28 Reports
Inspection Report — Feb 17, 2026
Date: Feb 17, 2026
Visit Reason
On-site inspection of Desert Highlands Care Center, a Nursing Care Institution, conducted 17 February 2026 for an Other type inspection with Emergency Preparedness and Life Safety Code compliance review.
Findings
The inspection found seven deficiencies related to emergency preparedness drills, kitchen safety, sprinkler system maintenance, corridor door compliance, smoke barrier penetrations, fire drill frequency, and electrical equipment maintenance.
Deficiencies (7)
§416.54(d)(2), §418.113(d)(2), §441.184(d)(2), §460.84(d)(2), §482.15(d)(2), §483.73(d)(2), §483.475(d)(2), §484.102(d)(2), §485.68(d)(2), §485.542(d)(2), §485.625(d)(2), §485.727(d)(2), §485.920(d)(2), §491.12(d)(2), §494.62(d)(2) — The facility failed to participate in required emergency preparedness drills, risking untrained staff during emergencies affecting all 76 residents and staff.
Cooking Facilities — The facility failed to ensure a restraint chain was properly installed on the kitchen oven gas connection and did not inspect and clean exhaust hoods semi-annually, increasing risk of fire events.
Sprinkler System - Maintenance and Testing — The facility failed to maintain sprinkler heads and ensure all parts met UL Listing, including missing escutcheon plates, risking harm from heat and smoke exposure.
Corridor - Doors — The facility failed to provide corridor doors in accordance with NFPA 101 - 2012 edition requirements, potentially affecting approximately 50 of 76 residents.
Subdivision of Building Spaces - Smoke Barrier Construction — The facility failed to fill penetrations in multiple smoke barriers, allowing smoke and heat to penetrate other areas, risking harm to all residents and staff.
Fire Drills — The facility failed to conduct fire drills as required by NFPA 101 - 2012 edition, potentially affecting all 76 residents and staff.
Electrical Equipment - Testing and Maintenance Requirements — The facility failed to provide records of electrical equipment tests, repairs, and modifications, risking resident harm if appliances malfunction.
Report Facts
Deficiencies cited: 7
Inspection Report — Sep 30, 2025
Complaint Investigation
Date: Sep 30, 2025
Visit Reason
On-site complaint investigation of complaints 00145314 and 00144834 at a Nursing Care Institution, conducted 30 September 2025. Federal complaints 2620729 and 2616402 were also investigated on the same date.
Complaint Details
The investigation of complaints 00145314 and 00144834 was conducted on September 30, 2025. The investigation of complaints 2620729 and 2616402 was also conducted on the same date. No deficiencies were cited.
Findings
No deficiencies were cited during this complaint investigation.
Report Facts
Complaints investigated: 4
Inspection Report — Sep 10, 2025
Complaint Investigation
Date: Sep 10, 2025
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On-site complaint investigation of complaints 00144270 and 25610828 at a Nursing Care Institution, conducted 10 September 2025.
Complaint Details
This complaint survey was conducted on September 10, 2025 with the investigations of complaints: 00144270 and 25610828. There were no deficiencies cited.
Findings
This inspection found no deficiencies.
Report Facts
Complaints investigated: 2
Inspection Report — Jul 31, 2025
Complaint Investigation
Date: Jul 31, 2025
Visit Reason
On-site complaint investigation of intakes 00134323, 00136979, AZ00224953, and 2567125 at a Nursing Care Institution, conducted 30-31 July 2025.
Complaint Details
An onsite complaint survey was conducted on July 30 through July 31, 2025 for the investigation of intake #00134323, 00136979. An onsite complaint survey was conducted on July 30 through July 31, 2025 for the investigation of intake #AZ00224953, 2567125. Following deficiencies were cited.
Findings
The inspection found two deficiencies related to failure to timely activate procedures when a resident eloped, risking unidentified missing residents.
Deficiencies (2)
§483.25(d) — The facility failed to ensure procedures were activated timely when Resident #11 failed to return, risking unidentified residents who eloped.
R9-10-425 — The facility failed to ensure procedures were activated timely when Resident #11 failed to return to the facility.
