Desert Peak Care Center
DESERT PEAK CARE CENTER in PHOENIX, AZ — inspection on November 19, 2025.
Found 3 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
responded by throwing pieces of candy at Resident #3 and ultimately swatted at Resident #3 with an open hand. Resident #3 swatted back at Resident #5 with an open hand; however, a CNA separated Residents #3 and #5 before the altercation could escalate.
Staff #34 stated that they assisted another ADON (Staff #23) with the investigation, during which both residents were assessed for injuries, and complete skin checks were conducted, revealing no evidence of injuries or skin concerns.
Staff #34 stated that following the incident, Resident #5 was moved to another unit.
Interviews with both Resident #3 and #5 had been conducted, as well as interviews with other residents and the staff in the unit.
Staff #34 stated that their conclusion of the investigation is that a resident-to-resident altercation did occur, which began when Resident #5 threw candy at Resident #3.An interview was conducted on October 7, 2025, at 3:59 PM, with the Administrator (Staff #30), the Director of Nursing (Staff #20), and an Administrator in Training (Staff #28).
The Administrator stated that the facility provides training and education regarding what abuse is, how to identify abuse, and what to do if abuse or neglect is identified.
The Administrator also stated that abuse and neglect training also included an overview of the Elder Justice Act and the facility process as a witness to alleged abuse or neglect.
Regarding the incident between Residents #3 and #5, Staff #34 stated that the allegation of resident-to-resident abuse was substantiated following a review of the collected evidence, which was compiled by Staff #23 (ADON) and Staff #34 (ADON).A review of a facility policy titled Abuse Policy revealed that the resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation.
The policy also defined abuse as the willful infliction of injury, unreasonable confinement, or punishment that can have the result of physical harm, pain, or mental anguish or deprivation.
The policy also revealed that incidents of abuse or allegations of abuse, including but not limited to resident-to-resident altercations, are to be reported within two hours from the time the facility is made aware of the incident.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
11/19/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Desert Peak Care Center
8825 South 7th Street Phoenix, AZ 85042
SUMMARY STATEMENT OF DEFICIENCIES
abuse should be reported to the state agency within two hours.
Staff #32 stated that allegations of rape would be considered a verbal threat and should be reported, and the risk of not reporting can cause more harm to the resident.
Review of the facility policy titled Abuse Policy states, Our residents have the right to be free from abuse, neglect, misappropriation of resident property, and exploitation.
This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, neglect, deprivation of goods or services, or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms.3.
Develop and implement policies and procedures to aid our facility in preventing abuse, neglect, or mistreatment of our residents.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
11/19/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Desert Peak Care Center
8825 South 7th Street Phoenix, AZ 85042
SUMMARY STATEMENT OF DEFICIENCIES
state agency within two hours.
Staff #32 stated that allegations of rape would be considered a verbal threat and should be reported, and the risk of not reporting can cause more harm to the resident.
Review of the facility policy titled Abuse Policy states, Our residents have the right to be free from abuse, neglect, misappropriation of resident property, and exploitation.
This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, neglect, deprivation of goods or services, or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms.6.
Identify and assess all possible incidents of abuse or allegations of abuse, including but not limited to are to be reported within 2 hours from the time the facility is made aware.
Facility ID: