Desert Mountain Care Center

In the surveyor’s words

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

• Actual harm, isolatedF686Jan 12, 2023

  Based on observation, interview and record review, the facility failed to assess and monitor the skin integrity underneath the right arm sling immobilizer (a device used to support and keep still an injured part of the body), for one of three residents reviewed (Resident A) for pressure injury (the breakdown of skin integrity due to pressure). This failure to assess and monitor skin integrity resulted in the development of a Stage 4 pressure ulcer (a full thickness tissue loss with exposed bone, tendon, or muscle) on Resident A ' s right elbow area, during admission at the skilled nursing facility. Findings: On November 9, 2022, at 9:20 a.m., an unannounced visit was conducted at the facility to investigate an allegation related to quality care issue. […]

• No harm, potential for more than minimal, patternF880May 13, 2026

  Based on observation, interview, and record review, the facility failed to ensure infection control and prevention measures were implemented according to the facility's policy and procedure and national guidelines, of using a dedicated patient-care equipment (e.g. blood pressure [BP] cuff and pump, thermometer, and pulse oximeter) on residents requiring contact and droplet precautions (infection control measures used to prevent the spread of diseases transmitted through large respiratory droplets), for three of three residents (Residents 1, 2 and 3).This failure had the potential to spread known infections to other residents or staff in the facility.Findings:On May 13, 2026, at 9:10 a.m., an unannounced visit was conducted to investigate a facility reported incident regarding infection… […]

• No harm, potential for more than minimal, patternF755Jun 26, 2025

  Based on observation, interview, and record review, the facility failed to ensure provision of pharmacy services to meet the needs of the residents, when: 1. Four discontinued bags of large volume fluid for injections containing normal saline (electrolyte supplement in water) 0.45% remained stored in the medication room available for use; 2. One discontinued bag for IV (intravenous, into vein) infusion containing vancomycin (antibiotic for infection) 1 gram in 250 ml (milliliter, unit of measurement) remained stored in the medication refrigerator available for use; 3. One discontinued blister card containing ondansetron (medication for nausea and/or vomiting [N/V]) 4 mg (milligram, a unit of measurement) tablets remained in the medication cart available for use for Resident 55; 4. […]

• No harm, potential for more than minimal, patternF812Jun 26, 2025

  Based on observation, interview, and record review, the facility failed to ensure safe, sanitary food preparation and storage practices were followed in the kitchen when wooden storage shelves in the dry supply area were observed to be chipped, splintered and the lacquered varnish peeled off. This failure had the potential to cause food-borne illness in a highly susceptible resident population. Findings: On June 23, 2025, at 9:52 a.m., an observation with the Dietary Supervisor (DS), was conducted in the dry goods supply room. […]

• No harm, potential for more than minimal, patternF741Apr 22, 2025

  Based an observation, interview, and record review, the facility failed to ensure trained staff were utilized to provide one on one (1:1) supervision of a resident with wandering behavior, for one of four sampled residents (Resident 4). This failure resulted to untrained staff providing 1:1 supervision to Resident 4 and had the potential for wandering residents to experience physical and psychosocial harm due to lack of training to handle residents with wandering behavior. Findings: On April 22, 2025, at 9:35 a.m., an unannounced visit to the facility was conducted to investigate complaints regarding quality of care. On April 22, 2025, at 12:15 p.m., an interview was conducted with Certified Nursing Assistant (CNA) 3. […]