Inspection Reports for
The Terraces of Phoenix
7550 N 16th St, Phoenix, AZ 85020, United States, AZ, 85020
Back to Facility Profile22 Reports
Inspection Report — Mar 13, 2026
Complaint Investigation State
Date: Mar 13, 2026
Visit Reason
On-site complaint investigation of intakes 00160339 and 00161610 at a Nursing Care Institution, conducted 13 March 2026.
Complaint Details
An onsite complaint survey was conducted on March 13, 2026 for the investigation of the intake #00160339, and 00161610. Federal comments noted investigation of intakes 2788179, 2789313, and 2799722 with compliance found.
Findings
This inspection resulted in no deficiencies or citations.
Report Facts
Complaints investigated: 2
Inspection Report — Jan 16, 2026
Complaint Investigation State
Date: Jan 16, 2026
Visit Reason
On-site complaint investigation of complaints 00154497 and 00154613 at a Nursing Care Institution, conducted 16 January 2026.
Complaint Details
This complaint survey was conducted on January 16, 2026, with the investigation of complaints: 00154497 and 00154613. No deficiencies were cited. Federal complaints 2703137 and 2703808 were also investigated with no deficiencies cited.
Findings
No deficiencies were cited during this complaint investigation.
Report Facts
Complaints investigated: 4
Inspection Report — Dec 26, 2025
Complaint Investigation State
Date: Dec 26, 2025
Visit Reason
On-site complaint investigation of intakes 00152963, 00152841, 0015628, 2687489, 2691064, 2689336, and 2687500 at a Nursing Care Institution, conducted 26 December 2025.
Complaint Details
A complaint survey was conducted on December 26, 2025, for the investigation of intake(s) #: 00152963, 00152841, 0015628, 2687489, 2691064, 2689336, 2687500, 2687489. There were no deficiencies cited.
Findings
This inspection resulted in no deficiencies cited or citations.
Inspection Report — Jun 13, 2025
Complaint Investigation CMS
Date: Jun 13, 2025
Visit Reason
The inspection was conducted to investigate a complaint regarding the facility's failure to provide showers for a resident (#89), potentially resulting in inadequate care for activities of daily living.
Complaint Details
Complaint investigation regarding failure to provide showers to resident #89; substantiation implied by findings of missed showers and no documented refusals.
Findings
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.
Deficiencies (1)
Failure to provide scheduled showers for resident #89, resulting in inadequate assistance with activities of daily living.
Report Facts
Length of shower lapse: 9
Shower frequency: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant/Restorative Nursing Assistant (CNA/RNA/Staff #21) | Interviewed regarding shower scheduling and documentation | |
| Licensed Practical Nurse (LPN/Staff #57) | Interviewed regarding shower scheduling and refusal documentation | |
| Director of Nursing (DON/Staff #109) | Interviewed regarding expectations for shower scheduling and review of documentation |
Inspection Report — Jun 13, 2025
Annual Inspection State
Date: Jun 13, 2025
Visit Reason
On-site complaint investigation of complaints 00127160, 00126457, AZ00220824 and federal complaints AZ00224201, AZ00224167, AZ00221687 at a Nursing Care Institution, conducted 10 June 2025 through 13 June 2025 in conjunction with the facility's annual recertification.
Complaint Details
The investigation of intake # 00127160, 00126457, AZ00220824 was conducted on 06/10/2025 through 06/13/2025 in conjunction with the facility's annual recertification. The investigation of intake # AZ00224201, AZ00224167, AZ00221687 was conducted on 06/10/2025 through 06/13/2025 in conjunction with the facility's annual recertification.
Findings
Six deficiencies were cited during this inspection. No evidence details were provided for any of the deficiencies.
Deficiencies (6)
R9-10-403 — No evidence text provided for the failure to ensure policies and procedures for physical and behavioral health services were established, documented, and implemented.
§483.15(c)(2) — No evidence text provided for the failure to document transfers or discharges in the resident's medical record and communicate appropriate information to the receiving provider.
R9-10-406 — No evidence text provided for the failure to maintain personnel records documenting compliance with A.R.S. § 36-411.
§483.24(a)(2) — No evidence text provided for the failure to provide necessary services to maintain good nutrition, grooming, and personal and oral hygiene for residents unable to carry out activities of daily living.
