Below average — CMS composite of the measures below.
A standard survey is most likely before around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Desert Haven Care Center during CMS and state inspections, most recent first.
A resident with dementia and behavioral issues was involved in a physical altercation with another resident who had PTSD, bipolar disorder, and a history of aggression. During an activity, the second resident became verbally and physically aggressive, threw items, and struck the first resident with a prosthetic arm/hand; staff heard yelling, rushed in to assist, and police were called. The first resident reported being hit and having minor pain, while the facility’s investigation did not verify the abuse allegation despite staff and resident statements describing the assault.
A resident with dementia, moderate cognitive impairment, behavioral symptoms, and hearing loss was seated in the dining room when another cognitively intact resident with schizophrenia, behavioral disturbances, and a history of aggression entered, asked about a blue folder, became agitated, and repeatedly struck the seated resident in the face with a closed fist before CNAs could separate them. The injured resident sustained bilateral nasal bone fractures, a laceration to the ear requiring sutures, and extensive facial bruising, with blood observed on his face, ear, and the surrounding area. Both residents had existing behavior care plans and psychiatric assessments addressing behavioral issues and the need to protect the rights and safety of others, but the interaction in the dining room escalated into physical abuse, which the facility’s investigation and DON confirmed met the definition of abuse under the facility’s Abuse Guidelines policy.
A resident with a history of psychosis-related behaviors and verbal aggression created a cardboard gun, covered his face with a bandana, entered another cognitively impaired resident’s room, and threatened to shoot him if he did not be quiet, causing the threatened resident to become intimidated and withdraw to bed. Staff, including a CNA and an LPN, witnessed the event and described the aggressor as intimidating and aggressive, particularly around women, and the LPN reported the incident to a unit manager and wrote a statement. However, there was no documentation of the incident in either resident’s clinical record, no self-report or grievance logged for the period, and the DON reported having no knowledge of the event, despite facility policy requiring immediate reporting and documentation of suspected abuse, including resident-to-resident abuse.
The facility failed to implement its abuse policy after an incident in which a resident with a history of aggressive behaviors created a cardboard gun, entered another cognitively impaired resident’s room, and threatened to shoot him if he did not quiet down. Staff, including a CNA and an LPN, witnessed the event, described it as resident-to-resident emotional abuse, and reported it verbally to a unit manager, but there was no documentation of the incident in either resident’s clinical record, no incident report, and no evidence of an investigation or required notifications. The DON, who is responsible for abuse coordination and reporting, was unaware of the event, despite facility policy requiring immediate reporting, documentation, resident examination, and notification of state agencies, the physician, and the resident representative for any suspected or alleged abuse.
The facility failed to report and document a resident-to-resident abuse incident in which a cognitively intact resident with a history of psychosis-related behaviors created a cardboard gun, covered his face, entered another cognitively impaired resident’s room, and threatened to shoot him if he did not be quiet. A CNA and an LPN witnessed the event, with the LPN stating the threatened resident appeared intimidated and became unusually withdrawn afterward. The LPN reported the incident and the cardboard gun to a unit manager and was told to write a statement, but the DON and unit manager later denied knowledge of or action on the incident. Review of clinical records, internal reports, and the state complaint database showed no documentation or external reporting of the event, despite facility policy and staff statements that abuse, including intimidation and resident-to-resident abuse, must be reported immediately and documented in progress notes and incident reports.
The facility failed to investigate and document an alleged resident-to-resident abuse incident in which a cognitively intact resident with a history of verbal aggression and threatening behaviors entered the room of a severely cognitively impaired resident while holding a cardboard gun, covered his face with a bandana, and threatened to shoot the other resident if he did not quiet down. Staff, including a CNA and an LPN, reported that they witnessed the event, considered it abuse, and informed a unit manager, but there was no documentation of the incident in either resident’s clinical record, no evidence of a self-report, grievance, or investigation, and the DON reported having no knowledge of the event. This inaction conflicted with the facility’s Abuse Guidelines policy, which required immediate reporting, documentation, examination, and investigation of all suspected abuse, including resident-to-resident abuse.
A resident with type 1 diabetes and a history of diabetic ketoacidosis experienced repeated failures in blood glucose monitoring and insulin administration, including missed and undocumented blood sugar checks, lack of provider notification for abnormal readings or refusals, and insufficient monitoring for symptoms of hypo- or hyperglycemia. These deficiencies led to the resident's hospitalization in the ICU for hyperglycemia and diabetic ketoacidosis.
A resident with type 1 diabetes had multiple physician orders for frequent blood glucose (BS) checks and insulin administration, including use of both fingerstick and continuous glucose monitoring devices. Despite these orders, staff failed to consistently document BS readings in the medical record, with many values missing or only noted as 'high' or 'low' without specifics. Interviews revealed the facility lacked a specific BS monitoring policy, and staff did not always ensure orders were properly reflected in the MAR, leading to incomplete and inaccurate medical records.
