Below average — CMS composite of the measures below.
A standard survey is most likely before around August 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 Arizona State Veteran Home-phx during CMS and state inspections, most recent first.
A resident with a prior elopement history, moderate cognitive impairment, and use of a motorized wheelchair was allowed limited independent travel and had inconsistent care plan documentation regarding a wander-guard and supervision needs. The resident signed out to the portico, was later found missing, and was located at home about 24 miles away after a code pink was called. Staff interviews and the record showed the resident was not accompanied as planned and a staff member who saw him leaving did not stop him or notify others.
A resident with cognitive impairment and behavioral disturbances was subjected to physical abuse by another resident with a known history of disruptive behaviors. The incident occurred in a common area when one resident, aggravated by the other's vocalizations, physically grabbed and moved the other resident's head. Staff intervened and separated the residents, but the event highlighted a failure to prevent abuse despite existing care plans and supervision.
The facility did not submit required PBJ staffing data to CMS for one quarter due to the absence of a staffing coordinator and lack of clarity regarding responsibility for the submission. Interviews confirmed that key staff were either unfamiliar with the process or not available, and the prior leadership was aware of the missed submission.
The facility did not ensure accurate and complete documentation of resident weights, resulting in significant discrepancies and a lack of follow-up on abnormal findings. Staff used inconsistent methods for obtaining weights, particularly with Hoyer lifts, and there was insufficient training and unclear procedures, leading to inaccurate records and a failure to notify the physician or address potential errors.
A resident with multiple mental health diagnoses, including major depressive disorder, was admitted without all conditions being accurately reflected on the PASARR Level I screening. The assessment omitted the major depressive disorder diagnosis, leading to a lack of referral for further evaluation, despite facility policy and staff expectations that all mental health diagnoses be included.
A resident with multiple psychiatric diagnoses was receiving antidepressant medication, and the consultant pharmacist recommended discontinuing one medication due to the resident's weight and BMI, suggesting an alternative. The attending physician did not document review or response to this recommendation, and the psychiatric nurse practitioner also did not address it in her notes. Facility policy requires timely review and documentation of pharmacy recommendations, but no evidence was found that this process was followed for the resident.
A resident with multiple medical conditions and intact cognition was found with a fractured finger of unknown origin. Although the incident was reported to authorities, the facility did not follow its abuse investigation policy, as required interviews with staff, family, visitors, and others were not conducted or documented, resulting in an incomplete investigation.
A resident with multiple medical conditions and intact cognition reported unexplained pain in a finger, which was found to be fractured. The facility reported the incident but did not conduct a thorough investigation as required by policy, failing to obtain written statements from staff, family, or others who may have had relevant information. Staff interviews confirmed that the expected investigative process was not followed, resulting in an incomplete investigation.
The facility did not conduct thorough investigations into allegations of abuse, neglect, or misappropriation of property, as evidenced by missing interviews with residents, staff, and witnesses, incomplete documentation, and lack of follow-up on reported incidents such as injuries, missing items, and abuse allegations. Investigative reports often lacked key details, and staff were uncertain about investigation procedures and record retention.
A resident with a history of cognitive impairment and physical ability to leave the facility eloped multiple times, despite initial assessments indicating no elopement risk. Care plans and risk assessments did not consistently address the resident's potential for wandering, and staff interviews revealed inconsistent understanding and implementation of elopement prevention protocols. The resident was able to leave the premises unsupervised on more than one occasion, demonstrating a failure in adequate supervision and hazard prevention.
A resident with dementia and a cognitive communication deficit, who was care planned for elopement risk and required a Wander-guard with hourly checks, was able to leave the facility unsupervised in a wheelchair. The resident was found by a staff member at a nearby intersection after leaving to buy a drink, and was returned to the facility. Staff interviews revealed that the security guard responsible for monitoring did not know the resident's restrictions or how to use the video cameras, and required checks of the independent travel book were not performed.
A resident with multiple medical conditions experienced a Fentanyl overdose after staff failed to remove a previous Fentanyl patch before applying a new one, did not notify supervisors or the physician when the patch was missing, and did not follow facility protocols for patch application and disposal. The resident was found unresponsive, required hospitalization, and was diagnosed with Fentanyl overdose and related complications.