Report Facts
Deficiencies cited: 2
Complaints investigated: 4
Inspection Report — Jul 31, 2025
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 — May 14, 2025
Complaint Investigation
Date: May 14, 2025
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On-site complaint investigation of intake numbers 00129186 and AZ00224363 at a Nursing Care Institution, conducted 13-14 May 2025.
Complaint Details
A complaint survey was conducted on May 13, 2025 through May 14, 2025 for the investigation of intakes #'s:00129186 and AZ00224363. There were no deficiencies cited.
Findings
This inspection resulted in no deficiencies cited or citations.
Report Facts
Complaints investigated: 2
Inspection Report — Apr 17, 2025
Complaint Investigation
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 a resident.
Complaint Details
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.
Findings
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.
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: 0.4
Pressure ulcer measurements: 0.4
Pressure ulcer measurements: 0.2
Pressure ulcer measurements: 1
Pressure ulcer measurements: 1.3
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: 5.6
Pressure ulcer measurements: 1.5
Pressure ulcer measurements: 7
Pressure ulcer measurements: 5.7
Pressure ulcer measurements: 1.5
Medication dose: 1
CNA staffing: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff #115 | Certified Nursing Assistant | Interviewed regarding CNA scheduling, shower assistance, and skin issue reporting. |
| Staff #32 | Certified Nursing Assistant | Interviewed regarding shower schedule, charting, and skin issue reporting. |
| Staff #106 | LPN/Wound Nurse | Provided wound care, assessed resident's wounds, reported resident non-compliance with turning, and coordinated wound treatment. |
| Staff #400 | Nurse Practitioner | Provided wound care consults, ordered treatments, and managed resident's wound care from March 11, 2025 onward. |
Inspection Report — Mar 18, 2025
Date: Mar 18, 2025
Visit Reason
On-site inspection of type Other at a Nursing Care Institution conducted 18 March 2025.
Findings
Twelve deficiencies were cited, but no evidence was provided for any of the violations. The facility met federal Life Safety Code standards based on acceptance of a plan of correction.
Deficiencies (12)
No evidence was provided to support the deficiency related to emergency preparedness policies and procedures.
No evidence was provided to support the deficiency related to the emergency preparedness communication plan.
No evidence was provided to support the deficiency related to means of egress being free of obstructions.
No evidence was provided to support the deficiency related to emergency lighting of at least 1-1/2-hour duration.
No evidence was provided to support the deficiency related to installation of the fire alarm system according to NFPA standards.
No evidence was provided to support the deficiency related to testing and maintenance of the fire alarm system per NFPA requirements.
No evidence was provided to support the deficiency related to installation of the sprinkler system in accordance with NFPA standards.
No evidence was provided to support the deficiency related to selection, installation, inspection, and maintenance of portable fire extinguishers.
No evidence was provided to support the deficiency related to corridor doors resisting passage of smoke and having positive latching hardware.
No evidence was provided to support the deficiency related to smoke barrier construction with a 1/2-hour fire resistance rating.
No evidence was provided to support the deficiency related to maintenance and testing of the essential electrical system and generator.
No evidence was provided to support the deficiency related to testing and maintenance requirements for electrical equipment used in patient care.
Report Facts
Deficiencies cited: 12
Inspection Report — Mar 14, 2025
Annual Inspection
Date: Mar 14, 2025
Visit Reason
On-site complaint investigation of multiple complaint intakes along with the annual compliance survey at a Nursing Care Institution, conducted 11 through 14 March 2025.
Complaint Details
The State compliance survey was conducted on March 11, 2025, through March 14, 2025 along with the investigation of complaint intakes #AZ00213928, AZ00213922, AZ00214117, AZ00209951, AZ00209732, AZ00207618, AZ00199662, AZ00197503, AZ00195119, AZ00194699, AZ00194573, AZ00193362, AZ00193205, AZ00184955, AZ00184809, AZ00183808, AZ00183446, AZ00181440, AZ00178484, AZ00177693, AZ00175801, AZ00174901, AZ00174488, AZ00173930, AZ00172914, AZ00172875, AZ00172443, AZ00171419, AZ00171009, AZ00166698, AZ00163586, AZ00143359. The Federal Comments section also references a recertification and complaint survey conducted during the same dates with similar complaint intake numbers.
