Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Peak Care Center during CMS and state inspections, most recent first.
The facility failed to prevent resident-to-resident verbal and physical abuse involving two separate pairs of residents with known psychiatric and behavioral issues. In one case, a cognitively intact resident with a history of agitation and verbal aggression insulted another cognitively intact resident with schizoaffective disorder and intermittent explosive disorder during dinner; after repeated verbal exchanges, the second resident stood up, shoved the table, and punched the first resident in the eye, resulting in an orbital fracture and retrobulbar hemorrhage. In another case, a resident with schizophrenia, bipolar disorder, and documented verbal aggression argued over a soda with a peer who had borderline personality disorder and a care plan for bullying and physical aggression; the argument escalated from name-calling to one resident standing and swinging at the other, with the alleged victim later reporting facial and chin pain despite no visible injury on assessment. In both incidents, residents with identified behavior risks and existing behavior plans engaged in escalating verbal conflicts in common areas that were not effectively de-escalated before they became physical or attempted physical assaults.
A resident with severe cognitive impairment, dementia, and behavioral symptoms had an existing care plan addressing elopement risk and sundowning behaviors, but the plan was not revised after multiple significant elopement and behavioral events. The resident repeatedly exited the unit and facility, climbed over fences and walls, ran off the grounds, displayed agitation, refused medications and vitals, entered other residents’ rooms and the nurses’ station, and called 911 multiple times. Staff attempted redirection and maintained visual contact, and the resident was returned with assistance from police and EMS and sent for hospital and psychiatric evaluations, but no new elopement or behavioral interventions were added to the care plan. Interviews with a CNA, an LPN, and the DON confirmed that the resident had climbed the fence several times, that hospital and psych evaluations were not reflected in the care plan, and that the care plan was not updated despite these events, contrary to facility policy requiring care plan review and revision after significant changes or unmet outcomes.
A resident with multiple comorbidities, contractures, moderate cognitive impairment, and a documented fall risk was care planned for Hoyer lift transfers and a safe environment, including staff assistance with ADLs. One morning, a CNA used a Hoyer lift alone to transfer the resident from bed to a wheelchair, did not follow the facility’s two‑person transfer process, and failed to properly manage the sling, resulting in the resident sliding from the chair to the floor. The resident later reported that the transfer occurred in the dark, that he told the CNA the sling strap was stuck, and that the CNA continued pulling until he fell onto his bottom, after which he experienced increased leg and knee problems. Staff interviews and facility policy confirmed that Hoyer transfers are required to be performed by two staff members with all sling loops correctly attached and unhooked after transfer, and that failure to follow this process can allow a resident to slip off the sling.
A resident with dementia and a history of behavioral issues entered another resident's room and allegedly committed physical abuse, resulting in visible bruising. Despite care plans and interventions for supervision, the incident occurred and was reported after the fact, with staff and documentation confirming the abuse. The facility's policies require prompt reporting and investigation, but the events leading up to the incident showed a failure to protect the resident from abuse.
Failure to Protect Residents from Resident-to-Resident Abuse: Two residents became involved in a physical altercation after one resident threw candy at the other and then slapped her, with the other resident slapping back. A CNA separated them immediately, and later interviews and documentation confirmed the event as a resident-to-resident abuse allegation involving physical contact.
A facility failed to report an abuse allegation involving two residents to the State Agency after one resident reported sexually explicit verbal abuse and fear of the other resident. The resident involved had intact cognition and multiple psychiatric diagnoses, while the other resident had a history of aggressive and verbally abusive behaviors. Staff and the administrator confirmed awareness of the allegation, and the administrator acknowledged the report should have been made.
Failure to report allegation of verbal abuse: A resident with multiple psychiatric diagnoses and intact cognition reported that another resident used sexually explicit, threatening language toward her during a smoking-patio confrontation. Staff were aware of the incident, the residents were separated, and the allegation was discussed with nursing, social services, and administration, but the abuse allegation was not reported to the State Survey Agency within the required 2-hour timeframe.
The facility failed to protect residents from all forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, by any individual.
A resident with severe dementia and behavioral disturbances experienced two major accidents: one during a hoyer lift transfer, where movement and manipulation of the sling led to a fall and multiple injuries, and another after sliding from a wheelchair due to inadequate supervision and improper use of wheelchair cushions. The care plans did not address the resident's specific behavioral risks during transfers or specify supervision requirements, and staff were unclear about the circumstances and interventions in place at the time of both incidents.
Multiple incidents occurred in which residents physically assaulted other residents, including hitting, slapping, and kicking, during disputes in shared rooms and on the smoking patio. Despite existing care plans addressing behavioral issues and staff presence, these altercations were witnessed by staff and other residents, and facility investigations substantiated the abuse. The facility did not prevent these episodes of resident-to-resident physical abuse.
A resident with morbid obesity, immobility, and incontinence did not receive timely incontinence care as required by her care plan and facility policy. The resident was found in bed with a strong odor of urine and reported discomfort and distress due to inadequate repositioning and lack of space in her bed. Staff interviews confirmed that the assigned CNA had not checked or changed the resident since the start of the shift, citing short staffing and workload as reasons for the delay. Nursing leadership confirmed that this did not meet facility expectations for incontinence care.
