors wroteBased on observation and interview, the facility failed to post nurse staffing data on a daily basis that included the following: a. Facility name. b. The current date. c. The total number and the actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift: i. Registered nurses. ii. Licensed practical nurses. iii. Certified nurse aides. iv. Resident census. This deficient practice could likely result in resident not knowing the staf working.

Inspectors wrotePast Noncompliance: Compliance Date was 04/06/24. Based on record review and interview, the facility failed to prevent an accident for 1 (R #1) of 1 (R #1) residents reviewed for falls, when the facility failed to: 1. Ensure beds were fully locked. 2. Ensure staff was familiar with equipment. These deficient practices resulted in R #1 falling and sustaining injuries that required treatment at the hospital.

Inspectors wroteBased on observation and interview, the facility failed to label food in accordance with professional standards of food service safety. This failure had the potential to affect all 74 residents in the facility who eat food prepared in the kitchen. Residents were identified by the Resident Matrix provided by the Administrator on 01/22/24. If the facility fails to adhere safe food storage, residents are likely to be exposed to foodborne illnesses.

Inspectors wroteBased on interview and record review, the facility failed to provide quarterly statements for resident's personal funds entrusted to the facility for 1 (R #23) of 2 (R #23, and R #54) residents sampled for personal funds. If residents are not provided quarterly statements for their personal funds accounts, then residents could experience unnecessary anxiety or depression, because they are unaware of their finances.

Inspectors wroteBased on record review and interview, the facility failed to ensure residents, resident representatives, and Ombudsman received a written notice of transfer as soon as practicable for 2 (R #50 and R # 72) of 2 (R #50 and R #72) residents reviewed. This deficient practice could likely result in the resident and/or representatives not knowing the reason or location the resident was transferred or discharged or their options to appeal the transfer or discharge.

Inspectors wroteBased on record review and interview, the facility failed to provide a written notice to the resident or resident representative that specified the bed-hold policy and the number of days the facility would hold a bed for the resident at the time of the transfer for 2 (R # 50, R # 72) of 2 (R # 50, R # 72) residents sampled for hospitalizations. This deficient practice could likely result in the resident and/or representatives being unaware of the resident's ability to return to their previous bed or the next available bed upon return from the hospital.

Inspectors wroteBased on record review and interview, the facility failed to ensure the MDS accurately reflected the resident's status at the time of the assessment for 1 (R #37) of 3 (R #11, R #23, and R #37) residents sampled for MDS accuracy. This deficient practice could likely result in residents not receiving the care and treatment they need.

Inspectors wroteBased on record review and interview, the facility failed to develop and implement a comprehensive person-centered care plan for 4 (R #3, R #30, R #43, and R #70) of 4 (R #3, R #30, R #43, and R #70) residents reviewed for comprehensive care plans. Failure to develop a person-centered care plan could likely result in staff's failure to understand the needs, preferences, and treatments for residents to achieve their highest level of well-being.

Inspectors wroteBased on record review and interview, the facility failed to revise the care plan for 2 (R #23 and R #37) of 4 (R #23, R #37, R #48, and R #63) residents reviewed for care plans. This deficient practice could likely result in staff being unaware of changes in care provided, and residents not receiving the care related to changes in their health status or healthcare decisions.

Inspectors wroteBased on record review and interview, the facility failed to provide an ongoing activity program to support residents in their choice of activities designed to support their physical, mental, and psychosocial well-being for 2 (R #43 and R #70) of 3 (R #43, R #48, and R #70) residents reviewed for activities. If the facility does not ensure all residents receive an ongoing activity program and make in-room activity accommodations, then residents are likely to demonstrate an increase in isolation and depression and could likely experience a decline in independence.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents received proper treatment to maintain vision and hearing for 4 (R #3, R #37, R #51, and R #63) of 6 (R #3, R #12, R #37, R #48, R #51, and R #63) residents reviewed for vision and hearing. This deficient practice could likely result in residents losing some independence if they cannot see or hear, which would compromise their quality of life.

