Inspection Reports for
Desert Terrace Healthcare Center
2509 N 24th St, Phoenix, AZ 85008, United States, AZ, 85008
Back to Facility Profile36 Reports
Inspection Report — May 16, 2026
Complaint Investigation
Date: May 16, 2026
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On-site complaint investigation at a Nursing Care Institution conducted 16 May 2026.
Complaint Details
An offsite follow up survey was conducted on May 16, 2026. There were no deficiencies cited.
Findings
No deficiencies were found during this inspection.
Inspection Report — Apr 21, 2026
Complaint Investigation
Date: Apr 21, 2026
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On-site complaint investigation of complaints 00164710, 00164056, 00159842, 00159751, and 00158599 at a Nursing Care Institution, conducted 21 April 2026.
Complaint Details
An onsite complaint survey was conducted on April 21, 2026 for the investigation of intake # 00164710, 00164056, 00159842, 00159751, 00158599.
Findings
This inspection resulted in no deficiencies or citations.
Report Facts
Complaints investigated: 5
Inspection Report — Mar 23, 2026
Complaint Investigation
Date: Mar 23, 2026
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On-site complaint investigation at Desert Terrace Healthcare Center, a Nursing Care Institution, conducted 23 March 2026.
Complaint Details
An offsite follow up survey was conducted on March 23, 2026. There were no deficiencies cited.
Findings
The inspection found no deficiencies; all cited deficiencies had plans of correction provided and no evidence text was included.
Deficiencies (8)
R9-10-403 — No evidence was provided regarding policies and procedures to protect residents' personal accounts.
R9-10-403 — No evidence was provided regarding policies and procedures for physical and behavioral health services.
R9-10-403 — No evidence was provided regarding reporting suspected abuse, neglect, or exploitation of residents.
§483.10(f)(10) — No evidence was provided regarding residents' rights to manage financial affairs and facility fiduciary responsibilities.
§483.12(b) — No evidence was provided regarding policies to prohibit and prevent abuse, neglect, exploitation, and retaliation.
§483.12(c) — No evidence was provided regarding timely reporting and investigation of allegations of abuse, neglect, exploitation, or mistreatment.
§483.45(g) and §483.45(h) — No evidence was provided regarding proper labeling and secure storage of drugs and biologicals.
R9-10-421 — No evidence was provided regarding policies for receiving, storing, inventorying, tracking, dispensing, and discarding medication.
Report Facts
Deficiencies cited: 8
Inspection Report — Mar 6, 2026
Complaint Investigation
Date: Mar 6, 2026
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On-site complaint investigation of complaints 00161002 and 00161246 at a Nursing Care Institution, conducted 6 March 2026.
Complaint Details
This complaint survey was conducted on March 6, 2026 with the investigation of complaints: 00161002 and 00161246. No deficiencies were cited.
Findings
No deficiencies were cited during this complaint investigation.
Report Facts
Complaints investigated: 2
Inspection Report — Feb 20, 2026
Complaint Investigation
Date: Feb 20, 2026
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On-site complaint investigation of complaints 00159376 and 00159526 at a Nursing Care Institution, conducted 20 February 2026.
Complaint Details
An onsite complaint survey was conducted on February 20, 2026, for the investigation of intake #00159376 and 00159526. There were no deficiencies cited.
Findings
No deficiencies were cited during this complaint investigation.
Report Facts
Complaints investigated: 2
Inspection Report — Feb 17, 2026
Enforcement
Date: Feb 17, 2026
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Civil monetary penalty, action 00159442 (invoice INV-326679), assessed 17 February 2026.
Findings
A $1,000.00 penalty was assessed and paid in full on 17 March 2026.
Report Facts
Penalty amount: 1000
Amount paid: 1000
Amount remaining: 0
Inspection Report — Jan 22, 2026
Complaint Investigation
Date: Jan 22, 2026
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On-site complaint investigation of multiple complaints including 2723194, 2723177, 00156499, and others at a Nursing Care Institution, conducted 20 through 22 January 2026.
Complaint Details
A complaint survey was conducted from January 20 through January 22, 2026 for the investigation of multiple intake numbers including 2723194, 2723177, 00156499, 00156517, 00156516, 00156504, 00156508, 00156487, 00156486, 00156481, 00156483, 00156480, 00156523, 00156522, 00156524, 00156515, 00156514, 00156484, 00156495, 00156669, 00154587, 00154905, 00155779, 00141988, 00147859, 00148404, and 00155826. Federal comments also referenced investigations of additional intake numbers.
Findings
The inspection found eight deficiencies related primarily to failures in safeguarding residents' personal funds, implementing policies to prevent financial misappropriation, reporting alleged violations, and medication storage practices.
