Inspection Reports for
Desert Terrace Healthcare Center

The complaint involved an incident on October 5, 2025, where Resident #2 hit Resident #1 causing superficial wounds. Resident #1 wanted to press charges. Resident #2 left the facility against medical advice the same day. The investigation included interviews with staff and residents, confirming the incident as an isolated event.

The facility failed to protect one resident from abuse by another resident, resulting in actual harm with superficial wounds. The incident was determined to be unanticipated and isolated, occurring despite adequate staff supervision.

Complaint investigation with one deficiency cited related to abuse reporting.

The complaint investigation found that resident #44 was assaulted by resident #55 on April 24, 2023. The abuse was substantiated based on documentation, staff interviews, and facility policy review.

The facility failed to ensure that resident #44 was protected from abuse by resident #55, who punched resident #44 behind the right ear unprovoked. The incident was witnessed by staff, and resident #44 sustained minimal harm with redness noted but refused hospital evaluation. The facility staff acknowledged the incident as abuse and confirmed expectations for monitoring and intervention.

Complaint survey with one deficiency cited related to abuse.

The complaint investigation found substantiated incidents of resident-to-resident abuse involving resident #75, who was verbally aggressive and physically assaulted residents #20 and #40. Staff interviews confirmed the behavioral issues and the facility's response included increased supervision and petitioning resident #75 for psychiatric care.

The facility failed to ensure that residents #20 and #40 were free from abuse by resident #75, who was verbally and physically aggressive. The incidents included verbal altercations and physical contact, leading to increased supervision and eventual petitioning of resident #75 to a psychiatric facility.

Complaint survey with one deficiency cited related to abuse.

Investigation of complaints with two deficiencies cited related to quality of care and care planning.

The facility failed to ensure accurate documentation of vital signs and blood glucose monitoring for Resident #12, with missing vital signs on evening shifts of June 25 and June 27, 2024, and no blood glucose tests recorded prior to insulin administration on June 25 and June 26, 2024. This deficient practice could result in inaccurate records and potential harm to residents.

Complaint investigation with two deficiencies cited related to policies for health services and pharmacy services.

The complaint investigation focused on allegations that residents did not receive their antibiotics on time. Interviews with residents and staff confirmed late administration of medications, with explanations including pharmacy delivery delays and medication supply restrictions.

The facility failed to ensure timely administration of antibiotics to three residents, with multiple doses given outside the allowed one-hour window before or after the scheduled time. Pharmacy supply limitations and medication delivery schedules contributed to delays, but all doses were documented as administered.

The facility failed to ensure that the activities program was directed by a qualified professional. The Activities Director did not have certification as a qualified therapeutic specialist or activities professional but was enrolled in a program. Facility policies regarding verification of licenses and employment applications were noted.

Recertification survey for Medicare under Life Safety Code 2012 with five deficiencies cited related to hazardous areas, smoke barriers, fire drills, electrical systems, and power cords.

State compliance survey with two deficiencies cited related to activities program qualifications and designation of qualified individual.

The facility was found deficient in multiple areas including failure to ensure informed consent for psychotropic medications, failure to notify physicians of critical vital signs, failure to administer medications as ordered, inconsistent bathing and showering of residents, inadequate pressure ulcer care, lack of appropriate colostomy care, absence of physician orders for oxygen use, inaccurate nurse staffing postings, and failure to ensure timely availability and administration of medications.

The facility was found deficient in multiple areas including failure to ensure residents' rights to privacy and dignity, inadequate assessment for self-administration of medications, incomplete care planning for oxygen use, failure to provide ordered treatments such as tubigrip stockings, inadequate urinary catheter care, lack of physician order for oxygen use, insufficient nursing staff to meet resident needs, and failure to maintain infection prevention and control standards including proper use of PPE and handling of soiled laundry.