Findings
The inspection cited 14 deficiencies. No specific evidence was provided for any deficiency in the report.
Deficiencies (14)
§483.21 Comprehensive Person-Centered Care Planning — No evidence text provided for the baseline care plan development and implementation requirements.
§483.24(a)(2) — No evidence text provided regarding services to maintain good nutrition, grooming, and personal and oral hygiene for residents unable to carry out activities of daily living.
§483.35(g) Nurse Staffing Information — No evidence text provided about posting daily nurse staffing data as required.
§483.45(g) and (h) Labeling and Storage of Drugs and Biologicals — No evidence text provided regarding proper labeling and secure storage of drugs and biologicals.
§483.60(d) Food and drink — No evidence text provided concerning food preparation methods and food and drink quality.
§483.60(i) Food safety requirements — No evidence text provided about procuring, storing, preparing, distributing, and serving food in accordance with safety standards.
§483.80 Infection Control — No evidence text provided regarding establishment and maintenance of an infection prevention and control program.
R9-10-411 — No evidence text provided about ensuring resident medical records contain care plans.
R9-10-412 — No evidence text provided about documentation of nursing personnel present on the premises each day.
R9-10-414 — No evidence text provided about ensuring care plans assist residents in maintaining their highest practicable well-being.
R9-10-421 — No evidence text provided about medication storage according to container instructions.
R9-10-422 — No evidence text provided about policies and procedures for hand cleaning when visibly soiled and before and after providing services.
R9-10-423.A — No evidence text provided about the nursing care institution's ability to store, refrigerate, and reheat food to meet dietary needs when contracting with a food establishment.
R9-10-423.B — No evidence text provided about food preparation methods conserving nutritional value, flavor, and appearance.
Report Facts
Deficiencies cited: 14
Inspection Report — Mar 14, 2025
Routine
Date: Mar 14, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, medication management, staffing, food safety, infection control, and care planning at Desert Highlands Care Center.
Findings
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.
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 left unattended and unlocked during medication pass.
Food served to residents at unsafe and unappetizing temperatures, including cold meals and inadequate hot food temperatures.
Expired refrigerated tomato juice found in kitchen refrigerator.
Failure to ensure proper hand hygiene during pressure ulcer care for resident #27, including no hand cleansing between glove changes.
Report Facts
BIMS score: 1
BIMS score: 6
BIMS score: 15
BIMS score: 15
Food temperature: 110
Food temperature: 103
Food temperature: 57.3
Date of medication cart observation: 1
Date of expired food observation: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff #11 | Licensed Practical Nurse (LPN) | Interviewed about care plan development |
| Staff #22 | Minimum Data Set Coordinator (MDS) | Confirmed care plan formulation process |
| Staff #13 | Director of Nursing (DON) | Confirmed care plan review process and staffing posting issues |
| Staff #77 | Certified Nursing Assistant (CNA) | Discussed ADL refusal documentation and nail care |
| Staff #14 | Licensed Practical Nurse (LPN) | Discussed shower and nail care routines |
| Staff #19 | Registered Nurse (RN) | Observed medication cart left unlocked |
| Staff #17 | Licensed Practical Nurse (LPN) | Discussed medication cart security and hand hygiene |
| Staff #68 | Dietary Manager | Discussed food temperature and expired food |
| Staff #27 | Licensed Practical Nurse (LPN) | Observed during wound care and hand hygiene |
| Staff #39 | Certified Nursing Assistant (CNA) | Discussed hand hygiene expectations |
| Staff #17 | Registered Nurse (RN) | Discussed hand hygiene expectations |
Inspection Report — Mar 5, 2025
Complaint Investigation
Date: Mar 5, 2025
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On-site complaint investigation of intakes 00120853 and AZ00223641 at a Nursing Care Institution, conducted 4 through 5 March 2025.
Complaint Details
An onsite complaint survey was conducted on March 04 through March 05, 2025 for the investigation of intake # 00120853. An onsite complaint survey was conducted on March 04 through March 05, 2025 for the investigation of intake # AZ00223641. There were no deficiencies cited.
Findings
No deficiencies were cited during this inspection.
