Inspection Reports for
Desert Highlands Care Center

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 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. Temperature measurements of food items were below expected standards.

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 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.

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 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.