Desert Springs Post Acute

In the surveyor’s words

From the most serious findings on record at Desert Springs Post Acute, in the surveyor’s own words.

• Actual harm, patternF688Jun 23, 2023

  Based on observation, interview, and record review, the facility failed to provide consistent range of motion exercises for five of eight residents reviewed for limited range of motion (ROM - the full movement potential of a joint) (Residents 9, 36, 42, 45, and 52). The facility did not have a restorative nursing program (a program that promotes and maintains resident's function which would include passive range of motion exercises [stretching muscles, moving body part around the joint] and active range of motion exercises [performed solely by the resident, who moves the joint without assistance]) for the residents at the facility. […]

• Actual harm, isolatedF600Jul 1, 2026

  Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1), was free from sexual abuse when there were no interventions developed to protect Resident 1 after Resident 2 subjected the resident to sexual abuse on May 19, 2026. Resident 1 was witnessed by facility staff being kissed and inappropriately touched on the breast by Resident 2. In addition, the facility staff did not immediately intervene when Resident 1 was witnessed being kissed and sexually inappropriately touched by Resident 2. […]

• Actual harm, isolatedF689Jul 15, 2024

  Based on observation, interview, and record review, the facility failed to provide a two person assist and use a gait belt during transfer from a regular chair to a wheelchair for one of three sampled residents (Resident A). In addition, the facility failed to ensure the wheelchair's brake was functioning well during the transfer. These failures had resulted in a fall for Resident A, which led to the development of genu valgum (knock-knee - the knees angle in and touch each other when the legs are straightened) deformity. Findings: On June 25, 2024, at 11:55 a.m. during a concurrent observation and interview inside Resident A's room, Resident A was oberved in bed, with surgical incision on the right knee. Resident A stated she was having back pain since she fell a week ago. […]

• Actual harm, isolatedF686Jan 12, 2024

  Based on interview and record review, the facility failed to provide care and services in preventing development of pressure injury (skin or soft tissue injuries that form due to prolonged pressure exerted over specific areas of the body), for one of three sampled residents (Resident 1), as evidenced by the following: 1. There was no skin evaluation conducted when Resident 1 was admitted on [DATE], in accordance with the policy and procedure titled, Skin Management Guidelines, dated March 2022. 2. There was no interventions developed to address Resident 1's risk for pressure ulcer on admission. The resident was assessed to be at risk for developing pressure injury. 3. […]

• No harm, potential for more than minimal, widespreadF814Jan 10, 2025

  Based on observation, interview, and record review, the facility failed to ensure garbage bins were not overflowing and properly closed, for two of five garbage bins. In addition, trash was found on the ground beneath the dumpsters. This failure had the potential to attract pests and rodents. Findings: On January 6, 2025, at 4:50 p.m., the loading dock was observed with the Food Service Director (FSD). Two of five dumpsters were observed overflowing with boxes, the lids were not fully closed, and trash was found on the ground beneath the dumpsters. […]