§483.60(a) — No evidence text provided for the failure to employ sufficient qualified staff with appropriate competencies and skills in the food and nutrition service.
R9-10-414 — No evidence text provided for the failure to ensure care plans assist residents in maintaining their highest practicable well-being.
Report Facts
Deficiencies cited: 6
Complaints investigated: 6
Inspection Report — Apr 24, 2025
Complaint Investigation State
Date: Apr 24, 2025
Visit Reason
On-site complaint investigation of intake #00127973 and intake #AZ00224343 at a Nursing Care Institution, conducted 24 April 2025.
Complaint Details
The complaint survey was conducted on April 24, 2025 for the investigation of intake #00127973 and intake #AZ00224343. No deficiencies were cited.
Findings
No deficiencies were cited during this complaint investigation.
Inspection Report — Dec 24, 2024
Complaint Investigation State
Date: Dec 24, 2024
Visit Reason
On-site complaint investigation of intakes AZ00214563, AZ00213529, AZ00213243, AZ00206777, AZ00214672, AZ00209082, and AZ00206846 at a Nursing Care Institution, conducted 24 December 2024.
Complaint Details
A complaint survey was conducted on December 24, 2024 for the investigation of intakes # AZ00214563, AZ00213529, AZ00213243, AZ00206777, AZ00214672, AZ00209082, AZ00206846. There were no deficiencies cited.
Findings
This inspection found no deficiencies.
Inspection Report — Oct 24, 2024
Complaint Investigation State
Date: Oct 24, 2024
Visit Reason
On-site complaint investigation of intakes AZ00193464, AZ00195034, AZ00213811, AZ00216150, and AZ00216437 at a Nursing Care Institution, conducted 23-24 October 2024.
Complaint Details
The complaint survey was conducted October 23, 2024 through October 24, 2024 for the investigation of intakes #AZ00193464, AZ00195034, AZ00213811, AZ00216150, AZ00216437. No deficiencies were cited.
Findings
No deficiencies were cited during this complaint investigation.
Inspection Report — Sep 24, 2024
Enforcement State
Date: Sep 24, 2024
Visit Reason
Civil monetary penalty, action 00110535 (invoice INV-257538), assessed 24 September 2024.
Findings
A $2,000.00 penalty was assessed and paid in full on 4 January 2025.
Report Facts
Penalty amount: 2000
Amount paid: 2000
Amount remaining: 0
Inspection Report — Sep 16, 2024
Complaint Investigation State
Date: Sep 16, 2024
Visit Reason
On-site complaint investigation of intakes AZ00215906, AZ00215581, and AZ00213715 at a Nursing Care Institution, conducted 16 September 2024.
Complaint Details
An onsite complaint survey was conducted on September 16, 2024 for the investigation of intake # AZ00215906, AZ00215581, AZ00213715 and AZ00215974, AZ00215581, AZ00213715.
Findings
This inspection resulted in no deficiencies cited.
Report Facts
Complaints investigated: 3
Inspection Report — Sep 4, 2024
Complaint Investigation State
Date: Sep 4, 2024
Visit Reason
On-site complaint investigation of complaints AZ00215070 and AZ00215169 at a Nursing Care Institution, conducted 4 September 2024.
Complaint Details
The investigation of complaint AZ00215070 and complaint AZ00215169 were conducted on 9/4/24. No deficiencies were cited.
Findings
No deficiencies were cited during this inspection.
Report Facts
Complaints investigated: 2
Inspection Report — Aug 10, 2024
Complaint Investigation State
Date: Aug 10, 2024
Visit Reason
On-site complaint investigation of complaint AZ00214325 at a Nursing Care Institution, conducted 9-10 August 2024.
Complaint Details
The investigation of complaint AZ00214325 was conducted 08/09/2024 through 08/10/2024. An onsite complaint survey was conducted for intake # AZ00214325. The facility failed to ensure allegations of sexual abuse were reported immediately to the administrator, State Agency, Adult Protective Services, and law enforcement, placing residents at risk.
Findings
The facility failed to ensure allegations of sexual abuse by one resident against two others were reported immediately to the administrator, State Agency, Adult Protective Services, and law enforcement. Four deficiencies were cited related to failure to report, protect residents from abuse, and implement effective interventions, including a period of Immediate Jeopardy that was removed after corrective actions.
