Inspection Reports for
Desert Peak Care Center

The complaint involved an allegation that Resident #2 entered Resident #1's room and physically abused her by hitting and kicking, resulting in bruises. The allegation was substantiated by skin assessments and staff interviews. Resident #2 was moved to another room and placed on 15-minute checks. Police and family were notified. The investigation included multiple staff interviews and review of video footage, which was unavailable due to deletion.

The facility failed to protect Resident #1 from abuse by Resident #2, resulting in bruises and physical harm. The investigation included interviews, skin assessments, and notifications to family, police, and providers. Resident #2 was moved to another room and placed on 15-minute checks.

The complaint investigation substantiated abuse allegations involving Resident #5 being physically grabbed and slapped by Resident #10 on November 8 and November 16, 2025. The facility placed Resident #10 on 15-minute checks and one-to-one supervision after the incidents. The facility did not provide incident reports to the surveyors, citing internal document policy, which was contrary to State Operations Manual requirements.

The facility failed to protect Resident #5 from abuse by Resident #10, with documented incidents on November 8 and November 16, 2025, involving physical altercations. The facility also failed to provide internal investigation documents to the State Agency during the survey process, impeding the State's ability to confirm findings.

The complaint investigation substantiated resident-to-resident abuse between Residents #3 and #5, including a physical altercation initiated by Resident #5 throwing candy and slapping Resident #3. Additionally, Resident #5 reported verbal abuse and sexual harassment by Resident #10, which was not reported timely to the State Survey Agency. The facility acknowledged the failure to report and took corrective actions including moving residents to separate units and conducting internal investigations.

The facility failed to protect residents from abuse, including resident-to-resident altercations involving Residents #3 and #5, and failed to timely report allegations of abuse involving Residents #5 and #10 to the State Survey Agency. Investigations confirmed incidents of verbal and physical abuse, and the facility's internal processes for reporting and preventing abuse were deficient.

The complaint investigation substantiated that Resident #5 was physically abused by Resident #10. The facility responded by separating the residents, providing 1:1 supervision for Resident #10, notifying authorities including APS, DHS, and police, and Resident #10 was discharged. Resident #5 reported feeling safe after the incident and would report further incidents.

The facility failed to ensure Resident #5 was protected from abuse by Resident #10, who hit Resident #5 in the back of the head. The incident was documented with interviews, assessments, and notification of authorities, resulting in Resident #10 being discharged from the facility.

The complaint investigation focused on Resident #6's fall from a hoyer lift on January 2, 2025, and a fall from a wheelchair on April 8, 2025. The resident sustained serious injuries including fractures and lacerations. The facility did not provide incident or risk management reports citing internal use only. Interviews revealed uncertainty about the cause of the falls and lack of corrective actions or staff training following the incidents.

The facility failed to ensure Resident #6 was protected from accidents during a hoyer lift transfer and wheelchair use, resulting in major injuries including fractures and lacerations. The investigation revealed inadequate supervision, lack of specific care plans addressing behaviors during transfers, and issues with equipment use and safety protocols.

The complaint investigation substantiated resident-to-resident abuse involving residents #2 and #4, #4 and #6, and #8 and #10. The facility confirmed physical altercations through staff and resident interviews and camera footage. Some residents were placed on 1:1 supervision or moved to different rooms or units. The facility was unable to substantiate abuse in one verbal argument incident between residents #6 and #8.

The facility failed to protect residents from physical abuse by other residents, substantiating several incidents of resident-to-resident abuse. Investigations confirmed physical altercations including hitting, kicking, and use of objects as weapons, with some residents placed under increased supervision or moved to different rooms or units for safety.

The investigation was complaint-driven, focusing on allegations that resident #2 did not receive adequate incontinence care, was not provided the ordered bariatric bed, and did not receive prescribed opioid pain medication. The complaints were substantiated based on interviews, clinical record reviews, and staff statements.

The facility failed to provide timely incontinence care, resulting in potential skin integrity issues; failed to provide the ordered bariatric bed due to insurance denial and supply issues, causing discomfort and risk of skin breakdown; and failed to ensure timely administration of prescribed opioid medication, resulting in unmanaged pain for resident #2.

The complaint investigation revealed incidents of resident-to-resident abuse involving residents #1 and #3, including physical altercations causing injury. The facility relocated residents due to emergency plumbing issues, placing them in non-residential rooms such as dining rooms and medical record rooms, impacting resident safety and comfort.