A resident with morbid obesity and chronic pain did not receive a physician-ordered bariatric bed of appropriate size due to insurance denial and supplier limitations, resulting in discomfort and inability to reposition. Additionally, the resident's scheduled opioid pain medication was not administered as ordered due to delays in prescription processing and lack of medication availability, leading to unmanaged pain and distress.
A resident with chronic pain and opioid dependence did not receive a scheduled dose of long-acting opioid medication due to the facility's failure to reorder and obtain the necessary prescription in time. Nursing staff did not follow established procedures for medication reordering and did not check the medication dispensing system before the missed dose, resulting in unmanaged pain and resident dissatisfaction.
During a period of construction, the facility repurposed its dining, activity, day care, and medical record rooms to house displaced residents, resulting in the absence of a dedicated space for communal dining and activities. Residents received meals and care at their bedsides in these temporary sleeping areas, with staff confirming the lack of a designated dining or activity room throughout the construction period. Several cognitively intact residents were affected, and personal belongings were stored in a maintenance area.
Following a major plumbing failure, residents were relocated to non-traditional spaces such as the dining room, day care room, and medical record room, where beds, call bells, and privacy curtains were set up as temporary accommodations. Residents ate meals at their bedsides, shared bathrooms, and had personal belongings stored in a maintenance area with housekeeping equipment. Staff and resident interviews confirmed that these arrangements persisted for at least a week, impacting the safety, sanitation, and comfort of the environment.
Two residents with behavioral health diagnoses were involved in a physical altercation, resulting in one sustaining a finger laceration after being slapped and grabbed by her roommate. Despite care plans addressing behavioral risks and staff training on abuse prevention, the incident was not witnessed and led to injury, indicating a failure to protect residents from abuse.
A resident with dysphagia was not given the prescribed honey thick liquid diet, leading to coughing during a meal. The restorative nursing assistant altered the liquid's consistency without a physician's order, contrary to facility policy. The resident was at risk for aspiration and on antibiotics for aspiration pneumonia.
Two residents experienced abuse in a facility due to inadequate intervention and oversight. One resident, with severe cognitive impairment, was physically assaulted by a cognitively intact roommate after a confrontation over personal belongings. Another resident, who was cognitively intact, suffered verbal abuse from an LPN, despite previous warnings and discussions about separating them. The facility's failure to implement its abuse prevention policies led to these incidents.
A resident with a history of diabetes and other conditions experienced swelling and redness in the right leg, which was not promptly reported or addressed by LTC facility staff. Despite symptoms of cellulitis, there was a delay in communicating lab results to the provider, leading to inadequate treatment and eventual hospitalization. Interviews revealed systemic communication and documentation issues, contributing to the resident's deteriorating condition and subsequent leg amputation.
Failure to Prevent Resident-to-Resident Verbal and Physical Abuse
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from physical and verbal abuse by other residents. One incident involved a resident with borderline personality disorder, schizophrenia, major depressive disorder, generalized anxiety disorder, a history of traumatic brain injury, and chronic pain syndrome, who had intact cognition and documented patterns of agitation, aggression, yelling, cursing, and threatening others. While in the dining room during dinner, this resident verbally insulted another cognitively intact resident with schizoaffective disorder, bipolar type, intermittent explosive disorder, and personality change due to a physiological condition. Multiple accounts from staff and both residents indicate that after being told not to talk to him, the verbally aggressive resident continued speaking, and the other resident stood up, shoved the table, and struck him in the left eye with a closed fist. As a result of this altercation, the assaulted resident reported pain, nausea, and later requested psychiatric support and antidepressant therapy. Clinical documentation and hospital imaging confirmed an acute left inferior orbital wall fracture and retrobulbar hemorrhage, with visible bruising to the left eye. Prior to this event, the aggressor had known psychiatric diagnoses and was receiving multiple psychotropic and mood-stabilizing medications for mood swings, aggression, disorganized thinking, paranoia, and intermittent explosive disorder. The facility’s records show that the aggressor had behavior care plans related to behavior problems and intermittent explosive disorder, but there is no indication in the report that staff anticipated or intervened to prevent this specific escalation in the dining room before the physical strike occurred. A second incident involved two other residents with significant psychiatric and behavioral histories. One resident had schizophrenia, bipolar disorder, anxiety disorder, intellectual disabilities, and obesity, with a behavioral care plan noting verbal aggression, demanding behaviors, and instructions for staff not to provide requests when made in a rude, threatening, or aggressive manner. The other resident had borderline personality disorder, bipolar disorder, pseudobulbar affect, anxiety disorder, PTSD, and type 1 diabetes, with a behavioral treatment plan for bullying or physical aggression toward peers and interventions directing staff to intervene promptly, remind the resident of respectful behavior expectations, and separate and redirect her if needed. Despite these identified risks and care plan directives, the two residents engaged in a verbal argument over a soda at the nurses’ station, during which one resident called the other a “fat b****” and continued name-calling after being told to stop, leading the other resident to stand up and swing at her. Documentation from behavior notes, incident notes, and the facility’s investigation shows that both residents stood up from their wheelchairs and approached each other during the argument. One resident reported being slapped in the face and later complained of chin pain, while the other resident was documented as having swung her arm at the peer. A skin assessment performed shortly after did not show visible injury, redness, trauma, or swelling, and witnesses, including staff and another resident, reported seeing a swing but were unsure if physical contact occurred. The facility’s investigation ultimately concluded that it could not determine whether physical contact was made, but the event was characterized as a verbal altercation that escalated to at least an attempted physical strike. In both sets of incidents, residents with known behavioral risks and existing behavior plans engaged in escalating verbal conflicts that were not effectively de-escalated or prevented from becoming physical, resulting in at least one resident sustaining a confirmed serious injury and another reporting pain after an alleged slap. Across these events, the facility had identified behavioral risks for the involved residents and had documented care plans and behavior interventions addressing aggression, bullying, and inciting peers. However, during the actual incidents, residents engaged in escalating verbal abuse in common areas (dining room and nurses’ station) that progressed to physical aggression or attempted physical aggression. The report describes that staff were present in the vicinity and, in some cases, intervened only after the physical act occurred or as the residents were already standing and approaching each other. The survey findings conclude that the facility failed to ensure that the affected residents were free from physical or verbal abuse by other residents, as required, resulting in resident-to-resident altercations that included verbal insults, threats, and at least one confirmed physical assault causing an orbital fracture and retrobulbar hemorrhage.
