The woman had lived in her previous room for over a year before Desert Canyon Post Acute staff informed her in April that she needed to move because they were converting her room into an isolation unit. She received no written explanation for the transfer and no orientation to her new accommodations.
"The facility did not orient her in her new room and Resident 1 was having a hard time to maneuver in the bathroom, room, and keep bumping to her extra dresser because her closet was too small compared to her previous room and she was blind," federal inspectors wrote after interviewing the woman on April 24.
The resident told inspectors she felt the facility didn't care about her, knowing she was blind yet placing her in the most remote location. She said she was upset about the room change and found the space too small for herself and her roommate.
Two other residents described similar experiences during the same inspection. One woman said staff "came in our room and telling us that they are moving us and did not even ask me anything." She told inspectors the move made her feel horrible and "felt like they just threw us in the other room like a garbage."
That resident said she never received any written documentation explaining the room change and "did not practice her right to make a decision for herself."
A third resident complained about her roommate being loud at night. Her family called the facility about the issue. Staff responded by informing the complaining resident that "whoever is the complainant they are the one who needs to be moved."
"Resident 3 stated she felt she was forced to moved and felt it was unfair and left her with no choice," inspectors documented.
None of the three residents received written notifications explaining their room changes, despite facility policy requiring such documentation.
During interviews with administrators, the Social Service Director acknowledged that she "did not provide any written notification indicating the reason of the room change to the residents or responsible party."
The Director of Nursing admitted the facility's room change policy failed to meet federal requirements. After reviewing state guidance requiring written explanations when residents are moved at staff request, the nursing director said "the facility's policy and procedures did not indicate that resident must receive an explanation in writing of why the move is required as indicated in the State Operation Manual guidance."
She said the policy would need to be reviewed and updated by the governing body to comply with regulations.
The inspection also revealed blocked emergency exits and cluttered hallways that could delay care during emergencies. On April 25, inspectors observed a Hoyer lift parked directly in front of an emergency exit door in Station A. An emergency crash cart sat beside a utility room, and two wheelchairs were parked between the right side of the hallway.
A Licensed Vocational Nurse accompanying the inspectors stated the Hoyer lift should not block the emergency exit. She said wheelchairs and carts should be parked on one side of hallways only, noting that the equipment was "blocking the hallways and exit door and could cause delay in the care of the residents during an emergency."
The Director of Nursing agreed, telling inspectors "the emergency exit should not be blocked because the residents possibly will not be able to go out during an emergency."
Desert Canyon Post Acute admitted its first resident in November 2022. The facility's policy on safe environments states that residents have "a right to a safe, clean, comfortable, and homelike environment" and that "the physical layout of the facility maximizes resident independence and does not pose a safety risk."
The three residents who spoke with inspectors all had intact thought processes according to their assessments. One was diabetic, another had suffered a stroke, and the third had been treated for a urinary tract infection. All required varying levels of assistance with daily activities like bathing and dressing.
The blind resident who was moved to the back of the building continues to struggle with her smaller closet space and bumps into furniture while trying to navigate her new room.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Desert Canyon Post Acute, LLC from 2025-04-25 including all violations, facility responses, and corrective action plans.
Additional Resources
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