Average — CMS composite of the measures below.
A standard survey is most likely before around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Desert Terrace Healthcare Center during CMS and state inspections, most recent first.
A nurse was hired and worked as an RN for an extended period without a valid Arizona RN license after HR verified the wrong individual’s license based on a similar name and did not obtain a copy of the actual license. The nurse functioned as a floor RN, passing meds and assessing residents, while only holding an RN license from a non-compact state and awaiting Arizona endorsement. AZBN later informed HR that the nurse did not have an active Arizona license and should not be working as an RN, but the nurse continued to be scheduled for several days after this notification. The Administrator and DON initially believed or assumed the out-of-state license allowed practice, and only later confirmed that the other state was not part of the Nurse Licensure Compact, contrary to facility policy requiring verification and documentation of valid licensure before staff work in licensed roles.
A resident with vascular dementia and moderate cognitive impairment became private pay after insurance coverage ended, and the business office processed a credit card payment using a "Credit Card Authorization Form" that lacked the resident’s signature and did not document the time of completion. Staff recorded detailed card information and the amount to be charged, but only wrote "via phone" on the signature line to reflect the resident’s telephone consent, without any additional documentation of the exchange. Financial records showed room and board charges, a partial payment, and an outstanding balance, while the resident’s later-appointed fiduciary reported that funds were taken during the resident’s stay and that financial mail was left unsecured in the room. Review of federal guidance and facility policies showed that required systems for written authorization and complete documentation of resident fund transactions were not followed.
A resident with vascular dementia and moderate cognitive impairment, who transitioned from insurance coverage to private pay, had large sums of money allegedly drained from personal accounts while residing in the facility. The resident’s private fiduciary reported suspected fraud to the facility and police, requested records, and stated that the resident’s financial mail and retirement statements were kept unsecured in a nightstand accessible to anyone entering the room. Although the Business Manager notified the then-administrator of the fiduciary’s allegations and request that facility staff be investigated, the current administrator later acknowledged that no investigation was conducted, contrary to the facility’s abuse policy requiring prompt, thorough investigation of all allegations of misappropriation and exploitation.
A resident with vascular dementia and moderate cognitive impairment had a private fiduciary who reported that the resident’s account had been drained of a large sum of money and that police were investigating possible fraud involving facility staff. The BM documented the fiduciary’s allegations and informed the administrator, who indicated he would seek further advice, but no investigation or self-report to the state agency was completed. Later, the fiduciary stated that money had been taken while the resident was in the facility and that she could not pay the facility, yet records confirmed there were no self-reports, despite facility policies requiring external reporting of suspected crimes, abuse, and misappropriation.
A resident with multiple chronic conditions and a cognitively intact BIMS score was found with two medications, including Fluticasone nasal spray and Bacitracin ointment, left at the bedside without any care plan, physician order, or interdisciplinary documentation authorizing self-administration. The resident reported using the medications independently, and a follow-up observation with the DON again confirmed the medications at the bedside, contrary to facility policies requiring interdisciplinary assessment for self-administration and locked storage of all drugs and biologicals.
A resident with cognitive and physical impairments was physically assaulted by a roommate, resulting in multiple facial lacerations. The incident was discovered after another resident alerted a CNA, who found the injured resident and the aggressor in the room. The aggressor admitted to the assault following a verbal altercation. Facility documentation and staff interviews confirmed the event, which occurred despite policies prohibiting abuse and requiring resident protection.
Two residents with significant cognitive and physical impairments, both dependent on staff for personal hygiene, were found with markedly overgrown and discolored toenails, and in one case long fingernails with food debris, indicating that nail care was not consistently provided as part of ADL assistance. Observations over several days showed one resident’s toenails curling over the tops and pads of the toes despite an existing podiatry-related order and shower documentation noting the need for nail clipping, with no corresponding podiatry visit ordered or documented. For the other resident, shower sheets were inconsistently completed regarding nail care, and toenails remained long even after fingernails were clipped. Staff interviews across CNAs, an RN, an LPN, MDS, social services, and case management revealed confusion and conflicting understandings about who was responsible for arranging nail care and podiatry services, contributing to the failure to meet grooming and hygiene needs as required by facility policy.
A resident with a history of mood disorders and substance abuse assaulted another resident on the smoking patio, resulting in a physical altercation. Despite staff training on deescalation and supervision, the incident occurred, indicating a lapse in monitoring and intervention. The facility's policy on preventing abuse was not effectively implemented, leading to a deficiency in resident protection.
