Inspection Reports for Desert Peak Care Center
8825 S 7th St, Phoenix, AZ 85042, United States, AZ, 85042
Back to Facility ProfileDeficiencies per Year
32
24
16
8
0
Unclassified
Inspection Report
Complaint Investigation
Capacity: 194
Deficiencies: 29
Mar 18, 2025
Visit Reason
State-compiled facility profile showing 26 inspections from 2023-03 to 2025-03 with deficiency history and complaint investigations.
Findings
Multiple complaint investigations and compliance surveys were conducted between 2023 and 2025, revealing numerous deficiencies related to resident care, safety, infection control, medication administration, physical plant maintenance, and resident rights. Several inspections found no deficiencies, while others cited multiple violations requiring corrective actions.
Complaint Details
Multiple complaint investigations were conducted for various intake numbers between 2023 and 2025, with findings including abuse allegations, failure to provide proper care, inadequate documentation, and failure to notify appropriate parties of transfers and incidents.
Deficiencies (29)
| Description |
|---|
| R9-10-403.C.2.b. Policies and procedures for physical health services and behavioral health services are established, documented, and implemented to protect the health and safety of a resident that cover the provision of physical health services and behavioral health services. |
| R9-10-411.C.22.d.i. Documentation of a medication administered for pain on a PRN basis: An evaluation of the resident's pain before administering the medication. |
| R9-10-414.B.3.b. Ensures that a resident is provided nursing care institution services that assist the resident in maintaining the resident's highest practicable well-being according to the resident's comprehensive assessment. |
| R9-10-410.B.3.a. A resident is not subjected to abuse. |
| R9-10-425.A.1.b. A nursing care institution's premises and equipment are free from a condition or situation that may cause a resident or an individual to suffer physical injury. |
| (2) Testing. The facility failed to participate in required emergency plan drills and exercises. |
| Corridor - Doors: Doors protecting corridor openings failed to maintain proper smoke resistance and positive latching hardware. |
| Subdivision of Building Spaces - Smoke Barrier Construction: Failed to seal penetrations in smoke barriers allowing smoke and heat to penetrate. |
| Utilities - Gas and Electric: Failed to provide protective guards on light bulbs and exposed wiring. |
| Electrical Systems - Essential Electric System Maintenance and Testing: Failed to ensure a remote stop or kill switch for the generator was installed. |
| R9-10-403.C.1.m. Policies and procedures cover contracted services; failed to ensure timely transportation for dialysis for resident #117. |
| R9-10-403.C.2.a. Policies and procedures cover resident screening, admission, transport, transfer, discharge planning, and discharge; failed to refer resident #93 to appropriate mental health authority. |
| R9-10-406.I.2. Recreational Activities: Failed to ensure activities program was directed by a qualified professional. |
| R9-10-414.B.3.b. Failed to ensure insulin treatment was provided as ordered for resident #89. |
| R9-10-423.B.4.a. Failed to provide a diet that meets the resident's nutritional needs as specified in the resident's comprehensive assessment and care plan for resident #23. |
| R9-10-410.B.3.a. Failed to ensure two residents (#8, #12) remained free from abuse. |
| §483.80 Infection Control: Failed to ensure staff followed infection control standards related to personal protective equipment (PPE). |
| R9-10-410.B.2. Failed to ensure resident #123 was treated with dignity, respect, and consideration. |
| R9-10-403.C.2.d. Failed to ensure pharmaceutical services were adequately provided for medication administration for four residents. |
| §483.10(c)(6), (8), (g)(12) Failed to ensure resident #10 had the correct advance directive in place. |
| §483.65 Specialized rehabilitative services: Failed to ensure resident #10 received required specialized services including prosthetic fitting and therapy. |
| R9-10-422.3.c. Failed to ensure proper use of personal protective equipment such as aprons, gloves, gowns, masks, or face protection when applicable. |
| R9-10-426. Failed to maintain physical plant standards including repair of holes and baseboards in resident #106's room. |
| §483.15(c)(3), (4), (5) Failed to ensure all transfer/discharge notifications were made for resident #13. |
| §483.15(d)(1), (2) Failed to provide resident #13 with written notice of bed-hold policy before transfer to hospital. |
| §483.20(k) Failed to complete accurate PASRR level I and send level II for resident #13. |
| §483.25 Quality of care: Failed to provide treatment and care related to shearing and pressure ulcers for resident #1. |
| §483.25(b) Skin Integrity: Failed to provide consistent pressure ulcer treatments as ordered for resident #2. |
| R9-10-414.B.3.b. Failed to assist resident #2 in maintaining highest practicable well-being according to comprehensive assessment. |
Report Facts
Inspections on page: 26
Total deficiencies: 46
Complaint inspections: 23
Total capacity: 194
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Terry Speth | Administrator | Named as facility administrator in facility information |
| Staff #223 | Administrator/Executive Director | Named in abuse and grievance investigation findings related to resident #123 |
| Staff #80 | Director of Nursing | Named in multiple findings related to resident care, PASRR, and investigations |
| Staff #66 | Social Services Director | Named in PASRR and advance directive findings |
| Staff #1 | Activities Director | Named in deficiency for lack of proper qualifications |
| Staff #342 | Certified Nursing Assistant Lead | Named in infection control and call device accessibility findings |
| Staff #125 | Licensed Practical Nurse | Named in medication administration and call device accessibility findings |
| Staff #297 | Licensed Practical Nurse | Named in medication administration and infection control findings |
| Staff #516 | Director of Therapy | Named in specialized rehabilitative services findings |
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