Deficiencies (4)
R9-10-403.E — The facility failed to ensure allegations of sexual abuse for two residents by another resident were reported immediately to the administrator, State Agency, Adult Protective Services, and law enforcement, placing residents at increased risk of harm.
§483.12 — The facility failed to protect the rights of two residents to be free from sexual abuse by another resident, resulting in increased risk for further abuse and harm.
§483.12(c) — The facility failed to ensure allegations of sexual abuse were reported immediately to the administrator and other officials, resulting in Immediate Jeopardy that was later removed after acceptance of a removal plan.
R9-10-410 — The facility failed to protect two residents from sexual abuse by another resident, and failed to implement interventions to prevent reoccurrence despite documented inappropriate behaviors.
Report Facts
Deficiencies cited: 4
Complaints investigated: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff #5 | Registered Nurse | Witnessed and documented inappropriate touching by resident #45; involved in reporting and intervention. |
| Staff #6 | Certified Nursing Assistant | Witnessed inappropriate touching by resident #45 and reported incident to RN (staff #5). |
Inspection Report — Jun 11, 2024
State
Date: Jun 11, 2024
Visit Reason
On-site other inspection of a Nursing Care Institution at THE TERRACES OF PHOENIX conducted 11 June 2024.
Findings
Two deficiencies were found related to fire protection separation and emergency generator equipment. The facility failed to meet fire separation requirements for the outpatient rehabilitation area and lacked a remote stop switch and operable remote monitoring panel for the emergency generator.
Deficiencies (2)
Multiple Occupancies - Sections of health care facilities failed to provide the required minimum fire protection separation for the outpatient rehabilitation area, as doors were only 20 minute rated instead of the required 90 minute rating.
NFPA 110 — The facility failed to install a remote stop or kill switch for the emergency generator and the remote monitoring panel was not operable, risking loss of power during an emergency.
Report Facts
Deficiencies cited: 2
Inspection Report — May 31, 2024
Annual Inspection State
Date: May 31, 2024
Visit Reason
On-site complaint investigation and annual recertification survey conducted 28 May 2024 through 31 May 2024 at a Nursing Care Institution, including investigation of complaints AZ00210875, AZ00210458, AZ00209111, AZ00206906, AZ00200789, AZ00198034, AZ00193050, AZ00192887, AZ00192715, and AZ00191774.
Complaint Details
This recertification survey was conducted 05/28/2024 through 5/31/2024, in conjunction with the investigation of complaints #AZ00210875, AZ00210458, AZ00209111, AZ00206906, AZ00200789, AZ00198034, AZ00193050, AZ00192887, AZ00192715, AZ00191774. Federal comments also referenced complaints #AZ002100320, AZ00210624, AZ00210458, AZ00206906, AZ00210620, AZ00198034, AZ00193048, AZ00192886, AZ00192715, AZ00191774.
Findings
The inspection found ten deficiencies related to inaccurate advance directives, failure to designate a qualified Infection Preventionist, inadequate infection control practices including lack of enhanced barrier precautions and signage, incomplete personnel training documentation, and failure to revise care plans to reflect residents' current needs.
Deficiencies (10)
R9-10-403 — The facility failed to ensure that advance directives were accurate for one resident (#9), with conflicting code status orders between DNR and Full Code documented in the clinical record.
R9-10-403 — The facility failed to designate a qualified individual as the Infection Preventionist; the designated staff lacked a certificate of completion for infection prevention training.
The facility failed to ensure advance directives were accurate for one resident (#9), risking residents' wishes not being honored due to conflicting code status documentation.
R9-10-406 — Personnel records for two staff (#150 and #56) lacked documentation of orientation and in-service education as required by policies and procedures.
The facility failed to revise the care plan for one resident (#53) to reflect the level of assistance required for toileting, transfers, and personal hygiene after a fall incident.
§483.80 — The facility failed to ensure transmission-based precautions, including enhanced barrier precautions, signage, and personal protective equipment, were in place to prevent infection transmission for resident #352.
§483.80(b) — The facility failed to designate a qualified Infection Preventionist who had completed specialized training in infection prevention and control.
§483.95(g) — Personnel records for two staff (#150 and #56) lacked documentation of required orientation and in-service training, risking inadequate care of residents.
R9-10-414 — The facility failed to revise the care plan for resident #53 based on changes in the resident's assessment, resulting in care plans not reflecting required assistance levels.