Two residents were involved in separate incidents of abuse by another resident with behavioral issues. The first incident involved a verbal altercation where a cellphone was thrown, and the second involved a physical kick. Both incidents were witnessed by staff, who noted the aggressor's history of verbal aggression and behavioral issues.
A resident with type 2 diabetes and other conditions had missing documentation of blood sugar results and vital signs in their medical records. Insulin was administered without recorded blood glucose monitoring, contrary to facility policy. Staff interviews revealed inconsistencies in documentation practices, and the Director of Nursing acknowledged the failure to meet facility expectations.
Unlicensed RN Allowed to Work Due to Faulty License Verification
Penalty
Summary
The facility failed to ensure that a licensed nursing staff member possessed a valid Arizona RN license during the entire period of her employment as an RN. The staff member applied for employment in March 2025 and indicated on her application that she held a valid RN license, with a handwritten note that she was to be endorsed upon arrival. A license verification report dated March 31, 2025, in her personnel file showed an active, unencumbered RN license for a different individual with the same first and last name but a different middle initial. There was no evidence in the personnel file of a valid Arizona RN license or any other state license verification belonging to this staff member, despite her being hired and classified as an RN. Staffing and payroll records showed that the staff member worked as a floor RN from mid-April 2025 until mid-February 2026, passing medications and assessing and caring for residents. A CNA reported that this RN functioned as a floor nurse, and that floor nurses are responsible for assessing residents when notified of changes in condition. The Arizona State Board of Nursing (AZBN) confirmed that the staff member had only been an RN license applicant by endorsement in Arizona and that she was considered foreign-educated, requiring additional steps such as language proficiency testing and third-party education verification. The AZBN stated that the staff member never held an Arizona RN license until April 6, 2026, and that she had been working at the facility as an RN without Arizona licensure or endorsement. The AZBN notified the facility’s HR Director on February 4, 2026, that the staff member did not have an active Arizona RN license and should not be working as an RN. The HR Director acknowledged that she was responsible for obtaining onboarding documents and verifying licenses via an online portal, and that the process did not include requesting a copy of the nursing license. She recognized that the verification in the file belonged to a different person and described this as an oversight. Despite the AZBN notification, payroll records showed that the staff member continued to work until February 11, 2026. The Administrator and DON both stated that they believed the staff member had an active license from another state and, at least initially, believed or assumed that this allowed her to practice, though the other state was not part of the Nurse Licensure Compact. The DON later confirmed via the compact website that the other state was not a compact state and that endorsement through Arizona was required. The facility’s written policy required verification of current, valid licensure and placement of license verification documents in the applicant’s file, which was not done correctly for this staff member, resulting in her working as an RN without a valid Arizona license for an extended period. The staff member herself stated that she first applied for an Arizona RN license sometime in 2024, did not receive it, then obtained an RN license from another state in March 2025 and subsequently applied for Arizona licensure by endorsement. She reported ongoing difficulties completing Arizona’s requirements, including language proficiency testing and education verification, while she was working at the facility. She stated that she believed she could work under her other state license and assumed it would be acceptable. She also reported that the HR Director had asked her shortly before the AZBN’s February 2026 call whether her Arizona license had arrived, and she replied that she was still working on the requirements. The Administrator later acknowledged that the license verification in the file was for another person and that, per facility policy, the staff member had not been qualified to work as an RN during the time she was employed in that role.
Failure to Obtain Proper Written Authorization for Resident Financial Transaction
Penalty
Summary
The facility failed to ensure proper safeguarding of a resident’s personal funds by not obtaining written authorization as required for financial transactions. A resident with a history of anxiety disorder, ureteral calculus, mood affective disorder, and vascular dementia was admitted and later became private pay after insurance coverage ended. An MDS assessment showed a BIMS score of 11, indicating moderate cognitive impairment. When the resident transitioned to private pay, the business office processed a credit card payment using a "Credit Card Authorization Form" that was completed by the Assistant Business Manager but did not contain the resident’s signature or a documented time of completion. The Credit Card Authorization Form listed the resident as the cardholder, described the services as private pay room and board for specific dates, and included the credit card number, expiration date, security code, and total amount to be charged. The form also contained a pre-printed statement agreeing to pay the total amount according to the card issuer agreement. However, in the signature section, staff documented only the words "via phone" instead of obtaining the resident’s written signature. Facility staff, including the Business Manager and Assistant Business Manager, stated that the form was required for each monetary transaction and that the resident had insisted on paying over the phone while away from the facility, but they did not document the details of the phone consent anywhere other than the notation "via phone" on the form. Financial records, including the Resident Ledger Report and Resident Activity Reports, showed the posting of room and board charges, a partial payment, and an outstanding balance. Later documentation indicated that, after the resident’s death, the resident’s private fiduciary reported to the facility that money had been taken from the resident while at the facility and that she was unable to pay the remaining balance. The fiduciary also reported that the resident’s mail, including financial statements and retirement fund information, had been kept in a nightstand drawer and left vulnerable to anyone entering the room. Review of the State Operations Manual and the facility’s job descriptions and policies showed that the facility was required to have systems and internal controls to ensure resident funds were maintained in accordance with federal and state regulations, including written authorization and documentation of date, time, amount, and source or recipient of funds, which were not followed in this case.