A resident with dementia, muscle weakness, type 2 DM, and unstageable pressure ulcers to the sacrum and right ischium had active orders for wound care that required cleansing with wound cleanser, patting dry, applying skin prep, then packing with Dakin’s-soaked gauze and covering with a dry dressing. During an observed treatment, an LPN removed old dressings and packed both wounds with Dakin’s-soaked gauze without cleansing them first, despite the orders. The LPN reported being told by the wound provider not to clean the wounds and was unsure if this was correct. The DON referenced an unsigned statement suggesting Dakin’s did not require prior cleansing, which was not supported by the manufacturer’s article cited, while the wound physician later clarified that wounds should be cleansed at treatment and that Dakin’s could be used to cleanse and then separately to pack the wound, consistent with facility policy requiring medications to be administered per orders.
Surveyors observed kitchen staff preparing food without required hair nets and beard covers while a pot of vegetables was actively cooking on the stove. The Food Service Director later confirmed that the item being prepared was buttered spinach for a meal service and acknowledged that staff are required by facility policy to wear hair restraints and facial hair guards to prevent hair from getting into food. The Administrator also stated that staff are expected to follow infection control policies, including use of appropriate PPE such as hair nets and facial hair covers during food prep, consistent with the written personal hygiene and sanitation policy.
A resident with severe cognitive impairment and mobility issues was found with a call light out of reach, leading to distress and inability to call for help. Observations revealed the call light was improperly placed, and the facility lacked a Call Light Policy, contributing to the deficiency.
A resident with a high risk of wandering and a history of elopement exited the facility unsupervised after a nurse was distracted by a medication delivery. Despite being on 1:1 monitoring, the resident managed to leave when the alarm was triggered. The resident was found the next day with blisters on both feet, indicating a lapse in supervision and monitoring.
The facility failed to maintain a dignified dining experience by using disposable dishware and utensils due to a lack of dishwashing staff on certain nights. A resident noted that Styrofoam was used occasionally, and the dietary director confirmed this practice occurred monthly. The Executive Director was unaware of the staffing issue until recently and expected a homelike dining environment.
The facility failed to update the PASRR for two residents with new psychiatric diagnoses, potentially impacting their care. One resident had a new diagnosis of anxiety disorder, and another was diagnosed with schizoaffective disorder, but their PASRR screenings were not updated. Interviews with staff confirmed the oversight, despite the facility's policy requiring such updates.
The facility failed to properly label and store food items, as well as maintain the correct potency of the Quaternary Sanitizer solution. Observations revealed unsealed and undated food items, including bacon and various bread products, in the kitchen. The Dietary Director was uncertain about storage requirements, and the Executive Director confirmed the need for proper sealing and dating to prevent oxidation. Additionally, the Quat solution was found to be too strong, requiring adjustment to meet the recommended 200 ppm.
A facility failed to implement enhanced barrier precautions (EBP) for a resident with a PEG tube, risking the transmission of multi-drug resistant organisms. Despite the resident's severe cognitive impairment and the presence of a PEG tube, no EBP signs or PPE were visible. Staff interviews revealed a lack of adherence to EBP guidelines, with the DON expressing disagreement with the guidelines due to concerns about maintaining a homelike environment.
The facility failed to maintain a safe and clean environment, with broken window blinds, stained walls, and dusty vents observed in residents' rooms. Staff interviews revealed that maintenance issues were not consistently reported or addressed, despite expectations for prompt action. The maintenance director acknowledged that housekeeping should have cleaned the affected areas.
Failure to Protect a Resident from Physical Abuse by Another Resident
Penalty
Summary
The facility failed to protect one resident from physical abuse by another resident. Resident #16 had diagnoses including unspecified dementia with behavioral disturbance, anxiety disorder, delusional disorder, reduced mobility, weakness, homicidal ideations, traumatic brain injury history, drug-induced subacute dyskinesia, and depression. His care plan addressed physical aggression, hallucinations, and intrusive behaviors, with interventions to protect others’ rights and safety, divert attention, and remove him from situations as needed. Resident #22 had diagnoses including PTSD, chronic stimulant abuse, multiple traumatic amputations, other specified mental disorders due to a known physiological condition, and bipolar disorder. His care plan addressed socially inappropriate and manipulative behaviors, including physical aggression and self-isolation. On April 15, 2026, during an activity, Resident #22 became verbally and physically aggressive, threw items, and punched another resident multiple times, prompting police involvement and removal from the facility. The incident documentation for Resident #16 stated that he was attending an activity, attempted to intervene during a verbal disagreement, and was struck in the head, neck, and arms with Resident #22’s prosthetic hand and arm. Resident #16 complained of minor pain but declined hospital evaluation, and a skin assessment found no visible injuries. An SBAR and behavior note documented Resident #16’s account that Resident #22 swung at him and that he raised his hands to protect himself. Facility interviews and records showed conflicting accounts of the event, and the 5-day investigation concluded it was uncertain whether Resident #22 made contact with Resident #16 and did not verify the abuse allegation. However, staff interviews confirmed that yelling was heard from the activity room, staff rushed to assist, police were called, and one staff member observed Resident #22 charge toward Resident #16 and begin swinging, making contact. The DON stated that unwanted contact such as hitting or slapping would be considered abuse and that the incident failed to meet expectations and placed residents at risk for injury or psychosocial harm. The facility policy defined abuse as the willful infliction of injury resulting in physical harm, pain, or mental anguish and stated that residents with behavioral problems should be assessed and care planned.
