Average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Camelback Post Acute Care And Rehabilitation during CMS and state inspections, most recent first.
A resident with multiple chronic conditions and intact cognition, care planned for structured communication and support, was being transferred with a Hoyer lift by two CNAs when the resident began screaming in pain after a foot contacted the lift bar. One CNA shouted at the resident to be quiet and commented that the resident was behaving as if the foot were broken, while the other CNA immediately told her this was inappropriate. The resident later cried and reported feeling abused by the CNA’s words. Other staff, including a CNA, RN, DON, and operations manager, stated that telling a resident to be quiet while in pain is disrespectful and inconsistent with the facility’s abuse prevention policy, which defines verbal abuse as disparaging or derogatory language directed toward residents.
The facility failed to properly store soiled linens and laundry, leaving overflowing bins in a hallway, which were not covered, leading to potential infection risks. Staff interviews revealed that linens should be bagged and tied, but a recent procedural change led to improper storage practices. The facility's policy requires covered containers for soiled linens.
The facility failed to properly store soiled linens, leaving bins overflowing in a hallway, causing odor and potential contamination risks. Staff interviews revealed inconsistencies in handling procedures, with some staff unaware of proper protocols. The facility's policy requires covered containers for soiled linens, which was not followed.
The facility failed to assess and manage pain for two residents, leading to deficiencies in care. One resident was not assessed for pain upon admission and was given incorrect medication for their pain level. Another resident received pain medication outside of prescribed parameters, with Oxycodone given for low pain levels and Tylenol for high pain levels. Staff interviews confirmed these discrepancies, highlighting a failure to follow facility policies on pain management and medication administration.
The facility failed to ensure proper food labeling, dating, and sanitation, leading to potential food safety risks. Observations revealed unlabeled and undated food items, expired products, and incomplete temperature logs. Sanitary conditions were compromised with dusty equipment and a foreign object found in food, which was not discarded as required by policy.
The facility failed to maintain proper infection control by leaving dirty dishes and food remnants in common areas and not adequately sanitizing a hallway with feces. Staff interviews confirmed the risk of cross-contamination and infection due to these practices.
A resident with severe cognitive impairment was not represented by his primary emergency contact during care planning. The facility failed to notify the primary contact, despite policy requirements for advance notice. Interviews revealed inconsistencies in scheduling care conferences, with no tracker in place to monitor them.
A potentially dangerous item, a blue razor, was left unattended on a resident's mobile tray in a public area of the facility. The tray was placed in the hallway due to space constraints for the resident's wheelchair. A CNA acknowledged the oversight but initially failed to remove the razor until prompted by a surveyor. Interviews with staff, including an RN and the DON, confirmed that razors should be disposed of in a sharps container immediately after use to prevent injuries, aligning with the facility's policy to maintain a safe environment.
A resident with quadriplegia and muscle spasms was not properly assessed for the risk of entrapment when using full-size bed rails. The facility failed to consistently document informed consent and conduct ongoing assessments for the necessity and safety of the bed rails. Observations and staff interviews revealed that the resident used the bed rails for balancing a communication board and accessing a remote and call-light, but there was no recent assessment to confirm the continued need for the bed rails.
The facility did not ensure RN coverage for eight hours in a 24-hour period, as required. On a day with a census of 82, no RN was scheduled, and the staffing consisted of LPNs and CNAs. The Staffing Coordinator confirmed the absence of an RN, and the DON acknowledged the responsibility to ensure RN coverage.
The facility failed to update the daily staff posting with the correct date and census, as required by their policy. Observations showed outdated information, and staff interviews revealed confusion about responsibility for updates. The Staffing Coordinator had not designated weekend updates, leading to the deficiency.
A resident with complex medical conditions left the facility against medical advice, but the facility failed to document the arrival of EMS or provide necessary discharge information. Interviews with staff revealed inconsistencies in the discharge process, and the facility's policy on AMA discharge was not followed, leading to a lack of documentation and potential risk to the resident's continuation of care.