Failure to Investigate Alleged Financial Misappropriation and Protect Resident Financial Information
Penalty
Summary
The facility failed to implement its policies prohibiting financial misappropriation for one resident when it did not investigate allegations of fraud involving the resident’s finances. The resident had a history of anxiety disorder, calculus of the ureter, mood affective disorder, and vascular dementia, and an MDS BIMS score of 11 indicating moderate cognitive impairment. The resident was initially not private pay but became private pay after insurance coverage ended, and the business office monitored her financial status because private pay residents were considered rare and the office’s role was to collect money and be aware of when residents might need financial assistance. On a date in April, the Business Manager documented a call from the resident’s private fiduciary, who reported filing a Victim of Fraud claim on behalf of the resident, stating that the resident’s account had been drained of $265,000 and that the police were investigating. The fiduciary requested facility participation in the investigation and copies of financial statements and documentation of the resident’s private pay status. The Business Manager documented that she informed the then-Executive Director/Administrator of the fiduciary’s allegations, including that the fiduciary was asking for facility staff to be investigated for fraud. The fiduciary later stated in interview that the facility had paid itself from the resident’s accounts before she became the financial power of attorney, that she had reported the suspected fraud to both the police and the facility while the resident was still there, and that the resident kept a nightstand drawer full of mail and financial documents, including statements and retirement fund information, which were left vulnerable to anyone entering the room. In subsequent interviews, the current Administrator reported that he and the previous Administrator had gone over the fiduciary’s allegations with her, but that, after speaking with the previous Administrator, it appeared that nothing had been done in response to the fraud allegations and that the previous Administrator had determined there was nothing to investigate. The facility’s abuse policy, revised in October, stated that residents have the right to be free from misappropriation of resident property and exploitation, that staff with knowledge of an actual or potential violation must immediately report it to a supervisor or the Administrator, and that all allegations of abuse, neglect, misappropriation, or exploitation would be promptly and thoroughly investigated with interviews, record review, and documentation of the investigation and its results. Despite this policy, the allegation of financial misappropriation involving this resident was not investigated at the time it was reported.
Failure to Report Alleged Financial Misappropriation to Authorities
Penalty
Summary
The facility failed to report an alleged financial misappropriation involving a resident in accordance with state law and facility policy. The resident, who had vascular dementia and a BIMS score of 11 indicating moderate cognitive impairment, had a private fiduciary (RPF) managing finances. On April 22, 2025, the Business Manager documented that the RPF reported filing a victim of fraud claim on the resident’s behalf, stating the resident’s account had been drained of $265,000 and that the police were investigating. The RPF requested that the facility be part of the investigation and asked for copies of financial statements and documentation related to the resident’s private pay status. Shortly thereafter, the Business Manager documented that she informed the then-Executive Director/Administrator of the RPF’s allegations, including that the RPF was asking for facility staff to be investigated for fraud, and the Administrator stated he would reach out to another staff member for advice. Subsequent documentation on September 2, 2025, reflected that the resident had died and that the RPF stated money had been taken while the resident was at the facility, leaving her unable to pay the facility. During interviews, the Business Manager confirmed she recognized financial abuse as a form of abuse and that she immediately informed the Administrator when the RPF made the fraud allegation. The current Administrator, who had been operations manager at the time, stated that after reviewing the prior allegations and speaking with the former Administrator, it appeared that nothing was done in response and that the former Administrator had determined there was nothing to investigate. The Administrator also confirmed that the allegations of fraud were not reported to the state agency. A review of facility records showed no self-reports related to this resident, despite facility policies requiring that suspected crimes, including fraud and forgery, and allegations of abuse, misappropriation, or exploitation be reported to the State Survey Agency and other appropriate agencies within required timeframes.
