Inspection Reports for
Desert Highlands Care Center

Onsite complaint survey investigating intake #00134323 and #00136979 with 2 deficiencies cited related to accident hazards and premises safety.

The complaint involved Resident #11 who left the facility on July 17, 2025, and failed to return timely. The facility did not have a sign-out sheet for the resident, delayed attempts to contact him, and did not notify Adult Protective Services or police until the next day. The resident was found at a regional medical center. Interviews with multiple staff revealed communication and procedural failures regarding resident transport and sign-out policies.

The facility failed to ensure adequate supervision and timely response when Resident #11 left the facility and did not return as expected. There was a lack of proper sign-out documentation, delayed attempts to locate the resident, and failure to notify appropriate authorities promptly, which could result in unidentified residents who eloped.

The facility failed to ensure timely activation of procedures when Resident #11 did not return as expected, resulting in a potential risk of unidentified elopement. Documentation and communication regarding the resident's absence and return were inadequate, and staff interviews revealed gaps in coordination and follow-up.

The investigation was complaint-driven, focusing on Resident #2's pressure ulcer care. The resident was found to have multiple pressure ulcers that worsened over time despite treatment. The resident was non-compliant with turning and repositioning, and care plans were not always updated accordingly. The resident was eventually sent to the hospital due to severity of wounds.

The facility failed to ensure that Resident #2 received adequate care to prevent pressure ulcers from developing or worsening, resulting in multiple unstageable and stage 3 pressure ulcers. The resident was non-compliant with repositioning, and care plans were not consistently updated. Despite treatment orders and wound care interventions, the resident's wounds worsened, leading to hospital transfer.

The complaint investigation focused on Resident #2's pressure ulcer care. The resident developed multiple pressure ulcers including unstageable sacral wounds and stage 2 injuries. The resident was non-compliant with turning and repositioning. The facility failed to update care plans timely and ensure consistent treatment. The resident was eventually sent to the hospital due to severity of wounds and possible fistula formation.

The facility failed to ensure Resident #2 received adequate care to prevent pressure ulcers from developing or worsening, resulting in multiple unstageable and stage 2 pressure ulcers. The resident was non-compliant with repositioning, and care plans were not consistently updated. Despite treatment orders and wound care interventions, the resident's wounds worsened, leading to hospital transfer for further evaluation.

Recertification survey for Medicare under Life Safety Code 2012 with 12 deficiencies cited related to emergency preparedness, fire safety, and electrical systems.

State compliance survey with investigation of multiple complaint intakes and 14 deficiencies cited related to care planning, infection control, medication, and food safety.

The facility was found deficient in multiple areas including failure to develop timely baseline care plans for residents, inadequate nail care, improper posting of nurse staffing data, unsecured medication cart, food served at unsafe temperatures, expired refrigerated food, and improper hand hygiene during wound care. These deficiencies posed risks of decreased quality of care, potential infections, and resident safety concerns.

The facility was found deficient in timely development and implementation of baseline care plans for residents, inadequate provision of nail care, failure to post daily nurse staffing information visibly, unsecured medication cart left unattended, food served at unsafe temperatures, expired refrigerated food found, and improper hand hygiene during pressure ulcer care. All deficiencies were associated with minimal harm or potential for actual harm affecting a few residents.

The facility failed to ensure that food was distributed to residents at safe and appetizing temperatures, with observations and interviews confirming that meals were often served cold, potentially increasing the risk of bacterial growth and foodborne illness.

The facility failed to ensure that food was distributed to residents at safe and appetizing temperatures, with observations and interviews confirming that meals were often served cold, potentially increasing the risk of bacterial growth and foodborne illness. Temperature measurements of food items were below expected standards.

Investigation involved failure to protect residents from abuse and failure to report allegations timely.

Investigation for complaint AZ00219030 with 3 deficiencies cited related to abuse reporting and resident protection.

The complaint investigation was substantiated with findings that resident #10 exposed himself to resident #7 multiple times. The facility conducted a 5-day investigation, interviewed involved staff and residents, and reported the incident to the police and state agency. Resident #10 was discharged promptly due to a history of similar behavior in other facilities.

The facility failed to protect resident #7 from inappropriate sexual behavior by resident #10, failed to report the allegation of sexual abuse to the state agency within the required timeframe, and failed to prevent further potential abuse by resident #10. Resident #10 was discharged promptly after the incident. Staff supervision was insufficient to monitor resident #10's movements, and the facility's abuse prevention policies were not fully effective in preventing the incident.

The complaint investigation was substantiated by staff interviews and documentation. Resident #10 exposed himself to resident #7 multiple times, and the facility made a police report. Resident #10 was discharged promptly due to a similar history of behavior in other facilities.

