Desert Peak Care Center

Based on staff interviews, facility documentation, and a policy review, the facility failed to implement its abuse policy by not reporting an allegation of abuse involving two residents (#5 and #10) to the State Agency.

Based on clinical record review, interviews, and policy and procedures, the facility failed to ensure that an allegation of verbal abuse, for one resident (#5), was reported to the State Survey Agency within the required timeframe.

Based on staff interviews, facility documentation, and a policy review, the facility failed to implement its abuse policy by not reporting an allegation of abuse involving two residents (#5 and #10) to the State Agency. The deficient practice could result in further incidents of abuse.

Based on clinical record review, interviews, and policy and procedures, the facility failed to ensure that an allegation of verbal abuse, for one resident (#5), was reported to the State Survey Agency within the required timeframe.

Violation cited

Violation cited

Violation cited

Violation cited

Violation cited

Based on a record review and staff interviews, the facility failed to participate in drills as required. Failure to participate in drills may lead to untrained staff in an emergency and may result in harm to the residents during an emergency. Findings include: During the document review on January 23, 2025, it was revealed the facility was missing documents proving participation in a full-scale exercise (FSE) that was community-based, tabletop drills or a facility based full scale exercise within the last year. During the exit conference on January 23, 2025, facility management confirmed the facility could not provide proof of participation in a full-scale exercise that was community-based. or a facility based full scale exercise within the last year.

Based on observation the facility failed to maintain several doors in the building. Failing to maintain doors in the facility could allow heat and/or smoke to transfer which will cause harm to the patients and/or staff. NFPA 101, Life Safety Code, 2012 edition, Chapter 19, Section 19.3.6.3.5. "Doors shall be provided with a means for keeping the door closed that is acceptable to the authority having jurisdiction." NFPA 80 2010 edition, Chapter 5 Section 5.2.14 Maintenance of Closing Mechanisms. 5.2.14.1 Self-closing devices shall be kept in working condition at all times. Chapter 19, Section 19.3.6.3 Corridor Doors Section 19.3.6.3.1* Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas shall be substantial doors, such as those constructed of 1-3/4 inch solid-bonded core wood, or capable of resisting fire for at least 20 minutes. Doors in fully sprinklered smoke compartments are only required to resist the passage of smoke. Doors shall be provided with a means suitable for keeping the door closed. Findings include: Observations made while on tour on January 23, 2025, revealed the following: 1. Room 203 door is bowed from the handle to the top 1-inch gap. 2. Room 206 door \'bc inch gap at the top handle side. 3. Room 205 play in the door \'bd inch gap at the top. 4. Room 207 play in the door \'bc inch gap at the top. 5. Room 209 play in the door \'bc inch gap at the top. 6. Room 212 has gaps on both sides of the door as well as the top. 7. Room 211 play in the door 1/4/gap at the top of the door. 8. Room 213 has a gap at the top, can see light from the room. 9. Day room door at Victoria Lane missing door closure hardware as well gap at the top of the door, can see light from the room. 10. Room 216 has play in the door and \'bc in gap at the top. 11. Room 215 has a gap of \'bc inch at the top. 12. Room 218 the door drags at the bottom not allowing the door to close. 13. Room 222 play in the door, gap at the top and handle side of the door above the handle. 14. Room 306 gap at the top and side allowing light to come through. 15. Room 305 gap at the top and side allowing light to come through. 16. Room 308 the door frame is splitting top handle side. 17. Room 309 door will not close due to dragging on the floor. 18. Room 316 door handle coming apart will not secure. 19. Room 318 gap at the top handle side. 20. Room 31 gap along the top of the door. 21. Room 33 door will not close, drags on the floor. 22. Room 21 gap at the top handle side, allowing light to come through. 23. Room 101 gap at the top of the door allowing light to come through. 24. Room 107 gap at the top handle side, play in the door. 25. Room 109 gap at the top handle side, play in the door. 26. Room 112 gap at the top handle side, play in the door. 27. Room 111 gap at the top handle side, play in the door. The management team acknowledged during the facility tour and exit conference on January 23, 2025, the door deficien

