Desert Peak Care Center
DESERT PEAK CARE CENTER in PHOENIX, AZ — inspection on November 20, 2025.
Found 2 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
#150 responded, Yes, for the incident that happened on 11/16/25.Review of a policy revised in December 2016 titled Abuse Policy revealed a definition of abuse being the willful infliction of injury with resulting physical harm, pain, or mental anguish.
The policy further revealed that as part of the residents' abuse prevention, administration would protect their residents from abuse by anyone including, but not necessarily limited to, facility staff, other residents, consultants, volunteers, staff from other agencies, family members, legal representatives, friends, visitors, or any other individual.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
11/20/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Desert Peak Care Center
8825 South 7th Street Phoenix, AZ 85042
SUMMARY STATEMENT OF DEFICIENCIES
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Based on staff interviews, the facility failed to ensure that internal investigation documents were made available to the State Agency, as required, during the survey process.
This failure impeded the State's ability to confirm the findings of the investigations and QAPI processes for an abuse allegation between residents (#1,#5,#10,#15 & #20).Findings Include:A formal written request for the incident reports involving residents #1,#5, #10, #15, and #20 were submitted to the facility on November 19, 2025.During an interview conducted on November 20, 2025, at 1:18 PM, with the Administrator (Staff # 140) and Director of Nursing (DON / Staff #150), the Administrator stated that the facility's incident reports were internal PCC documents and for internal use only.
The Administrator explained that these reports were not shared with surveyors or any outsiders, noting that their sister facilities also didn't show the incident reports and that this practice was standard in the industry.Staff #140 further elaborated that incident reports were used internally to keep track of stuff, to fix stuff, to be aware of stuff, but it was not something that they shared with outsiders.
The Administrator adamantly stated, We cannot share those documents even for the Department of Health.
The staff # 140 reported that the facility provided progress notes, care plans, and other clinical information, but not incident reports.During the same interview, the staff #150 corroborated staff #140's statement , stating she had to side with the Administrator on that one because it was an internal document, and confirmed that the facility did not provide incident reports to surveyors.A signed memorandum by Staff #140 dated November 19, 2025 stated that the facility considered incident reports to be internal documents and, as such, do not share those documents with anyone who was not an employee of their company.The policy titled Designated Record Set Policy and Procedure, revised in 2025, indicated that the facility would provide personal health records that excluded incident reports.
Review of the State Operations Manual revised July 9, 2025 indicated that incident and accident reports, wound logs, infection control logs, and other reports or records used to track adverse events were not protected from disclosure and could be requested by surveyors.
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