Report Facts
Complaints investigated: 2
Inspection Report — Feb 5, 2025
Complaint Investigation
Date: Feb 5, 2025
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On-site complaint investigation of complaints AZ00222598 and AZ00222933 at a Nursing Care Institution, conducted 4-5 February 2025.
Complaint Details
An investigation of complaints AZ00222598 and AZ00222933 were conducted from February 4, 2025 through February 5, 2025. There were no deficiencies cited.
Findings
This inspection resulted in no deficiencies or citations.
Inspection Report — Jan 16, 2025
Complaint Investigation
Date: Jan 16, 2025
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On-site complaint investigation of intakes AZ00207409, AZ00214832, AZ00214412, AZ00211243, and AZ00221942 at a Nursing Care Institution, conducted 16 January 2025.
Complaint Details
A complaint survey was conducted on January 16, 2025 for the investigation of intakes #AZ00207409, AZ00214832, AZ00214412, AZ00211243, and AZ00221942. Federal comments noted investigation of intakes #AZ00207407, AZ00214832, AZ00214411, AZ00211243, and AZ00221937 with no deficiencies cited.
Findings
This inspection found no deficiencies.
Report Facts
Complaints investigated: 5
Inspection Report — Nov 21, 2024
Complaint Investigation
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 in the facility, raising concerns of sexual abuse and failure to protect residents.
Complaint Details
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.
Findings
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.
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.
Report Facts
Date of incident: Nov 17, 2024
Date of report to state agency: Nov 18, 2024
Investigation duration: 5
Number of female residents on East Hall: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant (CNA) / Licensed Nursing Aid (LNA) / Staff #12 | Reported the incident of resident #10 exposing himself and provided detailed observations | |
| Director of Nursing (DON) / Staff #60 | Received report of incident, provided training information, and participated in investigation | |
| Licensed Practical Nurse (LPN) / Staff #8 | Reiterated restrictions to resident #10 and participated in investigation | |
| Registered Nurse (RN) / Staff #2 | Informed resident #10 of allegations and monitored resident behavior | |
| Administrator / Staff #1 | Initiated formal investigation and reported to state agency |
Inspection Report — Oct 16, 2024
Complaint Investigation
Date: Oct 16, 2024
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On-site complaint investigation of intake #AZ00216511 and #AZ00216507 at a Nursing Care Institution, conducted 15-16 October 2024.
Complaint Details
The complaint survey was conducted October 15, 2024 through October 16, 2024 for the investigation of intake #AZ00216511 and intake #AZ00216507. No deficiencies were cited.
Findings
No deficiencies were cited during this complaint investigation.
Inspection Report — Aug 28, 2024
Complaint Investigation
Date: Aug 28, 2024
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On-site complaint investigation of intake AZ00213950 and AZ00213949 at a Nursing Care Institution, conducted 28 August 2024.
Complaint Details
An onsite complaint survey was conducted on August 28, 2024 for the investigation of intake # AZ00213950 and intake # AZ00213949. There were no deficiencies cited.
Findings
No deficiencies were cited during this inspection.
Inspection Report — Jun 4, 2024
Complaint Investigation
Date: Jun 4, 2024
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On-site complaint investigation of complaints AZ00211093 and AZ00211080 at a Nursing Care Institution, conducted 4 June 2024.
Complaint Details
An onsite complaint survey was conducted on June 4, 2024 for the following complaints: AZ00211093 and AZ00211080. No deficiencies were cited.
Findings
No deficiencies were cited during this complaint investigation.
Report Facts
Complaints investigated: 2
Inspection Report — Mar 5, 2024
Complaint Investigation
Date: Mar 5, 2024
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On-site complaint investigation of intakes AZ00207168 and AZ00207202 at a Nursing Care Institution, conducted 4-5 March 2024.
Complaint Details
An onsite complaint survey was conducted on March 4, 2024 through March 5, 2024 for the investigation of intakes #AZ00207168 and AZ00207202. There were no deficiencies cited.
Findings
This inspection found no deficiencies.
Inspection Report — Feb 22, 2024
Complaint Investigation
Date: Feb 22, 2024
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On-site complaint investigation of complaints AZ00206631, AZ00206695, and AZ00206630 at a Nursing Care Institution, conducted 21 and 22 February 2024.
Complaint Details
An investigation of complaints AZ00206631, AZ00206695, and AZ00206630 was conducted February 21 and 22, 2024. The investigation focused on allegations of sexual abuse and failure to report as required by facility policy and regulations.
Findings
The inspection found two deficiencies related to the facility's failure to report an allegation of sexual abuse for one resident. The facility did not comply with state and federal reporting requirements for abuse allegations.
Deficiencies (2)
R9-10-403.E — The facility failed to report an allegation of sexual abuse for one resident (#15) despite staff and policy requirements to do so promptly.
§483.12(c) — The facility did not report an allegation of sexual abuse for resident #15 within the required timeframes, risking resident safety and regulatory noncompliance.
Report Facts
Deficiencies cited: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff #22 | Certified Nursing Assistant | Provided continence care to resident #15 and was involved in the incident where the resident alleged abuse. |
| Staff #10 | Certified Nursing Assistant | Assisted staff #22 during continence care of resident #15 and was present during the alleged abuse incident. |
| Staff #56 | Certified Nursing Assistant | Interviewed and stated knowledge of abuse reporting requirements. |
| Staff #38 | Licensed Practical Nurse | Present in the room during continence care and stated that CNAs should have reported the resident's statements. |
Inspection Report — Jan 18, 2024
Complaint Investigation
Date: Jan 18, 2024
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On-site complaint investigation of complaints AZ00205041, AZ00197747, AZ00194371, and AZ00204084 at a Nursing Care Institution, conducted 17-18 January 2024.
Complaint Details
The investigation of complaint AZ00205041, AZ00197747, AZ00194371, AZ00204084 was conducted on January 17, 2023 through January 18, 2023. No deficiencies were cited. The investigation of complaint AZ00205040, AZ00197746, AZ00194370, AZ00204084 was conducted on January 17, 2023 through January 18, 2023. No deficiencies were cited.
Findings
No deficiencies were found during this complaint investigation.
Inspection Report — Oct 24, 2023
Complaint Investigation
Date: Oct 24, 2023
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On-site complaint investigation of complaints AZ00201954 and AZ00201952 at a Nursing Care Institution, conducted 24 October 2023.
Complaint Details
The investigation of complaint AZ00201954 was conducted on 10/24/23. The investigation of complaint AZ00201952 was conducted on 10/24/23. No deficiencies were cited.
Findings
No deficiencies were found during this complaint investigation.
Report Facts
Complaints investigated: 2
Inspection Report — Sep 8, 2023
Date: Sep 8, 2023
Visit Reason
On-site inspection of type Other at a Nursing Care Institution, conducted 8-9 September 2023. This was a recertification survey for Medicare under the Life Safety Code 2012, Chapter 19, Existing.
Findings
The inspection found multiple deficiencies related to emergency preparedness, fire safety, electrical systems, and medical gas storage. The facility failed to develop a facility-based risk assessment, maintain required policies and procedures, conduct required testing and inspections, and ensure safe storage and egress. A total of 19 deficiencies were cited.
Deficiencies (19)
Failure to develop a facility-based risk assessment prior to developing the facility's emergency plan, posing potential risk to patients and staff during emergencies.
Failure to develop emergency preparedness policies and procedures based on a current risk assessment, including missing policies for required CMS hazards such as extreme temperatures and emerging infectious diseases.
Failure to develop and implement emergency preparedness policies and procedures addressing subsistence needs for staff and patients, including insufficient water supply to meet seven-day requirements.
Failure to have policies and procedures for safe evacuation that include all required elements, such as handling residents who refuse to evacuate during an emergency.
Failure to develop and implement emergency preparedness policies and procedures describing the facility's role in providing care at alternate care sites under an 1135 waiver.
Failure to develop an emergency officials contact list including complete contact information for Federal, State, tribal, regional, and local emergency preparedness staff and other sources of assistance.
Failure to participate in required emergency preparedness drills, including missing documentation of full-scale or tabletop exercises for the last two cycles.
Failure to provide a safe means of egress due to equipment and laundry carts obstructing emergency exit corridors, narrowing pathways to less than 5 feet.
Soiled utility room and laundry room doors did not have the required one-hour fire rating, compromising fire barrier protection.
Failure to test the fire alarm system monthly as required, with no documentation of monthly testing available.
