Cascades at Desert View

In the surveyor’s words

From the most serious findings on record at Cascades at Desert View, in the surveyor’s own words.

• Actual harm, isolatedF600May 31, 2024

  Based on policy review, record review, and staff interview, it was determined the facility failed to ensure residents' rights were protected to be free from neglect. This was true for 2 of 2 residents (#191 and #192) reviewed for neglect. This failure caused physical harm to Resident #191 when she suffered a cut to her lower left leg and to Resident #192 when her thighbone was fractured. Findings include: The facility's Abuse policy, undated, documented Residents are to be free from abuse, neglect, misappropriation of resident property, and exploitation. […]

• Actual harm, isolatedF686Mar 4, 2021

  Based on record review, staff interview, and review of facility policy, it was determined the facility failed to assess and provide treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #1 was harmed when facility nurses did not assess or obtain a treatment order on 12/26/20 for a superficial pressure ulcer located on her coccyx (tailbone) until 1/18/21 and the pressure ulcer worsened to an unstageable pressure ulcer (full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar [dead tissue]). […]

• No harm, potential for more than minimal, widespreadF585May 15, 2026

  Based on review of the Grievances, Resident Council Meeting minutes, resident's interview, review of records, policy review, and staff interview, it was determined the facility failed to ensure grievances were responded to and investigated. This was true for 2 of 2 residents (#5 and #25) reviewed for grievances. This failure created the potential for psychosocial harm if residents' grievances were not acted upon. Findings include:The facility's Grievances policy dated 10/2024, documented the Administrator was the Grievance Officer. […]

• No harm, potential for more than minimal, widespreadF727May 15, 2026

  Based on record review, policy review, and staff interview, it was determined the facility failed to ensure sufficient RN services at least eight consecutive hours per day, every 24 hours, seven days a week, as required. This failure had the potential to affect all residents in the facility who may require higher level of nursing assessment and intervention. Findings include: The facility policy titled Staffing, Sufficient and Competent Nursing, revised August 2022, documented, a registered nurse provides services at least eight consecutive hours every 24 hours, seven days a week. Review of the facility's three-week nursing schedule dated 4/19/26 through 5/10/26, documented the facility did not provide 8 consecutive hours of registered professional nursing coverage on: 5/9/26. […]

• No harm, potential for more than minimal, widespreadF804May 15, 2026

  Based on observation, FDA 2022 Food Code, and resident and staff interviews, it was determined the facility failed to ensure resident meals were palatable and maintained their correct temperature. This directly impacted all residents who dined in the facility. This failed practice had the potential to negatively affect residents' nutritional status and psychosocial well-being. Findings include:The FDA food Code Section 3-501.16 Time/Temperature Control for Safety Food, Hot and Cold Holding documented bacterial growth and/or toxin production can occur if time/temperature control for safety food remains in the temperature Danger Zone of 5 degrees C to 57 degrees C (41 degrees F to 135 degrees F) too long. […]