Deficiencies (8)
R9-10-403 — The facility failed to ensure that safeguarding of personal funds included a system of written authorization for Resident #8.
R9-10-403 — The facility failed to ensure policies prohibiting financial misappropriation were implemented for Resident #8.
R9-10-403 — The facility failed to ensure that alleged violations concerning financial misappropriation were reported in accordance with state law for Resident #8.
The facility failed to ensure that safeguarding of personal funds included a system of written authorization for Resident #8, risking verbal monetary agreements that hinder identification and investigation of financial misappropriation.
§483.12(b) — The facility failed to ensure policies prohibiting financial misappropriation were implemented for Resident #8, risking lack of measures to prevent financial misappropriation.
§483.12(c) — The facility failed to ensure that alleged violations concerning financial misappropriation were reported in accordance with state law, risking continued financial abuse to residents.
§483.45(g)–(h) — The facility failed to ensure that medications were not left at the bedside for one Resident #12, risking harm to residents and visitors.
R9-10-421 — The facility failed to ensure that medications were not left at the bedside for one Resident #12.
Report Facts
Deficiencies cited: 8
Inspection Report — Dec 23, 2025
Date: Dec 23, 2025
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On-site inspection of type Other at a Nursing Care Institution conducted 23 December 2025.
Findings
The inspection found two deficiencies related to fire safety and door maintenance. The facility failed to maintain several doors properly and did not provide all required fire drills per NFPA 101.
Deficiencies (2)
Corridor doors were not properly maintained, which could allow heat and/or smoke to transfer and potentially harm patients and staff.
The facility failed to provide all required fire drills per NFPA 101, which could result in harm to residents and staff during an actual fire or emergency.
Report Facts
Deficiencies cited: 2
Inspection Report — Dec 11, 2025
Complaint Investigation
Date: Dec 11, 2025
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On-site complaint investigation of complaints 00152828, 00151887, 00152760, 2688813, and 2679742 at a Nursing Care Institution, conducted 11 December 2025.
Complaint Details
The onsite complaint survey was conducted on December 11, 2025, and investigated complaints #00152828, 00151887, 00152760, 2688813, and 2679742. There were no deficiencies noted.
Findings
This inspection resulted in no deficiencies or citations.
Report Facts
Complaints investigated: 5
Inspection Report — Dec 3, 2025
Complaint Investigation
Date: Dec 3, 2025
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On-site complaint investigation of complaints 00146911, 00148203, 00146910, 00148195, 2646882, 2646902, 2635480, and 2635499 at a Nursing Care Institution, conducted 3 December 2025.
Complaint Details
The onsite complaint survey was conducted on October 22, 2025, for complaints # 00146911, 00148203, 00146910, and 00148195. The onsite complaint was conducted on October 22, 2025, for complaints # 2646882, 2646902, 2635480, and 2635499.
Findings
The inspection found two deficiencies related to the facility's failure to protect a resident from abuse by another resident. Plans of correction were provided for both deficiencies.
Deficiencies (2)
§483.12 — The facility failed to protect the rights of one resident (#1) to be free from abuse by another resident (#2), risking further abuse when appropriate actions were not taken.
R9-10-410 — The administrator failed to ensure that a resident (#1) was not subjected to abuse by another resident (#2).
Report Facts
Deficiencies cited: 2
Complaints investigated: 8
Inspection Report — Sep 26, 2025
Annual Inspection
Date: Sep 26, 2025
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On-site complaint investigation and annual compliance survey conducted from September 23 to 26, 2025, at Desert Terrace Healthcare Center, involving multiple complaints including 2246263, 2246256, and 2246249.
Complaint Details
The State Compliance Survey was conducted in conjunction with complaints 2246263, 2246256, 2246249, 2246252, 2246260, 2245816, 2246207, 2246204, 2246205, 2246168, 2246184, 2246255, 2246185, 2246248, 2246231, 2246240, 2246172, 2246227, 2246215, 2246154, 2246201, 2246203, 2246197, 2246189, 2246009, 2245822, 2246187, 2246179, 2246178, 2245930, 2246175, 2246152, 2246138, 2246150, 2246146, 2246148, 2246134, 2246140, 2246141, 2246137, 2246133, 2246125, 2246123, 2246120, 2246111, 2246087, 2246116, 2246118.
Findings
The inspection found two deficiencies related to failure to provide nail care for two residents, which could affect resident grooming and hygiene needs.
Deficiencies (2)
§483.24(a)(2) — The facility failed to ensure nail care was provided for two residents (#18 and #28), risking unmet grooming and hygiene needs.
