Inspection Reports for
The Terraces of Phoenix

Complaint investigation regarding failure to provide showers to resident #89; substantiation implied by findings of missed showers and no documented refusals.

The facility failed to ensure showers were provided for resident #89 as scheduled, with documentation showing a nine-day lapse without a shower and no refusal documented. Interviews with staff and the Director of Nursing confirmed expectations for twice-weekly showers and identified the lapse as a concern.

The complaint investigation found that resident #45 inappropriately touched residents #12 and #23 multiple times. Staff failed to report these incidents immediately. The facility was cited for failure to protect residents and failure to timely report abuse. The condition of Immediate Jeopardy was identified on August 9, 2024 and removed on August 10, 2024 after corrective actions were implemented.

The facility failed to protect two residents from sexual abuse by another resident and failed to immediately report the allegations to the administrator, State Agency, Adult Protective Services, and law enforcement. The investigation revealed multiple incidents of inappropriate touching, inadequate staff response, and delayed reporting. A condition of Immediate Jeopardy was identified and later removed after the facility implemented a removal plan including assessments, staff training, and monitoring.

Investigation of complaint AZ00214325

Investigation of complaint AZ00214325 with 4 deficiencies cited related to abuse reporting and resident protection.

Recertification survey for Medicare under Life Safety Code 2012 found 2 deficiencies related to multiple occupancies and electrical systems.

The complaint investigation found that the facility did not update the care plan for resident #53 after a fall on 7/16/2023, despite the resident requiring extensive assistance. The complaint was substantiated with evidence from clinical record review, staff interviews, and policy review.

The facility failed to ensure the care plan for resident #53 was revised to reflect the level of assistance required with toileting, transfers, dressing, and personal hygiene following a fall. Interviews with staff revealed discrepancies in assistance provided and documentation, and the care plan did not align with the resident's assessed needs.

The facility failed to ensure accurate advance directives for a resident, lacked proper enhanced barrier precaution signage and PPE to prevent infection transmission, did not designate a fully qualified infection preventionist, and failed to maintain required orientation and in-service education documentation for certain staff members. These deficiencies posed risks of residents receiving unwanted medical interventions, infection spread, and inadequate care.

Investigation of complaints #AZ00210875, AZ00210458, AZ00209111, AZ00206906, AZ00200789, AZ00198034, AZ00193050, AZ00192887, AZ00192715, AZ00191774

Recertification survey with complaint investigations citing 10 deficiencies related to administration, care plans, infection control, and personnel records.

Investigation of intake #s AZ00193499 and AZ00195907

Onsite complaint survey citing 4 deficiencies related to notification of changes, care plan implementation, and nursing director notifications.

The complaint investigation found that the facility did not notify the resident's representative of the pressure ulcers from March 12 through 25, 2023, and failed to implement pressure relief interventions as care planned, resulting in potential harm to the resident.

The facility failed to notify the representative of resident #1 timely about bilateral heel pressure ulcers and failed to implement the care plan interventions for pressure relief and wound care as ordered. Documentation of pressure relief measures was lacking, and wound assessments showed worsening conditions.

The facility failed to ensure medications and supplements were administered only with physician orders, failed to maintain infection prevention during wound care, and failed to discard expired food products, posing risks of inappropriate treatment, infection, and foodborne illness.

Recertification survey for Medicare under Life Safety Code 2012 citing 3 deficiencies related to egress doors, corridor doors, and gas equipment storage.

State compliance survey conducted with 3 deficiencies cited related to comprehensive care plans, skin integrity, and food safety.