Unauthorized Medications Left at Bedside Without Self-Administration Orders
Penalty
Summary
Surveyors identified a deficiency related to medication storage and self-administration when a resident was found with medications left at the bedside without authorization. The resident, who had a history of Type 2 Diabetes Mellitus with diabetic neuropathy, COPD, dementia, and major depressive disorder, had a quarterly MDS with a BIMS score of 13, indicating cognitive intactness. Review of the resident’s care plan, physician’s orders, and electronic medical record showed no care plan, orders, or interdisciplinary team documentation authorizing self-administration of medications. Despite this, during a room observation, two medications—Fluticasone Propionate Suspension 50 mcg/act and Bacitracin Zinc 400 units—were observed at the resident’s bedside. During interviews, the resident confirmed that one medication was used every other day on her toes and that the other was a nasal spray used occasionally. A subsequent observation with the DON again revealed the two medications at the bedside. The DON confirmed that residents without self-administration orders should not have medications left out and acknowledged that this situation did not meet facility expectations. Review of facility policies showed that self-administration requires an interdisciplinary assessment and documentation in the chart, and that all drugs and biologicals must be stored in locked compartments accessible only to authorized personnel, which was not followed in this instance.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
A deficiency occurred when the facility failed to protect a resident from physical abuse by another resident. The incident involved a resident with hemiplegia, major depressive disorder, and cataracts, who was found with multiple superficial wounds and blood on his face after being struck by his roommate. The aggressor, who was cognitively intact and had diagnoses including cellulitis and diabetes, admitted to hitting the victim following a verbal altercation involving a racial slur. The incident was not directly witnessed by staff, but was reported by another resident who heard the altercation and alerted a CNA. Upon entering the room, the CNA observed the aftermath, with the victim wheeling himself into the bathroom and the aggressor walking away. Clinical documentation and staff interviews confirmed that the injured resident sustained lacerations to the forehead, nose, lip, and chin, but was not transferred to the hospital. The aggressor left the facility against medical advice the same day. The facility's investigation concluded that the event was unanticipated and isolated, occurring in an area with adequate staff supervision. However, prior to the incident, there were indications of behavioral issues, as the aggressor had been observed yelling at another resident the day before. Facility policies reviewed indicated that residents have the right to be free from all forms of abuse, including physical abuse. Despite these policies, the facility failed to prevent the physical altercation between the two residents, resulting in injury. Staff interviews revealed an understanding of abuse protocols, but the incident still occurred, demonstrating a lapse in protecting resident rights as required by both facility policy and regulatory guidelines.
Failure to Provide Adequate Nail Care as Part of ADL Assistance
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate nail care as part of activities of daily living (ADLs) for two residents who were unable to perform their own hygiene. One resident had generalized muscle weakness, lack of coordination, cognitive communication deficit, toxic encephalopathy, type 2 diabetes mellitus, and morbid obesity, with an MDS BIMS score indicating moderate cognitive impairment and a care plan identifying ADL deficits related to weakness. Observations over several days showed this resident in bed with feet exposed and toenails that were yellow-brown, markedly overgrown, and curling over the tops and onto the pads of the toes on both feet. Despite an active order stating the resident "may see Podiatry of Choice" and shower sheets on two dates indicating that nails needed clipping, there were no orders or documentation for a podiatry visit, and the toenails remained long and discolored on repeated observations. Multiple staff interviews revealed inconsistent and unclear processes for nail care and referrals. A CNA stated that podiatry would be called to clip nails and that the approach depended on whether the resident was diabetic or if nails were long and curving. An RN reported not knowing the process for clipping nails and needing to ask the CNA. An LPN described a process that began with asking a CNA, then notifying the physician for a podiatry order for diabetic residents, and stated that responsibility for clipping nails belonged to all staff. The MDS coordinator indicated that long toenails identified on assessment would be referred to social services, while the social services director stated she only scheduled podiatry and other services for long-term residents and that case managers handled skilled residents. The case manager, however, stated that she did not schedule appointments and believed social services did, indicating a breakdown in role clarity and follow-through. The second resident had hemiplegia and hemiparesis following cerebral infarction, opioid dependence, cognitive communication disorder, and anxiety disorder, with an MDS BIMS score indicating severe cognitive impairment and dependence on staff for personal hygiene with assistance of one staff member per the care plan. During a dining room observation, this resident was seen eating with the left hand while fingernails were long and had food noted under them, and the feet were covered. A later observation showed that the fingernails had been clipped, but the resident had no shoes or socks on and toenails on both feet were long and extended over the ends of the toes. Review of this resident’s shower sheets showed they were not consistently completed regarding whether nails were clipped or needed clipping, and on one date a CNA marked that nail clipping was not needed. The facility’s ADL policy stated that if a resident is unable to carry out ADLs, necessary services to maintain grooming and personal hygiene would be provided by qualified staff, but the documented observations and records showed that nail care needs for these two residents were not met.