R9-10-414 — The facility failed to ensure nail care was provided for two residents (#18 and #28), compromising the residents' highest practicable well-being.
Report Facts
Deficiencies cited: 2
Complaints investigated: 48
Inspection Report — Sep 3, 2025
Complaint Investigation
Date: Sep 3, 2025
Visit Reason
On-site complaint investigation of complaints 2246113 (AZ00187655), 2246109 (AZ00187022), 00141173, 2246112 (AZ00187654), 2246109 (AZ00187022), and 2590994 at a Nursing Care Institution, conducted 3 September 2025.
Complaint Details
The state complaint survey was conducted on September 3, 2025 of the following complaint numbers: 2246113 (AZ00187655), 2246109 (AZ00187022), and 00141173. The complaint survey was conducted on September 3, 2025 of the following complaint numbers: 2246112 (AZ00187654), 2246109 (AZ00187022), 2590994. There were no deficiencies cited.
Findings
This inspection resulted in no deficiencies or citations.
Report Facts
Complaints investigated: 6
Inspection Report — Jul 8, 2025
Complaint Investigation
Date: Jul 8, 2025
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On-site complaint investigation of intakes 00134616, 00127092, 00130029, AZ00221345, AZ00224991, AZ00221337, AZ00224458 and AZ00224241 at a Nursing Care Institution, conducted 8 July 2025.
Complaint Details
A complaint investigation was conducted on July 8, 2025 through July 8, 2025 of intake# 00134616, 00127092, 00130029, AZ00221345. There were no deficiencies cited. A complaint investigation was conducted on July 8, 2025 through July 8, 2025 of intake# AZ00224991, AZ00221337, AZ00224458 and AZ00224241. There were no deficiencies cited.
Findings
This inspection resulted in no deficiencies cited.
Report Facts
Complaints investigated: 8
Inspection Report — Jun 5, 2025
Complaint Investigation
Date: Jun 5, 2025
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On-site complaint investigation of intakes AZ00224714, SF00131426, AZ00186786, AZ00186788, AZ00186250, and AZ00186254 at a Nursing Care Institution, conducted 5 June 2025.
Complaint Details
A complaint survey was conducted on June 5, 2025 for the investigation of intakes #'s: AZ00224714, SF00131426, AZ00186786, AZ00186788, AZ00186250, and AZ00186254. There were no deficiencies cited.
Findings
This inspection resulted in no deficiencies cited.
Inspection Report — Apr 3, 2025
Complaint Investigation
Date: Apr 3, 2025
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On-site complaint investigation of intake numbers 00123412 and AZ00223884 at a Nursing Care Institution, conducted 3 April 2025.
Complaint Details
A complaint investigation was conducted on April 3, 2025 through April 3, 2025 of intake #00123412. A complaint investigation was conducted on April 3, 2025 through April 3, 2025 of intake #AZ00223884. There were no deficiencies cited.
Findings
This inspection found no deficiencies.
Report Facts
Complaints investigated: 2
Inspection Report — Jan 24, 2025
Complaint Investigation
Date: Jan 24, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding an incident where one resident (#44) was allegedly abused by another resident (#55) at the facility.
Complaint Details
The complaint investigation found that resident #44 was assaulted by resident #55 on April 24, 2023, on the smoking patio. The assault was witnessed by a certified nursing assistant. Resident #44 had a small reddened area behind the right ear but refused hospital evaluation. Resident #55 had a history of aggressive behavior and was transported to the hospital later due to increased agitation. Staff interviews confirmed expectations for supervision and abuse prevention.
Findings
The facility failed to ensure that resident #44 was protected from abuse by resident #55, resulting in physical and emotional harm. The investigation included documentation of the incident, staff interviews, and review of care plans and medical notes, confirming the occurrence of abuse and inadequate supervision.
Deficiencies (1)
Failure to protect resident #44 from abuse by resident #55, resulting in physical and emotional harm.
Report Facts
Residents Affected: 2
Mental status score: 15
Mental status score: 14
Date of incident: Apr 24, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant (CNA/staff #13) | Witnessed the assault and described supervision expectations | |
| Licensed Practical Nurse (LPN/staff #21) | Interviewed about recognizing agitation and abuse | |
| Director of Nursing (DON/staff #1) | Interviewed about staff expectations for supervision and abuse prevention |
Inspection Report — Oct 25, 2024
Complaint Investigation
Date: Oct 25, 2024
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On-site complaint investigation of intake #AZ00217450 and #AZ00217448 at a Nursing Care Institution, conducted 25 October 2024.
Complaint Details
The complaint survey was conducted October 25, 2024 for the investigation of intakes #AZ00217450 and #AZ00217448. No deficiencies were cited.