Inspectors wroteBased on observation and interview, the facility failed to keep residents free from the potential for accidents for 1 (R #32) of 1 (R #32) residents reviewed for accidents, when they failed to ensure the mattress fit the bed. This deficient practice could likely result in injury.

Inspectors wroteBased on record review and interview, the facility failed to ensure ongoing communication and collaboration with the dialysis (clinical purification of blood as a substitute for the normal function of the kidney) facility regarding dialysis care and failed to monitor the resident before and after dialysis treatment for 1 (R #30) of 1 (R #30) residents reviewed for dialysis care. This deficient practice could likely result in the facility being unaware of the resident's condition or possible complications that arise during dialysis treatment, and residents may not receive the appropriate monitoring and care.

Inspectors wroteBased on record review and interview, the facility failed to ensure staff demonstrated competency, were tested, or evaluated in skills and techniques necessary to care for residents' needs for 6 (CNA #31, CNA #32, CNA #33, LPN #34, LPN #35, LPN #36) of 6 (CNA #31, CNA #32, CNA #33, LPN #34, LPN #35, LPN #36) staff sampled for staff competency. This deficient practice could likely result in staff working who are not competent to give care to residents.

Inspectors wroteBased on record review and interview, the facility failed to ensure the consultant pharmacist's recommendations were reviewed and acted on for 3 (R #11 and R #23, R #30) of 5 (R #11, R #23, R #30, R #48, and R #50) residents reviewed for pharmacy medication regimen review. This deficient practice could likely result in residents suffering from unnecessary adverse side effects.

Inspectors wroteBased on record review and interview, the facility failed to ensure residents did not receive psychotropic medications unless the medication was necessary to treat a specific psychiatric diagnosis and was documented in the medical record for 2 (R #48 and R #69) of 4 (R #11, R #30, R #48 and R #69) residents reviewed for unnecessary psychotropic medications. This deficient practice could likely result in residents receiving medications without a medical reason and being at a higher risk of adverse side effects (unwanted, harmful, or abnormal result).

Inspectors wroteBased on observation and interview, the facility failed to properly store medications, when they failed to ensure medications were not expired in the Pyxis (medication management software and medication dispensing machine). This deficient practice could affect all 73 residents in the facility. Residents were identified by the resident matrix provided by the Administrator on 01/15/24. This deficient practice could likely result in residents obtaining medications that are no longer effective, resulting in adverse side effects.

Inspectors wroteBased on record review and interview, the facility failed to obtain laboratory testing for 1 (R #23) of 1 (R #23) residents reviewed for laboratory services. If the facility fails to obtain labs that have been ordered this could delay treatment of potential medical issues and could cause unnecessary harm to the resident.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure residents obtained routine dental care to include an annual inspection of the mouth for signs of disease, dental cleaning, fillings, or minor partial or full denture adjustments for 1 resident (R #3) of 1 resident (R#3) resident reviewed for dental services. This deficient practice is likely to cause the resident unnecessary pain, embarrassment over the condition/appearance of teeth, and potential dental or oral complications.

Inspectors wroteBased on record review and interview, the facility failed to ensure the medical records contained documentation each resident received or was offered pneumococcal (a bacteria that causes pneumonia infection of the respiratory tract) and influenza (an acute respiratory infection caused by influenza viruses) immunizations for 2 (R #43 and R #70) of 5 (R #11, R #19, R #30, R #43, and R #70) residents reviewed for immunizations. This deficient practice could likely lead to residents contracting respiratory infections and could result in the spread of infection to other residents.

Inspectors wroteBased on record review and interview, the facility failed to ensure the residents' medical record contained documentation each resident received or was offered covid-19 (an acute respiratory infection caused by the SARS-CoV-2 virus) immunization for 1 (R #43) of 5 (R #11, R #19, R #30, R #43, and R #70) residents reviewed for immunizations. This deficient practice could likely lead to residents contracting respiratory infections and could result in the spread of infection to other residents.