Deficiencies (last 4 years)
Deficiencies (over 4 years)
18 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
386% worse than Arizona average
Arizona average: 3.7 deficiencies/year
Deficiencies per year
40
30
20
10
0
Inspection Report
Complaint Investigation
Capacity: 120
Deficiencies: 0
Date: Sep 30, 2025
Visit Reason
Investigation of complaints 00145314 and 00144834 with no deficiencies cited.
Findings
Investigation of complaints 00145314 and 00144834 with no deficiencies cited.
Inspection Report
Complaint Investigation
Capacity: 120
Deficiencies: 0
Date: Sep 10, 2025
Visit Reason
Complaint survey investigating complaint 00144270 with no deficiencies cited.
Findings
Complaint survey investigating complaint 00144270 with no deficiencies cited.
Inspection Report
Complaint Investigation
Capacity: 120
Deficiencies: 2
Date: Jul 31, 2025
Visit Reason
Onsite complaint survey investigating intake #00134323 and #00136979 with 2 deficiencies cited related to accident hazards and premises safety.
Findings
Onsite complaint survey investigating intake #00134323 and #00136979 with 2 deficiencies cited related to accident hazards and premises safety.
Deficiencies (2)
§483.25(d) Accidents
R9-10-425.A Premises and equipment safety
Inspection Report
Deficiencies: 1
Date: Jul 31, 2025
Visit Reason
The inspection was conducted to evaluate the facility's compliance with regulations regarding resident safety and supervision, specifically related to a resident who failed to return to the facility after leaving.
Findings
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.
Deficiencies (1)
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Report Facts
Residents Affected: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant (CNA) staff #7 | Certified Nursing Assistant | Interviewed regarding resident transportation and supervision |
| Unit Coordinator staff #81 | Unit Coordinator | Interviewed about scheduling resident transportation |
| Director of Social Services staff #39 | Director of Social Services | Interviewed about resident transport and supervision |
| Driver staff #14 | Facility Driver | Interviewed about resident transportation and return |
| Licensed Practical Nurse (LPN) staff #90 | Licensed Practical Nurse | Interviewed about resident sign-out procedures and follow-up |
| LPN staff #47 | Licensed Practical Nurse | Interviewed about resident sign-out and follow-up procedures |
| LPN staff #19 | Licensed Practical Nurse | Interviewed about resident sign-out and follow-up procedures |
| Director of Nursing (DON) staff #37 | Director of Nursing | Interviewed about policies and expectations for resident sign-out and follow-up |
Inspection Report
Complaint Investigation
Capacity: 120
Deficiencies: 0
Date: May 14, 2025
Visit Reason
Complaint survey investigating intake #00129186 with no deficiencies cited.
Findings
Complaint survey investigating intake #00129186 with no deficiencies cited.
Inspection Report
Complaint Investigation
Capacity: 120
Deficiencies: 0
Date: Apr 17, 2025
Visit Reason
Complaint survey investigating multiple intakes with no deficiencies cited.
Findings
Complaint survey investigating multiple intakes with no deficiencies cited.
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Apr 17, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to provide appropriate pressure ulcer care and prevent new ulcers from developing in Resident #2.
Complaint Details
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.
Findings
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.
Deficiencies (1)
Failure to provide appropriate pressure ulcer care and prevent new ulcers from developing or worsening in Resident #2.
Report Facts
Braden Scale score: 18
Pressure ulcer measurements: 7.1
Pressure ulcer measurements: 7
Pressure ulcer measurements: 0.1
Pressure ulcer measurements: 5.5
Pressure ulcer measurements: 5.6
Pressure ulcer measurements: 0.5
Pressure ulcer measurements: 6
Pressure ulcer measurements: 5.7
Pressure ulcer measurements: 1.5
Medication start date: 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff #115 | Certified Nursing Assistant (CNA) | Interviewed regarding scheduling, shower routines, and skin issue reporting. |
| Staff #32 | Certified Nursing Assistant (CNA) | Interviewed about shower schedules and skin issue reporting. |
| Staff #106 | LPN/Wound Nurse | Provided wound care, assessed resident's wounds, and described treatment and resident non-compliance. |
| Staff #400 | Nurse Practitioner (NP) | Provided wound care consults, treatment orders, and follow-up visits; notified about wound severity and hospital transfer. |
Inspection Report
Capacity: 120
Deficiencies: 12
Date: Mar 18, 2025
Visit Reason
Recertification survey for Medicare under Life Safety Code 2012 with 12 deficiencies cited related to emergency preparedness, fire safety, and electrical systems.
