Desert Springs Healthcare & Wellness Centre

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure wound care and management were implemented according to the facility's policy and procedure and national guidelines, for two of three residents reviewed (Residents 1 and 2), when:1. For Resident 1, the pressure injury (PI - a localized damage to the skin and underlying tissue caused by constant pressure, usually over a bony prominence) on the sacrococcyx (tail bone) area was not properly assessed. In addition, the treatment for Resident 2's PI on bilateral buttocks was not appropriate according to the facility's treatment protocol; and2. For Resident 2, infection control measures were not implemented while providing wound care. These failures had the potential for delayed wound healing and placed the resident at risk for further complications such as infection and worsening of the wound.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure refrigerated medications and biologicals were stored at temperatures in accordance with facility policy and manufacturer's specifications, when one of two medication refrigerators was identified with documented temperature readings below the normal range on multiple days in September 2025. This failure had the potential for residents to receive ineffective medications which could result in the residents not receiving the full benefit of the medications, leading to further health complications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure clean linens (pillows) were handled and stored in a manner that prevented the spread of infection, when clean pillows were observed improperly stored in an area designated for soiled materials. This deficiency had the potential to cause harm by placing residents at risk for contamination from microorganisms. FindingsOn September 18, 2025, at 12:25 p.m., during a tour of the laundry area, multiple clean pillows wrapped in a clear plastic bag, were found stacked in the soiled area of the laundry. The plastic bag of clean pillows were observed tied in one knot but with open areas to escape in and out of the bag. On September 18, 2025, at 12:27 p.m., an interview was conducted with the Laundry Director (LD). The LD stated they did not have room to store the clean pillows. [...]

Inspectors wroteBased on interview and record, the facility failed to ensure, for one out of one resident reviewed in the care planning process (Resident 7), was involved in the care planning process when Resident 7 was not notified of the gradual dose reduction (GDR - stepwise tapering of a dose to determine if symptoms, conditions, or risks can be managed by a lower dose of if the dose or medication can be discontinued) for the medication Depakote (medication used to treat bipolar disorder [ mental health condition that causes extreme mood swings]). This failure resulted in Resident 7 feeling suppressed when changes were made to her plan of care without her knowledge, involvement, or consent. As a result, this violated Resident 7's right to be involved in her care and provide informed consent.

Inspectors wroteBased on interview and record review the facility failed to ensure a copy of the Advance Directive (AD - written instruction for the provision of care and services when unable to make decisions for oneself) was readily available in the chart, for one of 13 residents reviewed for Advance Directives (Resident 4). This failure had the potential for Resident 4's wishes for health care services not to be honored.

Inspectors wroteBased on interview and record review, the facility failed to ensure, for two of five residents (Resident 5 and 10) were free from unnecessary psychotropic (drugs that affects brain activities associated with mental processes and behavior) medications when:1. Resident 10 was administered Aripiprazole (medication to treat mental illness) without potential adverse effect monitoring documented during use of risperidone; and2. Resident 5 was given quetiapine (medication to treat mental illness) without following the manufacturer's monitoring guidelines. These failures could have led to unnecessary medications for Residents 5 and 10, increasing the risk of medication interactions, adverse reactions, and side effects such as dyslipidemia (an abnormal balance of lipids or fats in the bloodstream), sedation, respiratory depression, constipation, anxiety, agitation, and memory loss.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Minimum Data Set (MDS - a clinical assessment tool) was accurately coded, for one of three residents reviewed for nutrition (Resident 41). This failure resulted in an inaccurate MDS assessment to be submitted to CMS (Centers for Medicare and Medicaid Services).

Inspectors wroteBased on interview, and record review, the facility failed to ensure the Consultant Pharmacist (CP) identified and reported irregularities during the monthly medication regimen review (MRR), for two of five sampled residents (Resident 5 and 10) when: 1. Resident 10 was administered aripiprazole (an antipsychotic medication for mental illness) without potential adverse effect monitoring documented during use of aripiprazole; and 2. Resident 5 was given quetiapine (an antipsychotic medication for mental illness, depression, and schizophrenia) without following the manufacturer's monitoring guidelines. These failures had the potential for medications not being optimized for best possible health outcome, and increased risk for adverse effects for Resident 5 and 10.

Inspectors wroteBased on interview and record review, the facility failed to ensure the personal funds of a deceased resident was provided to the resident's legal representative with the required timeframe, for one of three residents reviewed (Resident 1). In addition, the facility failed to provide the final financial statement and invoices of the breakdown of personal funds after multiple requests from Resident 1's legal representative. This deficient practice had the potential for loss and misuse of Resident 1's personal funds.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure an alternative option was offered when a bed bath was refused, for one of five residents reviewed (Resident 1). This failure had the potential for the resident to not receive proper hygiene, feel unclean, and may result to skin irritation and/or skin breakdown.