Two residents with cognitive and behavioral health issues engaged in a physical altercation that was initially unwitnessed by staff, resulting in a deficiency for failing to protect residents from abuse. Staff and camera footage confirmed the incident, and both residents had documented behavioral symptoms prior to the event.
A resident with multiple sclerosis and identified as a fall risk experienced a fall resulting in a fracture due to the facility's failure to implement the prescribed care plan. The care plan included maintaining the bed in a low position and placing a floor mat, but these interventions were not followed, as observed during a facility visit. Interviews with CNAs revealed a lack of awareness of the care plan requirements, and facility staff confirmed the resident's fall risk status and the importance of the preventive measures.
A resident with hypertension was administered Amlodipine outside the prescribed parameters, as the medication was given despite the diastolic blood pressure being below the threshold. This was confirmed by an LPN and the ADON, who acknowledged the risk of the resident's blood pressure dropping too low. The facility's policy requires adherence to prescriber orders, which was not followed.
A deficiency was identified when two residents with cognitive impairments and behavioral issues were involved in an altercation in the dining room, with one resident allegedly hitting the other. The incident occurred due to a lack of supervision, as no staff were present to monitor the residents during meal time, despite facility policy requiring such oversight. The Director of Nursing confirmed the absence of staff and acknowledged the need for targeted interventions to reduce risks.
A resident with Alzheimer's disease engaged in inappropriate behavior by using racial slurs towards another resident with quadriplegia, despite existing interventions to manage such behaviors. The incident was confirmed through staff and resident interviews, highlighting a failure to uphold the facility's policy on resident dignity and respect.
A resident with cognitive deficits reported being accosted by two staff members, but the facility failed to conduct a thorough investigation. The investigation lacked staff and resident interviews, and there was no evidence of a complete investigation as required by the facility's policy.
A facility failed to ensure a resident's right to independent travel by enforcing a policy requiring a 24-hour advance notice and physician's order. The cognitively intact resident felt restricted and degraded, and staff interviews confirmed the policy's enforcement despite its perceived excessiveness and disagreement from the resident's physician.
The facility failed to ensure residents' rights to independent travel, requiring a 24-hour advance notice and physician's order, leading to feelings of restriction and embarrassment among residents with functional quadriplegia, generalized anxiety disorder, and major depressive disorder.
Elopement Supervision Failure
Penalty
Summary
The facility failed to ensure adequate supervision to prevent elopement for one resident with a history of leaving the facility without authorization. The resident had diagnoses including hemiplegia and hemiparesis following cerebral infarction, hypertensive heart disease, and PTSD, and records showed a prior elopement in December 2022 when the resident was found about 11 miles from the facility. The care plan did not reflect that prior elopement, and later documentation showed inconsistent tracking of wandering risk, including a physician order to document wandering behaviors and a behavioral symptoms care plan that identified unsafe travel outside the facility without responsible party or proper authorization. The record also showed inconsistent documentation regarding the wander-guard. A physician order allowed placement of a wander-guard, and a progress note stated the spouse requested permanent removal and the NP determined the resident was safe to have it removed. However, the care plan was not updated to reflect removal of the device, and later the care plan still did not show that the wander-guard had been removed. The resident’s MDS indicated moderate cognitive impairment with a BIMS score of 10, that the resident could operate a motorized wheelchair independently, and that elopement alarms were not used. The resident was later approved for an independent travel pass to the park entrance, but the clinical record did not show that the resident was accompanied to the park by staff or other authorized persons as described in the care plan. On May 1, 2026, the resident signed out of the building at 8:10 a.m. with the destination listed as the portico. Staff later initiated a code pink when the resident was not located in the facility or nearby areas. The resident was found at home approximately 24 miles away and was returned to the facility by the spouse. A staff statement indicated the resident was seen heading away from the facility toward a major intersection, but the statement did not show that the staff member stopped the resident or notified anyone at that time. Interviews with staff and the spouse confirmed that the resident had been allowed limited independent travel, that he was not being supervised while outside, and that he left the facility and traveled home on his own.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
A deficiency occurred when a resident with dementia and behavioral disturbances was not protected from physical abuse by another resident with a history of socially inappropriate and disruptive behaviors. The incident took place in a common area, where one resident, aggravated by the other's habit of counting out loud, approached from behind and placed his hands over the other resident's ears, moving the resident's head side to side. This event was witnessed by a CNA, who intervened and separated the residents. No injuries were observed, but the resident who was subjected to the physical contact was unable to defend himself due to cognitive impairment. The resident who initiated the contact had a documented history of behavioral symptoms requiring continuous supervision and interventions such as redirection. Despite these known risks, the resident was able to approach and physically interact with another resident in a manner that constituted abuse. The care plans for both residents acknowledged their cognitive and behavioral challenges, but the measures in place did not prevent the altercation from occurring. Staff interviews confirmed that the incident was reported to supervisory staff and documented in the clinical records. The facility's policy states that residents have the right to be free from abuse, and the administrator acknowledged that the event constituted physical abuse. The report details the sequence of events and the failure to prevent resident-to-resident abuse, as well as the facility's recognition of the incident as a violation of resident rights.
