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.

The complaint investigation substantiated that Resident #1 was physically abused by Resident #2, resulting in multiple superficial wounds. Resident #2 admitted to hitting Resident #1 due to use of a racial slur. The incident was reported by staff and witnessed by another resident. Resident #2 left the facility AMA on the same day. The facility investigation concluded the incident was isolated and occurred with adequate staff supervision.

The facility failed to protect Resident #1 from abuse by Resident #2, resulting in actual harm with superficial wounds. The incident was unanticipated and isolated, occurring under adequate staff supervision. Resident #2 left the facility against medical advice the same day.

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.

The complaint investigation found that resident #44 was assaulted by resident #55 on April 24, 2023, on the smoking patio. The assault was witnessed by a certified nursing assistant. Resident #44 had a small reddened area behind the right ear but refused hospital evaluation. Resident #55 had a history of aggressive behavior and was transported to the hospital later due to increased agitation. Staff interviews confirmed expectations for supervision and abuse prevention.

The facility failed to ensure that resident #44 was protected from abuse by resident #55, resulting in physical and emotional harm. The investigation included documentation of the incident, staff interviews, and review of care plans and medical notes, confirming the occurrence of abuse and inadequate supervision.

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.

The complaint investigation found substantiated incidents of resident-to-resident abuse involving resident #75. The facility responded by separating the residents, placing resident #75 on 1 to 1 staff supervision, and petitioning for transfer to a psychiatric facility.

The facility failed to ensure that residents #20 and #40 were free from abuse by resident #75. Multiple incidents of verbal and physical altercations were documented, and staff interviews confirmed behavioral issues with resident #75 leading to these incidents.

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.

The complaint investigation found that vital signs were not documented on the evening shifts of June 25 and June 27, 2024, and blood glucose monitoring was not performed prior to insulin administration on June 25 and June 26, 2024, for Resident #12. The deficiency was substantiated with staff interviews and record reviews.

The facility failed to document vital signs on specified dates and did not record blood glucose results prior to insulin administration for Resident #12, which could lead to inaccurate medical records and potential harm. Interviews with staff confirmed non-compliance with facility policies on vital sign and blood glucose monitoring.

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 complaint investigation substantiated that three residents did not receive their antibiotics in a timely manner. Interviews with residents and staff confirmed late medication administration, with pharmacy supply constraints cited as a cause.

The facility failed to ensure timely administration of medications to three residents, with multiple documented late doses of antibiotics. Pharmacy supply limitations and scheduling issues contributed to delays, though no missed doses were documented. Staff interviews confirmed late administration but indicated minimal harm.

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 failed to ensure the activities program was directed by a qualified professional as required. The Activities Director did not have the required certification but was enrolled in a professional course. Additionally, the facility policies regarding verification of licenses and employment applications were reviewed.

The facility was found deficient in multiple areas including failure to obtain timely consent for psychotropic medication, failure to notify physicians of critical changes in resident conditions, inconsistent medication administration, failure to provide scheduled showers and bathing, inadequate pressure ulcer care, failure to provide ostomy care as ordered, lack of physician order for oxygen use, inaccurate nurse staffing postings, and failure to ensure medications were administered as ordered.

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, lack of baseline care plans for oxygen use, failure to provide ordered treatments such as tubigrip stockings, inadequate urinary catheter care, missing physician orders for oxygen therapy, insufficient nursing staff to meet resident needs, and failure to maintain infection prevention and control standards including improper use of PPE and handling of soiled laundry.

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.