Desert Peak Care Center

Inspectors wroteBased on clinical record review, staff interviews, facility documentation, policies and procedures, the facility failed to protect the rights of two residents (#63 and #69) to be free from abuse from each other. The deficient practice could result in further abuse of residents.

Inspectors wroteBased on clinical record review, resident and staff interviews, and policy review, the facility failed to ensure that 2 of 34 sampled residents (#84 and #75) were free from physical or verbal abuse from other residents (#39 and #37). The deficient practice could result in residents being physically and emotionally harmed. Findings Include: -Regarding Resident #84: Resident #84 (alleged victim) was admitted to the facility on [DATE], with diagnoses of borderline personality disorder, other schizophrenia, major depressive disorder, generalized anxiety disorder, personal history of traumatic brain injury, and chronic pain syndrome. The clinical record revealed documentations that decisions and consent were made by the resident's legal guardian/Brother. [...]

Inspectors wroteBased on observations, clinical record review, and staff interviews, the facility failed to ensure one Resident (#88) out of one sampled residents were assessed and care planned for the ability to self-administer medications to include tube-feedings. The universe was 157. The deficient practice could result in incorrect administration of tube feedings, leading to aspiration, choking, severe infections, nutritional mismanagement, and tube clogging.

Inspectors wroteBased on clinical record review, resident and staff interviews, and policy review, the facility failed to ensure that advance directives were accurate, consistent, and clearly defined in the medical record for 1 of 30 sampled residents (#8). The deficient practice could result in residents not receiving proper care according to their preferences or potential harm to the resident's life.

Inspectors wroteBased on observations, interviews, review of clinical record, and review of facility policy and procedure, the facility failed to ensure medications were not left at the bedside for two residents (Resident #94 and Resident #73) out of 30 sampled residents. The universe was 149. The deficient practice could increase the likelihood of medication overdose and residents having unrestricted access to medications.

Inspectors wroteBased on observations, clinical record review, staff interviews, and facility policy review, the facility failed to ensure that the care plan was reviewed and updated for one out of three sample Residents (#1). The deficient practice could lead residents to not receive proper care. Findings Include: Resident #1 was initially admitted on [DATE], and re-admitted on [DATE], with a diagnosis that included vascular dementia, mood disorder, constipation, venous thrombosis and embolism, hypotension, dysphagia, anxiety disorder, and post-traumatic stress disorder. The Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed no Brief Interview for Mental Status (BIMS) assessment. It also revealed that cognitive skills for daily decision-making are severely impaired. [...]

Inspectors wroteBased on the clinical record review, resident interview, resident representative interview, facility documentation, and policy review, the facility failed to ensure the resident received adequate assistance devices to prevent falls for one of the three sampled Residents (#1). The deficient practice could lead to further accidents. Findings Include: Resident #1 was admitted on [DATE], with a diagnosis of bipolar disorder, chronic obstructive pulmonary disease, hypo-osmolality, anxiety disorder, extrapyramidal and movement disorder, hyponatremia, and age-related osteoporosis. The care plan dated October 15, 2025, had a focused care area for Resident #1, who is at risk for falls related to high-risk medication use, incontinence, poor mobility, hand contractures, and involuntary movements. [...]

Inspectors wroteBased on clinical record review, staff interviews, WebMD, and review of facility documentation and policies, the facility failed to protect the rights of one resident (#1) to be free from abuse by another resident (#2). The deficient practice could result in further abuse of residents when appropriate actions are not taken. Findings Include:-Resident #1(alleged victim) was admitted to the facility on [DATE] with diagnoses of dementia, COPD (Chronic Obstructive Pulmonary Disease), and essential hypertension. The census report revealed that Resident #1 shared the same unit with Resident #2 since May 21, 2025. A comprehensive care plan dated June 5, 2025, revealed that the resident had a potential for a psychosocial well-being problem related to disease process, and the resident was at risk for impaired cognitive function. The interventions included anticipate and meet resident's needs; [...]

Inspectors wroteBased on interviews, review of records, and review of facility policy and procedure, the facility failed to protect the rights of one resident (#5) to be free from abuse by another resident (#10). The deficient practice could lead to ongoing abuse, leading to harm of other residents.-Findings Include:Regarding Resident #5Resident #5 (Alleged Victim) was admitted to the facility on [DATE], with diagnoses including: Essential hypertension, hypo-osmolality and hyponatremia, constipation, schizoaffective disorder, unspecified convulsions, other psychoactive substance abuse, uncomplicated, catatonic disorder due to known physiological condition, acute respiratory failure with hypoxia, adult failure to thrive, anoxic brain damage, anxiety disorder, dysphagia, weakness, personal history of sudden cardiac arrest. [...]