Failure to Prevent Resident‑on‑Resident Physical Abuse Resulting in Facial Trauma
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from abuse by another resident, resulting in significant facial trauma. One resident with dementia, moderate cognitive impairment (BIMS score of 8), behavioral symptoms, a history of falling, and hearing loss was care planned for behavior problems such as placing himself on the floor, banging his head, yelling, paranoia, refusing care and medications, verbal and physical aggression, territorial behavior in the dining room, and making false accusations. His care plan included anticipating his care needs before he became overly stressed and implementing interventions as needed to protect the rights and safety of others. On the day of the incident, he was seated in his wheelchair in the dining room watching television when another resident approached him. The other resident, who was cognitively intact (BIMS score of 15) and had diagnoses including schizophrenia, mild neurocognitive disorder with behavioral disturbance, psychoactive substance use disorder, anxiety disorder, insomnia, suicidal and homicidal ideations, and schizoaffective disorder bipolar type, had a care plan for behavioral problems including self-isolation, aggression, and a history of suicidal and homicidal ideation. Interventions for this resident included intervening as needed to protect the rights and safety of others, approaching him calmly, diverting his attention, and removing him from situations as needed. A psychiatry assessment recommended maintaining firm boundaries regarding appropriate and acceptable communication and behavior and consideration of a two-person assist for safety and accountability. On the day of the incident, this resident approached the nurse at the medication cart asking to speak with the unit manager about paperwork, was informed the manager had left, stated he did not need assistance, and then walked into the dining room. Shortly after entering the dining room, the cognitively intact resident approached the resident with dementia and asked about a blue folder. Due to hearing loss, the seated resident responded that he did not have the folder or said “what,” and the interaction quickly became confrontational. Two CNAs in the dining room observed the resident who had entered calmly become agitated and strike the seated resident with a closed fist. Staff reported that, due to the size and strength of the aggressor, it required significant effort to separate them, and the aggressor was able to strike the other resident multiple times (approximately five times) before they were fully separated. A nurse, alerted by CNA yelling, arrived after the residents had been separated and found the injured resident in his wheelchair with blood dripping from his nose, blood coming from his left ear, a hematoma near his left eyebrow, and blood on the floor and surrounding area, with his hearing aids in his hand. The injured resident was transported to the hospital, where CT imaging revealed mildly displaced bilateral nasal bone fractures and a 1.5 cm laceration to the left ear that required suture repair. Upon return, he was noted to have a swollen nose, bruising around the nose and left eye, and later two black eyes, with ongoing bruising and discoloration documented in weekly skin assessments. He reported that his hearing aids were damaged by his attacker and stated he had been beaten up by another resident. The facility’s investigation, including staff interviews and review of the incident, concluded that the allegation of physical abuse was verified. The DON stated that the incident met the definition of physical abuse under the facility’s Abuse Guidelines policy, which defines abuse as the willful infliction of injury resulting in physical harm, pain, or mental anguish and requires assessment and care planning for residents with behavioral problems to protect the rights and safety of others.
Failure to Recognize, Document, and Report Resident-to-Resident Abuse Involving Threats with a Cardboard Gun
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from abuse by another resident and to recognize, document, and report the incident as required by policy. One resident had a documented history of behavioral problems related to psychosis, including delusions, refusing care, verbal aggression, intrusiveness, wandering, and inappropriate sexual advances toward females. Care plans identified these behaviors and included an intervention to protect the rights and safety of others. Behavior progress notes over several weeks documented multiple episodes of verbal aggression, threats toward peers and staff, and at least one incident where the resident physically placed his hands on another resident’s arms while attempting to redirect him, leading to an argument that required staff separation. Despite this pattern of escalating behaviors, there was no documentation in the clinical record regarding a later resident-to-resident incident that occurred on January 20, 2026. The other resident involved had vascular dementia with severe cognitive impairment, as evidenced by a BIMS score of 03, and a care plan that identified behavioral symptoms such as physical aggression, verbal outbursts, hallucinations, wandering, and refusal of care. Interventions included psychoactive medications as ordered, recording behavioral symptoms, and educating the resident on appropriate behaviors when on the patio with peers. The clinical record for this resident also lacked any documentation of the resident-to-resident incident on January 20, 2026. When surveyors requested the facility’s self-reports, grievances, and investigations for the prior four months, the facility reported that there had been no incidents or grievances during that period, despite staff accounts of a serious resident-to-resident event. Multiple staff interviews described the unreported incident and the facility’s failure to follow its abuse policy. A CNA stated that the aggressive resident had a pattern of trying to intimidate people, especially when women were present, and reported that within the prior week he made a cardboard gun, covered his face with a bandana, entered the cognitively impaired resident’s room, and threatened to “teach [him] a lesson” if he did not be quiet. An LPN reported witnessing the same event, stating that the resident held a pretend cardboard gun, told the other resident to go to sleep or he would shoot him, and that the threatened resident appeared intimidated and later stayed in bed and did not want to do anything, which was not his usual behavior. The LPN stated she picked up the cardboard gun when it fell, saw it had been colored to look more realistic, but returned it to the resident because she was afraid of what he might do. She reported the incident to the unit manager and was told to write a statement, but the DON later stated she was unaware of any such abuse incident, and the unit manager stated she did not recall the incident being reported and had not investigated it. The facility’s abuse policy required immediate reporting of suspected abuse to the DON and administrator and documentation of incidents, but there was no evidence of documentation, self-reporting, or investigation of this resident-to-resident abuse. The DON stated that allegations of abuse were expected to be documented in an incident report and progress note and reported within two hours to applicable state agencies, physicians, case managers, and family, and that resident-to-resident physical or verbal abuse was considered reportable. The unit manager similarly stated that staff were expected to document all progress notes, including incidents of abuse or allegations, and that allegations should be reported immediately, but no longer than two hours, to the DON. Despite these stated expectations and the written Abuse Guidelines policy defining abuse as willful infliction of injury, intimidation, or punishment causing physical harm, pain, or mental anguish, and requiring immediate reporting of suspected abuse, the incident involving the cardboard gun and threats was not documented in either resident’s clinical record, not entered as a self-report or grievance, and not brought to the DON for investigation. This failure to follow policy and to recognize and report the resident-to-resident intimidation and threats constituted the identified deficiency.