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect a resident from abuse by another resident, resulting in a physical altercation. Resident #44, who has diagnoses including bipolar disorder and anxiety, was assaulted by Resident #55 on the smoking patio. The incident occurred when Resident #55, who has a history of aggressive behavior and was experiencing increased agitation, approached Resident #44 unprovoked and punched him behind the ear. A certified nursing assistant witnessed the event and intervened to separate the residents. Resident #44 sustained a reddened area behind the ear but refused further medical assessment. Resident #55 has a history of mood disorders and substance abuse, and was noted to have a significant change in mental status on the day of the incident. Despite being prescribed psychotropic medications for paranoid delusions, Resident #55 exhibited increased agitation and refused medication. The facility's staff, including a CNA and an LPN, acknowledged that they are trained to recognize and deescalate such situations, but the incident still occurred, indicating a lapse in supervision and intervention. Interviews with staff, including the Director of Nursing, revealed that there is an expectation for staff to monitor residents' behaviors and intervene when necessary to prevent harm. The facility's policy emphasizes the right of residents to be free from abuse, yet the incident highlights a failure to adhere to this policy, resulting in a deficiency in protecting residents from abuse.
Resident-to-Resident Abuse Incidents
Penalty
Summary
The facility failed to protect two residents from abuse by another resident, leading to incidents of resident-to-resident abuse. Resident #20, who had no cognitive impairment, was involved in a verbal altercation with resident #75, who also had no cognitive impairment but had a history of trauma and behavioral issues. During the altercation, resident #75 threatened resident #20 and threw her cellphone on the floor. A Certified Nursing Assistant (CNA) reported that resident #75 had previous altercations with other residents and was often the instigator. In another incident, resident #40, who also had no cognitive impairment, was involved in a verbal exchange with resident #75 in the hallway. During this exchange, resident #75 physically kicked resident #40 in the abdomen. A CNA witnessed the incident and confirmed that resident #75 had been verbally aggressive before but had not been physically aggressive until this incident. The Licensed Practical Nurse (LPN) noted that resident #75 was alert and oriented but had behavioral issues and made paranoid statements. The Director of Nursing (DON) acknowledged that resident #75 had not been at the facility long and was on psychiatric medications. The DON initially thought the first incident with resident #20 was isolated but recognized a pattern after the second incident with resident #40. The facility's policy on abuse prevention states that each resident has the right to be free from abuse, neglect, and exploitation, and that willful actions are deliberate, even if not intended to inflict harm.
Deficient Documentation of Vital Signs and Blood Glucose Monitoring
Penalty
Summary
The facility failed to ensure accurate documentation of medical records for a resident, specifically regarding vital signs and blood glucose monitoring. The resident, who was readmitted with multiple diagnoses including type 2 diabetes mellitus and stage 4 pressure ulcers, had missing records of blood sugar results on two occasions when insulin glargine was administered. Additionally, there was no evidence of vital signs being recorded during specific evening shifts, which was against the facility's policy. Interviews with staff revealed inconsistencies in the documentation process. A CNA admitted to not completing documentation for the resident on a particular day, and an LPN confirmed that CNAs are responsible for charting vital signs. The Director of Nursing acknowledged that the lack of documentation did not meet facility expectations and could potentially lead to missing acute changes in the resident's condition. The facility's policies on documentation and insulin administration were not followed, as evidenced by the lack of blood glucose monitoring prior to insulin administration. Staff interviews highlighted that blood glucose levels should be checked before administering insulin, yet there was no record of such monitoring for the resident since a specific date. The Director of Nursing noted that insulin glargine is not held for low blood glucose levels, but the standard of care involves monitoring for hypoglycemia signs in the absence of specific physician orders.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Phoenix
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Desert Haven Care Center | 0.7 mi | ★★★★★ | 10 | 0 |
| Haven Health Sky Harbor, Llc | 1.7 mi | ★★★★★ | 9 | 0 |
| Camelback Post Acute Care And Rehabilitation | 2.3 mi | ★★★★★ | 1 | 0 |
| Haven Of Phoenix | 4.3 mi | ★★★★★ | 12 | 0 |
| Maryland Gardens Post Acute | 4.5 mi | ★★★★★ | 0 | 0 |
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