Desert Terrace Healthcare Center

Inspectors wroteBased on interviews, review of clinical record, and review of facility policy and procedure, the facility failed to protect a resident's (#2) right to be free from physical abuse from another resident (#1), for one of three sampled residents. The deficient practice could lead to physical or psychosocial harm of a resident.

Inspectors wroteBased on interviews, review of clinical and personnel records, and review of facility policy and procedure, the facility failed to ensure that one sampled licensed nursing staff (#60) possessed a valid Arizona state license to practice as a Registered Nurse (RN) during employment, in accordance with state and federal regulations. The deficient practice could result in an unlicensed individual providing nursing care to residents for an extended period, and could potentially affect the safety and quality of care delivered to all residents receiving services.

Inspectors wroteBased on facility documentation, staff interviews, Long Term Care State Operations Manual, and facility policies review the facility failed to ensure that safeguarding of personal funds included a system of written authorization for Resident #8. The deficient practice could result in verbal monetary agreements that do not allow identification and/or investigation of financial misappropriation.

Inspectors wroteBased on clinical record review, resident and staff interviews, and policy review, the facility failed to ensure policies prohibiting financial misappropriation were implemented for Resident #8. The deficient practice could result in lack of measures that prevent financial misappropriation of residents.

Inspectors wroteBased on clinical record review, resident and staff interviews, and policy review, the facility failed to ensure that alleged violations concerning financial misappropriation were reported in accordance with state law for Resident #8. The deficient practice could result in continued financial abuse to residents.

Inspectors wroteBased on review of clinical records and policy, observations, and staff interviews the facility failed to ensure that medications were not left at the bedside for one Resident #12. The deficient practice could result in harm to the residents, and/or visitors who have access to medications.

Inspectors wroteBased on clinical record review, staff interviews, and review of facility documentation and policies, the facility failed to protect the rights of one resident (#1) to be free from abuse by another resident (#2). The deficient practice could result in further abuse of residents when appropriate actions are not taken. Findings Include:-Resident #1(alleged victim) was readmitted to the facility on [DATE], with diagnoses that included hemiplegia and hemiparesis of the left non-dominant side, major depressive disorder, and age-related bilateral cataract. The census report revealed that Resident #1 shared the same room with Resident #2 since September 26, 2025. A review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 13.0, indicating that the resident was cognitively intact. [...]

Inspectors wroteBased on observations, staff interviews, review of the clinical record and the facility policy and procedures, the facility failed to ensure nail care was provided for two residents (#18 and #28) out of 89. The deficient practice could result in resident grooming and hygiene needs not being met.-

Inspectors wroteBased on documentation, staff interviews, and the facility policy and procedures, the facility failed to ensure that one resident (#44) was not abused by another resident (#55). The deficient practice could result in residents being physically and emotionally harmed.

Inspectors wroteBased on clinical record reviews, facility documentation, resident and staff interviews, and policy review, the facility failed to ensure that two residents (#20) and (#40) were free from abuse from other residents (resident #75). The deficient practice could result in further incidents of resident to resident abuse.

Inspectors wroteBased on staff interviews, review of records and review of policies and procedures, the facility failed to ensure that medical records were documented accurately and in accordance with accepted professional standards and practices for one resident (#12) regarding vital signs and blood glucose monitoring. The deficient practice could result in inaccurate records being documented for additional residents.

Inspectors wroteBased on observations, staff interviews, facility documents, and resident records, the facility failed to ensure 3 residents received medications in a timely manner. The sample size was 3.

Inspectors wroteBased on personnel file review, staff interview, and facility documentation and policy review, the facility failed to ensure the activities program was directed by a qualified professional. The deficient practice could result in the activities provided not meeting the assessed needs of the residents.

Inspectors wroteBased on clinical record reviews, staff interviews and facility policies and procedures, the facility failed to ensure two residents (#116 and #121) were provided with showers or bathing. The sample size was 4. The deficient practice could result in residents' hygiene needs not being met.

Inspectors wroteBased on clinical record review, facility documentation, resident and staff interviews, and policies and procedures, the facility failed to ensure bathing or showers were consistently provided to one resident (#31). The sample size was 4. The deficient practice could result in hygiene needs not being met.

Inspectors wroteBased on clinical record reviews, staff interviews, and facility policies and procedures, the facility failed to ensure care and services related to pressure ulcers were consistently provided to two residents (#124 and #125). The sample size was 3. The deficient practice could result in residents not receiving appropriate treatment for pressure ulcers.

Inspectors wrote-Resident #67 was admitted to the facility on [DATE] at 7:15 p.m. with diagnoses of intracranial abscess and granuloma and periapical abscess with sinus. The physician order summary dated July 15, 2022 included an order for ampicillin-sulbactam sodium solution reconstituted 3 grams (2-1), use 3 grams intravenously four times a day for wound care for 18 days. The order was revised on July 16, 2022 at 7:04 a.m. to be given every six hours. The original and revised order were transcribed onto the medication administration record (MAR) for July to be administered at the following scheduled times: 8:00 a.m., 12:00 p.m., 4:00 p.m., and 8:00 p.m., and was then changed to 12:00 a.m., 6:00 a.m., 12:00 p.m., and 6:00 p.m., respectively. Upon further review, the MAR revealed the resident missed the scheduled dose at 8:00 p.m. on July 15, 2022. Review of a medication administration note at 3:02 a.m. [...]

Inspectors wroteBased on clinical record reviews, staff interviews, and facility policy, the facility failed to ensure three residents (#6, #31, #34) received medications as ordered by the physician. The sample size was 5. The deficient practice could result in unnecessary medication administration.

Inspectors wroteBased on clinical record review, staff interviews, and facility policy, the facility failed to ensure that risks and benefits of a psychotropic medication were explained to one resident (#34) prior to receiving the medication. The sample size was 5 residents. The deficient practice could result in residents and/or their representatives not being informed of the risks and benefits of psychotropic medications.

Inspectors wroteBased on clinical record review, staff interviews and facility policies and procedures, the facility failed to ensure the physician was notified of one resident's (#126) low blood pressure. The sample size was 1. The deficient practice could result in delayed treatment.

Inspectors wroteBased on clinical record review, staff interviews, and policy review, the facility failed to meet professional standards of quality, by failing to ensure one resident (#6) received medications as ordered by the physician. The sample size was 5. The deficient practice could result in residents not receiving physician ordered medications and their pain not being relieved.

Inspectors wroteBased on clinical record review, resident and staff interviews, and policies and procedures, the facility failed to ensure one sampled resident (#31) received ostomy care in accordance with professional standards of practice. The deficient practice could result in untimely waste removal, unpleasant odor and skin breakdown.

Inspectors wroteBased on observations, clinical record review, staff interviews, and policy review, the facility failed to ensure one sampled resident (#375) had an order for oxygen use. The deficient practice could result in residents receiving oxygen without a physician order.

Inspectors wroteBased on observation, staff interviews, and policy review, the facility failed to ensure current nurse staffing information was accurate for actual hours worked by licensed and unlicensed direct care nursing staff. The deficient practice could result in residents and visitors not being informed of accurate and current staffing information.