Failure to Implement Abuse Policy After Resident-to-Resident Threat with Cardboard Gun
Penalty
Summary
The deficiency involves the facility’s failure to implement its abuse policy following a resident-to-resident abuse incident involving two residents. The facility’s own "Abuse Guidelines" policy requires that any suspected or actual abuse, including intimidation and resident-to-resident abuse, be immediately reported to facility management, that the DON and administrator be notified, that the resident be examined by a physician or licensed nurse with findings documented in the medical record, and that an unusual occurrence form and written witness statements be completed with an immediate investigation. Despite these requirements, there was no documentation in either resident’s clinical record of the alleged abuse incident that occurred on January 20, 2026, and the DON reported having no knowledge of any recent abuse incident between the two residents. One of the residents involved, identified as Resident #89, had a history of behavioral issues documented in the clinical record. Diagnoses included mild neurocognitive disorder, major depressive disorder, and other chronic medical conditions. Care plans noted behavior problems related to psychosis, including delusions, verbal aggression, intrusiveness, wandering, and inappropriate sexual advances, with interventions to protect the rights and safety of others. Behavior notes over several weeks documented repeated episodes of verbal aggression, threats toward staff and peers, and at least one incident where he physically placed his hands on another resident’s arms during an argument. However, there was no behavior note or other documentation regarding the cardboard gun incident on January 20, 2026, despite staff describing it as resident-to-resident abuse. The other resident, identified as Resident #78, had vascular dementia with severe cognitive impairment (BIMS score of 03) and multiple chronic conditions. His care plan documented behavioral symptoms related to dementia, including physical aggression, verbal aggression, hallucinations, wandering, and refusal of care. Staff interviews revealed that within the week prior to the survey, Resident #89 created a cardboard gun, entered Resident #78’s room, and threatened him, telling him to be quiet or he would "teach [him] a lesson" and stating "go to sleep, or I am going to shoot you." Staff witnesses, including a CNA and an LPN, described the incident as resident-to-resident emotional abuse and reported that Resident #78 appeared intimidated and frightened afterward, staying in bed and not wanting to do anything. The LPN who witnessed the event stated she reported the incident to the unit manager and was instructed to write a statement, but the unit manager later stated she did not recall the incident being reported and did not investigate it. The facility’s records showed no self-reports, grievances, or investigations for the prior four months, and there was no clinical documentation or formal reporting of this abuse incident as required by the facility’s abuse policy. Interviews with multiple staff members further demonstrated the breakdown in implementing the abuse policy. The CNA described Resident #89 as aggressive and intimidating, especially around women, and confirmed that the cardboard gun incident occurred and that he considered it resident-to-resident abuse. The LPN who witnessed the incident stated that abuse incidents should be documented in progress notes and reported immediately to the DON or administrator, and that she did report the event to the unit manager and requested that the cardboard gun be taken away. The DON stated that allegations of abuse must be documented in the clinical record and reported to state agencies within two hours, and that resident-to-resident verbal or physical abuse is reportable, yet she was unaware of the incident. The unit manager stated that abuse allegations should be reported immediately and documented, but she denied having recently reported anything and said she only learned of the cardboard gun situation minutes before her interview and did not investigate it. This combination of absent documentation, lack of reporting to the DON and state agencies, and failure to initiate an investigation after a witnessed resident-to-resident abuse incident constitutes the core deficiency in implementing the facility’s abuse policy.