Failure to Update Care Plan After Repeated Elopement and Behavioral Incidents
Penalty
Summary
The deficiency involves the facility’s failure to review and update a resident’s comprehensive care plan after multiple elopement and behavioral incidents. The resident had vascular dementia, mood disorder, constipation, venous thrombosis and embolism, hypotension, dysphagia, anxiety disorder, and post-traumatic stress disorder. A quarterly MDS showed severely impaired cognitive skills for daily decision-making and no BIMS assessment. The existing care plan, dated June 9, 2025, identified the resident as at risk for elopement related to a history of elopement before admission and during the stay, with interventions such as assessing for fall risk, monitoring for fatigue and weight loss, and residing on a secure unit. A behavioral treatment care plan dated November 24, 2025, addressed sundowning behaviors with interventions including reassurance, a structured and soothing environment, reduced stimulation before sundown, a consistent evening routine, calming activities, gentle redirection, and monitoring for physical needs. On December 4, 2025, an incident occurred in which the resident was pacing in the hallway, appeared restless, and then ambulated toward a north exit door, exiting into the smoking area. Staff followed immediately and observed the resident climbing a wall. Verbal redirection was attempted but was not effective, and a facility code was initiated. One nurse positioned outside the wall while additional staff remained inside with the resident. The resident jumped over the wall to the outside area and began running off facility grounds. Staff continued attempts to redirect the resident back to safety but were unsuccessful. The resident was ultimately returned with assistance from 911 and sent to the hospital for evaluation, with no injuries noted. Despite this elopement event, review of the care plan showed no updated care plan or new interventions for the elopement risk focus area, and no evidence that the behavioral care plan was updated after this incident. A second incident on December 7, 2025, documented that the resident was restless, agitated, and pacing in the hallway, refusing all medications, treatments, and vital signs. The resident entered other residents’ rooms, entered the nurses’ station, went through drawers, and called 911 multiple times. Redirection and distraction were unsuccessful, and after the police arrived, the resident exited the unit and the facility. Staff called 911, and the ADON was notified. The resident was observed with a large rock, posturing and attempting to throw it at staff, then climbing a brick wall with the rock in hand and proceeding toward the street. The nurse and another staff member remained present, and with the arrival of the ADON and police, the resident was helped back to the facility. A scrape on the left wrist was noted, and a psych provider ordered psychiatric evaluation and stabilization at a medical center. Review of the care plan again revealed no updated care plan or new interventions for elopement risk after this second incident, and no updates to the behavioral care plan or elopement care plan were found. A discharge summary later documented that the resident made his way outside by holding the exit door onto the patio, climbed over the fence, and jumped, with uncertainty about whether he hit his head. Staff went outside and called 911 for assistance; the resident returned inside the facility and later exited the patio again, leading to a call to AMR for assessment as directed by the DON. Interviews with staff showed that a CNA recognized elopement risk by resident behaviors such as wandering and stated that interventions included close observation, redirection, and monitoring movements, but also stated she did not handle care plans or know what new interventions would be placed after the resident left the facility. An LPN stated that nurses do not create care plans and that the ADON and DON update care plans and add interventions, and that she could only suggest interventions. The DON stated that the resident had climbed the fence three times, that the resident was sent to the hospital after the first and second incidents and seen by a psych provider, and that these actions were not reflected in the care plan. The DON acknowledged that no new interventions or medication changes were placed when the resident returned and that interventions should have been implemented in the care plan but were not, and that failure to update the care plan can risk a resident not getting proper care. The facility’s care plan policy required the interdisciplinary team to review and update the care plan when there has been a significant change in the resident’s condition or when desired outcomes are not met, which did not occur in this case.