Inspectors wroteBased on clinical record review, facility documentation, and staff interviews, the facility failed to ensure that residents are free from abuse from another resident (Residents #3 and #5). The universe was 144, and the sample size was 3. The deficient practice could lead to further instances of resident-to-resident altercations, thereby promoting an unsafe environment.

Inspectors wroteBased on staff interviews, facility documentation, and a policy review, the facility failed to implement its abuse policy by not reporting an allegation of abuse involving two residents (#5 and #10) to the State Agency. The deficient practice could result in further incidents of abuse.

Inspectors wroteBased on clinical record review, interviews, and policy and procedures, the facility failed to ensure that an allegation of verbal abuse, for one resident (#5), was reported to the State Survey Agency within the required timeframe.

Inspectors wroteBased on interviews, review of records, and review of facility policy and procedure, the facility failed to ensure a resident (#5) was not abused by another resident (#10). The deficient practice could lead to psychosocial or physical harm of a resident. -Regarding Resident #5 (alleged victim):Resident #5 was admitted to the facility November 30, 2023, with diagnoses that included schizoaffective disorder, bipolar type, post-traumatic stress disorder, unspecified, schizoaffective disorder, unspecified, unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, borderline personality disorder. Review of the quarterly minimum data set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 13 indicating cognition is intact. Further review revealed no indicators for mood or behaviors. [...]

Inspectors wroteBased on observation, interviews, review of the clinical record, and review of facility policy and procedure, the facility failed to ensure one resident (#6) was prevented from an accident during a hoyer transfer with major injury, and from sustaining an avoidable fall from a wheelchair with major injury. The deficient practice could lead to residents being physically harmed, with major injuries or death. Findings Include: -Regarding Resident #6's accident during a hoyer transfer: Resident #6 was initially admitted to the facility June 21, 2024, with diagnoses that included unspecified dementia with other behavioral disturbance, depression, type 2 diabetes mellitus, hypotension, chronic obstructive pulmonary disease, and chronic kidney disease. [...]

Inspectors wroteBased on resident and staff interviews, clinical record reviews, and review of facility documentation, the facility failed to protect the rights of four residents (#2, #4, #6, #8, and #10) to be free from physical abuse by another resident (#2 and #10). The deficient practice could result in residents subjected to continued abuse.

Inspectors wroteBased on review of clinical record review, staff interviews, facility policy and procedure, the facility failed to ensure incontinence care was provided for one resident (#2). The deficient practice could result in residents not receiving necessary care and services to maintain skin integrity and personal hygiene.

Inspectors wroteBased on resident and staff interviews, clinical record review, and facility policy, the facility failed to ensure services/treatment and accommodation of needs are provided per plan of care and physician orders for one resident (#2) regarding the need for a bariatric bed and opioid medication. The deficient practice could result in residents not receiving the services as outlined in their care plan.

Inspectors wroteBased on clinical record review, staff interviews, and facility policy, the facility failed to ensure one resident (#2) was provided services consistent with professional standards of practice. The deficient practice could result in unmanaged pain for the resident.

Inspectors wroteBased on observations, clinical record reviews, interviews and policy review, the facility failed to provide a designated room to accommodate residents dining and activities while undergoing construction. The deficient practice could result in resident's individual needs and preferences not accommodated.

Inspectors wroteBased on observations, record reviews, interviews and policy review, the facility failed to ensure safe and comfortable environment for residents. The deficient practice could impact the residents' safe, sanitary, and homelike environment.

Inspectors wroteBased on clinical record review, residents and staff interviews, facility documentation and policies and procedures, the facility failed to ensure two residents (#1 and #3) were free from abuse. The deficient practice could result in continued abuse to residents.

Inspectors wroteBased on clinical record review and staff interviews, the facility failed to ensure one resident (#93) with a diagnosis of a serious mental illness was referred to the appropriate state-designated mental health or intellectual disability authority for review. The deficient practice could result in necessary specialized services not being provided for residents who need it.

Inspectors wroteBased on personnel file review, staff interview, and the job description, the facility failed to ensure that the activities program was directed by a qualified professional.