Findings
No deficiencies were found during this complaint investigation.
Inspection Report — Oct 10, 2024
Complaint Investigation
Date: Oct 10, 2024
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The inspection was conducted due to complaints regarding resident-to-resident abuse incidents involving resident #75 and other residents (#20 and #40).
Complaint Details
The complaint investigation found substantiated incidents of resident-to-resident abuse involving resident #75. The facility responded by separating the residents, placing resident #75 on 1 to 1 staff supervision, and petitioning for transfer to a psychiatric facility.
Findings
The facility failed to ensure that residents #20 and #40 were free from abuse by resident #75. Multiple incidents of verbal and physical altercations were documented, and staff interviews confirmed behavioral issues with resident #75 leading to these incidents.
Deficiencies (1)
Failed to protect residents #20 and #40 from abuse by resident #75, including verbal threats and physical contact.
Report Facts
Residents Affected: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Interviewed regarding incidents involving resident #75 and facility response |
Inspection Report — Sep 17, 2024
Complaint Investigation
Date: Sep 17, 2024
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On-site complaint investigation of intake AZ00215273 and AZ00215272 at a Nursing Care Institution, conducted 17 September 2024.
Complaint Details
A complaint survey was conducted on September 17, 2024 for the investigation of intake #AZ00215273 and intake #AZ00215272. There were no deficiencies cited.
Findings
This inspection found no deficiencies.
Inspection Report — Sep 12, 2024
Complaint Investigation
Date: Sep 12, 2024
Visit Reason
On-site complaint investigation of multiple complaints including AZ00140090, AZ00145179, AZ00145485, AZ00146812, AZ00149016, AZ00150315, AZ00155299, AZ00163019, AZ00163995, AZ00168882, AZ00169507, AZ00171987, AZ00172316, AZ00172350, AZ00172590, AZ00172916, AZ00173120, AZ00173184, AZ00173408, AZ00175063, AZ00175975, AZ00176762, AZ00176804, AZ00177606, AZ00177645, AZ00178930, AZ00179617, AZ00180710, AZ00181390, AZ00181518, AZ00182264, AZ00182862, AZ00182894 at a Nursing Care Institution, conducted 9 through 12 September 2024.
Complaint Details
A complaint survey was conducted from September 9 to 12, 2024 for the investigation of complaints AZ00140090, AZ00145179, AZ00145485, AZ00146812, AZ00149016, AZ00150315, AZ00155299, AZ00163019, AZ00163995, AZ00168882, AZ00169507, AZ00171987, AZ00172316, AZ00172350, AZ00172590, AZ00172916, AZ00173120, AZ00173184, AZ00173408, AZ00175063, AZ00175975, AZ00176762, AZ00176804, AZ00177606, AZ00177645, AZ00178930, AZ00179617, AZ00180710, AZ00181390, AZ00181518, AZ00182264, AZ00182862, AZ00182894.
Findings
The inspection found one deficiency related to failure to ensure two residents were not subjected to abuse. A plan of correction was provided and accepted.
Deficiencies (1)
R9-10-410 — The facility failed to ensure two residents were not subjected to abuse, including a resident-to-resident altercation where one resident hit another on the shoulder. Investigations and interviews revealed inadequate prevention and reporting measures despite policies and training.
Report Facts
Deficiencies cited: 1
Inspection Report — Aug 26, 2024
Complaint Investigation
Date: Aug 26, 2024
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On-site complaint investigation of complaints AZ00214212 and AZ00214211 at a Nursing Care Institution, conducted 26 August 2024.
Complaint Details
The complaint survey was conducted on August 26, 2024 of the following complaint # AZ00214212. The complaint survey was conducted on August 26, 2024 of the following complaint # AZ00214211. No deficiencies were cited.
Findings
No deficiencies were found during this complaint investigation.
Report Facts
Complaints investigated: 2
Inspection Report — Jul 18, 2024
Complaint Investigation
Date: Jul 18, 2024
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On-site complaint investigation of complaints AZ00213288 and AZ00213286 at a Nursing Care Institution, conducted 18 July 2024.
Complaint Details
The complaint survey was conducted on July 18, 2024 of the following complaint #s AZ00213288 and AZ00213286. No deficiencies were cited.
Findings
No deficiencies were found during this complaint investigation.
Inspection Report — Jul 3, 2024
Complaint Investigation
Date: Jul 3, 2024
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On-site complaint investigation of complaints AZ00212534 and AZ00212620 at a Nursing Care Institution, conducted 3 July 2024.