Improper One‑Person Hoyer Lift Transfer Leads to Resident Fall
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate assistance and proper use of assistive devices, specifically a mechanical (Hoyer) lift, for a resident identified as being at risk for falls. The resident had multiple diagnoses, including bipolar disorder, COPD, anxiety disorder, extrapyramidal and movement disorder, hyponatremia, and age-related osteoporosis, and was care planned as at risk for falls related to high‑risk medication use, incontinence, poor mobility, hand contractures, and involuntary movements. The care plan interventions included anticipating and meeting needs, ensuring a reachable call light, prompt response to requests for assistance, maintaining a safe environment, and using a Hoyer lift for transfers with monitoring for safety. The resident also had an ADL self‑care performance deficit care plan that specified the need for staff assistance with ADLs due to pain and contractures and identified Hoyer lift transfers as part of the resident’s care. On a morning in November, the resident reported to a CNA that he had fallen at approximately 5:30 a.m. The nurse’s post‑fall assessment documented that the resident stated he had been helped with a Hoyer lift by a CNA who forgot to remove the sling, and that he slid down to the floor. The RN assessment noted the resident’s range of motion was within normal limits for his baseline, with contractures to his legs and hands, intact skin without bruising or abrasions, and resident‑reported mild to moderate pain in the knees and left hip. Neuro checks were within normal limits, and the resident denied hitting his head. An X‑ray of the left hip and knee later showed no acute fracture or dislocation, with intact osseous structures and modest joint space narrowing. A fall risk evaluation completed in November documented that the resident was chair‑bound, had 1–2 falls in the last three months, was at risk for falls with a score of 14, and had a BIMS score of 11 indicating moderate cognitive impairment. Interviews and facility documentation described the circumstances leading to the fall and the manner in which the Hoyer lift was used. The resident’s representative stated that the resident told her a staff member attempted to get him up with a mechanical lift in the dark, that the resident asked for the light to be turned on, and that the staff member proceeded anyway, resulting in a fall. The resident stated that the CNA came alone at about 5:30 a.m. to assist him with the Hoyer lift, hooked the sling strap to the lift, and that the strap felt stuck; despite the resident telling the CNA it was stuck, the CNA continued pulling until the resident suddenly fell onto his bottom. The resident reported that he already had trouble with his left knee and that his leg became worse after this incident. Review of the CNA’s employee file showed a disciplinary action documenting that the CNA transferred the resident from bed to wheelchair alone using the Hoyer lift, did not have a second staff member present, and that the resident slipped from the wheelchair onto the floor. The documentation also stated that the CNA failed to report the incident to a nurse and got the resident up before an assessment for injuries could be completed. Multiple staff interviews confirmed the facility’s established process for Hoyer lift use and contrasted it with what occurred for this resident. CNAs and licensed nursing staff consistently stated that the facility’s process requires two staff members for Hoyer transfers, that all four sling loops must be correctly attached and double‑checked before lifting, and that the sling must be unhooked after the transfer is completed. Staff described that one staff member operates the lift while the other supports and guides the resident’s body, and that improper hookup or incomplete securing of the sling can allow a resident to slip off. The DON stated that the facility’s process is to have two staff members perform a Hoyer transfer, with the sling placed under the resident, color‑coded loops attached to the lift, the resident lifted and transferred to the receiving surface, and the sling then removed. The DON acknowledged that, for this resident, the staff member did not use a second person and forgot to unhook the sling, which resulted in the resident sliding from the chair to the floor. A written policy titled “Lifting Machine, Using A Mechanical,” revised in October 2017, specified that at least two nursing assistants are needed to safely move a resident with a mechanical lift, underscoring that the actions taken with this resident did not follow the facility’s own policy and procedures for safe mechanical lift use.
Failure to Protect Resident from Abuse by Another Resident
Penalty
Summary
A deficiency occurred when a resident with dementia, COPD, and hypertension, who was cognitively intact according to a recent assessment, reported being physically abused by another resident with severe cognitive impairment and a history of behavioral issues. The incident involved the alleged perpetrator entering the victim's room, hitting her, and causing visible bruising to her arm and face. Documentation and staff interviews confirmed that the victim reported the abuse to staff, and a skin assessment revealed multiple bruises consistent with her account. The alleged perpetrator had a documented history of wandering, impulsive behavior, and physical aggression, as noted in his behavioral treatment plan. The facility's records show that the two residents had been sharing the same unit for an extended period, and the care plans for both included interventions for supervision and maintaining a safe environment. Despite these interventions, the resident with a history of behavioral symptoms was able to enter the other resident's room and allegedly commit physical abuse. Staff interviews indicated that the incident was reported after the fact, and the victim had to leave her room to alert staff. The facility's investigation included interviews, notification of authorities, and review of video footage, although the footage was no longer available at the time of the investigation. The deficiency was further substantiated by the facility's own policies, which require prompt reporting and thorough investigation of abuse allegations. Staff acknowledged the importance of immediate reporting and recognized the incident as abuse. However, the events leading up to the incident, including the lack of effective supervision and the ability of the perpetrator to access the victim's room, directly contributed to the failure to protect the resident from abuse as required by federal and state regulations.