Inspectors wroteBased on interview and record review, the facility failed to ensure an appropriate orthostatic (standing upright) blood pressure (BP - measurement of the force of blood pushing against the blood walls) monitoring were conducted, for one of three residents reviewed (Resident 6). This failure had the potential for Resident 6 to experience complications related to orthostatic blood pressure.

Inspectors wroteBased on interview and record review, the facility failed to assess the interventions for revisions to address multiple incidents of falls for two of three sampled residents (Residents 7 and 8). This failure had the potential to result in unmet needs and a potential for falls with possible injury.

Inspectors wroteBased on observation, interview, and record review, for one of five residents reviewed (Resident A), the facility failed to ensure effective pain management was provided when the pain medications were not administered as ordered by the physician after spine surgery. This failure resulted in Resident A to experience severe pain which affected her quality of life and psychosocial well-being. Resident A was eventually transferred to acute hospital for pain management.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents' mail or packages were not opened without prior consent from the resident, for two of five residents sampled (Residents B and C). This failure resulted in Resident B and C's rights not being respected.

Inspectors wroteBased on interview and record review, the facility failed to ensure pharmaceutical services were provided to meet the needs of a resident, for one of five residents reviewed (Resident A), when medications (pain medications and Nictoine patch [medication for smoking cessation]) were not acquired by the facility timely. This failure resulted in a delay in the care and treatment of Resident A's overall health condition. In addition, this failure had the potential for other residents to have a delay in the care and treatment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure, for one of five residents sampled (Resident A) had equipment to use was being maintained in a safe and operable condition when the left brakes of the wheelchair was not working. This failure had the potential to cause injury to Resident A when she was using a wheelchair.

Inspectors wroteBased on interview and record review the facility failed to ensure sufficient licensed nurses with the appropriate competencies and skill sets necessary to care for one (Resident A) of six sampled residents' needs, as identified through resident assessments, and described in the plan of care. This failure has the potential to affect the provision of care for Resident A and other residents at the facility.

Inspectors wroteBased on interview and record review the facility failed to ensure one (Resident A) of six sampled residents was consistently assessed and was provided treatment and care in accordance with the professional standards of practice, when Resident A had a fall and her vital signs became abnormal after the fall incident. These failures increased the risk for the current health condition of the resident to worsen due to delayed assessment and delayed provision of appropriate care.

Inspectors wroteBased on interview and record review, the facility failed to ensure a safe environment was provided, for one of three resients reviewed (Resident 1), when the otuside patio had an open sunken area of dirt, approximately 2 inches below the level of surrounding concrete pavement. This failure resulted in Resident 1 being stuck in the dirt between a tree and the edge of the concrete pavement.

Inspectors wroteBased on interview and record review, the facility failed to ensure information regarding formulating an Advance Directives (AD- a written document that indicates a resident's medical wishes,) was provided to the resident or resident representative (RR), for three of six residents reviewed for AD, (Residents 6, 29, and 52). This failure had the potential for the resident/resident representative's current wishes for medical care not to be honored.

Inspectors wroteBased on interview and record review, the facility failed to ensure a comprehensive care plan (specific interventions to provide effective and person-centered care to meet the resident's needs) was initiated for the use of apixaban (brand name Eliquis, an anti-coagulant, or blood thinning medication), for one of five residents reviewed for unnecessary medications (Resident 6). This failure had the potential to result in the delay in the care and treatment for Resident 6.