The facility failed to ensure two residents were free from abuse, resulting in minimal harm or potential for harm. Additionally, the facility failed to provide a safe, comfortable, and appropriate environment for residents during plumbing-related construction, relocating residents to rooms not designed for resident care such as dining rooms, day care rooms, and medical record rooms.

The facility was found deficient in coordinating pre-admission mental health screenings, ensuring the activities program was directed by a qualified professional, providing insulin treatment according to physician orders, and ensuring timely transportation for dialysis patients. These deficiencies posed risks of inadequate specialized services, uncontrolled blood sugar levels, and incomplete dialysis treatments.

The facility failed to ensure that the liquid diet order for resident #23 was administered as ordered by the physician, resulting in the resident receiving a thicker consistency liquid than prescribed. Staff altered the resident's diet without a physician order, increasing the risk of aspiration. The facility conducted staff in-service training following the incident.

The complaint investigation substantiated abuse incidents involving Resident #8 being hit by Resident #26, and verbal abuse by Staff #1 towards Resident #12. The investigation included interviews with residents, family members, staff, and administrators. Staff #1 was terminated following corroborated verbal abuse.

The facility failed to protect residents from abuse, including physical and verbal abuse incidents involving residents #8, #12, and #26, and staff #1. The investigation confirmed minimal harm with a few residents affected, and actions including staff termination were taken.

A complaint was filed with the State Board of Nursing against the Director of Nursing alleging negligence on behalf of all nurses. The complaint stated that a resident admitted to the behavior unit had a severe infection on the right lower extremity that went unnoticed and untreated, and that treatment was initiated with oral antibiotics instead of intravenous antibiotics.

The facility failed to provide appropriate treatment and care according to professional standards for one resident, resulting in hospitalization and above-the-knee amputation due to severe cellulitis and infection. Delays in reporting critical lab results and inadequate documentation and communication were noted, contributing to the worsening condition.

The complaint investigation was substantiated with findings of multiple deficiencies including resident mistreatment, failure to respond to call lights, improper advance directive documentation, maintenance issues, failure to report misappropriation, notification failures, PASARR screening issues, hospice communication failures, medication administration errors, lack of specialized rehabilitative services, and infection control breaches.

The facility failed to ensure dignified treatment of a resident, timely response to call lights, proper advance directive documentation, maintenance of resident rooms, reporting of misappropriation of resident property, timely notification of transfers and discharges, accurate PASARR screening, hospice communication with family, medication administration protocols, specialized rehabilitative services, and infection control practices.

The complaint was substantiated that resident #1 had ulcerations for two weeks that were not treated by the facility, as confirmed by clinical record review and hospital notes.

The facility failed to provide appropriate treatment and care for two residents with skin integrity issues, including untreated shearing and inconsistent pressure ulcer care as ordered by physicians. Documentation and treatment deficiencies were noted, with minimal harm or potential for actual harm to a few residents.

The facility failed to ensure medications were administered as ordered for one resident and failed to maintain medication error rates below 5%, with a 7.69% error rate observed during medication pass observations. These deficiencies could result in adverse effects to residents.

The complaint investigation found that resident #12 was sent unescorted to a cardiology appointment despite being identified as an elopement risk, resulting in the resident going missing and subsequent hospitalization. The investigation also found that resident #11 fell between the bed and wall during care when bed wheels were unlocked and care was continued despite resident agitation. The facility failed to follow its own policies on resident supervision and safety.

The facility failed to provide adequate supervision to prevent elopement for one resident and failed to ensure safety during care resulting in a fall and injury for another resident. The investigation revealed lapses in following facility policies on bed safety, resident escort to appointments, and elopement risk management.

The complaint investigation substantiated that resident #12 physically abused residents #3 and #8. The facility was found to have inadequate supervision and safety measures, contributing to the incidents. The Arizona Department of Health Services and Phoenix Police Department were notified. Resident #12 was transferred from the dementia unit to the behavioral unit due to aggression and safety concerns.

The facility failed to protect residents from abuse by another resident (#12), resulting in actual harm to a few residents. Multiple incidents of physical aggression and injury were documented, including falls and lacerations, with inadequate supervision and failure to consistently implement safety measures such as door signage and hallway monitoring.