Failure to Protect Residents from Resident-to-Resident Abuse
Penalty
Summary
The facility failed to ensure that residents were free from abuse from another resident involving Residents #3 and #5. Resident #3 was admitted with diagnoses including bipolar disorder, depression, PTSD, unspecified convulsions, borderline personality disorder, and antiphospholipid syndrome. An MDS assessment showed a BIMS score of 15, indicating intact cognition, and a skin assessment on September 18, 2025, showed no skin issues or injuries. Resident #5 was admitted with diagnoses including type 2 diabetes with unspecified complications, personality disorder, cerebrovascular disease, anxiety disorder due to a known physiological condition, and chronic kidney disease. An MDS assessment on August 5, 2025, showed a BIMS score of 6, indicating severe cognitive impairment and significant problems with thinking and memory. The incident occurred when Resident #3 returned to the unit from the business office with a CNA escort who brought three pieces of candy for Resident #5 and then chatted with Resident #5. Resident #3 interrupted the conversation, Resident #5 threw the candy at Resident #3, and Resident #3 positioned herself in front of Resident #5. Resident #5 then slapped Resident #3, and Resident #3 slapped Resident #5 back. The CNA separated the residents immediately. Documentation later confirmed that the event involved resident-to-resident physical contact and was investigated as an altercation between the two residents. Progress notes documented that both residents had no skin alterations after the incident and were alert and oriented at the time of assessment. Resident #3 denied psychological or psychosocial disturbance and stated she felt safe. Resident #5 also denied psychological or psychosocial disturbance and reported that she threw the candy because Resident #3 was not respecting her personal space. Interviews with Resident #3, Resident #5, the CNA witness, and an ADON consistently described the exchange as escalating from verbal conflict to physical contact, with the CNA witness stating that the incident involved physical contact and should have been reported immediately as alleged abuse. The facility’s investigation concluded that a resident-to-resident altercation did occur and that Resident #5 initiated the physical contact by throwing candy and slapping Resident #3.
Failure to Report Resident-to-Resident Abuse Allegation
Penalty
Summary
The facility failed to implement its abuse policy by not reporting an allegation of abuse involving two residents to the State Agency. The report states that the facility conducted an internal investigation after a resident reported feeling unsafe with another resident on the same unit, but the allegation was not reported to the State Agency even though staff later acknowledged that allegations of rape or verbal threats should have been reported. Resident #5 was admitted with diagnoses including bipolar disorder, depression, PTSD, borderline personality disorder, anxiety disorder, nicotine dependence, and panic disorder. Her care plan addressed PTSD and behavior problems related to bipolar disorder, depression, PTSD, and borderline personality disorder, with interventions including medication administration, care in pairs, and intervening as necessary to protect the rights and safety of others. Her MDS showed a BIMS score of 13, indicating intact cognition, and no indicators for mood or behaviors. Behavior charting documented that she was increasingly annoyed with another resident’s vulgar language and stated she was nearing the point of “doing something.” Resident #10 was admitted with diagnoses including bipolar disorder, anxiety disorder, and chronic osteomyelitis. His MDS also showed a BIMS score of 13 with no indicators for mood or verbal behavioral symptoms directed toward others. His care plan addressed behavior problems related to bipolar disorder with aggressive behaviors, and a behavior care plan listed past behaviors including physical aggression, threatening, leaving AMA, mood swings, and false accusations, with current behaviors including anxiety, agitation, intrusiveness, cursing, and abrasive tone. Staff interviews described him as verbally aggressive and disruptive toward others, and one staff member reported that he used curse words and vulgar references toward Resident #5 during a smoke break. Resident #5 stated that Resident #10 repeatedly harassed her and that on the incident date he called her vulgar names and made sexually explicit comments, including statements about rape. She reported that staff were present, that she asked to be moved multiple times, and that she eventually filed a police report and obtained an order of protection. Facility staff confirmed awareness of the allegation, and the internal investigation documented that Resident #5 reported calling APS and police because she did not feel safe with Resident #10 on the same unit. The administrator stated that the allegation should have been reported to the State Agency and acknowledged, “I messed up; it should have been reported.”
Failure to Report Allegation of Verbal Abuse
Penalty
Summary
The facility failed to ensure that an allegation of verbal abuse involving one resident was reported to the State Survey Agency within the required timeframe. The resident involved had diagnoses including bipolar disorder, depression, PTSD, borderline personality disorder, anxiety disorder, nicotine dependence, and panic disorder. Her care plan addressed PTSD and behavior problems related to bipolar disorder, depression, PTSD, and borderline personality disorder, and her MDS showed a BIMS score of 13, indicating intact cognition. The allegation involved a confrontation between two residents on a smoking patio. One resident reported that the other used vulgar sexual language toward her, including statements that she had two p****** and should be raped. The resident stated that staff were present during the incident and that she later contacted police and obtained an order of protection. Facility interviews showed that staff were aware of the conflict, that the residents were separated, and that the incident was discussed among nursing, social services, and administration. The facility’s internal investigation documented that the resident reported the sexual comments and that she contacted police the next day. The administrator stated he became aware of the allegation on October 24, 2025 and acknowledged that it should have been reported. The DON stated that all allegations of abuse should be reported to the State Survey Agency within two hours and that allegations of rape would be considered a verbal threat and should be reported. The facility policy also stated that allegations of abuse are to be reported within 2 hours from the time the facility is made aware.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report documents that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's responsibility to ensure resident safety and well-being. No specific details about the residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Prevent Accidents During Hoyer Transfer and Wheelchair Use
Penalty
Summary
