Desert Cove Nursing Center

In the surveyor’s words

From the most serious findings on record at Desert Cove Nursing Center, in the surveyor’s own words.

• Actual harm, isolatedF689Jun 16, 2023

  Based on clinical record review, staff interviews and review of policy, the facility failed to ensure 2 residents (#45 and #22) did not sustain injuries related to preventable accidents. The facility census was 62. The deficient practice increased the risk for pain, injury and rehospitalization . Findings include: -Resident #45 admitted to the facility on [DATE] with diagnoses that included cognitive social or emotional deficit following cerebral infarction, dementia without behavioral, psychotic or mood disturbance and tachycardia. An activity of daily living (ADL) self care performance deficit care plan was initiated on 08/27/19 related to activity intolerance, contracture of right hand and bilateral foot drop, muscle weakness, knee contractures and total assistance with ADLs. […]

• No harm, potential for more than minimal, patternF842Apr 15, 2026

  Based 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. Findings include:-Regarding Resident #7:Resident #7 was admitted on [DATE], with diagnoses that included major depressive disorder, anemia, and sepsis. […]

• No harm, potential for more than minimal, patternF880Nov 19, 2025

  The 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. […]

• No harm, potential for more than minimal, patternF684Apr 24, 2025

  Based 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. Findings include: Resident # 23 was admitted to the facility April 3, 2023 with diagnoses that included heart failure, cellulitis of left lower limb, Diabetes Type 2 with ulcers, obesity, and muscle weakness. Review of the resident's Break in Skin Integrity care plan, initiated on February 20, 2023 revealed the resident was to have treatment as ordered and weekly skin checks. […]

• No harm, potential for more than minimal, patternF677Feb 9, 2024

  Based 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. Findings include: Resident #39 was admitted on [DATE] with diagnoses that included paraplegia, chronic pain, polyneuropathy, retention of urine, anxiety disorder, benign prostatic hyperplasia with lower urinary tract symptoms, calculus in the bladder, neuromuscular dysfunction of the bladder and muscle weakness. […]