Failure to Report and Document Resident-to-Resident Abuse Incident
Penalty
Summary
The facility failed to timely report and document a resident-to-resident abuse incident involving intimidation and threats, as required by its abuse policy and staff expectations. One resident, identified as having mild neurocognitive disorder, major depressive disorder, and a history of psychosis-related behaviors including verbal aggression, intrusiveness, and inappropriate sexual advances, had multiple prior behavior notes documenting verbal aggression and threats toward peers and staff. Another resident, diagnosed with vascular dementia and severe cognitive impairment, had a care plan identifying behavioral symptoms such as physical aggression, verbal outbursts, hallucinations, wandering, and refusal of care. Despite these known behavioral risks, there was no documentation in either resident’s clinical record regarding the specific resident-to-resident incident that occurred on January 20, 2026. Staff interviews revealed that within the week prior to the survey, the first resident created a cardboard gun, covered his face with a bandana, and entered the second resident’s room, telling him that if he did not be quiet, he would “teach [him] a lesson.” An LPN reported witnessing the resident holding the pretend cardboard gun and telling the other resident to go to sleep or he would shoot him, and stated that the second resident appeared intimidated and subsequently stayed in bed and did not want to do anything, which was not his usual behavior. The LPN stated she picked up the cardboard gun when it fell, then returned it to the resident because she was afraid of what he might do to her. She further stated that she reported the incident to the unit manager, was instructed to write a statement on paper, and requested that the unit manager take the cardboard gun from the resident. Despite this report, the DON stated she was unaware of any recent abuse incident between these two residents and only knew that the first resident had been verbally aggressive to staff over a recent weekend. The unit manager initially stated that she had not reported anything recently and only learned shortly before her interview that the resident had made a cardboard gun and was playing with staff and the other resident; she stated she did not recall the incident being reported to her and did not investigate or report it. Review of the facility’s self-reports, grievances, and investigations for the prior four months showed no reported incidents or grievances, and review of the State Agency complaint database showed no evidence that the incident had been reported. This inaction occurred despite the facility’s written Abuse Guidelines policy, which required immediate reporting of suspected abuse, including intimidation, to facility management, immediate notification of the administrator, and prompt notification of state agencies, the ombudsman, the resident representative, APS, and the physician, as well as documentation in incident reports and progress notes. The facility’s own policy defined abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment resulting in physical harm, pain, or mental anguish, and explicitly stated that resident abuse by anyone, including other residents, would not be condoned. Staff interviews confirmed that they understood reportable incidents to include physical, verbal, and resident-to-resident abuse, and that such incidents were to be reported immediately to the DON, administrator, or designated supervisor, and documented in the clinical record. Nonetheless, there was no evidence of progress notes, incident reports, or external notifications related to the cardboard gun incident, and the DON and unit manager both denied having reported or investigated it. This lack of reporting and documentation of a witnessed resident-to-resident abuse incident constituted the deficiency identified by the surveyors.
Failure to Investigate Alleged Resident-to-Resident Abuse Involving Threats with a Cardboard Gun
Penalty
Summary
The deficiency involves the facility’s failure to investigate and document an alleged incident of resident-to-resident abuse involving two residents. One resident had a history of behavioral issues, including psychosis-related behaviors, verbal aggression, intrusiveness, and inappropriate sexual advances, with care plan interventions to protect the rights and safety of others. Behavior notes over several weeks documented multiple episodes of verbal aggression, threats toward peers, and menacing behavior toward staff, including threatening language and attempts to put hands on another resident. Despite this pattern, there was no documentation in the clinical record regarding a specific resident-to-resident incident that occurred on January 20, 2026. The other resident involved had vascular dementia with severe cognitive impairment, as indicated by a BIMS score of 03, and a care plan identifying behavioral symptoms such as physical aggression, verbal aggression, hallucinations, wandering, and refusal of care. Interventions included psychoactive medications as ordered, recording behavioral symptoms, and education on appropriate behaviors. This resident’s MDS also showed frequent verbal behaviors. However, similar to the first resident, there was no documentation in this resident’s clinical record regarding the alleged resident-to-resident incident on January 20, 2026. Staff interviews revealed that a CNA described the first resident as aggressive and intimidating, particularly around women, and reported that within the prior week the resident made a cardboard gun, covered his face with a bandana, and entered the second resident’s room, telling him that if he did not be quiet, he would “teach [him] a lesson.” The CNA stated that staff removed the resident from the room and that he considered the event resident-to-resident abuse, and that two nurses present reported it to their supervisor. An LPN separately reported witnessing an incident in which the same resident entered the other resident’s room with a cardboard gun and threatened to shoot him if he did not quiet down, stating, “go to sleep, or I am going to shoot you,” and that the other resident felt intimidated. This LPN reported the incident to the unit manager and was instructed to write a statement, but did not know if it was reported further or investigated. The DON, who is responsible for abuse coordination, investigation, and reporting, stated she was unaware of any recent abuse incident between these residents, and the unit manager stated she did not recall the incident being reported to her and did not investigate the cardboard gun incident. Review of facility records showed no self-reports, grievances, or investigations for the prior four months, and the facility’s Abuse Guidelines policy required immediate reporting, documentation, examination, and investigation of suspected abuse, including resident-to-resident abuse, which did not occur in this case. The facility’s Abuse Guidelines policy defined abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish, and stated that the facility would not condone abuse by anyone, including other residents. The policy required employees, consultants, and physicians to immediately report suspected abuse to the DON or, in her absence, to the nurse supervisor, and required immediate notification of the administrator, state licensing agency, ombudsman, resident representative, adult protective services, and the resident’s physician when an allegation or suspected case of mistreatment or abuse was reported. It further required that a physician or licensed nurse immediately examine the resident, record findings in the medical record, complete an unusual occurrence form with written witness statements, and conduct an immediate investigation with a copy provided to the administrator. Despite these policy requirements and staff accounts of a threatening resident-to-resident interaction involving a cardboard gun and verbal threats, there was no evidence that the incident was documented in either resident’s clinical record, reported to the DON or administrator, or investigated in accordance with facility policy.