Complaint Details
The investigation of complaint intake #s AZ00212534, AZ00212620 and AZ00212617 was conducted on July 03, 2024. The following deficiencies were cited.
Findings
The inspection found two deficiencies related to failure to accurately document vital signs and blood glucose monitoring for one resident, which could result in inaccurate medical records and potential harm.
Deficiencies (2)
§ 483.25 — The facility failed to ensure medical records were accurately documented for one resident regarding vital signs and blood glucose monitoring, missing vital signs on evening shifts and blood sugar results prior to insulin administration.
R9-10-414 — The administrator failed to ensure the care plan provided nursing care institution services that assist the resident in maintaining the highest practicable well-being, as evidenced by inadequate documentation of vital signs and blood glucose monitoring for one resident.
Report Facts
Deficiencies cited: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff #1 | Certified Nursing Assistant | Failed to complete documentation for Resident #12's vital signs on June 28, 2024 evening shift. |
| Staff #2 | Licensed Practical Nurse | Stated CNA responsibility for charting resident vitals and described blood sugar monitoring policy. |
| Staff #3 | Licensed Practical Nurse | Reviewed medical record and found no evidence of blood glucose testing prior to insulin administration. |
| Staff #4 | Certified Nursing Assistant | Confirmed no evidence of vital signs conducted on June 25 and June 27, 2024 evening shifts. |
| Staff #5 | Licensed Practical Nurse | Described facility policy for CNA vital sign completion twice daily prior to nurses' shift. |
| Staff #6 | Director of Nursing | Reviewed medical record and stated expectations for vital signs and blood glucose monitoring were not met. |
Inspection Report — Jul 3, 2024
Date: Jul 3, 2024
Visit Reason
The inspection was conducted to evaluate compliance with medical record documentation standards, specifically regarding vital signs and blood glucose monitoring for Resident #12.
Findings
The facility failed to ensure accurate documentation of vital signs and blood glucose monitoring for Resident #12, with missing vital signs on evening shifts of June 25 and June 27, 2024, and no blood glucose tests recorded prior to insulin administration on June 25 and June 26, 2024. This deficient practice could result in inaccurate records and potential harm to residents.
Deficiencies (2)
Failure to document vital signs on evening shifts June 25 and June 27, 2024 for Resident #12.
Failure to perform and document blood glucose monitoring prior to insulin administration on June 25 and June 26, 2024 for Resident #12.
Report Facts
Dates of missing vital signs: 2
Dates of insulin administration without blood glucose test: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant (CNA) | Staff #1 interviewed regarding missing vital sign documentation on June 28, 2024 | |
| Licensed Practical Nurse (LPN) | Staff #2 interviewed about CNA responsibilities and blood sugar monitoring policy | |
| Licensed Practical Nurse (LPN) | Staff #3 interviewed regarding blood glucose monitoring and insulin administration | |
| Licensed Practical Nurse (LPN) | Staff #5 interviewed about facility policy on vital signs documentation | |
| Certified Nursing Assistant (CNA) | Staff #4 interviewed about vital signs documentation requirements | |
| Director of Nursing (DON) | Staff #6 interviewed regarding expectations for vital signs and blood glucose monitoring |
Inspection Report — Jun 27, 2024
Complaint Investigation
Date: Jun 27, 2024
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On-site complaint investigation of intake numbers AZ00189726, AZ00186574, AZ00211805, AZ00211928 at a Nursing Care Institution, conducted 27 June 2024.
Complaint Details
A complaint survey was conducted on June 27, 2024 for the investigation of intake numbers AZ00189726, AZ00186574, AZ00211805 and AZ00211928. There were no deficiencies cited.
Findings
This inspection found no deficiencies.
Report Facts
Complaints investigated: 4
Inspection Report — Apr 23, 2024
Complaint Investigation
Date: Apr 23, 2024
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On-site complaint investigation of complaints AZ00209241 and AZ00209243 at a Nursing Care Institution, conducted 23 April 2024.
Complaint Details
The investigation of complaint AZ00209241 and AZ00209243 was conducted on April 23, 2024. No deficiencies were cited.
Findings
No deficiencies were cited during this complaint investigation.
Report Facts
Complaints investigated: 2
Inspection Report — Apr 17, 2024
Complaint Investigation
Date: Apr 17, 2024
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On-site complaint investigation of intakes AZ00207976, AZ00207972, AZ00209028, and AZ00209091 at a Nursing Care Institution, conducted 17 April 2024.
Complaint Details
An onsite complaint survey was conducted on April 17, 2023 for the investigation of intake #s AZ00207976, AZ00207972, AZ00209028, AZ00209091. There were no deficiencies cited. Federal comments confirm the same intake numbers with no deficiencies cited.