Failure to Submit Required PBJ Staffing Data to CMS
Penalty
Summary
The facility failed to submit the required direct care staffing information and CASPER Payroll-Based Journal (PBJ) data to CMS for one quarter, specifically for fiscal year quarter four (July 1 - September 30) 2024. This deficiency was identified through a review of the facility's PBJ Staffing Data Report, which showed missing data for the specified quarter. Attempts to interview the staffing coordinator responsible for PBJ data submission were unsuccessful, as the individual was not available. Further interviews revealed that the previous staffing coordinator, who was responsible for submitting PBJ data, was no longer employed at the facility, and the new staffing coordinator had not yet assumed these responsibilities. The Assistant Director of Nursing (ADON) was not familiar with the PBJ data submission process, and the Regional Compliance Director of Nursing confirmed that there was currently no staffing coordinator in place. It was acknowledged by staff that the prior Administrator and DON were aware of the missed submission, but the reason for the failure was not provided.
Failure to Ensure Accurate and Complete Weight Documentation
Penalty
Summary
The facility failed to ensure that the medical record, specifically the documentation of resident weights, was complete and accurate for two residents. For one resident with diagnoses including cirrhosis of the liver, major depressive disorder, and enterocolitis due to clostridium difficile, there were significant discrepancies in the recorded weights over several months. The Minimum Data Set (MDS) did not indicate any weight gain or loss, but the documented weights varied widely, with one notably low weight not addressed or explained in the medical record. There was no evidence in the progress notes that staff acknowledged or investigated the low weight, nor was there documentation of staff notifying the physician or dietician of this abnormal finding as required by the care plan and physician orders. Interviews with staff revealed inconsistent practices and a lack of standardized procedures for obtaining and recording weights, particularly when using a Hoyer lift with a scale. Certified Nursing Assistants (CNAs) and Restorative Nursing Assistants (RNAs) reported varying methods, such as subtracting an estimated weight for the sling, which was not supported by facility policy. Staff also indicated insufficient training on proper weighing techniques, and some expressed concern that many staff did not know the correct procedures, potentially leading to inaccurate documentation. The Diet Technician and Nurse Supervisor both stated that re-weighs should be performed if a weight appears abnormal, but there was no clear timeframe or documentation of this process being followed in the case reviewed. Facility policy required significant weight changes to be reported to the nurse supervisor and outlined procedures for weighing residents using various types of scales, but did not address the use of a Hoyer lift with a scale. The Director of Nursing (DON) and Assistant DON acknowledged that the low weight recorded was likely an error but could not find any documentation that it was addressed or confirmed as inaccurate. The attending physician was not notified of the abnormal weight and stated that such discrepancies could affect resident care, especially for those with conditions requiring close weight monitoring.
Incomplete PASARR Assessment for Mental Health Diagnoses
Penalty
Summary
The facility failed to ensure that a resident's Preadmission Screening and Resident Review (PASARR) was completed accurately and that all relevant mental health diagnoses were included. The resident was admitted with diagnoses including diffuse traumatic brain injury, bipolar disorder, and major depressive disorder. Documentation review showed that the PASARR Level I screening did not reflect the resident's diagnosis of major depressive disorder, despite this diagnosis being present in the medical record and care plan. The PASARR indicated that a referral for a Level II evaluation was not necessary, based on incomplete information. Interviews with facility staff, including a medical social worker and the Director of Nursing, confirmed that the PASARR assessment did not accurately list all of the resident's mental health diagnoses. The facility's policy required that all mental health-related diagnoses be reflected in the PASARR assessment and that individuals meeting criteria for a mental disorder be referred for further evaluation. The omission of the major depressive disorder diagnosis on the PASARR resulted in the resident not being properly evaluated for specialized services.