R9-10-422 — The facility failed to ensure an infection control program included proper transmission-based precautions, signage, and PPE to prevent infection spread for resident #352.
Report Facts
Deficiencies cited: 10
Complaints investigated: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff #9 | Resident | Resident #9 had conflicting advance directives and code status orders. |
| Staff #38 | Registered Nurse | Staff #38 reviewed resident #9's chart and identified incorrect code status orders. |
| Staff #5 | Interim Director of Nursing | Staff #5 focused on advance directives and confirmed corrections for resident #9; also involved in infection prevention and care plan oversight. |
| Staff #100 | Licensed Practical Nurse / Infection Preventionist | Staff #100 was designated Infection Preventionist without completed infection prevention training. |
| Staff #150 | Registered Nurse | Staff #150's personnel file lacked required orientation and in-service education documentation. |
| Staff #56 | Activity Coordinator | Staff #56's personnel file lacked required orientation and in-service education documentation. |
| Staff #105 | Certified Nursing Assistant | Staff #105 assisted resident #53 and reported lack of care plan reflecting assistance needs. |
| Staff #39 | Registered Nurse | Staff #39 was involved in resident #53's care and transfer assistance. |
| Staff #352 | Resident | Resident #352 had infection control deficiencies related to catheter care and transmission-based precautions. |
| Staff #80 | Certified Nursing Assistant | Staff #80 cared for resident #352 and reported lack of enhanced barrier precautions. |
Inspection Report — May 31, 2024
Complaint Investigation CMS
Date: May 31, 2024
Visit Reason
The inspection was conducted due to a complaint regarding the facility's failure to revise the care plan for resident #53 to reflect the required level of assistance after a fall incident.
Complaint Details
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.
Findings
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.
Deficiencies (1)
Failure to revise the care plan for resident #53 to reflect the required level of assistance after a fall incident.
Report Facts
Date of fall incident: Jul 16, 2023
Date of care plan effective: Jul 12, 2023
BIMS score: 15
Assistance level: 3
Survey completion date: May 31, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA staff #105 | Certified Nursing Assistant | Provided assistance to resident #53 during fall incident and reported lack of nurse assistance |
| RN staff #39 | Registered Nurse | Interviewed regarding assistance provided to resident #53 during fall incident |
| DON staff #5 | Interim Director of Nursing | Reviewed care plan and MDS for resident #53 and confirmed deficiencies |
Inspection Report — May 31, 2024
Routine CMS
Date: May 31, 2024
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements related to resident rights, infection prevention and control, designation of qualified infection preventionist, and staff training in a nursing home facility.
Findings
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.
Deficiencies (4)
Failed to ensure advance directives were accurate for one resident, resulting in conflicting code status orders.
Failed to provide and implement an infection prevention and control program, including lack of enhanced barrier precaution signage and PPE.
Failed to designate a qualified infection preventionist responsible for the infection prevention and control program.
Failed to ensure nurse aides had required orientation and in-service education documentation, risking inadequate resident care.
Report Facts
Residents with indwelling devices: 4
Residents with multi-drug-resistant organisms (MDRO): 2
Residents with wounds: 21
Personnel records missing training documentation: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse (staff #38) | Reviewed resident's chart and identified incorrect code status orders | |
| Interim Director of Nursing (staff #5) | Focused on advance directives and confirmed correction of resident's code status; also discussed infection preventionist role and staff training | |
| Certified Nursing Assistant (staff #80) | Interviewed regarding PPE signage and use of precautions | |
| Registered Nurse (staff #50) | Interviewed about risks of missing PPE signage | |
| Licensed Practical Nurse / Infection Preventionist (staff #100) | Designated Infection Preventionist without completed certification; provided EBP training | |
| Human Resource Director (staff #125) | Interviewed about staff training and orientation policies |
Inspection Report — Dec 19, 2023
Complaint Investigation State
Date: Dec 19, 2023
Visit Reason
On-site complaint investigation of complaints AZ00204105, AZ00201188, AZ00201157, AZ00201119, and AZ00199566 at a Nursing Care Institution, conducted 19 December 2023.
Complaint Details
The complaint survey was conducted on December 19, 2023, for complaint numbers AZ00204105, AZ00201188, AZ00201157, AZ00201119, AZ00199566, AZ00204322, AZ00201187, and AZ00201155. There were no deficiencies cited.