Findings
Recertification survey for Medicare under Life Safety Code 2012 with 12 deficiencies cited related to emergency preparedness, fire safety, and electrical systems.
Deficiencies (12)
Emergency preparedness policies and procedures
Emergency preparedness communication plan
Means of Egress - General
Emergency Lighting
Fire Alarm System - Installation
Fire Alarm System - Testing and Maintenance
Sprinkler System - Installation
Portable Fire Extinguishers
Corridor - Doors
Subdivision of Building Spaces - Smoke Barrier Construction
Electrical Systems - Essential Electric System Maintenance and Testing
Electrical Equipment - Testing and Maintenance Requirements
Inspection Report
Complaint Investigation
Capacity: 120
Deficiencies: 14
Date: Mar 14, 2025
Visit Reason
State compliance survey with investigation of multiple complaint intakes and 14 deficiencies cited related to care planning, infection control, medication, and food safety.
Findings
State compliance survey with investigation of multiple complaint intakes and 14 deficiencies cited related to care planning, infection control, medication, and food safety.
Deficiencies (14)
§483.21 Comprehensive Person-Centered Care Planning
§483.24(a)(2) Services to maintain nutrition and grooming
§483.35(g) Nurse Staffing Information
§483.45(g) Labeling of Drugs and Biologicals
§483.60(d) Food and drink nutritive value
§483.60(i) Food safety requirements
§483.80 Infection Control
R9-10-411.C Medical record care plans
R9-10-412.B Nursing personnel documentation
R9-10-414.B Care plan review and revision
R9-10-421.D Medication storage
R9-10-422 Policies and procedures
R9-10-423.A Food establishment contracts
R9-10-423.B Food preparation methods
Inspection Report
Routine
Deficiencies: 7
Date: Mar 14, 2025
Visit Reason
The inspection was conducted as a routine survey to assess compliance with regulatory requirements related to resident care, medication management, staffing, food safety, and infection control at Desert Highlands Care Center.
Findings
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.
Deficiencies (7)
Failure to ensure a baseline care plan was developed and implemented timely for two residents (#42 and #56).
Failure to provide nail care for resident #42, resulting in long fingernails with brown debris.
Failure to post nurse staffing information daily in a visible location accessible to residents and visitors.
Medication cart was left unsecured and unattended, allowing potential access to medications.
Food served to residents was not consistently at safe and appetizing temperatures.
Expired refrigerated food (tomato juice) was found in the kitchen.
Failure to ensure proper hand hygiene was conducted during pressure ulcer care for resident #27, risking contamination.
Report Facts
BIMS score: 1
BIMS score: 6
BIMS score: 15
BIMS score: 15
Food temperature: 110
Food temperature: 103
Food temperature: 57.3
Expired food date: 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff #11 | Licensed Practical Nurse (LPN) | Interviewed regarding care plan development |
| Staff #22 | Minimum Data Set Coordinator (MDS) | Confirmed responsibility for care plans |
| Staff #13 | Director of Nursing (DON) | Interviewed regarding care plan process and staffing postings |
| Staff #77 | Certified Nursing Assistant (CNA) | Interviewed about ADL refusal documentation and nail care |
| Staff #14 | Licensed Practical Nurse (LPN) | Interviewed about shower and nail care practices |
| Staff #19 | Registered Nurse (RN) | Observed medication cart left unsecured and interviewed |
| Staff #17 | Licensed Practical Nurse (LPN) | Interviewed about medication cart security and hand hygiene |
| Staff #68 | Dietary Manager | Interviewed about food temperatures and expired food |
| Staff #27 | Licensed Practical Nurse (LPN) | Observed and interviewed regarding wound care and hand hygiene |
| Staff #39 | Certified Nursing Assistant (CNA) | Interviewed about hand hygiene expectations |
| Staff #17 | Registered Nurse (RN) | Interviewed about hand hygiene expectations |
Inspection Report
Annual Inspection
Deficiencies: 1
Date: Mar 14, 2025
Visit Reason
The inspection was conducted to evaluate the facility's compliance with food safety and dietary service regulations, specifically ensuring that food and drink are palatable, attractive, and served at safe and appetizing temperatures.
Findings
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.
Deficiencies (1)
Failed to ensure food and drink were palatable, attractive, and served at safe and appetizing temperatures.