Failure to Address Pharmacy Medication Recommendations
Penalty
Summary
The facility failed to ensure that pharmacy recommendations for a resident were reviewed and addressed by the attending physician, as required by facility policy. The resident in question had multiple psychiatric diagnoses, including dementia with agitation, depression, and schizophrenia, and was receiving antidepressant medication as part of his care plan. The consultant pharmacist conducted a monthly medication regimen review and recommended discontinuing the resident's mirtazapine due to the resident's weight and BMI, suggesting an alternative antidepressant. This recommendation was documented and a note was written to the physician. However, there was no evidence in the clinical record that the attending physician had reviewed or acknowledged the pharmacist's recommendation. The physician stated during interview that he typically reviews pharmacy recommendations every one or two weeks and responds by marking agree or disagree on the form, which is then uploaded to the medical record. In this case, the physician was unsure if the recommendation had been addressed and could not confirm whether he had seen it. The psychiatric nurse practitioner also did not document any review or consideration of the pharmacist's recommendation in her progress notes. Facility policy requires that within twenty-four hours of the medication regimen review, the consultant pharmacist provides a written report to the attending physician, who must document in the medical record that the irregularity was reviewed and what action, if any, was taken. Interviews with the Director of Nursing and Assistant Director of Nursing confirmed that the process involves placing pharmacy recommendations in the provider's folder for review and response, but upon review, they could not locate any documentation that the recommendation for this resident had been addressed. This resulted in a failure to ensure that medication irregularities identified by the pharmacist were reviewed and acted upon by the physician.
Failure to Adhere to Abuse Investigation Policy After Injury of Unknown Origin
Penalty
Summary
The facility failed to adhere to its abuse policy following an incident involving an injury of unknown origin for one resident. The resident, who had multiple diagnoses including type 2 diabetes, PTSD, and depression, was found to have a red, swollen, and painful pinky finger, which was later confirmed by x-ray to be a nondisplaced fracture. The resident was cognitively intact and did not recall any fall or incident that could have caused the injury. The facility reported the incident to the appropriate authorities and documented the event, but the internal investigation was unsubstantiated due to the resident's underlying bone conditions. Despite the reporting, the facility's investigation did not include interviews with staff, family, visitors, other departments, or other residents, as required by the facility's abuse policy. Interviews with facility staff, including the RN, CNA, DON, ADON, and Administrator, revealed that the expected process for investigating injuries of unknown origin included interviewing all relevant parties and obtaining written, signed statements. However, in this case, these steps were not followed, and the investigation documentation lacked evidence of comprehensive interviews. The facility's policy clearly stated that all allegations of abuse, including injuries of unknown origin, must be thoroughly investigated with interviews of all potential witnesses and involved parties, and that these interviews should be documented in writing. The failure to conduct and document these interviews represented a deviation from the established policy and resulted in an incomplete investigation of the incident.
Failure to Thoroughly Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to thoroughly investigate an incident involving an injury of unknown origin for one of three sampled residents. The resident, who had a history of multiple medical conditions including type 2 diabetes, depression, and osteopenia, reported pain in the left pinky finger, which was found to be red, swollen, and fractured upon x-ray. The resident was cognitively intact and did not recall any fall or incident that could have caused the injury. The facility reported the incident to the appropriate authorities and documented the resident's statement, but the investigation was deemed unsubstantiated based on the x-ray findings and the resident's lack of recollection. Despite the facility's policy requiring a thorough investigation—including interviews with the person reporting the incident, witnesses, the resident or representative, staff members in contact with the resident, the resident's roommate, family members, and visitors—there was no evidence that such comprehensive interviews were conducted. The investigation documentation lacked statements from staff, family, visitors, other departments, or other residents who may have had relevant information about the incident. Interviews with facility staff, including the DON, ADON, and Administrator, confirmed that the expected process would involve obtaining written, signed, and dated statements from all potentially involved parties, but this was not done in this case. The deficiency was further highlighted by staff interviews, which revealed an understanding of the required investigative process, yet the actual investigation for this incident did not follow those protocols. The Administrator acknowledged that interviews were not conducted because the resident denied issues with staff, but also stated that interviews are required during such investigations. The facility's failure to follow its own policy and thoroughly investigate the injury of unknown origin resulted in an incomplete investigation for the resident.