Findings
No deficiencies were cited during this complaint investigation.
Report Facts
Complaints investigated: 8
Inspection Report — Jun 30, 2023
Complaint Investigation State
Date: Jun 30, 2023
Visit Reason
On-site complaint investigation of intakes AZ00196767 and AZ00196614 at a Nursing Care Institution, conducted 29-30 June 2023.
Complaint Details
A complaint survey was conducted on June 29, 2023 through June 30, 2023 for the investigation of intake #AZ00196767 and #AZ00196614. There were no deficiencies cited.
Findings
No deficiencies were cited during this complaint investigation.
Inspection Report — Jun 6, 2023
Complaint Investigation State
Date: Jun 6, 2023
Visit Reason
On-site complaint investigation of intakes AZ00193499, AZ00195907, and AZ00193498 at a Nursing Care Institution, conducted 6 June 2023.
Complaint Details
An onsite survey was conducted on June 6, 2023 for the investigation of intake #s AZ00193499 and AZ00195907. The complaint survey was conducted on June 6, 2023 for the investigation of intake #s AZ00193498 and AZ00195907.
Findings
The inspection found four deficiencies related to failure to timely notify a resident's representative of significant changes in condition and failure to implement and document care plans for pressure ulcer interventions. Plans of correction were provided for all deficiencies.
Deficiencies (4)
§483.10(g)(14) — The facility failed to timely notify one resident's representative of a significant change in condition related to pressure ulcers, resulting in delayed notification until discharge.
Care plan implementation — The facility failed to implement and document pressure ulcer/skin impairment interventions as care planned for one resident, including pressure relief and repositioning.
R9-10-412 — The facility failed to notify a resident's attending physician and representative timely of a significant change in condition related to pressure ulcers for one resident.
R9-10-414 — The facility failed to ensure a care plan was implemented and documented for pressure ulcer interventions within seven days after assessment for one resident.
Report Facts
Deficiencies cited: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff #20 | Registered Nurse | Interviewed regarding notification and care for resident #1's pressure ulcers. |
| Staff #21 | Director of Nursing | Interviewed regarding notification and care plan expectations for resident #1. |
| Staff #22 | Certified Nursing Assistant | Interviewed regarding repositioning and pressure relief for resident #1. |
Inspection Report — Feb 2, 2023
Routine CMS
Date: Feb 2, 2023
Visit Reason
The inspection was conducted to assess compliance with professional standards of quality in medication administration, wound care, and food safety at the nursing facility.
Findings
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.
Deficiencies (3)
Two residents were administered supplements without physician orders, violating medication administration policies.
Failure to maintain infection prevention during wound care for one resident, including improper glove use and hand hygiene.
Food items, including onion and bell pepper mixture, were not discarded by the expiration date, risking foodborne illness.
Report Facts
Sample size: 18
Medication administration date: 2023
Food expiration date: 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN/staff #112) | Administered Visifree capsules to resident #24 without physician order | |
| Registry Licensed Practical Nurse (LPN/staff #170) | Administered Centrum Mini and Florastar capsules to resident #14 without physician order | |
| Director of Nursing (DON/staff #113) | Interviewed regarding medication order policies and deficiencies | |
| Registered Nurse (RN/staff #119) | Interviewed regarding medication order policies | |
| Licensed Practical Nurse (LPN/staff #118) | Observed performing wound care with improper glove use | |
| Director of Nursing (DON/staff #133) | Interviewed regarding wound care expectations | |
| Registered Nurse (RN, Wound Nurse/staff #115) | Interviewed regarding wound care expectations | |
| Director of Dining (staff #11) | Interviewed regarding food storage and expiration practices | |
| Registered Dietician (staff #117) | Interviewed regarding food storage and expiration practices | |
| Dietary Porter (staff #52) | Interviewed regarding food storage and expiration practices | |
| Sous Chef (staff #101) | Interviewed regarding food storage and expiration practices | |
| Chef (staff #19) | Interviewed regarding food storage and expiration practices |
Inspection Report — Feb 2, 2022
CMS
Date: Feb 2, 2022
Visit Reason
The inspection was conducted as a regulatory survey of The Terraces of Phoenix nursing home facility.
Findings
No health deficiencies were found during the inspection.
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