Inspectors wroteBased on interview, and record review, the facility failed to ensure the Consultant Pharmacist (CP) identified and reported irregularities during monthly medication regimen review (MRR), four of five residents reviewed for unnecessary medications (Residents 9, 6, 40, and 52), when: and three residents (Resident 6, 40, 52) on anticoagulation (medications also referred to as blood thinners) did not have monitoring for signs of bleeding: 1. Resident 9 was administered aripiprazole (an anti-psychotic medication for schizophrenia and bipolar depression) without adequate behavioral monitoring documented during use of aripiprazole; and 2. Residents 6, 40, and 52 were not monitored for signs and symptoms of adverse effects related to the use of anti-coagulants (blood thinners). [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure three of four sampled residents (Residents 6, 40 and 52) were free from unnecessary medications when: 1. Resident 6 received apixaban (brand name Eliquis, an anti-coagulant, or blood thinning medication) without monitoring for signs and symptoms of adverse effects related to the use of apixaban; 2. Resident 40 received apixaban without monitoring for signs and symptoms of adverse effects related to the use of apixaban; and 3. Resident 52 received enoxaparin (brand name Lovenox, an anti-coagulant, or blood thinning medication) without monitoring for signs and symptoms of adverse effects related to the use of enoxaparin. These failures had the potential to result in unnecessary use of medications for Residents 6, 40 and 52 and had the potential for side effects of this medication (such as bleeding, excessive bruising, etc. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow the menu during tray line (food preparation and assembly at the steam table) observation on July 17, 2024, for three of 68 residents who consumed food in the facility (Residents 9, 45 and 35). This failure had the potential to negatively impact the residents' nutritional status and further compromise the residents' medical status.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure Infection Prevention and Control practices were properly implemented when: 1. The direct care staff were not aware which patients were on Enhanced Barrier Precautions (EBP- a type of infection prevention measure requiring the use of gowns and gloves during high contact resident care); 2. Certified Nursing Assistant (CNA) 1 observed EBP while feeding Resident 40. Resident 40 was not on the list for EBP; 3. Cohorting (placing residents in the same room) guidelines for EBP were not observed for Residents 6 and 117. These failures had the potential to spread infection throughout the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to treat two of four sampled residents, with dignity and respect when the Certified Nursing Assistants (CNA) did not sit at eye level while feeding the residents (Residents 40 and 43). This failure did not promote resident's dignity, did not allow social interaction, and had the potential promote more serious negative outcomes.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure were provided the necessary level of assistance to meet their activities of daily living needs, for two of two sampled residents (Residents 30 and 29), when: 1. Resident 30 was observed with lunch meal tray set up incomplete, with plastic covering/seal on food items and the milk carton was left unopened. Resident 30 was unable to remove the plastic covering nor able to open the milk carton; and 2. Resident 29 was observed with lunch meal tray set up incomplete, with plastic covering/seal on plated food items. Resident 29 was unable to remove the plastic covering on the plated food or reach her drinking cup. These failures resulted in the residents not receiving direct necessary care and services needed at mealtime and had the potential to compromise the health and wellbeing of the residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure the abnormal results of the chest x-ray (radiology procedure of the chest) was addressed by the physician timely, for one of three closed record reviewed (Resident 22). In addition, the physician's order for antibiotic to treat the abnormal chest x-ray was not administered timely. These failures resulted in a delay in the care and treatment for Resident 22.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure interventions to prevent falls were implemented, for one of two residents (Resident 40) when 1:1 sitter was not provided to address impulsive behavior and falls. This failure had a potential to result in Resident 40 to have falls and sustain injury.

Inspectors wroteBased on interview and record review, the facility failed to ensure accurate accountability of controlled medications (those with high potential for abuse and addiction) for one of four residents (Resident 62) when a random controlled medication audit did not reconcile. The controlled medication was signed out of the Individual Narcotic Record (a controlled drug record, an inventory sheet that keeps record of the usage of controlled medications) but not documented on the Medication Administration Records (MAR) to indicate it was administered to Resident 62. This failure resulted in inaccurate accountability of controlled medications, which had the potential for misuse or diversion.

Inspectors wroteBased on interview and record review, the facility failed to ensure was free from unnecessary psychotropic (drugs that affects brain activities associated with mental processes and behavior) medications, for one of five residents reviewed for unnecessary medications (Resident 9), when Resident 9 was administered aripiprazole (brand name Abilify, an anti-psychotic medication for schizophrenia and bipolar disorder) without adequate behavioral monitoring documented during use of aripiprazole. This failure had the potential to result in unnecessary use of medications for Resident 9, which increased the potential for medication interactions, adverse reactions, and unidentified risks associated with the use of psychotropic medications that included but not limited to sedation, respiratory depression, constipation, anxiety, agitation, and memory loss.

Inspectors wroteBased on interview and record review, the facility failed to ensure the antibiotics were prescribed and administered to the residents under the guidance of their antibiotic stewardship program, for one of three residents reviewed for closed record (Resident 22), when: - Resident 22's condition did not meet the McGeer's criteria (a set of specific definitions to identify true infections in long term nursing facilities) for the use of antibiotic for UTI (Urinary Tract Infection); and - The physician's order to discontinue Macrobid (a medication to treat UTI) was not carried out as ordered. These failures had the potential for antibiotics to be used when it was not indicated and the development of antibiotic-resistant bacteria.

