Inspection Reports for The Terraces of Phoenix
7550 N 16th St, Phoenix, AZ 85020, United States, AZ, 85020
Back to Facility Profile
Inspection Report
Complaint Investigation
Census: 64
Capacity: 64
Deficiencies: 26
Apr 24, 2025
Visit Reason
State-compiled facility profile showing 15 inspections from 2023-01 to 2025-04 with deficiency history and complaint investigations.
Findings
Across multiple inspections, the facility had numerous complaint investigations mostly with no deficiencies cited, but some inspections revealed deficiencies related to failure to report and prevent resident abuse, infection control lapses, care plan inaccuracies, and life safety code violations. The most recent complaint investigation found serious deficiencies related to sexual abuse reporting and resident safety.
Complaint Details
Multiple complaint investigations were conducted between 2023 and 2025, mostly resulting in no deficiencies cited except for the complaint investigation in August 2024 which identified serious deficiencies related to sexual abuse reporting and resident safety.
Severity Breakdown
Immediate Jeopardy: 1
Deficiencies (26)
| Description | Severity |
|---|---|
| R9-10-403.E. Failure to report allegations of sexual abuse immediately to administrator, State Agency, Adult Protective Services and law enforcement for two residents. | — |
| §483.12 Freedom from Abuse, Neglect, and Exploitation: Failed to protect residents from sexual abuse by another resident. | — |
| §483.12(c) Failure to report allegations of abuse immediately and failure to implement acceptable removal plan for Immediate Jeopardy condition. | Immediate Jeopardy |
| R9-10-410.B.3.a. Failure to protect residents from abuse including sexual abuse by another resident. | — |
| Multiple Occupancies - Sections of Health Care Facilities: Failed to meet fire protection requirements for outpatient treatment center separation. | — |
| Electrical Systems - Essential Electric System Maintenance and Testing: Failed to install remote stop/kill switch and maintain operable remote monitoring panel for generator. | — |
| R9-10-403.C.1.j. Failed to ensure advance directives were accurate for one resident. | — |
| R9-10-403.C.2.e. Failed to designate a qualified individual as Infection Preventionist. | — |
| §483.10(c)(6), §483.10(c)(8), §483.10(g)(12) Failed to ensure advance directives were accurate and honored for one resident. | — |
| R9-10-406.F.3.d. Failed to maintain personnel records documenting orientation and in-service education for two staff members. | — |
| §483.21(b) Failed to revise care plan for one resident to reflect current needs and assessments. | — |
| §483.80 Infection Control: Failed to ensure transmission-based precautions and PPE were in place to prevent infection transmission. | — |
| §483.80(b) Failed to designate a qualified Infection Preventionist with required training and certification. | — |
| §483.95(g) Failed to ensure personnel records documented required in-service training for nurse aides. | — |
| R9-10-414.B.2. Failed to review and revise care plan based on resident's comprehensive assessment changes. | — |
| R9-10-422.1.c. Failed to develop corrective measures to minimize or prevent spread of infections and communicable diseases. | — |
| §483.10(g)(14) Failed to timely notify resident representative of significant change in resident's condition related to pressure ulcers. | — |
| §483.21(b) Failed to develop and implement comprehensive person-centered care plan including measurable objectives for resident's medical and psychosocial needs. | — |
| R9-10-412.B.6.c. Failed to notify resident's attending physician and representative within 24 hours of significant change in condition. | — |
| R9-10-414.B.1. Failed to develop, document, and implement care plan within seven days after comprehensive assessment. | — |
| Egress Doors: Failed to post complete 15 second alarm sign at exterior exit door. | — |
| Corridor - Doors: Failed to maintain doors to resist passage of smoke and maintain positive latching hardware. | — |
| Gas Equipment - Cylinder and Container Storage: Failed to segregate empty and full oxygen cylinders in storage. | — |
| §483.21(b)(3) Failed to ensure residents received care and services meeting professional standards resulting in administration of un-ordered medications/supplements. | — |
| §483.25(b) Failed to maintain infection prevention and control during wound treatment for one resident. | — |
| §483.60(i) Failed to discard food items on or before expiration date in accordance with professional standards. | — |
Report Facts
Inspections on page: 15
Total deficiencies: 26
Complaint inspections: 12
Facility capacity: 64
Census: 64
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kordell Erickson | Administrator | Named as facility administrator in facility information |
| Staff #5 | Registered Nurse / Interim Director of Nursing | Named in multiple findings related to abuse reporting and infection prevention |
| Staff #6 | Certified Nursing Assistant | Witnessed and reported resident inappropriate touching |
| Staff #38 | Registered Nurse | Reviewed resident advance directives and code status |
| Staff #100 | Licensed Practical Nurse / Infection Preventionist | Designated Infection Preventionist lacking certification |
| Staff #150 | Registered Nurse | Personnel file missing required training documentation |
| Staff #56 | Activity Coordinator | Personnel file missing required training documentation |
| Staff #105 | Certified Nursing Assistant | Interviewed regarding care plan and resident assistance |
| Staff #39 | Registered Nurse | Interviewed regarding resident assistance and care plan |
| Staff #20 | Registered Nurse | Interviewed regarding pressure ulcer notification |
| Staff #21 | Director of Nursing | Interviewed regarding pressure ulcer notification and care plan expectations |
| Staff #22 | Certified Nursing Assistant | Interviewed regarding wound care and repositioning |
| Staff #118 | Licensed Practical Nurse / Wound Care Nurse | Observed and interviewed regarding wound care practices |
| Staff #113 | Director of Nursing | Interviewed regarding medication administration policies |
| Staff #112 | Licensed Practical Nurse | Observed administering medications |
| Staff #170 | Licensed Practical Nurse (Registry) | Observed administering medications |
| Staff #119 | Registered Nurse | Interviewed regarding medication administration policies |
| Staff #80 | Certified Nursing Assistant | Interviewed regarding infection prevention practices |
| Staff #125 | Human Resource Director | Interviewed regarding staff training and orientation policies |
| Staff #11 | Director of Dining | Interviewed regarding food safety and storage |
| Staff #117 | Registered Dietician | Interviewed regarding food safety and storage |
| Staff #52 | Dietary Porter | Interviewed regarding food storage and expiration |
| Staff #101 | Sous Chef | Interviewed regarding food safety and expiration |
| Staff #19 | Chef | Interviewed regarding food safety and expiration |
Loading inspection reports...