Report Facts
Food temperature: 110
Food temperature: 103
Food temperature: 57.3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dietary Manager (staff #68) | Interviewed regarding food temperatures and preparation | |
| Administrator (staff #2) | Interviewed regarding expectations for food tray temperatures and potential risks |
Inspection Report
Complaint Investigation
Capacity: 120
Deficiencies: 3
Date: Nov 21, 2024
Visit Reason
Investigation for complaint AZ00219030 with 3 deficiencies cited related to abuse reporting and resident protection.
Complaint Details
Investigation involved failure to protect residents from abuse and failure to report allegations timely.
Findings
Investigation for complaint AZ00219030 with 3 deficiencies cited related to abuse reporting and resident protection.
Deficiencies (3)
R9-10-403.F Abuse reporting and protection
R9-10-403.F Abuse reporting and protection
R9-10-410.B Resident abuse prevention
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Nov 21, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding an allegation that resident #10 exposed himself to resident #7, potentially constituting sexual abuse.
Complaint Details
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.
Findings
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.
Deficiencies (3)
Failed to protect resident #7 from inappropriate sexual behavior by resident #10.
Failed to report an allegation of sexual abuse to the state agency within the regulated timeframe.
Failed to protect residents from further abuse by resident #10 during the investigation.
Report Facts
Date of incident: Nov 17, 2024
Date of report to state agency: Nov 18, 2024
Mental status score: 9
Mental status score: 14
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Administrator | Reported the incident, initiated formal investigation, and provided statements about the allegation and facility policies |
| Director of Nursing | Director of Nursing (DON) | Received report from staff, provided training information, and gave statements about abuse and supervision |
| Staff #12 | Licensed Nursing Aid (LNA) | Reported witnessing resident #10 exposing himself and provided detailed observations |
| Staff #8 | Licensed Practical Nurse (LPN) | Provided statements about the incident and supervision of resident #10 |
| Staff #2 | Registered Nurse (RN) | Reported information about resident #10's behavior and supervision |
Inspection Report
Complaint Investigation
Capacity: 120
Deficiencies: 2
Date: Feb 22, 2024
Visit Reason
Investigation of complaints AZ00206631 and AZ00206695 with 2 deficiencies cited related to failure to report allegations of sexual abuse.
Complaint Details
Failure to report allegations of sexual abuse for one resident.
Findings
Investigation of complaints AZ00206631 and AZ00206695 with 2 deficiencies cited related to failure to report allegations of sexual abuse.
Deficiencies (2)
R9-10-403.E Abuse reporting
§483.12(c) Response to allegations of abuse
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Feb 22, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to timely report an allegation of sexual abuse involving one resident (#15).
Complaint Details
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.
Findings
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.
Deficiencies (1)
Failure to timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Report Facts
Residents Affected: 1
Date of survey completed: Feb 22, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant (CNA) | Staff #22 involved in providing continence care and applying ointment during the incident | |
| Certified Nursing Assistant (CNA) | Staff #10 involved in providing continence care and stabilizing the resident | |
| Licensed Practical Nurse (LPN) | Staff #38 present during continence care, responsible for reporting abuse | |
| Administrator | Planned additional staff training on abuse prevention |
Inspection Report
Complaint Investigation
Capacity: 120
Deficiencies: 10
Date: Sep 8, 2023
Visit Reason
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.
Findings
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.
Deficiencies (10)
R9-10-403.C Policies and procedures for health services
§483.21(b) Comprehensive Care Plans
§483.21(b)(3) Comprehensive Care Plans
§483.24(a)(2) Services to maintain nutrition and grooming
§483.25(b) Skin Integrity
§483.25(k) Pain Management
§483.80 Infection Control
R9-10-414.B Care plan review and revision
R9-10-414.B Care plan nursing care provision
R9-10-421.B Medication administration policies
Inspection Report
Annual Inspection
Deficiencies: 6
Date: Sep 8, 2023
Visit Reason
The inspection was conducted as part of the annual survey to assess compliance with regulatory requirements and ensure quality of care at Desert Highlands Care Center.
Findings
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.
Deficiencies (6)
Failure to revise care plan regarding resident refusals for turning/repositioning and air mattress for resident #22.
Failure to ensure medications were administered as ordered for residents #20 and #51.
Failure to provide scheduled showers and document refusals for residents #14 and #230.
Failure to provide appropriate pressure ulcer care and prevent new ulcers for resident #22.
Failure to provide safe and appropriate pain management and documentation for residents #229 and #223.
Failure to maintain infection prevention and control standards during medication administration, including failure to sanitize hands and equipment between residents.