Failure to install and maintain quick response sprinkler heads under a wooden overhang exceeding 4 feet, violating NFPA 13 installation requirements.
Failure to perform required monthly and five-year internal and gauge inspections of the sprinkler systems, lacking proof of compliance with NFPA 25 standards.
Failure to inspect and maintain fire/smoke dampers or fusible links every four years, with no documentation found of recent maintenance.
Missing fire drill documentation for some quarters, including unsigned participant lists and absent drill reports for the third shift second and third quarters of 2023.
Lack of written documentation of annual inspection and testing of fire door assemblies as required by NFPA 80.
Failure to conduct, maintain, and document annual electrical receptacle testing in patient care areas, risking ignition hazards.
Improper use of power strips and extension cords, including daisy chaining and use as permanent power sources for appliances, increasing fire risk.
Failure to maintain records of electrical equipment tests, repairs, and modifications, lacking policies and documentation for preventive maintenance.
Failure to properly store full oxygen cylinders in an enclosed noncombustible space and failure to secure cylinders, increasing fire and projectile risks.
Report Facts
Deficiencies cited: 19
Inspection Report — Sep 8, 2023
Annual Inspection
Date: Sep 8, 2023
Visit Reason
On-site complaint and annual compliance inspection at Desert Highlands Care Center conducted from August 28 through September 8, 2023.
Complaint Details
The State compliance survey and Recertification survey were conducted from August 28 through September 8, 2023. The following deficiencies were cited.
Findings
The inspection found ten deficiencies related to infection control, care plan revisions, medication administration, skin integrity, pain management, and activities of daily living. Plans of correction were provided for all deficiencies.
Deficiencies (10)
R9-10-403 — The facility failed to ensure infection prevention and control standards during medication administration, including failure to sanitize hands and equipment between residents, increasing risk of infection transmission.
The facility failed to revise a resident's care plan to reflect refusals of turning/repositioning and use of an air mattress, risking inadequate treatment.
The facility failed to administer prescribed medications prednisone and triamcinolone as ordered for a resident, with no documentation explaining omissions.
The facility failed to provide scheduled showers to a resident multiple times and did not document refusals appropriately, risking hygiene and skin integrity.
The facility failed to provide wound care treatments as ordered for a resident's pressure ulcer on multiple dates without documentation of refusal or reason.
The facility failed to ensure pain management was provided and documented properly for two residents, including lack of pain scale parameters and monitoring of medication effectiveness.
The facility failed to maintain an infection prevention and control program during medication administration, including failure to sanitize hands and equipment between residents, risking infection transmission.
R9-10-414 — The facility failed to revise a resident's care plan to include refusals of turning/repositioning and use of an air mattress, risking inadequate care.
R9-10-414 — The facility failed to ensure nursing care services met the resident's highest practicable well-being by not properly managing pain medication administration and documentation for two residents.
R9-10-421 — The facility failed to administer medications as ordered for two residents, including failure to provide supplements and laxatives without documentation of refusal or reason.
Report Facts
Deficiencies cited: 10
Inspection Report — Sep 5, 2023
Complaint Investigation
Date: Sep 5, 2023
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On-site complaint investigation of intake #AZ00199721 and #AZ00199719 at a Nursing Care Institution, conducted 5 September 2023.
Complaint Details
An onsite survey was conducted on August 25 and September 5, 2023 for the investigation of intake #AZ00199721. The complaint survey was conducted on August 25 and September 5, 2023 for the investigation of intake #AZ00199719. No deficiencies were cited.
Findings
No deficiencies were cited during this complaint investigation.
Inspection Report — Jul 18, 2023
Complaint Investigation
Date: Jul 18, 2023
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On-site complaint investigation of intake numbers AZ00193274, AZ00193279, AZ00197723 and AZ00197724 at a Nursing Care Institution, conducted 18 July 2023.
Complaint Details
An onsite survey was conducted on July 18, 2023 for the investigation of intake #s: AZ00193274, AZ00193279, AZ00197723 and AZ00197724. No deficiencies were cited. The complaint survey was conducted on July 18, 2023 for the investigation of intake #s: AZ00193274, AZ00193279, AZ00197723 and AZ00197724. No deficiencies were cited.
