Desert Terrace Healthcare Center

In the surveyor’s words

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

• Actual harm, isolatedF600Dec 3, 2025

  Based on clinical record review, staff interviews, and review of facility documentation and policies, the facility failed to protect the rights of one resident (#1) to be free from abuse by another resident (#2). The deficient practice could result in further abuse of residents when appropriate actions are not taken.Findings Include:-Resident #1(alleged victim) was readmitted to the facility on [DATE], with diagnoses that included hemiplegia and hemiparesis of the left non-dominant side, major depressive disorder, and age-related bilateral cataract.The census report revealed that Resident #1 shared the same room with Resident #2 since September 26, 2025.A review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of… […]

• No harm, potential for more than minimal, patternF755Jan 16, 2024

  Based on observations, staff interviews, facility documents, and resident records, the facility failed to ensure 3 residents received medications in a timely manner. The sample size was 3. Findings include: 1) Resident #7 admitted to the facility on [DATE] with diagnoses that Osteomyelitis, Atherosclerotic Heart Disease, Anxiety Disorder, and Depression. According to the Minimum Data Set assessment completed on 12/29/2023, the Brief Interview for Mental Status revealed a score of 15 with suggested he was cognitively intact. He has an order dated 1/22/2024 for Ceftaroline Fosamil Intravenous Solution 600 MG (milligrams) intravenously two times a day for an infection of prosthetic knee joint. Review of his Medication Administration Report for January 2024, does not show any missed doses. […]

• No harm, potential for more than minimal, patternF676Sep 9, 2022

  Based on clinical record reviews, staff interviews and facility policies and procedures, the facility failed to ensure two residents (#116 and #121) were provided with showers or bathing. The sample size was 4. The deficient practice could result in residents' hygiene needs not being met. Findings include: The facility's bathing schedule revealed that showers are provided twice a week and residents receive showers based on their room numbers. The facility's skin observation- shower sheet included instruction to complete all bath or shower days. There was a section for comments and staff signatures. -Resident #116 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . […]

• No harm, potential for more than minimal, patternF677Sep 9, 2022

  Based on clinical record review, facility documentation, resident and staff interviews, and policies and procedures, the facility failed to ensure bathing or showers were consistently provided to one resident (#31). The sample size was 4. The deficient practice could result in hygiene needs not being met. Findings include: Resident #31 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Staff Assessment for Mental Status that the resident was independent of cognitive skills for daily decision making. […]

• No harm, potential for more than minimal, patternF686Sep 9, 2022

  Based on clinical record reviews, staff interviews, and facility policies and procedures, the facility failed to ensure care and services related to pressure ulcers were consistently provided to two residents (#124 and #125). The sample size was 3. The deficient practice could result in residents not receiving appropriate treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] Findings include: -Resident #124 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The care plan dated December 16, 2021 included the resident having pressure ulcer development related to limited mobility, weakness, full thickness wounds. […]