Report Facts
Dates medication not administered: 5
Dates wound treatment not administered: 10
Scheduled showers refused: 3
Scheduled showers missed: 5
Pain medication administered without documented pain scale: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN) staff #53 | Licensed Practical Nurse | Interviewed regarding medication administration failures, wound care, and pain management documentation. |
| Assistant Director of Nursing (ADON) staff #72 | Assistant Director of Nursing | Interviewed regarding care plan revisions and medication administration policies. |
| Director of Nursing (DON) staff #32 | Director of Nursing | Interviewed regarding shower schedules, pain management, infection control expectations, and overall facility policies. |
| Certified Nursing Assistant (CNA) staff #87 | Certified Nursing Assistant | Interviewed regarding turning/repositioning policies and documentation. |
| Certified Nursing Assistant (CNA) staff #47 | Certified Nursing Assistant | Interviewed regarding shower scheduling and documentation. |
| Registered Nurse (RN) staff #8 | Registered Nurse | Observed and interviewed regarding infection control lapses during medication administration. |
| Certified Nursing Assistant (CNA) staff #13 | Certified Nursing Assistant | Interviewed regarding shower documentation and refusal procedures. |
| Restorative Nurse Aide (RNA) staff #77 | Restorative Nurse Aide | Interviewed regarding sanitizing blood pressure cuffs between residents. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Apr 12, 2023
Visit Reason
The inspection was conducted following a complaint regarding a resident (#13) who eloped from the facility by exiting through a window, resulting in injury and potential harm.
Complaint Details
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.
Findings
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.
Deficiencies (1)
Failure to ensure adequate supervision to prevent resident elopement resulting in potential harm.
Report Facts
15-minute checks duration: 7
Distance resident found from facility: 0.9
Distance resident found from facility: 0.5
BIMS score: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN) | Reported checking on resident and described events around elopement | |
| Certified Nursing Assistant (CNA) staff #80 | Found resident in parking lot and reported missing resident | |
| Restorative Nursing Assistant (RNA) staff #27 | Saw resident climbing out window and reported incident | |
| Acting Director of Nursing (DON) staff #7 | Provided information on resident behaviors and supervision failures |
Inspection Report
Complaint Investigation
Deficiencies: 8
Date: Jul 14, 2022
Visit Reason
The inspection was conducted due to complaints and allegations related to abuse reporting, transfer notification, personal hygiene care, pressure ulcer care, food sanitation, advance directive documentation, and staff training deficiencies at Desert Highlands Care Center.
Complaint Details
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.
Findings
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.
Deficiencies (8)
Failed to implement policy to ensure an allegation of abuse for one resident was reported to the State agency and investigated.
Failed to timely report suspected abuse to the State Agency within 2 hours of allegation for one resident.
Failed to provide timely notification to resident and representative regarding transfer to hospital including appeal rights.
Failed to ensure two residents received necessary personal hygiene services as scheduled.
Failed to ensure ordered pressure ulcer intervention (multipodus boots) was consistently implemented for one resident.
Failed to maintain quaternary sanitizing solution at required strength level in kitchen.
Failed to ensure advance directive information in clinical record was accurate for one resident.
Failed to provide abuse, neglect, exploitation, misappropriation of resident property, and dementia management training to three sampled staff.
Report Facts
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 2
Residents affected: 1
Residents affected: 1
Residents affected: 1
Staff affected: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #66 | Licensed Practical Nurse | Named in abuse allegation reporting deficiency |
| Administrator #82 | Administrator | Interviewed regarding abuse reporting and facility expectations |
| Director of Nursing #47 | Director of Nursing | Interviewed regarding abuse reporting and transfer notification |
| Certified Nursing Assistant #45 | Certified Nursing Assistant | Interviewed regarding personal hygiene care |
| Registered Nurse #28 | Registered Nurse | Interviewed regarding personal hygiene care and advance directive documentation |
| Nurse Manager #12 | Nurse Manager | Interviewed regarding pressure ulcer care and sanitizing solution |
| Dietary Manager #36 | Dietary Manager | Interviewed regarding sanitizing solution maintenance |
| Dietary Staff #11 | Dietary Staff | Interviewed regarding sanitizing solution maintenance |
| Business Assistant #33 | Business Assistant | Interviewed regarding staff training follow-up |
| Rehabilitation Office Coordinator #135 | Rehabilitation Office Coordinator | Interviewed regarding staff training responsibilities |
| Director of Therapy #111 | Director of Therapy | Interviewed regarding staff training requirements |
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