Failure to Follow Physician Orders for Blood Glucose Monitoring and Insulin Administration
Penalty
Summary
The facility failed to ensure that physician orders for blood glucose monitoring and insulin administration were consistently followed for a resident with type 1 diabetes mellitus and a history of diabetic ketoacidosis. Despite multiple physician orders specifying the use of a Dexcom G7 sensor, scheduled blood glucose checks four times daily, and specific insulin administration parameters, the clinical record revealed repeated lapses. Blood glucose monitoring was not performed or documented as ordered, and the physician's order for scheduled checks was not transcribed onto the medication or treatment administration records for several months. There were also numerous instances where blood sugar readings were not recorded prior to insulin administration, and low or high blood sugar values were not consistently addressed or reported to the healthcare provider as required. The documentation showed that the resident frequently refused blood glucose checks and insulin administration, but there was no evidence that the physician was notified of these refusals or that the resident was monitored for signs and symptoms of hypo- or hyperglycemia following missed doses. On several occasions, the resident's blood sugar readings were outside of the ordered parameters, including both hypoglycemic and hyperglycemic episodes, yet there was no documentation of follow-up actions, rechecks, or provider notification. The care plan did not include specific interventions for blood sugar monitoring with either fingerstick or continuous glucose monitoring devices, and there was a lack of documentation regarding monitoring for symptoms or implementing change in condition protocols when abnormal readings occurred. Ultimately, the deficient practice resulted in the resident being admitted to the hospital's intensive care unit with hyperglycemia and diabetic ketoacidosis. The clinical record detailed that the resident was found with altered mental status, high blood sugar readings, and symptoms such as vomiting, tachypnea, and diaphoresis. Emergency services were called, and the resident was transferred to the hospital, where a diagnosis of diabetic ketoacidosis and acute encephalopathy was made. The failure to follow physician orders, monitor and document blood glucose levels, and notify the provider of abnormal findings directly contributed to the resident's acute medical deterioration.
Incomplete Documentation of Blood Glucose Monitoring
Penalty
Summary
The facility failed to ensure that the medical record for a resident with type 1 diabetes was complete and accurate regarding blood glucose (BS) monitoring. The resident had multiple physician orders for frequent BS checks and insulin administration, including the use of both fingerstick (accucheck) and a continuous glucose monitoring device (Dexcom G7). Despite these orders, there was a lack of consistent documentation of BS readings in the medical record, including the Medication Administration Record (MAR), progress notes, and vitals log. On numerous occasions, BS values were either missing, not recorded as numerical values, or only noted as 'high' or 'low' without further detail. There were also instances where the resident refused BS checks or insulin, but the attempts and outcomes were not always fully documented. Interviews with nursing staff and the DON revealed that the facility did not have a specific policy for BS monitoring and relied on physician orders to guide practice. Staff reported that BS values should be recorded on the MAR, but review of the MAR for the relevant months showed no such documentation. Staff also indicated that the process for ensuring BS monitoring orders were properly reflected in the MAR was not always followed, as the nurse practitioner entering the order did not select the necessary options to trigger MAR documentation. Additionally, there was confusion among staff regarding the interpretation of the Dexcom device readings and when to notify providers of abnormal results. The resident involved had a complex medical history, including type 1 diabetes, cerebral infarction, and dementia, and required close monitoring of blood glucose levels. The care plan did not include specific interventions for BS monitoring with either the accucheck or Dexcom device. Throughout the period reviewed, there were multiple days with missing or incomplete BS documentation, and on several occasions, there was no evidence that providers were notified of abnormal BS readings or that appropriate follow-up occurred. The lack of complete and accurate documentation could result in an incomplete medical record for the resident.
Failure to Cleanse Pressure Ulcers Before Applying Dakin’s-Soaked Dressings
Penalty
Summary
The deficiency involves the facility’s failure to provide wound care in accordance with physician orders and professional standards for a resident with pressure ulcers. The resident was admitted with diagnoses including dementia with mood disturbance, muscle weakness, and type 2 diabetes mellitus, and had an unstageable right ischial wound and an unstageable sacral wound. The care plan included an intervention to provide wound care as ordered by the physician. Active physician orders for both the right ischium and sacrum directed staff to cleanse the wounds with wound cleanser, pat dry, apply skin prep to the surrounding area, pack with Dakin’s soaked gauze, and cover with a dry dressing daily and as needed. During an observed wound care treatment, the LPN serving as the wound care nurse prepared Dakin’s half-strength solution and soaked gauze, stating she had been told by the wound provider not to clean the wound and expressing uncertainty about the correctness of this method. The LPN removed the old dressings, performed hand hygiene, donned clean gloves, and then packed both the sacral and right ischial wounds with Dakin’s soaked gauze without cleansing either wound beforehand, contrary to the physician’s orders. A 6x6 dressing was applied to the sacral wound and a 4x4 dressing to the right ischial wound. Interviews with another LPN and the DON confirmed that nurses are expected to follow provider orders and receive training from the wound nurse, while the DON referenced an unsigned statement suggesting Dakin’s solution did not require prior cleansing, which was not supported by the manufacturer’s article cited. The wound physician later clarified that nurses should follow his orders, that wounds should be cleansed at the time of treatment, and that Dakin’s solution could be used as a cleanser but should be used first to clean and then separately to pack the wound. Facility policy required all medications to be administered in accordance with orders.