Inspectors wroteBased on interview and record review, the facility failed to ensure the accurate administration of treatments, as ordered by the physician for Residents 1 & 2. This failure had the potential to delay Resident 1 & 2 ' s wound healing.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide an environment free from verbal abuse, for one of three residents reviewed (Resident 1), when Certified Nursing Assistant (CNA) 1 was heard threatening Resident 1 that she was going to be thrown on the floor during Resident 1's shower if she would not stop yelling. This failure resulted in Resident 1 being subjected to verbal abuse, which could result in emotional and psychological distress.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure, for one of three residents reviewed (Resident A), was free from physical abuse when the Certified Nursing Assistant (CNA) grabbed both Resident A's arms and hands and continued with care while the resident was being combative during provision of care. This failure resulted in Resident A to have discolorations on both arms, hands, left side of the cheek, and neck area. In addition, Resident A was not able to tell the CNA to stop as she was afraid and felt threatened by CNA 1.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a person-centered care plan for dementia (memory loss) was developed, for one of three residents (Resident A) reviewed for dementia care. This failure had the potential for Resident A not to receive the appropriate interventions to manage symptoms of dementia.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide two person-assist during incontinent care (cleaning the resident while in bed after periods of urination or bowel elimination) in accordance with the plan of care, for one of four residents reviewed (Resident 1). This failure resulted in Resident 1's fall from the bed and was sent out to the acute care hospital for further management. Resident 1 sustained a fracture (broken bone) to the right arm and required to have surgical repair of the fracture.

Inspectors wroteBased on interview and record review the facility failed to notify the physician for one of three sampled residents' (Resident 1) episode of hypoglycemia (low blood sugar) in accordance with the facility's policy and procedure. This failure had the potential for delayed treatment of hypoglycemia for Resident 1.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the trash containers were not overfilled and the lids kept securely closed to prevent the potential attraction of pests and vermin (nuisance animals that could spread diseases). This facility failure increased the potential for attracting insects and vermin, which could result in food-borne illnesses in a highly susceptible population of 68 residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure nutritional care and services were provided, for four of 14 residents reviewed (Residents 3, 5, 27, and 48) for nutrition, when: 1. For Resident 3, there was no follow up evaluations and interventions to address the resident's nutritional status after she had a 3.3% weight loss in a week on September 1, 2022, and continued to refuse to be weighed. In addition, Resident 3's low albumin and Vitamin D level were not referred to the Registered Dietitian (RD) for further evaluation and recommendation. This failure resulted in Resident 3's weight loss of 30 lbs. (pounds)/10% from September 1, 2022 to December 7, 2022 (three months). 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure: 1. The intravenous (IV - given through a vein) medication cart was locked when not in use. This failure had the potential for the IV medication cart to be accessible to residents, unlicensed staff, and visitors; 2. Expired IV medication were removed from the medication cart. This failure had the potential for the residents to receive expired medications with less potency and/or experience serious adverse outcomes; and 3. Three (3) bags of IV medications were removed from the medication cart after the order was completed. This failure had the potential for the medication to be available for use to other residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store food in accordance with professional standards for food service safety, when several food items were undated or stored beyond their use by dates, readily available for use. This failure had the potential to cause foodborne illnesses in a medically vulnerable resident population who consumed food in the facility. The facility census was 68.

Inspectors wroteBased on interview and record review, the facility failed to conduct and implement a Quality Assurance Performance Improvement (QAPI) program to address the residents' weight loss. This failure had the potential for the facility to not take preventative measures for weight loss.

Inspectors wroteBased on observation, interview, and record review, three Certified Nursing Assistants (CNA) failed to implement appropriate hand hygiene during passing of meal trays and feeding the residents. This failure had the potential to result in the spread of communicable diseases and infections to residents and other staff members.

Inspectors wroteBased on interview and record review, the facility failed to ensure a written notification regarding the facility's bed hold policy (holding a bed for up to seven [7] days if a resident is transferred to a general acute hospital or goes on therapeutic leave), was provided to the resident or resident representative, for one of three residents reviewed for hospitalization (Resident 37) when Resident 37 was transferred to the acute care hospital on September 9, 2022, September 16, 2022, and September 27, 2022. This failure had the potential to result in the resident or resident representative losing the opportunity to secure the right to reside in the facility past the bed hold duration policy time frame.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the Minimum Data Set (MDS - an assessment tool) was completed accurately, for one of one resident reviewed for smoking (Resident 12). This failure had the potential for not identifying the resident as a safety risk to self and other residents in the facility and implement appropriate interventions.

Inspectors wroteBased on interview and record review, the facility failed to conduct a comprehensive assessment regarding a resident's change of condition, for one of three residents reviewed for closed record (Resident 167). In addition, the facility failed to implement the physician's order for IV (intravenous - through the vein) hydration. This failure resulted in a rapid decline in Resident 167's condition and may have potentially contributed to Resident 167's demise.

Inspectors wroteBased on interview and record review, the facility failed to ensure a referral to an eye specialist was scheduled, for one of one resident reviewed for vision/hearing (Resident 24). This failure resulted in Resident 24 not receiving the proper evaluation to determine other contributing factors for her vision loss, and had the potential to have a delay in receiving the proper treatment to maintain and/or preserve her remaining vision.