The Terraces of Phoenix

In the surveyor’s words

From the most serious findings on record at The Terraces of Phoenix, in the surveyor’s own words.

• Actual harm, isolatedF600Aug 10, 2024

  Based on clinical record review, resident/staff interviews, facility documentation and policy review and the State Agency (SA) complaint tracking system, the facility failed to protect the rights of two residents (#12 and #23) to be free from sexual abuse by another resident (#45). The deficient practice could result in the potential for harm and had placed residents at increased risk for further abuse, serious injury, harm and psychosocial harm. The census was 43. Findings include: -Resident #23 admitted on [DATE] with diagnoses of dementia and depression. The care plan dated May 16, 2023 revealed the resident had impaired cognitive function. The goal was that the quality of life will be nurtured and the resident will be exposed to pleasurable events each day. […]

• No harm, potential for more than minimal, patternF880May 31, 2024

  Based on review of clinical records and policy, observations, and staff interviews the facility failed to ensure transmission-based precautions, particularly enhanced barrier precautions (EBP), signage and personal protective equipment were in-place to help prevent development or transmission of infections. The deficient practice could result in development or transmission of infections within the facility. Findings Include: Resident #352 was admitted on [DATE] with diagnosis including sepsis, unspecified organism, onset date May 22 2024, Unspecified Escherichia coli [E. […]

• No harm, potential for more than minimal, patternF882May 31, 2024

  Based on staff interviews and facility policy, the facility failed to designate a qualified individual as the Infection Preventionist (IP). The deficient practice could result in improper infection prevention practices in the facility. Findings include: An interview was conducted May 29, 2024 at 10:34 AM with Licensed Practical Nurse and designated Infection Preventionist (LPN/IP/Staff # 100) who stated although had coursework in Infection Prevention, did not have an infection prevention program certificate of completion at this time. Staff # 100 stated she had not taken the final cumulative assessment in order to receive her certificate of completion. […]

• No harm, potential for more than minimal, patternF947May 31, 2024

  Based on review of employee personnel file, staff interviews and policy review, the facility failed to ensure personnel records for 2 staff (#150 and #56) included documentation of orientation and in-service education as required by policies and procedure. The deficient practice could result in inadequate care of residents. Findings include: Review of the personnel file of a registered nurse (RN/staff 150) revealed a hire date of April 26, 2021. The file revealed no evidence of infection control and Abuse/neglect/exploitation training since January and July, 2022. Review of the personnel file of a activity coordinator (staff 56) revealed a hire date of January 21, 2014. […]

• No harm, potential for more than minimal, isolatedF628Jun 13, 2025

  Based on clinical record review, interviews, and policy, the facility failed to provide one resident (#21) and/or the resident's representative with bed-hold policy information before a transfer to the hospital. The deficient practice could result in residents being unaware of their bed-hold rights. Findings include: Resident # 21 was initially admitted to the facility on [DATE] and was re-admitted on [DATE] with diagnoses that includes metabolic encephalopathy, pulmonary coccidioidomycosis type 2 diabetes mellitus without complications, coccidioidomycosis meningitis, and chronic obstructive pulmonary disease. A progress note regarding resident's admission dated May 8, 2025 indicated that the resident was alert and oriented to person, place, and time. […]