Failure to Use Required Hair and Beard Restraints During Food Preparation
Penalty
Summary
The deficiency involves failure to maintain proper sanitary conditions in the kitchen during food preparation, specifically related to required use of hair restraints and facial hair covers. During a kitchen observation at 8:10 a.m. on September 2, 2025, one cook (Staff #107) was observed working in the kitchen without a hair net. Another cook (Staff #51) was observed in the kitchen without a hair net and with visible facial hair that was not covered by a beard guard/net. At the same time, a small pot containing a green substance resembling vegetables was observed boiling on the stove. In subsequent interviews, the Food Service Director (Staff #125) confirmed that staff working in the kitchen are required to wear hair nets and facial hair guards and acknowledged that failure to do so can result in hair getting into food, stating that the staff "know better." The Administrator (Staff #5) stated that expectations are for staff to follow facility policy and procedure to prevent cross contamination in the kitchen, including proper PPE such as hair nets and facial hair covers during food preparation. In a later interview, the Food Service Director identified the boiling green food observed during the initial kitchen observation as buttered spinach being prepared for lunch service and confirmed it is started early in the day for slow cooking. Review of the facility’s “Personal Hygiene and Health Reporting” policy showed that hair restraints must be worn around exposed foods in kitchen and food service areas, and that beards must be restrained with beard covers when around exposed foods.
Call Light Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that a call light was within reach for a resident, which could result in a preventable accident and the resident being unable to meet their needs. The resident, who was admitted to the facility with severe cognitive impairment and multiple diagnoses including atherosclerotic heart disease and bipolar disorder, was observed on two occasions with the call light out of reach. The resident has both upper and lower impairment on both sides and requires assistance with activities of daily living due to spinal stenosis and impaired mobility. On the day of observation, the call light was found in the resident's top dresser drawer and later pinned on the resident's lap, both positions out of reach. The resident was observed screaming for help, indicating distress and inability to access assistance. Interviews with the CNA and DON revealed that the call light should have been placed on the resident's upper chest for accessibility. The facility lacked a Call Light Policy, as confirmed by the DON, which contributed to the oversight in ensuring the call light was within reach.
Failure to Prevent Resident Elopement Due to Inadequate Supervision
Penalty
Summary
The facility failed to provide adequate supervision to prevent the elopement of a resident who was at high risk for wandering. The resident, who had a history of elopement and was diagnosed with conditions such as post-traumatic stress disorder, aphasia, and vascular dementia, was admitted to the facility with an incomplete minimum data set assessment. Despite being identified as a high risk for wandering, the resident was able to exit the facility when a nurse was distracted by a medication delivery and the exit door alarm was triggered. The resident was found the next day by a family member and returned to the facility with blisters on both feet. Interviews with staff revealed that the resident was initially on 1:1 monitoring, which was removed shortly before the elopement occurred. The staff were aware of the resident's elopement risk, and interventions were in place to distract the resident from wandering. However, the lapse in supervision allowed the resident to leave the facility unnoticed. The facility's policy required all nursing personnel to report and investigate missing residents, but the incident highlighted a failure in maintaining adequate supervision and monitoring of the resident's movements.
Use of Disposable Dishware in Dining Room
Penalty
Summary
The facility failed to ensure that residents were treated with dignity during dining by using disposable cutlery and dishware. During a dining observation, it was noted that seven residents were served their meals in Styrofoam containers, cups, and bowls, and were using plastic utensils. A resident mentioned that Styrofoam was used sometimes, but not consistently. This practice was attributed to the absence of dishwashing staff, as the dietary director explained that meals were served on Styrofoam when there was an emergency or when the dishwasher staff called off. The dietary director admitted that the use of Styrofoam dishware occurred on a monthly basis due to the lack of dishwashing staff on Monday nights, and the administrator was aware of this situation. The Executive Director (ED) stated that he supervises the dietary manager and was informed about the kitchen staffing needs. However, he did not review the kitchen staff schedule and was unaware of the dishwasher staffing issue on Monday nights until just before the interview. The ED expressed that it was his expectation for the facility to provide a homelike environment in the dining room and that Styrofoam dishware should not be used. The facility's policy on Dining Room Service emphasized maintaining a comfortable and attractive atmosphere in the dining room, which was not upheld in this instance.