Verbal Abuse of Resident During Painful Mechanical Lift Transfer
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident’s right to be free from verbal abuse by staff during a transfer. The resident had diagnoses including spinal stenosis, urinary retention, hypertension, fibromyalgia, obesity, muscle weakness, gait and mobility abnormalities, need for assistance with personal care, and low back pain. The care plan identified risk of impaired cognitive function or impaired thought process related to a new environment, with interventions such as using simple, directive sentences, identifying oneself at each interaction, reducing distractions, and providing cues if the resident became agitated. An admission MDS showed the resident was cognitively intact with a BIMS score of 15. Despite these identified needs and interventions, the resident experienced an incident of alleged verbal abuse during a mechanical lift transfer. During a Hoyer lift transfer from bed to wheelchair, the resident began screaming in pain, calling out about her legs or foot. One CNA involved in the transfer (Staff #5) reported that when the resident continued to scream, she told the resident to calm down and not to scream, stating that the resident had already received muscle relaxant and pain medication. Staff #5 stated she did not intend to diminish the resident and did not recall saying the resident’s feet were not broken. However, the other staff member assisting with the transfer (Staff #3) reported that the resident’s foot hit the Hoyer bar, causing pain and prompting the resident to scream. While the resident was screaming, Staff #3 stated that Staff #5 shouted at the resident to be quiet and said she was behaving as if her foot was broken. Staff #3 stated she immediately corrected Staff #5, telling her she could not speak to the resident that way. After the transfer, Staff #3 found the resident crying, and the resident stated that Staff #5’s words made her feel abused. Other staff interviewed, including another CNA and an RN, stated that it was not appropriate to tell a resident to be quiet while they were screaming in pain and that such language was disrespectful. The DON and Operations Manager described the facility’s abuse reporting expectations and confirmed that telling a resident to be quiet in this context was inappropriate and unprofessional. The facility’s abuse prevention policy defined verbal abuse as the use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents or within hearing distance, and the incident as described met the elements of verbal abuse toward the resident.
Improper Storage of Soiled Linens in Hallway
Penalty
Summary
The facility failed to ensure that soiled linens and laundry were not stored in public areas and were covered to prevent the spread of infection. On May 28, 2024, surveyors observed overflowing bins of soiled sheets and laundry items in the hallway on Hall 200 by the laundry room. A smaller container with dirty towels was also left uncovered in the hallway, emitting a smell of urine. A staff member was seen moving some of the bins outside, but the smaller container remained in the hallway. Interviews with staff revealed that the soiled linens and laundry were supposed to be bagged, tied, and taken directly to the soiled utility room to prevent odors and contamination. The Housekeeping Supervisor and the Director of Nursing confirmed that the bins should not be left in the hallway and should be covered to prevent the spread of infection. Despite this, it was noted that the bins were sometimes left in the hallway. A licensed practical nurse mentioned that a change in procedure about a month ago led to soiled items being placed in bins in the hallway, which were supposed to be covered and the items bagged and tied. The facility's policy stated that soiled linen containers should be covered at all times and transported to the laundry sorting room when three-fourths full.
Improper Storage of Soiled Linens in Hallway
Penalty
Summary
The facility failed to ensure that soiled linens and laundry were not stored in public areas and were covered to prevent odor and ensure a comfortable environment. On May 28, 2024, surveyors observed a yellow round bin and a gray square bin full of soiled sheets and other laundry items overflowing in the hallway on Hall 200 by the laundry room. Additionally, a smaller silver container full of dirty towels was not completely covered, and the hallway smelled of urine. A female staff member was seen moving the yellow and gray bins outside but left the smaller silver container in the hallway. Interviews with staff revealed inconsistencies in the handling of soiled laundry. A CNA stated that soiled items should be bagged, tied, and taken directly to the soiled utility room to reduce odor and contamination risk. The Housekeeping Supervisor confirmed that bins should not be left in the hallway due to the risk of spreading infection. An LPN mentioned that about a month ago, the practice of placing soiled items in hallway bins began due to complaints about odors. The facility's policy requires soiled linen containers to be covered and transported to the laundry sorting room when three-fourths full.
Deficiencies in Pain Management and Medication Administration
Penalty
Summary
The facility failed to properly assess and manage pain for two residents, leading to deficiencies in care. Resident #35 was admitted with a left tibial fracture and other medical conditions, but the facility did not assess the resident's pain level or take vital signs upon admission. The resident was not evaluated for pain until later in the evening, and when assessed with a pain level of five, was incorrectly administered Tylenol, which was only indicated for pain levels 1-3. Interviews with staff revealed that the initial pain assessment was not completed, and the baseline care plan was deleted when the resident left against medical advice. Resident #27, admitted with multiple fractures and wounds, also experienced improper pain management. The care plan required pain medication to be administered according to a pain scale, but the MAR showed that Oxycodone was given for pain levels of 0 and 1, which was outside the prescribed parameters. Conversely, Tylenol was administered for a pain level of 8, which was also outside the parameters. Staff interviews confirmed that pain medications were given outside of the prescribed parameters, and there was a lack of documentation regarding the resident's requests for specific pain medications. The facility's policies on pain management and medication administration were not followed, resulting in the potential for residents to be overmedicated or undermedicated. The Director of Nursing acknowledged the deficiencies, noting the importance of pain assessments and adherence to medication orders to ensure residents' comfort and safety. The failure to adhere to these policies and procedures led to the identified deficiencies in pain management for the residents involved.