Findings
No deficiencies were cited during this complaint investigation.
Inspection Report — Mar 28, 2024
Complaint Investigation
Date: Mar 28, 2024
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On-site complaint investigation of intakes AZ00206704, AZ00207729, AZ00206703, and AZ00207726 at a Nursing Care Institution, conducted 28 March 2024.
Complaint Details
An onsite complaint survey was conducted on March 28, 2024 for the investigation of intake #s AZ00206704 and AZ00207729. Federal comments note investigation of intake #s AZ00206703 and AZ00207726. There were no deficiencies cited.
Findings
This inspection found no deficiencies.
Inspection Report — Jan 16, 2024
Complaint Investigation
Date: Jan 16, 2024
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On-site complaint investigation of complaint AZ002049501 at a Nursing Care Institution, conducted 16 January 2024.
Complaint Details
The investigation of complaint AZ002049501 was conducted on 1/16/24. The following deficiencies were cited: The investigation of complaint AZ00204950 was conducted on 1/16/24. The following deficiencies were cited:
Findings
The inspection found two deficiencies related to the facility's failure to ensure timely administration of medications to three residents. Plans of correction were provided for both deficiencies.
Deficiencies (2)
R9-10-403 — The facility failed to ensure three residents received medications within the allowed time frames, with multiple late administrations documented despite care plans and nursing staff interviews acknowledging the delays.
§483.45 — The facility failed to provide pharmaceutical services that assure accurate acquiring, receiving, dispensing, and administering of drugs, resulting in late medication administration for three residents and inconsistent care plan interventions.
Report Facts
Deficiencies cited: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff #34 | Licensed Practical Nurse | Interview regarding medication administration timing and pharmacy supply issues. |
| Staff #4 | Licensed Practical Nurse | Chart review confirming late medication administration. |
| Staff #78 | Pharmacist Technician Supervisor | Interview regarding pharmacy medication supply and delivery. |
| Staff #7 | Director of Nursing | Interview regarding medication administration expectations. |
| Staff #20 | Clinical Resource Nurse | Interview regarding medication administration expectations. |
Inspection Report — Nov 22, 2023
Complaint Investigation
Date: Nov 22, 2023
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On-site complaint investigation at Desert Terrace Healthcare Center conducted 22 November 2023.
Findings
This inspection resulted in no deficiencies or citations.
Inspection Report — Oct 20, 2023
Annual Inspection
Date: Oct 20, 2023
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On-site complaint investigation and annual compliance survey conducted 16 to 20 October 2023 at Desert Terrace Healthcare Center, including investigation of complaints AZ00185985, AZ00190873, AZ00191573, AZ196416, AZ00199152, AZ00200258, AZ00190922, AZ00196417, AZ00197109, AZ00198807, AZ00198844, AZ00199122, AZ00199188, and AZ00200265.
Complaint Details
The state compliance survey was conducted 10/17/2023 through 10/20/2023 in conjunction with the investigation of complaints # AZ00185985, AZ00190873, AZ.00191573, AZ196416, AZ00199152, AZ00200258, AZ00190922, AZ00196417, AZ00197109, AZ00198807, AZ00198844, AZ00199122, AZ00199188, AZ00200265. The recertification survey was conducted 10/17/2023 through 10/20/2023, in conjunction with the investigation of complaints #AZ00185985, AZ00190873, AZ.00191573, AZ196416, AZ00199152, AZ00200258, AZ00190921, AZ00196414, AZ00197108, AZ00197105, AZ00198804, AZ00198843, AZ00199121, AZ00187, AZ00200263.
Findings
The inspection found two deficiencies related to the activities program not being directed by a qualified professional. Plans of correction were provided for both deficiencies.
Deficiencies (2)
§483.24(c)(2) — The facility failed to ensure the activities program was directed by a qualified professional. Staff #33 lacked certification as a qualified therapeutic recreation specialist or activities professional but was enrolled in a program.
R9-10-406 — The facility failed to ensure the activities program was directed by a qualified professional. Staff #33 did not have required certification but was the sole staff in charge of activities without corporate oversight.
Report Facts
Deficiencies cited: 2
Complaints investigated: 26
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff #33 | Activities Director | Failed to have required certification and was the sole staff in charge of activities. |
Inspection Report — Oct 20, 2023
Date: Oct 20, 2023
Visit Reason
This Other type inspection was a Nursing Care Institution survey conducted from October 16 to October 20, 2023, including a recertification survey for Medicare under the Life Safety Code 2012.
Findings
The inspection identified five deficiencies related to fire safety, smoke barrier penetrations, fire drill documentation, emergency generator testing, and improper use of extension cords and power strips. The facility provided plans of correction for all deficiencies.