Failure to Thoroughly Investigate Allegations of Abuse, Neglect, and Misappropriation
Penalty
Summary
The facility failed to ensure that allegations of abuse, neglect, and misappropriation of resident property were thoroughly investigated for multiple residents. In several cases, when residents or their families reported abuse, missing property, or injuries, the facility's investigative reports lacked critical components such as interviews with the alleged victims, potential perpetrators, or witnesses. For example, in one instance, a resident alleged that a male CNA threw him down the hall, but the investigation did not include interviews with the resident or the staff member in question, nor did it document a skin assessment following the allegation. Similarly, another resident reported missing clothing and rings, but there was no evidence that housekeeping staff were interviewed or that a thorough search was conducted. In other cases, residents reported abuse or injury during care or transportation, but the facility's investigations were incomplete. For example, a resident alleged rough handling by a CNA resulting in a skin injury, but the investigation did not include resident interviews or skin assessments. In several incidents involving transportation accidents or injuries, the facility failed to conduct or document interviews with the residents or staff involved, and there was no conclusive documentation of the investigation's findings. Additionally, reports of missing money and jewelry were not supported by documented investigations or interviews, and the facility was unable to provide records of grievances or investigations when requested. The facility's policies required that grievances and complaints be reviewed and investigated, with written reports maintained, but the documentation provided did not demonstrate compliance with these requirements. Staff interviews revealed uncertainty about the process for investigating and documenting allegations, as well as the retention of investigation records. The lack of thorough investigations and documentation could result in violations against residents not being identified or addressed appropriately.
Failure to Prevent Resident Elopement Due to Inadequate Supervision and Risk Assessment
Penalty
Summary
The facility failed to ensure that a resident was free from elopement, resulting in multiple incidents where the resident left the premises without authorization. The resident, who had diagnoses including hemiplegia, vascular dementia, psychotic disturbance, mood disturbance, anxiety, and major depressive disorder, was initially assessed as not being at risk for elopement or wandering. However, documentation and staff interviews revealed that the resident was physically able to leave the building independently, and there were previous unsuccessful attempts to elope prior to the documented incidents. Despite the resident's complex medical and cognitive history, care plans and risk assessments did not consistently identify or address the resident's potential for elopement. The resident was able to leave the facility on at least two occasions, once being found by his wife and another time by the director of rehab, both times outside the facility premises in his electric wheelchair. Staff interviews confirmed that the resident was not approved for independent travel and had not signed out, which was required for residents who were not independent travelers. The facility's process for monitoring and preventing elopement, including the use of wander guards and regular checks, was not effectively implemented or updated in response to the resident's changing behaviors and history of elopement. The deficiency was further evidenced by inconsistent documentation in care plans and risk assessments, as well as varying staff understanding of elopement protocols. Staff interviews indicated that while some interventions such as wander guards and increased monitoring were in place, these measures were not sufficient to prevent the resident from leaving the facility unsupervised. The facility's policy required monitoring and precautions for residents at risk of wandering or elopement, but these were not adequately followed, resulting in repeated incidents of elopement for this resident.
