Desert Highlands Care Center

In the surveyor’s words

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

• No harm, potential for more than minimal, patternF658Sep 8, 2023

  Based on closed clinical record review, staff interviews, and facility policy review, the facility failed to ensure medications were administered as ordered by the physician for two residents (#20 and #51). The deficient practice could result in adverse effects to the residents. Findings include: Resident #20 was admitted on [DATE] with a diagnosis of COPD (Chronic Obstructive Pulmonary Disease), dementia, essential hypertension and status post fall with left hip fracture. A review of the current active physician orders revealed the following orders for: -4-ounce health shake with all meals (order date of July 19, 2023); and, -Colace (laxative) 100 milligrams -daily (order date of September 29, 2022). […]

• No harm, potential for more than minimal, patternF677Sep 8, 2023

  Based on observations, clinical record reviews, resident and staff interviews, facility documentation and policy and procedures, the facility failed to ensure showers were provided for two residents (#14 and #230). Findings include: -Regarding Resident #14 Resident was admitted on [DATE] with diagnoses of COPD (chronic obstructive pulmonary disease) and major depressive disorder. The standard care plan dated July 7, 2023 included the resident needed help with daily activities, required assistance with mobility and transfers and further decline was expected. […]

• No harm, potential for more than minimal, patternF686Sep 8, 2023

  Based on clinical record review, staff interviews, and review of policy and procedures, the facility failed to ensure care and services was to promote healing of pressure ulcers was provided for one resident (#22). The deficient practice could result in the development and worsening of pressure ulcers. Findings include: Resident #22 was admitted on [DATE] with diagnoses of pyonephrosis, sepsis, protein calorie malnutrition, and lack of coordination. Review of a care plan dated March 21, 2022 included the resident had the potential for skin breakdown. The weekly skin assessments dated June 5 and 20, 2022 included the resident had a pressure ulcer. The coccyx area was circled in the body image of the note. […]

• No harm, potential for more than minimal, patternF697Sep 8, 2023

  Based on clinical record review, staff interviews, and facility policy and procedures, the facility failed to ensure pain management was provided to two residents (#229 and #223). The deficient practice could result in pain not being addressed. Findings include: -Resident #229 was admitted on [DATE] with diagnoses the included encephalopathy, sepsis, and acute kidney injury. The minimum data set (MDS) assessment included a brief interview for mental status (BIMS) score of 15 indicating the resident was cognitively intact. Review of the pain care plan dated August 24, 2023 revealed the resident was able to verbalize pain. […]

• No harm, potential for more than minimal, patternF880Sep 8, 2023

  Based on observations, staff interviews, and facility policy review, the facility failed to ensure infection prevention and control standards were maintained during medication administration. The deficient practice could result in transmission of infection. Findings include: During medication administration observation with a Registered Nurse (RN/staff #8), conducted on August 31 2023 at 8:05 a.m., the RN dropped a medication on the floor. The RN picked up the medication from the floor and discarded the medication in the sharps' container. The RN then replaced the medication, placed it into the medication cup, then entered the resident's room to administer the prepared medications. […]