Deficiencies (5)
Hazardous Areas - Enclosure Hazardous Areas - The facility failed to maintain rated doors for hazardous areas, including gaps on laundry and kitchen doors, compromising fire barrier integrity and self-closing hardware functionality.
Subdivision of Building Spaces - Smoke Barrier Construction - The facility failed to seal penetrations and holes in smoke barriers, including an 3 inch by 8 inch hole with a data line in the dining room fire wall, risking smoke and heat penetration.
Fire Drills - The facility failed to provide documentation for two fire drills on the same shift in 2023, preventing assurance that staff were familiarized with emergency procedures.
Electrical Systems - Essential Electric System Maintenance and Testing - The facility failed to ensure the required annual load bank test of the emergency generator was completed, with unresolved issues on the fuel injector pump.
Electrical Equipment - Power Cords and Extension Cords - The facility allowed use of extension cords and daisy chained power strips for appliances, creating potential electrical overload and fire hazards.
Report Facts
Deficiencies cited: 5
Inspection Report — Sep 9, 2022
Routine
Date: Sep 9, 2022
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, medication administration, pressure ulcer care, bathing, respiratory care, staffing, and pharmaceutical services.
Findings
The facility was found deficient in multiple areas including failure to ensure informed consent for psychotropic medications, failure to notify physicians of critical vital signs, failure to administer medications as ordered, inconsistent bathing and showering of residents, inadequate pressure ulcer care, lack of appropriate colostomy care, absence of physician orders for oxygen use, inaccurate nurse staffing postings, and failure to ensure timely availability and administration of medications.
Deficiencies (10)
Failure to ensure risks and benefits of psychotropic medication were explained and consent obtained prior to administration for one resident.
Failure to notify physician of low blood pressure and high pulse rate readings for one resident, resulting in delayed treatment and resident death.
Failure to administer medications as ordered, including pain medications and psychotropic drugs, resulting in residents receiving medications outside ordered parameters.
Failure to provide showers or bathing consistently to residents, with missing documentation and failure to follow shower schedules.
Failure to provide appropriate pressure ulcer care and monitoring for two residents, including delayed assessment and treatment.
Failure to provide appropriate colostomy care as ordered, with missed care and lack of documentation.
Failure to have a physician order for oxygen use for one resident who was observed receiving oxygen.
Failure to accurately post nurse staffing information reflecting actual hours worked by licensed and unlicensed nursing staff.
Failure to ensure timely availability and administration of medications, including antibiotics and bowel care medications, resulting in missed doses and lack of physician notification.
Failure to ensure residents received medications as ordered by the physician, including administration of pain medications outside ordered parameters.
Report Facts
Medication missed doses: 2
Staff posting discrepancies: 9
Medication administration outside parameters: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse | Staff #88 interviewed regarding psychotropic medication consent and medication administration. | |
| Licensed Practical Nurse | Staff #35 interviewed regarding psychotropic medication consent, bathing schedules, and medication administration. | |
| Director of Nursing | Staff #113 interviewed regarding facility policies, medication administration, wound care, staffing, and medication availability. | |
| Certified Nursing Assistant | Staff #96 and #93 interviewed regarding bathing schedules and vital signs reporting. | |
| Pharmacy Technician | Staff #110 and #114 interviewed regarding medication delivery and insurance issues. | |
| Registered Nurse | Staff #94 interviewed regarding oxygen orders and resident oxygen use. |
Inspection Report — Apr 8, 2021
Routine
Date: Apr 8, 2021
Visit Reason
The inspection was conducted to evaluate compliance with resident rights, medication administration, care planning, treatment, staffing, infection control, and other regulatory requirements in a nursing home.
Findings
The facility was found deficient in multiple areas including failure to ensure residents' rights to privacy and dignity, inadequate assessment for self-administration of medications, lack of baseline care plans for oxygen use, failure to provide ordered treatments such as tubigrip stockings, inadequate urinary catheter care, missing physician orders for oxygen therapy, insufficient nursing staff to meet resident needs, and failure to maintain infection prevention and control standards including improper use of PPE and handling of soiled laundry.
Deficiencies (8)
Failure to ensure residents were treated with respect and dignity by failing to knock before entering rooms and failing to provide privacy when requested.
Failure to assess resident #58 to safely self-administer arthritic ointment.
Failure to develop a baseline care plan for resident #382 regarding oxygen use.
Failure to provide care and services in accordance with physician orders regarding tubigrip stockings for resident #280.
Failure to ensure appropriate urinary catheter care for resident #34, including missing documentation and improper technique.
