Desert Peak Care Center

In the surveyor’s words

From the most serious findings on record at Desert Peak Care Center, in the surveyor’s own words.

• Actual harm, isolatedF600Apr 17, 2026

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

• Actual harm, isolatedF689Apr 14, 2025

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

• Actual harm, isolatedF684Jul 1, 2024

  Based on clinical record review, resident and staff interviews, and facility documentation and policy, the facility failed to ensure care and treatment according to professional standards of practice was provided to one resident (#1). The deficient practice resulted in the hospitalization of the resident and amputation of his leg. Findings include: Resident #1 was admitted on [DATE] with diagnoses of borderline personality disorder, obsessive-compulsive disorder, epilepsy, and an anxiety disorder. Review of the clinical record revealed documentation that the resident was in a car accident, had metal pieces in his left foot; and that, in October and November of 2019, he was again noted to be limping and complaining of pain to right lower leg. […]

• Actual harm, isolatedF689Mar 31, 2023

  Based on clinical record reviews, staff interviews, facility documentation, policy and procedures, the facility failed to ensure adequate supervision was provided for 1 of 3 sampled residents (#12) to prevent elopement; and, failed to ensure safety while providing care resulting to a fall for 1 of 3 sampled residents (#11). The deficient practice could result in avoidable accidents. Findings include: -Regarding Resident #11 Resident #11 was admitted on [DATE] with diagnoses of muscle weakness, history of falling, abnormal posture, anxiety disorder and mood disorder. A care plan initiated on April 10, 2017, revealed resident had self-care deficit. […]

• Actual harm, isolatedF600Feb 24, 2023

  Based on clinical review, staff and resident interviews, and the policy and procedures of the facility, the facility failed to ensure two residents (#3 and #8) were not abused by another resident (#12). The deficient practice could result in other residents being abused. Findings include: -Resident #3 was admitted to the facility on [DATE] with diagnoses that included Alzheimer disease with early onset, anxiety, and a traumatic brain injury. The Minimum Data Set (MDS) dated [DATE] included a staff assessment mental status score of 3 indicating the resident had a severe cognitive impairment. Review of the care plan dated January 23, 2023 revealed the resident had the potential for skin tears. On January 22, 2023, the resident had left shoulder swelling and abrasion of the left trapezium. […]