The facility failed to protect resident #7 from inappropriate sexual behavior by resident #10, who exposed himself multiple times. The facility also failed to report the allegation to the state agency within the required timeframe and did not adequately prevent further potential abuse during the investigation.

Failure to report allegations of sexual abuse for one resident.

Investigation of complaints AZ00206631 and AZ00206695 with 2 deficiencies cited related to failure to report allegations of sexual abuse.

The complaint investigation found that the facility failed to report an allegation of sexual abuse for resident #15. The allegation was made during continence care on February 12, 2024, but was not reported within the required 2-hour timeframe. Staff interviews confirmed awareness of abuse reporting requirements but failure to act accordingly.

The facility failed to report an allegation of sexual abuse for resident #15, despite statements made by the resident during continence care. Interviews with staff revealed a lack of timely reporting as required by facility policy. The administrator planned additional staff training on abuse reporting.

The complaint involved an allegation of sexual abuse by staff toward resident #15. The allegation was not reported timely as required by facility policy. The investigation included interviews with involved CNAs and nursing staff, confirming the resident's statements and staff's failure to report within the required timeframe.

The facility failed to report an allegation of sexual abuse for resident #15, who reported inappropriate touching by staff during continence care. Interviews with staff revealed a lack of timely reporting as required by facility policy, and the administrator planned additional staff training on abuse prevention.

State compliance survey conducted August 28 through September 8, 2023 with 10 deficiencies cited related to infection control, care planning, pain management, and medication administration.

The facility was found deficient in multiple areas including failure to revise care plans for resident refusals, failure to administer medications and treatments as ordered, failure to provide scheduled showers, inadequate pressure ulcer care, insufficient pain management documentation, and lapses in infection prevention practices during medication administration.

The facility was found deficient in multiple areas including failure to revise care plans to reflect resident refusals, failure to administer medications and treatments as ordered, inadequate assistance with activities of daily living such as showers, failure to provide appropriate pressure ulcer care, inadequate pain management documentation and monitoring, and lapses in infection prevention practices during medication administration.

The complaint investigation was substantiated. The resident eloped twice by removing window frames and exiting the facility, resulting in injuries. Staff failed to provide adequate supervision despite 15-minute checks and one-to-one staffing for 7 days. The resident was agitated due to concerns about his mother and refused medication. The facility's elopement precautions policy was not fully followed.

The facility failed to ensure adequate supervision to prevent resident #13 from eloping twice through windows, resulting in the resident being found outside with injuries. The resident was agitated, refused antianxiety medication, and was placed on 15-minute checks, which were deemed insufficient. The allegation was substantiated by evidence collected during the investigation.

The complaint investigation verified that the resident eloped twice through a window, was found injured outside the facility, and that supervision and monitoring were inadequate. The allegation was substantiated by evidence collected during the investigation.

The facility failed to provide adequate supervision to prevent the resident from eloping despite interventions including a WanderGuard and 15-minute checks. The resident exited through a removed window frame twice, was found injured outside the facility, and was transported to the hospital. Staff interviews and documentation confirmed the elopement and insufficient supervision.

The complaint investigation was triggered by an allegation of abuse for resident #6 that was not reported to the State agency as required. The allegation involved a CNA allegedly grabbing the resident's face and scratching her. The facility failed to report this allegation within the required 2-hour timeframe and failed to investigate it properly. The resident did not feel unsafe and no criminal charges were filed. The Administrator and Director of Nursing acknowledged the failure to report and investigate timely.

The facility failed to report an allegation of abuse to the State agency within the required timeframe and failed to investigate it properly. Additional deficiencies included failure to provide timely transfer/discharge notification to residents and representatives, inadequate personal hygiene care for residents, inconsistent pressure ulcer care, improper sanitizing solution levels in the kitchen, inaccurate advance directive documentation, and lack of required staff training on abuse and dementia care.

The complaint investigation focused on allegations that the facility failed to report abuse allegations timely, failed to notify residents and representatives properly about transfers, failed to provide adequate personal care, failed to implement pressure ulcer care orders, failed to maintain proper sanitizing solution levels, had inaccurate advance directive documentation, and failed to provide required staff training on abuse and dementia care.

The facility failed to report an allegation of abuse to the State agency timely, did not provide proper transfer/discharge notification to a resident and their representative, failed to ensure residents received scheduled personal hygiene care, did not consistently implement pressure ulcer interventions, maintained inadequate sanitizing solution levels in the kitchen, had inaccurate advance directive documentation for a resident, and failed to provide required abuse and dementia training to some staff.