Failure to have a physician order for oxygen use for resident #382 despite oxygen administration.
Insufficient nursing staff to meet the needs of residents, resulting in delayed response to call lights, late medication administration, and unmet resident needs.
Failure to maintain infection prevention and control standards including improper use of PPE, failure to perform hand hygiene, and improper handling of soiled laundry.
Report Facts
Call light response times: 15
Staff to resident ratio: 14
Registry staff percentage: 50
Registry staff percentage: 25
Oxygen liters: 3.5
Tubigrip stockings application: 0
Missing urinary catheter care documentation: 9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff #40 | Director of Nursing | Provided multiple interviews regarding privacy, call light response, staffing, and infection control |
| Staff #85 | Certified Nursing Assistant | Interviewed regarding privacy, call light response, medication administration, and performed urinary catheter care |
| Staff #86 | Licensed Practical Nurse | Interviewed regarding privacy, call light response, medication administration, and self-administration assessments |
| Staff #49 | Assistant Director of Nursing | Interviewed regarding ointment self-administration and infection prevention |
| Staff #52 | Staffing Coordinator | Interviewed regarding staffing schedules and coverage |
| Staff #64 | Certified Nursing Assistant | Observed and interviewed regarding PPE use and infection control |
| Staff #45 | Housekeeping Staff | Observed and interviewed regarding handling of soiled laundry and PPE use |
| Staff #33 | Registered Nurse | Interviewed regarding urinary catheter care |
| Staff #47 | Licensed Practical Nurse | Interviewed regarding urinary catheter care and oxygen orders |
| Staff #76 | Assistant Director of Nursing | Interviewed regarding urinary catheter care procedures |
| Staff #17 | Housekeeping Supervisor | Interviewed regarding laundry procedures and PPE |
Inspection Report — Apr 8, 2021
Annual Inspection
Date: Apr 8, 2021
Visit Reason
The inspection was conducted as a comprehensive annual survey to assess compliance with regulatory requirements and resident care standards at Desert Terrace Healthcare Center.
Findings
The facility was found deficient in multiple areas including failure to ensure residents' rights to privacy and dignity, inadequate assessment for self-administration of medications, incomplete care planning for oxygen use, failure to provide ordered treatments such as tubigrip stockings, inadequate urinary catheter care, lack of physician order for oxygen use, insufficient nursing staff to meet resident needs, and failure to maintain infection prevention and control standards including proper use of PPE and handling of soiled laundry.
Deficiencies (8)
Failure to ensure residents' right to privacy and dignity by not knocking before entering rooms and not providing privacy when requested.
Failure to assess resident #58 for safe self-administration of arthritic ointment.
Failure to develop a baseline care plan for resident #382 regarding oxygen use.
Failure to provide care and services in accordance with physician orders regarding tubigrip stockings for resident #280.
Failure to provide appropriate urinary catheter care for resident #34, including missed care and improper technique.
Failure to have a physician order for oxygen use for resident #382.
Insufficient nursing staff to meet the needs of residents, resulting in delayed response to call lights, late medication administration, and unmet resident needs.
Failure to maintain infection prevention and control standards including improper use of PPE, lack of hand hygiene, and improper handling of soiled laundry.
Report Facts
Call light response times: 15
CNA to resident ratio: 14
Oxygen liters: 3.5
Missing urinary catheter care documentation: 9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff #85 | Certified Nursing Assistant | Named in findings related to call light response and urinary catheter care |
| Staff #86 | Licensed Practical Nurse | Named in findings related to call light response and medication administration |
| Staff #40 | Director of Nursing | Named in multiple interviews regarding privacy, call light response, staffing, and infection control |
| Staff #49 | Assistant Director of Nursing / Infection Preventionist | Named in interviews regarding self-administration assessment and infection control |
| Staff #64 | Certified Nursing Assistant | Observed and interviewed regarding PPE use and infection control |
| Staff #45 | Housekeeping Supervisor | Interviewed regarding laundry handling and infection control |
| Staff #52 | Staffing Coordinator | Interviewed regarding staffing plans and coverage |
Report
8 CMS Surveys
CMS Survey — Jan 16, 2024
Jan 16, 2024
CMS Survey — Jul 3, 2024
Jul 3, 2024
CMS Survey — Oct 10, 2024
Oct 10, 2024
CMS Survey — Jan 24, 2025
Jan 24, 2025
CMS Survey — Dec 3, 2025
Dec 3, 2025
CMS Survey — Apr 8, 2021
Apr 8, 2021
CMS Survey — Sep 9, 2022
Sep 9, 2022
CMS Survey — Oct 20, 2023
Oct 20, 2023
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