Findings
No deficiencies were cited during this complaint investigation.
Inspection Report — May 31, 2023
Complaint Investigation
Date: May 31, 2023
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On-site complaint investigation of complaint AZ00195755 at a Nursing Care Institution, conducted 31 May 2023. Federal complaint AZ00195754 was also investigated during this survey.
Complaint Details
A complaint survey was conducted on May 31, 2023 for the investigation of AZ00195755. Federal complaint AZ00195754 was also investigated. No deficiencies were cited.
Findings
No deficiencies were found during this complaint investigation.
Report Facts
Complaints investigated: 2
Inspection Report — Apr 12, 2023
Complaint Investigation
Date: Apr 12, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to provide adequate supervision to prevent a resident (#13) from elopement, which posed a risk of injury or harm.
Complaint Details
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.
Findings
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.
Deficiencies (1)
Failure to ensure adequate supervision to prevent one resident (#13) from 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 |
|---|---|---|
| Staff #80 | Certified Nursing Assistant (CNA) | Found resident outside and reported missing resident; involved in supervision |
| Staff #1 | Licensed Practical Nurse (LPN) | Reported checking on resident and described events of elopement and supervision |
| Staff #27 | Restorative Aide | Saw resident climbing out of window and reported incident |
| Staff #7 | Acting Director of Nursing | Interviewed regarding resident behaviors, supervision, and medication refusal |
Inspection Report — Jul 14, 2022
Complaint Investigation
Date: Jul 14, 2022
Visit Reason
The inspection was conducted due to a complaint investigation regarding failure to report and investigate an allegation of abuse for one resident (#6), as well as other compliance concerns related to resident care, transfer notifications, pressure ulcer care, food sanitation, advance directives, and staff training.
Complaint Details
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.
Findings
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.
Deficiencies (8)
Failed to implement policies to ensure an allegation of abuse for one resident (#6) was reported to the State agency and investigated.
Failed to timely report suspected abuse to the State Agency within 2 hours for one resident (#6).
Failed to provide written notification to resident #172 and representative regarding transfer to hospital including appeal rights.
Failed to provide necessary personal hygiene care (showers) to residents #10 and #172 as scheduled.
Failed to ensure ordered pressure ulcer intervention (multipodus boots) was consistently implemented for resident #18.
Failed to maintain quaternary sanitizing solution at required strength level in kitchen.
Failed to ensure advance directive information was accurate and consistent in clinical record for resident #14.
Failed to provide training on abuse, neglect, exploitation, misappropriation of resident property, and dementia management to 3 of 10 sampled staff.
Report Facts
Date of survey completion: Jul 14, 2022
Sanitizer ppm level: 100
Staff training missing: 3
Residents affected: 1
Residents affected: 1
Residents affected: 2
Residents affected: 1
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN/staff #66) | Named in abuse allegation documentation and reporting failure | |
| Administrator (staff #82) | Interviewed regarding abuse allegation reporting and investigation | |
| Director of Nursing (staff #47) | Interviewed regarding abuse reporting expectations and transfer notification | |
| Certified Nursing Assistant (CNA/staff #45) | Interviewed regarding shower schedule and resident hygiene care | |
| Registered Nurse (RN/staff #28) | Interviewed regarding transfer notification and shower documentation | |
| Nurse Manager, Registered Nurse (RN/staff #12) | Interviewed regarding pressure ulcer care and sanitizing solution | |
| Certified Nursing Assistant (CNA/staff #55) | Interviewed regarding pressure ulcer care compliance | |
| Dietary Manager (staff #36) | Interviewed regarding sanitizing solution maintenance | |
| Dietary staff (staff #11) | Interviewed regarding sanitizing solution maintenance | |
| Registered Nurse (RN/staff #28) | Interviewed regarding advance directive documentation | |
| Director of Nursing (DON/staff #47) | Interviewed regarding advance directive process | |
| Business Assistant (staff #33) | Interviewed regarding staff training follow-up | |
| Rehabilitation Office Coordinator (staff #135) | Interviewed regarding staff training requirements | |
| Director of Therapy (staff #111) | Interviewed regarding staff training requirements | |
| Registered Nurse (RN/staff #12) | Interviewed regarding staff training summary |
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