Desert Haven Care Center

Based on clinical record review, staff interviews, and policy review, the facility failed to ensure that an incident involving resident-to-resident abuse between two residents (#89 and #78) was reported. The deficient practice could result in continued abuse and physical or emotional harm to residents.

Based on clinical record review, staff interviews, and policy review, the facility failed to ensure that an incident involving resident-to-resident abuse between two residents (#89 and #78) was investigated. The deficient practice could result in continued abuse and physical or emotional harm to residents.

Based on clinical record review, staff interviews, and policy review, the facility failed to ensure that one resident (#78) was free from abuse by another resident (#89).Â

Based on clinical record review, staff interviews, and policy review, the facility failed to ensure that the abuse policy was implemented following an incident involving resident-to-resident abuse between two residents (#89 and #78).

Based on clinical record review, staff interviews, and policy review, the facility failed to ensure that an incident involving resident-to-resident abuse between two residents (#89 and #78) was reported.Â

Based on clinical record review, staff interviews, and policy review, the facility failed to ensure that an incident involving resident-to-resident abuse between two residents (#89 and #78) was investigated.Â

Based on clinical record review, staff interviews, and policy review, the facility failed to ensure that one resident (#78) was free from abuse by another resident (#89). The deficient practice could result in residents being physically and emotionally harmed.

Based on clinical record review, staff interviews, and policy review, the facility failed to ensure that the abuse policy was implemented following an incident involving resident-to-resident abuse between two residents (#89 and #78). The deficient practice could result in continued abuse of residents and physical or emotional harm to residents.Â

Based on facility record review and staff interview, the facility failed to ensure blood sugar monitoring was conducted in accordance with the physician's order for one resident (#17). This deficient practice could result in undetected hypo or hyperglycemia, placing the resident at risk for adverse health outcomes.

Based on facility record review and staff interview, the facility failed to ensure complete documentation of blood sugar monitoring as ordered by the physician for one resident (#17). The deficient practice could result in incomplete medical record and had potential to impede continuity of care and timely clinical decision making.

Based on facility record review and staff interview, the facility failed to ensure complete documentation of blood sugar monitoring as ordered by the physician for one resident (#17).Â

Based on facility record review and staff interview, the facility failed to ensure blood sugar monitoring was conducted in accordance with the physician's order for one resident (#17).Â

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:Â

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.

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).

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).Findings Include:

Based on observation, clinical record review, staff interviews, and review of facility policy, the facility failed to ensure one resident (#3) was provided wound care in accordance with physician orders and professional standards. The deficient practice could result in wounds worsening or becoming infected.Â

Based on observations, staff interview, and policy review, the facility failed to ensure staff were maintaining proper sanitary conditions by not wearing hair nets and facial hair guards during food preparation. The deficient practice could result in infection and or contamination of food.

Based on observation, clinical record review, staff interviews, and review of facility policy, the facility failed to ensure one resident (#3) was provided wound care in accordance with physician orders and professional standards.

Based on observations, staff interview, and policy review, the facility failed to ensure staff were maintaining proper sanitary conditions by not wearing hair nets and facial hair guards during food preparation.Â