A deficiency occurred when the facility failed to prevent accidents and provide adequate supervision for a resident with severe cognitive impairment and multiple comorbidities, including dementia, diabetes, and chronic kidney disease. The resident required a hoyer lift for transfers and was known to exhibit behavioral disturbances, such as moving and yelling during care. Despite these known behaviors, there was no specific care plan addressing the resident's actions during hoyer transfers. During one transfer, the resident was moving and manipulating the sling straps, which resulted in a sling loop coming off the hook and the resident falling, sustaining significant injuries including head lacerations and fractures. Staff interviews revealed uncertainty about how the incident occurred, and there was no evidence of equipment malfunction or that staff failed to follow the two-person transfer policy, but the behavioral risks were not specifically addressed in the care plan. In a separate incident, the same resident, who was at risk for falls and known to wander and enter other residents' rooms, fell from a wheelchair and sustained fractures to the tibia and fibula. The care plan included general fall prevention interventions and the use of a Roho cushion to minimize falls, but did not specify the level or timing of supervision required. On the day of the fall, the resident was found alone in another resident's room, having slid out of the wheelchair along with the cushion. Staff interviews indicated that the cushion may have contributed to the fall, especially since there were two cushions present and only one piece of non-slip material (dycem) was used, which was insufficient to prevent sliding. The resident's tendency to wander and require frequent supervision was known, but the care plan lacked clear directives on supervision frequency or intensity. The facility's policies required thorough investigation and reporting of accidents, as well as individualized fall prevention plans based on assessment. However, the incident reports for both accidents were not made available for review, and staff interviews indicated a lack of clarity regarding the circumstances of the incidents and the interventions in place at the time. There was no evidence that the facility had implemented specific behavioral or supervision interventions tailored to the resident's known risks during transfers or while using the wheelchair, contributing to the occurrence of both accidents and resulting injuries.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect the rights of multiple residents to be free from physical abuse by other residents. Several incidents were documented in which residents engaged in physical altercations, resulting in substantiated cases of resident-to-resident abuse. In one case, a resident with a history of major depressive disorder, anxiety, and dementia became physically aggressive with her roommate following a dispute over bathroom use. Staff witnessed the resident strike her roommate multiple times on the back of the head, and the incident was confirmed through interviews and facility investigation. The care plans for both residents included interventions for behavioral issues, but the altercation still occurred, indicating a failure to prevent abuse. Another incident involved a resident with epilepsy and mood disorder who reported being slapped in the face by another resident during a disagreement on the smoking patio. Witnesses, including another resident, corroborated the account, stating that the aggressor used a partially closed hand to hit the victim twice. The aggressor, who had a history of bipolar disorder and severe cognitive impairment, did not recall the event. Staff interviews confirmed that the aggressor had recently exhibited increased aggression and had been moved to another unit due to these behaviors. The facility's investigation, supported by camera footage, substantiated the physical abuse. A further event involved the same aggressive resident physically assaulting another resident during an argument over the placement of an ashtray on the patio. The aggressor kicked the other resident and struck her with a smoking apron, as witnessed by staff and confirmed by the facility's investigation. The care plans for the involved residents included interventions for managing behavioral problems, but these measures did not prevent the incidents of abuse. The facility's policy states that residents have the right to be free from abuse, but the documented events demonstrate that this right was not upheld in these cases.
Failure to Provide Timely Incontinence Care for Dependent Resident
Penalty
Summary
A deficiency occurred when a resident with multiple complex medical conditions, including morbid obesity, immobility, and incontinence, did not receive timely incontinence care as required by her care plan and facility policy. The resident was dependent on staff for activities of daily living, including toileting and personal hygiene, and was at risk for pressure ulcers. Despite a care plan intervention to provide peri-care after each incontinent episode and to check the resident every two hours, staff failed to provide incontinence care for an extended period during a shift. On the day of the incident, the resident was found in bed with a strong odor of urine, expressing discomfort and distress due to being unable to reposition herself and not having adequate space in her bed. The resident reported that staff had difficulty turning her and that she felt unsafe and uncomfortable. Staff interviews confirmed that the assigned CNA had not checked or changed the resident since the start of her shift, citing being busy with other duties and short staffing as reasons for the delay. The CNA acknowledged that the resident should have been checked every two hours but had not been able to do so. Interviews with nursing leadership confirmed that the facility's expectation was for incontinent residents to be checked every two hours, and that failure to do so did not meet facility standards. The facility's policy required providing necessary care to maintain personal hygiene for residents unable to perform activities of daily living independently. The lack of timely incontinence care was directly observed and confirmed by staff and leadership interviews, as well as by review of the resident's care plan and medical record.
Failure to Provide Bariatric Bed and Timely Pain Medication per Care Plan
Penalty
Summary
The facility failed to provide services and treatments according to the care plan and physician orders for a resident with multiple complex medical conditions, including morbid obesity, chronic pain, and opioid dependence. The care plan specified the need for a bariatric bed and scheduled opioid medication for pain management. Despite a STAT order for a bariatric bed, the facility was unable to obtain the appropriate size bed due to insurance denial and supplier limitations. The resident was placed in a standard bariatric bed that was too small, limiting her ability to reposition and causing discomfort, as observed by staff and reported by the resident. Staff interviews confirmed the bed was insufficient for the resident's needs, and efforts to locate a suitable bed from other suppliers and facilities were ongoing but unsuccessful at the time of the survey. In addition to the bed issue, the facility did not ensure the resident received her scheduled long-acting opioid medication (Xtampza) as ordered. Documentation and staff interviews revealed that the medication was not pre-ordered in time, resulting in a missed dose. The process for obtaining a new prescription was delayed due to a lack of provider signature, and the medication was not available in the facility's medication dispensing system (PIXIS). The resident reported significant pain and distress due to the missed medication, and staff acknowledged the oversight in the medication ordering process. The resident expressed discomfort, pain, and emotional distress related to both the inadequate bed and the lack of scheduled pain medication. Observations noted the resident was unable to reposition herself, was at risk of skin breakdown, and experienced pain that was not managed according to her care plan. Staff interviews confirmed awareness of the deficiencies in both equipment provision and medication administration, and facility policies required adherence to care plans and timely medication ordering, which were not followed in this case.