Failure to Prevent Resident Elopement Due to Inadequate Supervision
Penalty
Summary
The facility failed to provide adequate supervision to prevent the elopement of a resident with diagnoses including Parkinson's disease, unspecified dementia, and a cognitive communication deficit. The resident was assessed as rarely understood and had a care plan in place due to demonstrated unsafe travel outside the facility without authorization. Interventions included the application of a Wander-guard and hourly checks, as well as orders for staff to verify the Wander-guard was in place and to perform alert charting for elopement risk every shift. Despite these interventions, the resident was able to leave the facility unaccompanied and was observed by the Social Services Manager at a nearby intersection, propelling himself in a wheelchair toward a gas station to buy a drink. The resident was last seen by staff at 1:30 p.m. and was returned to the facility at 1:40 p.m. after being assisted by staff. Interviews revealed that the security guard, responsible for monitoring residents on the front patio and using video cameras, was not aware that the resident was not permitted to leave alone and did not know how to operate the video monitoring system. The DON stated that the expectation was for the receptionist and guard to check the independent travel book to verify if a resident could leave independently, but this was not done. The facility's policy required monitoring and precautions for residents at risk of wandering or elopement, but these measures were not effectively implemented, resulting in the resident's unsupervised departure from the facility.
Failure to Prevent Significant Medication Error Resulting in Fentanyl Overdose
Penalty
Summary
A resident with diagnoses including acute on chronic right heart failure, urinary tract infection, and Parkinson's disease was prescribed a Fentanyl transdermal patch to be applied every 72 hours, with specific instructions to remove the old patch before applying a new one. The care plan to monitor for adverse reactions related to Fentanyl usage was not initiated until after the incident, and prior documentation did not indicate any focus on monitoring the resident's Fentanyl use or risk for adverse reactions. Medication administration records showed that patches were applied and removed on alternating sides of the chest, but on one occasion, the nurse could not locate the previous patch and applied a new one without notifying a supervisor or the physician, as required by facility protocol. Subsequently, the resident was found to be lethargic, difficult to arouse, and had missed both breakfast and lunch. Upon assessment, the resident exhibited low blood pressure, decreased oxygen saturation, and altered mental status. The resident was sent to the hospital, where it was discovered that two Fentanyl patches were present on his body, leading to a diagnosis of Fentanyl overdose, hypoxia, and acute kidney injury. The resident required treatment in the ICU, including a Narcan drip. Interviews with nursing staff and the Assistant Director of Nursing revealed that facility procedures required two nurses to be present for both application and disposal of Fentanyl patches, and that any missing patch should prompt a full-body check and physician notification. However, these procedures were not followed: the nurse did not notify the supervisor or physician when the patch was missing, and an extra patch was later found and removed without reporting. Additionally, patches were not always placed according to the provider's specified locations. Facility policy required medications to be administered safely and as prescribed, but these protocols were not adhered to in this case.
Failure to Prevent Resident-to-Resident Physical Altercation
Penalty
Summary
The facility failed to protect two residents from abuse, specifically resident-to-resident physical altercations. One resident with a history of neurocognitive disorder, encephalopathy, and PTSD, and another resident with major depressive disorder and dementia, were involved in a physical altercation. Both residents had documented behavioral symptoms, with one resident noted for occasional aggression and recent sexually inappropriate behaviors, and the other for disruptive behavior evidenced by the altercation. On the day of the incident, the two residents were observed sitting next to each other when they raised their fists and engaged in a physical struggle. The initial contact was unwitnessed by staff, but a CNA intervened after seeing the residents with raised fists. Interviews with staff revealed that one resident had been exhibiting increased behavioral issues, including aggression and sundowning behaviors, while the other had no prior history of aggression. The altercation was later confirmed by both residents, each claiming the other initiated the contact. Skin assessments found no injuries, and both residents did not recall the incident the following day. Review of camera footage showed one resident maneuvering his wheelchair close to the other, after which both raised their arms and engaged in a brief physical struggle before being separated by staff. The facility's policy states that residents have the right to be free from all forms of abuse, including physical abuse. The failure to prevent and adequately supervise to avoid resident-to-resident physical altercations constituted a deficiency in protecting residents from abuse.
Failure to Implement Fall Prevention Care Plan
Penalty
Summary
The facility failed to implement a comprehensive care plan for fall prevention for a resident diagnosed with multiple sclerosis and other conditions, who was identified as a fall risk. The resident required extensive assistance for bed mobility and transfers due to lower extremity impairment. Despite these needs, the care plan was not properly executed, as evidenced by an incident where the resident was found on the floor after attempting to reposition himself in bed, resulting in a non-displaced fracture of the right posterior acetabulum. The care plan for the resident included specific interventions such as maintaining the bed in a low position, placing a floor mat on the right side of the bed, and ensuring the call light was within reach. However, during an observation, the resident was found in bed with the bed in a high position and the floor mat not in place, indicating a failure to follow the prescribed interventions. Interviews with CNAs revealed a lack of awareness and adherence to the care plan, as they were unaware of the requirement to lower the bed and place the floor mat. Further interviews with facility staff, including a registered nurse supervisor and the Director of Nursing, confirmed that the resident was identified as a fall risk and that preventive measures were in place. However, the failure to implement these measures as outlined in the care plan posed a risk of injury to the resident. The facility's policy on care plans and fall risk management emphasized the importance of identifying and implementing interventions to prevent falls, but these were not effectively executed in this case.
