Desert Haven Care Center

In the surveyor’s words

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

• Actual harm, isolatedF600Mar 2, 2026

  Based 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.Findings include:-Resident #5 (alleged victim) was admitted to the facility on [DATE], with diagnoses including dementia with other behavioral disturbance, dementia in other diseases classified elsewhere with agitation, essential (primary) hypertension, major depressive disorder, recurrent severe… […]

• Actual harm, isolatedF684Dec 17, 2025

  Based 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… […]

• Actual harm, isolatedF689Aug 23, 2024

  Based 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. Findings include: Resident #1 was admitted to the facility on [DATE] with diagnoses that included post-traumatic stress disorder, aphasia following cerebral infarction, mild neurocognitive disorder due to known physiological condition with behavioral disturbance, anoxic brain damage, vascular dementia, mild, with agitation, dysphagia, epilepsy, intractable without status epilepticus. The minimum data set (MDS) assessment was currently in progress for new admission to facility and had not been completed. […]

• No harm, potential for more than minimal, patternF842Dec 17, 2025

  Based 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. […]

• No harm, potential for more than minimal, patternF550Apr 17, 2024

  Based 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. Findings include: During dining observation conducted on Monday, April 15, 2024 at 5:07 p.m., there were seven residents in the dining room eating dinner. The food, drinks and dessert for the seven residents were served in Styrofoam containers, cups, and bowls. The residents were also using plastic ware for utensils. In an interview One of the resident's (#80) stated that Styrofoam is used sometimes, but not all the time. An interview was conducted on April 16, 2024 at 12:35 p.m. […]