Inspection Reports for
Desert Peak Care Center

The complaint investigation was substantiated based on evidence including bruising on Resident #1, staff and family notifications, police involvement, and interviews confirming the incident. Resident #2 was identified as the alleged perpetrator with a history of cognitive impairment and behavioral issues.

The facility failed to protect Resident #1 from physical abuse by Resident #2, resulting in bruises on Resident #1's arm and face. The investigation included staff interviews, resident assessments, and notification of family and police. Resident #2 was moved to another room and placed on 15-minute checks to prevent further incidents.

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 incident involved hitting in the back of the head, verbal aggression, and required notification of Adult Protective Services, Department of Health Services, and police. Resident #10 was placed on 1:1 supervision and subsequently discharged.

The facility failed to ensure Resident #5 was protected from abuse by Resident #10, who physically hit Resident #5 in the back of the head. The incident was witnessed by staff, reported to authorities, and resulted 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.

A complaint investigation was conducted citing 3 deficiencies related to policies and procedures for physical and behavioral health services, medical record documentation, and care planning.

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 was triggered by allegations of resident-to-resident abuse involving residents #1 and #3, including physical altercations resulting in injury. The investigation also included concerns about the facility's failure to provide appropriate dining and activity spaces during plumbing repairs and construction.

The facility failed to protect residents from abuse, specifically involving two residents (#1 and #3) who had altercations resulting in injury. Additionally, the facility failed to provide a safe, designated dining and activity area during plumbing construction, resulting in residents being housed temporarily in rooms not designed for such use.

Complaint survey conducted with 2 deficiencies cited related to abuse prevention and premises maintenance.

Recertification survey for Medicare under Life Safety Code 2012; facility meets standards based on acceptance of plan of correction with 5 deficiencies cited related to emergency preparedness, corridor doors, smoke barriers, utilities, and electrical systems.

The facility was found deficient in multiple areas including failure to properly coordinate mental health referrals, lack of qualified activities director, improper insulin administration, and inadequate transportation for dialysis patients. These deficiencies posed risks of inadequate specialized services, uncontrolled blood sugar levels, and incomplete dialysis treatments.

State compliance survey with complaint investigations; 4 deficiencies cited related to policies and procedures, care planning, recreational activities, and care delivery.

Onsite complaint survey citing 1 deficiency related to dietitian or director of food services ensuring proper diet administration.

The facility failed to ensure that the liquid diet order for resident #23 was administered as ordered by the physician, resulting in a risk that the resident's dietary needs were not met. Staff altered the consistency of liquids without physician orders, increasing the risk of aspiration.

Investigation of complaints citing 1 deficiency related to abuse prevention.

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.

Complaint survey citing 2 deficiencies related to quality of care and care planning.

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.

State compliance survey with complaint investigations citing 23 deficiencies related to policies and procedures, abuse reporting, resident rights, infection control, pharmacy services, physical plant standards, and care planning.

Recertification survey for Medicare under Life Safety Code 2012; facility meets standards based on acceptance of plan of correction with 1 deficiency cited related to corridor doors maintenance.

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.

Complaint investigation citing 4 deficiencies related to policies and procedures, quality of care, skin integrity, and care planning.

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 investigation was complaint-driven, focusing on allegations that resident #12 physically abused residents #3 and #8. The complaint was substantiated with evidence of multiple incidents, including resident #12 kicking other residents and causing injuries. The facility was found to have inadequate supervision and safety protocols to prevent such abuse.

The facility failed to protect residents #3 and #8 from abuse by resident #12, who exhibited physical aggression including kicking other residents. Multiple incidents of residents found injured or on the floor in resident #12's room were documented, along with inadequate supervision and failure to maintain safety measures such as a Velcro stop sign on resident #12's door.