Failure to Administer Blood Pressure Medication Within Prescribed Parameters
Penalty
Summary
The facility failed to ensure that an order for blood pressure medication was administered within the prescribed parameters for a resident. The resident, who was admitted with diagnoses including generalized body pain, osteoarthritis, and essential hypertension, had a care plan indicating the need for pain monitoring and management, as well as a risk for complications related to hypertension. The medication order for Amlodipine 2.5 mg was to be administered every 12 hours for hypertension, with instructions to hold the medication if the systolic blood pressure (SBP) was less than 110 or the diastolic blood pressure (DBP) was less than 70. However, the medication administration records for September and October 2024 showed that the medication was administered on several occasions when the resident's DBP was below the prescribed threshold of 70. Interviews with a licensed practical nurse and the Assistant Director of Nursing confirmed that the medication was given outside of the specified parameters, which could result in the resident's blood pressure dropping too low. The facility's policy on medication orders and administration emphasizes adherence to prescriber orders, including any required time frames, which was not followed in this instance.
Inadequate Supervision Leads to Resident Altercation
Penalty
Summary
The facility failed to provide adequate supervision to prevent an altercation between two residents, resulting in a deficiency. Resident #12, who has a moderate cognitive impairment and various mood disorders, was involved in an incident with Resident #55, who has severe cognitive impairment and a history of disruptive behaviors. On the day of the incident, a recreational therapist found the two residents shouting at each other in the dining room, with Resident #55 allegedly hitting Resident #12. The care plan for Resident #12 included monitoring for mood or behavior changes, while Resident #55's care plan noted a need for continuous supervision due to a history of socially inappropriate behaviors. The incident occurred when the recreational therapist briefly left the dining room, and upon returning, found the two residents in an altercation. Resident #55 was seen grabbing Resident #12's arm, but no injuries were reported. The facility's policy requires staff to monitor residents, especially those with dementia and behavioral issues, during meal times. However, at the time of the incident, there was no staff present in the dining room to supervise the residents, as confirmed by the Director of Nursing who reviewed the surveillance tape. Interviews with facility staff revealed that the dining room was supposed to be monitored, particularly on the unit where the incident occurred, due to the residents' cognitive impairments and behavioral issues. The Director of Nursing acknowledged the lack of supervision and noted that the unit had been opened to create more space, which may have contributed to the oversight. The facility's policy emphasizes the importance of targeted interventions to reduce risks related to environmental hazards, including adequate supervision, which was not adhered to in this case.
Failure to Ensure Resident Dignity and Respect
Penalty
Summary
The facility failed to ensure that a resident was treated with dignity and respect by another resident, which could impact the emotional and psychological well-being of the affected resident. Resident #7, who is cognitively intact and has diagnoses including quadriplegia, chronic kidney disease, and Type II Diabetes, reported being verbally disrespected by Resident #25. Resident #25, who has Alzheimer's disease and unspecified dementia with behavioral disturbances, was documented to have engaged in socially inappropriate and disruptive behaviors, including verbal altercations with staff and peers. On April 6, 2024, Resident #25 yelled racial slurs at Resident #7, calling him derogatory names. Despite interventions in place to manage Resident #25's behavior, such as redirection and separation when agitated, the altercation occurred, and Resident #25 continued to use disrespectful language. Interviews with staff and residents confirmed the occurrence of these incidents, with Resident #7 expressing that the remarks were upsetting and derogatory. The facility's policy on Residents Rights emphasizes the right to be treated with respect and dignity, which was not upheld in this situation.