Inspectors wroteBased on clinical record reviews, resident and staff interviews, and a review of policies and procedures, the facility failed to ensure insulin treatment was provided in accordance with professional standards of practice for one of six sampled residents (#89), as ordered by the physician. This deficient practice could have resulted in uncontrolled blood sugar levels.

Inspectors wroteBased on clinical record review, resident and staff interviews, and policy review, the facility failed to ensure one resident (#117) was transported to and from dialysis in a timely manner. The deficient practice could result in the full dialysis treatment not being administered, which could result in a decline in the resident's health.

Inspectors wroteBased on clinical record review, staff interviews, and review of policy and procedures, the facility failed to ensure that liquid diet order for one of two sampled residents (#23) was administered as ordered by the physician. The deficient practice could result in resident's assessed dietary needs not met.

Inspectors wroteBased on clinical record review, staff interviews, and facility policy and procedures, the facility failed to ensure two residents (# 8, 12) out of five sampled remained free from abuse. The deficient practice may result in physical and/or psychosocial harm to residents as an outcome of abuse.

Inspectors wroteBased on clinical record review, resident and staff interviews, and facility documentation and policy, the facility failed to ensure care and treatment according to professional standards of practice was provided to one resident (#1). The deficient practice resulted in the hospitalization of the resident and amputation of his leg.

Inspectors wroteBased on observations, staff interviews, and policy review, the facility failed to ensure staff followed infection control standards related to personal protective equipment (PPE). The deficit practice could result in transmission of infection. Universe was 130.

Inspectors wroteBased on resident and staff interviews, the facility investigation report and documents, clinical record review, and policy review, the facility failed to ensure one resident (#123) was treated in a dignified manner. The deficient practice could negatively impact the psychosocial well-being of residents. The universe was 130 as all residents could be affected, the sample was one.

Inspectors wroteBased on observations, and resident and staff interviews the facility failed to ensure a resident (#6) had the means to communicate with staff, by failing to ensure the call device was accessible to the resident. The deficient practice can result in residents' needs not being met in a timely manner. The universe was 130 and the sample was one.

Inspectors wroteBased on clinical record review, staff interviews, and the facility policy and procedures, the facility failed to ensure one resident (#10) had the correct advance directive in place. The deficient practice could result in residents not being allowed to make their own medical decisions. The universe is 130 and the sample is one.

Inspectors wroteBased on observations, staff interviews, and policy reviews, the facility failed to ensure that maintenance and comfortable interior was provided for 1 resident (#106). The deficient practice could result in resident rooms not having a homelike environment. The universe was 130 the sample was one.

Inspectors wroteBased on clinical record reviews, facility documentation, staff interviews, and policy review, the facility failed to ensure that allegations of misappropriation of resident property were reported to the State Agency and that the results of the investigations were submitted to the State Agency within the required time frame for one resident (#123). The universe was 130 the sample was one.

Inspectors wroteBased on closed record review and staff interviews the facility failed to ensure that all transfer/discharge notifications were made for one resident (#13). The deficient practice could lead to notifications of resident transfer/ discharge not being made to all required parties. The universe was 130 the sample was 1.

Inspectors wroteBased on clinical record review, an interview, and policy, the facility failed to provide one resident (#13) and/or the resident's representative with bed-hold policy information before a transfer to the hospital. The deficient practice could result in residents being unaware of their bed-hold rights. The universe is 130 the sample is one.

Inspectors wroteBased on clinical record reviews, staff interviews and facility policy and procedures, the facility failed to ensure that a Preadmission Screening and Resident Review (PASRR) level I was completed accurately and a level II was sent to the state for determination for one resident (#13). The deficient practice could result in specialized services not being identified and provided to residents. The Universe was 22 the sample was 1.

Inspectors wrote1. Based on clinical record review, staff interviews and contract review, the facility failed to ensure one resident (#43) received treatment and care in accordance with professional standards of practice. The facility failed to ensure communication was provided to the family of the care and services provided by hospice. This failure has the potential for confusion between resident's family, the facility and the hospice provider. The universe is 130 the sample was 2.

Inspectors wroteBased on observations, staff interview, and policy reviews, the facility failed to ensure pharmaceutical services were adequately provided for medication administration for four residents. The census was 130. This deficient practice could result in adverse effects in the facilities residents.

Inspectors wroteBased on clinical record review, resident and staff interviews, and the facility policy and procedures, the facility failed to ensure one resident (#10) received required specialized services. The deficient practice could result in residents not being able to obtain the services needed to achieve medical/therapy goals. The Universe was 130, the sample is 1.