Based on observation the facility failed to fill penetrations in four (4) of the smoke barriers in the facility. Failing to seal the penetrations, holes, and openings in the smoke barriers will allow smoke and heat to penetrate other wings or possibly the whole facility which could cause harm to the patients in the time of a fire. NFPA 101 Life Safety Code, 2012, Chapter 19, Section 19.3.7.3 "Any required smoke barrier shall be constructed in accordance with Section 8.5 and shall have a fire resistance rating of at least \'bd hour." Chapter 8, Section 8.5.6.2 Penetrations for cables cable trays, conduits, pipes, tubes, vents wires and similar items to accommodate electrical, plumbing and communications systems that pass through a wall, floor or /ceiling assembly constructed as a smoke barrier, or through the ceiling membrane of the roof /ceiling of a smoke barrier assembly shall be protected by a system or material capable of restricting the transfer of smoke. Findings include: Observations made during a facility tour conducted on January 23, 2025, revealed that the facility failed to maintain the fire/ smoke barrier in the following areas: 1. Penetrations along the wall at room 205 as well as large squares cut in the drywall ceiling above the ceiling tiles measuring approximately 12" x 12" on both sides of the 90-minute doors. 2. Penetration to the wall above the ceiling tile at room 222. 3. Penetration (large holes) to the drywall ceiling above the ceiling tile at room 318. 4. Penetration (large holes) to the drywall ceiling above the ceiling tile outside of the staffing office. 5. Penetration (large holes) to the drywall ceiling above the ceiling tile outside of the maintenance storage room. 6. Wall penetration from the hot water heater room into the laundry room. 7. Wall penetration wall penetration at the door magnet by room 32. The management team acknowledged the wall/ceiling penetrations during the facility tour and during the exit conference on January 23, 2025.

Based on observation, the facility failed to provide a protective guard on light bulbs located throughout the facility and area with exposed wiring. Failure to keep light guards on the light bulbs and ensure all electrial wiring is covered could cause accidental damage or possibly a fire, which could cause harm to the patients. NFPA 101 Life Safety Code, 2012, Chapter 19, Section 19.5.1, "Utilities shall comply with the provisions of Section 9.1. Section 9.1.2, "Electrical wiring and equipment installed shall be in accordance with NFPA 70, 2011 Edition, "National Electrical Code." NEC, 2011, Article 110, Section 110-27 (b) Prevent Physical Damage." In locations where electric equipment is likely to be exposed to physical damage, enclosures or guards shall be so arranged and of such strength as to prevent such damage. NFPA 70, 2011 Edition Chapter 1 General "110.27(A) Live Parts Guarded Against Accidental Contact. Except as elsewhere required or permitted by this Code, live parts of electrical equipment operating at 50 volts or more shall be guarded against accidental contact by approved enclosures or by any of the following means: (1) By location in a room, vault, or similar enclosure that is accessible only to qualified persons. (2) By suitable permanent, substantial partitions or screens arranged so that only qualified persons have access to the space within reach of the live parts. Any openings in such partitions or screens shall be sized and located so that persons are not likely to come into accidental contact with the live parts or to bring conducting objects into contact with them Findings include: During the facility tour conducted on January 23, 2025, it was revealed the light bulbs in the following areas were missing covers: 1. The soiled utility room in the Victoria Lane area is missing light covers. 2. The laundry room closet is missing light covers. 3. The social services storage room is missing light covers. 4. The soiled utility room in the Apache area is missing light covers. The facility tour also revealed exposed wiring in the following locations: 1. The mechanical room across from the clean linen in the Rio unit had electrical equipment with exposed wiring. 2. The area above the ceiling tile at room 318, j-box missing cover. The management team confirmed during the exit conference conducted on January 23, 2025, that the facility was missing the protective covers over the lights in various rooms throughout the facility and the exposed wiring.

Based on observation and staff interviews, the facility failed to ensure that a remote stop or kill switch for the generator was installed. This could affect the entire facility and could result in a loss of power due to a generator malfunction during an emergency power outage. Failure to have an emergency stop on the generator could cause a fire or harm the residents and staff. Code reference: NFPA 110 2010 Edition; Standard for Emergency and Standby Power Systems 5.6.5.6 All installations shall have a remote manual stop station of a type to prevent inadvertent or unintentional operation, located outside the room housing the prime mover, where so installed, or elsewhere on the premises where the prime mover is located outside the building. A.5.6.5.6 For systems located outdoors, the manual shut-down should be located external to the weatherproof enclosure and should be appropriately identified. Findings include: During observations during a tour conducted on January 23, 2025, it was revealed that the facility's generator did not have the required remote stop or kill switch. The management team acknowledged the deficiency on the facility tour and the exit conference on January 23, 2025.