Failure to Provide Timely Pain Medication Administration
Penalty
Summary
A resident with multiple chronic conditions, including chronic pain syndrome and opioid dependence, was admitted with orders for scheduled and as-needed opioid pain medications. The resident's care plan specified the need for timely administration of pain medications and immediate response to pain complaints. Despite these interventions, the resident did not receive her scheduled dose of Xtampza ER, a long-acting opioid, as ordered on the morning of March 18, 2025. Review of the Medication Administration Record showed that the last dose of Xtampza ER was given the previous night, and the morning dose was missed due to the medication not being available. Nursing staff interviews revealed that the medication had not been pre-ordered in time, and the required prescription had not been signed by the provider. The nurse on duty was aware of the need to reorder but did not obtain the necessary e-script or check the medication dispensing system (PIXIS) until after the missed dose. The resident reported significant pain and dissatisfaction with her care, stating she was in a lot of pain and had to wait for her medication due to the facility's failure to order it. Further interviews with nursing leadership confirmed that the process for reordering medications was not followed as expected. Staff acknowledged that the oversight in obtaining the provider's signature and checking medication availability led to the missed dose. Facility policy required timely assessment and management of pain, but the failure to administer the scheduled pain medication as ordered resulted in unmanaged pain for the resident.
Failure to Provide Designated Dining and Activity Room During Construction
Penalty
Summary
The facility failed to provide a designated room for resident dining and activities during a period of construction, resulting in the use of the dining room, activity room, day care room, and medical record room as temporary sleeping quarters for displaced residents. The dining room/activity room, which is typically used for meals and activities, was repurposed to accommodate ten resident beds, while the day care room and medical record room were used for seven additional residents. This arrangement left no dedicated space for communal dining or activities, and residents were instead served meals at their bedside tables within these makeshift sleeping areas. Staff interviews confirmed that the relocation was due to an emergency plumbing issue in one of the facility's locked units, necessitating the movement of residents to available spaces throughout the building. The rooms were cleared and cleaned to accommodate the residents, and privacy curtains and call bells were provided at each bedside. However, the lack of a designated dining or activity area persisted throughout the duration of the construction, with staff and residents reporting that meals and activities were conducted at the bedside. Some residents expressed awareness of the temporary arrangement and described eating and receiving care in these non-traditional settings. Clinical record reviews indicated that several residents involved were cognitively intact, as evidenced by their Brief Interview for Mental Status (BIMS) scores. Staff also reported that residents' personal belongings were stored in a maintenance area, which was observed to contain maintenance tools and housekeeping equipment. Facility policies reviewed by surveyors referenced the use of dining and activity rooms as safe areas during partial evacuations, but did not address the prolonged lack of a designated dining or activity space for residents during extended construction events.
Deficient Practice in Resident Relocation Following Plumbing Failure
Penalty
Summary
The facility failed to ensure a safe, sanitary, and homelike environment for residents after an emergency plumbing issue rendered one of the locked units uninhabitable. As a result, residents from the affected unit were relocated to various areas throughout the facility, including the dining/activity room, day care room, and medical record room. These rooms, not originally intended for resident accommodation, were repurposed to house multiple residents in close proximity, with beds, call bells, and privacy curtains set up as temporary measures. Staff interviews confirmed that the relocation was due to ongoing plumbing repairs, and that the dining room, typically used for meals and activities, was now occupied by ten residents, while the day care and medical record rooms housed additional residents. Observations and interviews revealed that residents were eating meals at their bedside tables, and some residents' personal belongings, such as clothing, were stored in a maintenance area that also contained housekeeping equipment and tools. The maintenance and housekeeping staff confirmed that this area was being used for temporary storage of residents' clothes. The rooms used for resident accommodation were measured, and it was noted that the dining room, day care room, and medical record room varied in size, with the dining room being the largest. Despite the presence of call bells and privacy curtains, the environment was not consistent with a typical resident room, and the arrangement impacted the residents' privacy and comfort. Multiple residents interviewed reported being relocated for at least a week, with some indicating they had been in the dining room for up to three weeks. Residents described eating at their bedsides, using shared bathrooms, and receiving care such as showers outside of the temporary rooms. Staff also reported challenges related to staffing and the use of these non-traditional spaces for resident care. Facility policies reviewed indicated procedures for sheltering in place and partial evacuation, but the actual implementation resulted in residents being housed in areas not designed for long-term accommodation, affecting the overall safety, sanitation, and homelike environment for the residents involved.