Incomplete Investigation of Abuse Allegation
Penalty
Summary
The facility failed to conduct a thorough investigation into an allegation of sexual abuse involving a resident who reported being accosted by two staff members. The resident, who had a history of cerebral infarction and slight cognitive deficits, alleged that the staff were verbally aggressive and physically invasive. The incident was reported to various authorities, including the local police and Adult Protective Services, but the facility's investigation lacked essential components such as staff interviews, interviews with other residents, and witness statements. The facility's policy requires comprehensive documentation and interviews with all relevant parties, but these steps were not completed. The Social Services Supervisor acknowledged that the investigation should have included interviews with other residents and staff, but there was no evidence that these were conducted. The absence of a thorough investigation was noted, and the facility's documentation did not provide evidence of a complete investigation into the allegations.
Facility Restricts Resident's Independent Travel Rights
Penalty
Summary
The facility failed to ensure that a resident was free to exercise his rights regarding independent travel. Resident #35, who is cognitively intact with a BIMS score of 13, reported feeling restricted and degraded by the facility's policy requiring a 24-hour advance notice and a physician's order for independent travel. This policy was implemented during the COVID-19 pandemic and has continued, despite the resident's grievances and repeated discussions in Resident Council meetings. The resident expressed that the policy made him feel belittled and restricted his rights, as he was unable to leave the facility freely without following the cumbersome process. Interviews with staff members, including LPNs, RNs, the DON, and the Administrator, confirmed the existence of the policy and its enforcement. Staff members acknowledged that the process might be excessive for residents who simply want to go out for short trips. The DON and Administrator stated that the policy was in place for the residents' protection and to ensure their safety, but they also admitted that the policy was enforced by corporate directives. The staff also indicated that the policy required residents to fill out a request form and obtain a physician's approval for each instance of independent travel, even if the resident had previously been deemed appropriate for independent travel. The resident's physician also expressed disagreement with the policy, stating that it was unnecessary and restrictive. The physician emphasized that residents who had already been deemed appropriate for independent travel should not need to request permission each time they wanted to leave the facility. The facility's policy on resident rights, revised in August 2021, stated that residents should be treated with respect and dignity and should be able to exercise their rights without interference. However, the policy requiring advance notice and physician approval for independent travel was seen as a violation of these rights by both the resident and some staff members.
Facility's Restrictive Travel Policy Violates Resident Rights
Penalty
Summary
The facility failed to ensure that three residents were free to exercise their rights regarding independent travel. Resident #35, who was admitted with a diagnosis of functional quadriplegia and was cognitively intact, reported feeling restricted and belittled by the facility's policy requiring a 24-hour advance notice and physician's order for leaving the facility. This policy was implemented during the COVID-19 pandemic and has continued, causing the resident to feel embarrassed and shamed when attempting to leave the facility without prior approval. Resident #55, diagnosed with quadriplegia and generalized anxiety disorder, also expressed feeling restricted by the new policy. Previously, residents only needed to sign out and inform staff of their whereabouts. However, the current policy requires a 24-hour advance request and physician's approval, which led to an incident where a code was called on the resident for elopement. This incident caused the resident to feel embarrassed and that their rights were being restricted. Resident #42, diagnosed with major depressive disorder and anxiety disorder, similarly reported feeling treated like a child due to the policy requiring a doctor's approval for independent travel. Interviews with staff, including LPNs, RNs, the DON, the Administrator, and a physician, revealed that the policy was seen as overly restrictive and unnecessary by some staff members. The facility's policy on resident rights states that residents should be able to exercise their rights without interference, but the current practice contradicts this policy, leading to feelings of restriction and embarrassment among the residents.
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Illustrative
What surveyors actually found near you
We read the 310 citations issued within 25 miles in the last 12 months — including the 2 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Phoenix
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Phoenix Mountain Post Acute | 1.9 mi | ★★★★★ | 6 | 0 |
| Ridgecrest Post Acute | 3.9 mi | ★★★★★ | 2 | 0 |
| Life Care Center Of Paradise Valley | 4.1 mi | ★★★★★ | 9 | 0 |
| The Terraces Of Phoenix | 4.2 mi | ★★★★★ | 0 | 0 |
| North Mountain Medical And Rehabilitation Center | 4.7 mi | ★★★★★ | 2 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.