Failure to Update PASRR for Residents with New Diagnoses
Penalty
Summary
The facility failed to ensure that the Preadmission Screening and Resident Review (PASRR) was updated for two residents, which could result in residents not receiving the care and services they needed. Resident #73 was admitted with diagnoses including bipolar disorder, major depressive disorder, and severe intellectual disability. A new diagnosis of anxiety disorder was made, but the PASRR Level I screening was not updated to reflect this change. Interviews with the Social Services Director and the Director of Nursing confirmed that the PASRR should have been updated following the new diagnosis. Resident #22 was admitted with multiple diagnoses, including cerebral infarction and bipolar disorder. A PASRR Level I screening was completed, and a Level II determination was submitted. However, after a new diagnosis of schizoaffective disorder, the PASRR was not updated, nor was a Level II determination completed. The resident exhibited behavioral symptoms, and a behavioral care plan was revised, but the PASRR remained outdated. Interviews with the Director of Social Services and the Director of Nursing confirmed that the PASRR should have been updated and a Level II determination submitted. The facility's policy on PASRR, reviewed in July 2022, requires screening for all individuals being considered for admission to a Medicaid-certified nursing facility to determine if they have a mental illness, intellectual disability, or related condition. The policy aims to prevent inappropriate placement in nursing homes. Despite this policy, the facility did not update the PASRR for residents with new psychiatric diagnoses, as required by federal regulations.
Deficiency in Food Storage and Sanitizer Testing
Penalty
Summary
The facility failed to ensure proper labeling and storage of food items in accordance with professional standards. During an initial tour of the kitchen, it was observed that a 15-pound box of bacon was not stored in a sealed bag or container, and a bag of shredded lettuce was not sealed or dated. Additionally, various bread items, including wheat bread, hamburger buns, and Hawaiian sweet rolls, were found without open dates. The Dietary Director was unsure about the necessity of sealing the bacon and acknowledged that the shredded lettuce should have been sealed. The Executive Director confirmed that open products should be dated and sealed to prevent oxidation, which can affect the nutritive value and quality of the food. Furthermore, the facility did not adhere to the correct procedures for testing the Quaternary Sanitizer (Quat) solution. The Dietary Director tested the Quat solution and found it to be at 400 parts per million (ppm), which is higher than the recommended 200 ppm. The Director stated that the solution was too strong and required adjustment. The facility's policy on food storage and date marking specifies that leftover food should be stored in covered containers, clearly labeled, and dated if stored for over 24 hours, and used within seven days or discarded. The Quaternary Sanitizer Test Strip directions also require the solution to be tested at 200 ppm.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement enhanced barrier precautions (EBP) for a resident with a percutaneous endoscopic gastrostomy (PEG) tube, which could result in the transmission of multi-drug resistant organisms. The resident, who was admitted with diagnoses including hemiplegia, diabetes mellitus type 2, cerebral infarction, dementia, and gastrostomy status, had a severe cognitive impairment as indicated by a BIMS score of 03. Despite the resident's condition and the presence of a PEG tube, no signs related to EBP were posted outside the resident's room, and no personal protective equipment (PPE) was visible. Interviews with staff revealed a lack of adherence to EBP guidelines. A licensed practical nurse stated that no precautions were in use anywhere in the building, as it made it easier for staff to care for residents without having to gown up. The Director of Nursing also confirmed that no precautions were in use, expressing disagreement with the EBP guidelines due to concerns about maintaining a homelike environment. The facility's assessment indicated that infection prevention and control services were provided, yet the CDC and CMS guidelines for EBP, which include the use of gown and gloves during high-contact resident care activities for residents with indwelling medical devices, were not followed for the resident with a PEG tube.
Deficiencies in Facility Maintenance and Cleanliness
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment for its residents, as evidenced by several observations and staff interviews. In one resident's room, the window blinds were broken, a light brown substance had dried on the walls, there was a strong odor of urine, and the plaster and paint were chipped off in multiple areas. Additionally, the bathroom ceiling vent was covered in brown dust and dirt. Another room was observed to have broken window blinds as well. Interviews with staff, including a CNA and an LPN, revealed that there was an expectation for maintenance issues to be reported and addressed promptly, but this was not consistently happening. Further observations with the maintenance director highlighted additional cleanliness issues, such as a bathroom vent emitting a puff of white and brown dust when poked, and a bathroom wall stained with a brown substance. The maintenance director acknowledged that these areas should have been cleaned by housekeeping. The facility's policy on maintenance services states that the maintenance director is responsible for ensuring that the building and equipment are maintained in a safe and operable manner, but the observations indicate that this policy was not being effectively implemented.
What surveyors are citing around you — mapped
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What surveyors actually found near you
We read the 320 citations issued within 25 miles in the last 12 months — including the 2 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Phoenix
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Desert Terrace Healthcare Center | 0.7 mi | ★★★★★ | 7 | 0 |
| Haven Health Sky Harbor, Llc | 2.3 mi | ★★★★★ | 9 | 0 |
| Camelback Post Acute Care And Rehabilitation | 2.4 mi | ★★★★★ | 1 | 0 |
| Maryland Gardens Post Acute | 4.5 mi | ★★★★★ | 0 | 0 |
| Haven Of Phoenix | 4.7 mi | ★★★★★ | 12 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.