Failure to Prevent Resident-to-Resident Abuse Resulting in Injury
Penalty
Summary
The facility failed to protect two residents from abuse, resulting in an incident involving physical altercation between roommates. One resident, with diagnoses including schizoaffective disorder, dementia, and bipolar disorder, reported being slapped in the face and having her right index finger grabbed and cut by her roommate. Clinical records confirmed a laceration to the resident's finger, and staff documentation indicated that the resident complained of being yelled at and physically assaulted by her roommate. The care plan for this resident identified behavioral risks and included interventions for managing behaviors, but the incident still occurred. The other resident involved, who had diagnoses of paranoid schizophrenia, dementia, PTSD, anxiety disorder, and bipolar disorder, was also part of the altercation. This resident had a history of behavioral symptoms, including delusions and social isolation, and had recently been moved to a new room due to a plumbing issue in the facility. Staff interviews and clinical notes indicated that the two residents engaged in yelling and blaming each other, with one resident claiming the other cut her own finger. The residents were separated after the incident, and 15-minute checks were initiated. Staff interviews revealed that abuse training included immediate separation of residents and prompt reporting of allegations. However, the incident was not witnessed by staff, and the altercation resulted in a physical injury. The facility's policies state that residents have the right to be free from abuse, but the failure to prevent the altercation and injury constituted a deficiency in protecting residents from abuse.
Failure to Administer Liquid Diet as Ordered
Penalty
Summary
The facility failed to administer a liquid diet order as prescribed by the physician for a resident with a history of dysarthria, paralysis of vocal cords, and dysphagia. The resident was readmitted with specific dietary orders for a pureed texture with honey/moderate thick consistency and required 1:1 assistance during meals to prevent aspiration. Despite these orders, during a dining observation, the resident was served liquids that were not prepared according to the prescribed consistency, leading to coughing and the need for further thickening of the liquid by the restorative nursing assistant. The resident's care plan highlighted a nutritional risk due to swallowing difficulties and required monitoring for aspiration. However, during the meal, the restorative nursing assistant altered the consistency of the resident's drink without a physician's order, which is against the facility's policy. The registered nurse confirmed that the resident was at risk for aspiration and was on antibiotics for aspiration pneumonia, emphasizing that any changes to the diet should be made only by qualified personnel like a speech therapist. Interviews with the Director of Nursing and the facility administrator revealed that the staff involved were not authorized to make changes to the resident's diet. The facility's policy mandates that therapeutic diets are prescribed by the attending physician and should not be altered without proper evaluation and orders. The incident demonstrated a failure to adhere to these protocols, potentially compromising the resident's safety and health.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to protect two residents from abuse, resulting in a deficiency. Resident #8, who was severely cognitively impaired, was involved in an altercation with Resident #26, who was cognitively intact. Resident #8 was intrusive with Resident #26's belongings, leading to a verbal and physical confrontation. Resident #26 admitted to hitting Resident #8 in the face, resulting in a black eye. The facility's documentation and staff interviews revealed a lack of adequate intervention to prevent the altercation, despite prior warnings from Resident #8's daughter about potential behavioral issues. In another incident, Resident #12, who was cognitively intact, experienced verbal abuse from an LPN, identified as Staff #1. The resident was observed crying in the hallway after being called derogatory names by Staff #1. The social work assistant confirmed the verbal abuse and noted previous instances of aggression between Resident #12 and Staff #1. Despite discussions in interdisciplinary team meetings about separating the resident and staff, no changes were made to the care plan to prevent further incidents. The facility's policy on abuse prevention emphasizes the right of residents to be free from abuse and the need for adequate oversight to prevent such incidents. However, the facility failed to implement these policies effectively, as evidenced by the incidents involving Residents #8 and #12. The lack of timely and appropriate interventions contributed to the abuse and neglect of these residents, highlighting deficiencies in the facility's care and oversight practices.
Failure to Provide Timely Care Leads to Amputation
Penalty
Summary
The facility failed to provide care and treatment according to professional standards of practice for a resident, resulting in the hospitalization and subsequent amputation of the resident's leg. The resident, who had a history of diabetes mellitus and other conditions, was noted to have swelling and redness in the right leg, which was not promptly reported or adequately addressed by the facility staff. Despite the presence of symptoms indicative of a serious condition, such as cellulitis, the facility did not ensure timely communication of lab results to the provider, leading to a delay in appropriate medical intervention. The resident's clinical records showed multiple instances where swelling and redness were observed, but there was a lack of documentation and follow-up on these findings. The facility's staff, including CNAs and LPNs, failed to report significant changes in the resident's condition, such as the swelling and redness of the leg, to the attending physician or nurse practitioner in a timely manner. This oversight was compounded by the failure to review and act upon critical lab results that indicated a severe infection, which were only addressed five days after they were obtained. Interviews with facility staff revealed systemic issues in communication and documentation, with staff members acknowledging the delay in reporting lab results and the inadequacy of the initial treatment plan. The NP expressed concerns about the lack of notification regarding lab results and the presence of hardware in the resident's leg, which was only discovered at the hospital. The facility's policies on change in condition and wound care were not adhered to, contributing to the resident's deteriorating condition and eventual need for amputation.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 291 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
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
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) |
|---|---|---|---|---|
| South Mountain Post Acute | 0.6 mi | ★★★★★ | 1 | 0 |
| Resolve Harmony Center, Llc | 3 mi | ★★★★★ | 26 | 0 |
| Haven Health Sky Harbor, Llc | 6.2 mi | ★★★★★ | 6 | 0 |
| Ahwatukee Post Acute | 6.3 mi | ★★★★★ | 0 | 0 |
| Desert Terrace Healthcare Center | 7.9 mi | ★★★★★ | 7 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Desert Peak Care Center.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.