Desert Springs Healthcare & Wellness Centre

In the surveyor’s words

From the most serious findings on record at Desert Springs Healthcare & Wellness Centre, in the surveyor’s own words.

• Actual harm, isolatedF697Sep 18, 2024

  Based 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. Findings: On August 16, 2024, at 8:30 a.m., an unannounced visit to the facility was conducted to investigate a complaint of quality of care. On August 16, 2024, at 9:15 a.m., an interview was conducted with the Director of Nursing (DON). The DON stated Resident A was admitted to the facility on [DATE], after 3 p.m. […]

• Actual harm, isolatedF600Oct 25, 2023

  Based 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. Findings: On August 7, 2023, at 9:40 a.m., an unannounced visit to the facility was conducted to investigate an allegation of abuse. On August 7, 2023, at 9:46 a.m., an interview was conducted with the Director of Nursing (DON). […]

• Actual harm, isolatedF689Sep 18, 2023

  Based 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. Findings: On April 10, 2023, at 9:45 a.m., an unannounced visit to the facility was conducted to investigate a facility reported incident. On April 10, 2023, at 9:55 a.m., an interview was conducted with the Director of Nursing (DON). […]

• Actual harm, isolatedF689May 19, 2023

  Based on interview and record review, for one of three sampled residents reviewed for falls (Resident A), the facility failed to ensure the following: 1. Adequate supervision and close monitoring were provided when Resident A did not have a sitter at bedside consistently as recommended by the Interdisciplinary Team (IDT - a group of healthcare professionals); and 2. The effectiveness of the initial interventions were evaluated, and new interventions were developed to address the resident's falls on December 18, 21, and 29, 2022. These failures resulted to Resident A to have three falls on December 18, 21, and 29 of 2022, while at the facility. […]

• No harm, potential for more than minimal, widespreadF814Dec 12, 2022

  Based 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. Findings: During an initial kitchen tour on December 4, 2022, at 11:34 a.m., a concurrent observation and interview was conducted with the Dietary Supervisor (DS). There were three garbage bins located outside the kitchen approximately 40 feet away in the alley, by the iron fence in front of the back yard. […]