Deficiencies in Food Safety and Sanitation Practices
Penalty
Summary
The facility failed to ensure proper food labeling and dating, which was observed during multiple kitchen inspections. Items in the walk-in freezer were found unmarked and undated, and cereal dispensers lacked expiration dates. There was confusion over whether dates on bins of oatmeal and lentils were fill or expiration dates. Additionally, peanut butter and jelly sandwiches and jello cups were found undated, and bread loaves lacked transcribed product information. The facility's policy required all containers to be labeled and dated, especially for TCS foods, but this was not adhered to. Expired food items were also found during the inspection, including a container of low-fat cottage cheese with a best if used by date that had passed. The facility's policy stated that foods with expiration dates should be used before the date on the package, but this was not followed. Furthermore, temperature logs for the walk-in fridge and freezer had not been updated for three days, contrary to the facility's policy that required daily checks to ensure proper functioning. Sanitary conditions in the kitchen were compromised, with a dusty ceiling fan above the dishwasher station and a dusty, grimy hood above the oven. The cleaning checklists for various shifts were incomplete, and during a tray line observation, a foreign object was found in the spinach/greens, which was not discarded as per policy. Dusty conditions persisted in follow-up observations, and the Dietary Supervisor admitted that the kitchen should be clean and sanitary, acknowledging the failure to discard contaminated food. The facility's policy required a comprehensive cleaning schedule to maintain kitchen sanitation, which was not followed.
Inadequate Infection Control Practices
Penalty
Summary
The facility failed to ensure proper infection prevention and control practices, as evidenced by the presence of dirty dishes and food remnants left unattended in common areas accessible to residents. On multiple occasions, surveyors observed trays with leftover food and drinks in hallways and dining areas, which were not promptly removed by staff. This practice poses a risk of cross-contamination and infection, as confirmed by staff interviews. A CNA acknowledged the risk associated with leaving leftover food and drinks in common areas, while an RN emphasized the importance of removing dirty dishes immediately to prevent resident access and potential infection. Additionally, the facility did not adequately address the presence of feces in a hallway, which was observed by surveyors. A nurse informed the surveyor that someone would clean it up, but the feces remained on the floor, and a CNA was seen picking it up without disinfecting the area. This lack of proper sanitation was further compounded when a staff member wheeled a cart over the contaminated area. The Director of Nursing confirmed that the expectation is for staff to remove dirty dishes and sanitize areas with feces to prevent contamination and infection spread.
Failure to Include Resident's Representative in Care Planning
Penalty
Summary
The facility failed to ensure that a resident's representative was able to participate in the care planning process. Resident #44, who has severe cognitive impairment as indicated by a BIMS score of 2, was not represented by his primary emergency contact, his son, during care planning. The resident was admitted with diagnoses including urinary tract infection, atrial fibrillation, aphasia, and cognitive communication deficit. The facility's records showed that the last documented contact regarding a care conference was directed to the resident's other son, not the primary emergency contact, and there was no documentation of a completed care conference. Interviews with the Director of Nursing and the Social Services Director revealed that care conferences are supposed to be conducted quarterly, but the process was not consistently followed. The Social Services Director admitted that there was no tracker to monitor care plan conferences and that the scheduling was not aligned with the MDS due dates. The facility's policy requires advance notice to residents and their representatives for care planning conferences, but this was not adhered to, as evidenced by the lack of notification to the primary emergency contact.
Failure to Remove Hazardous Item from Public Area
Penalty
Summary
The facility failed to ensure a potentially dangerous item, a blue razor with a clear plastic cover, was not left unattended in a public area on a resident's mobile tray. This incident was observed in the hallway by a room, where the tray was placed due to space constraints for the resident's wheelchair. A certified nursing assistant (CNA) acknowledged placing the tray outside the resident's room and admitted that the razor should have been disposed of after use to prevent the risk of residents cutting themselves. Despite this acknowledgment, the CNA initially walked away without removing the razor until prompted by the surveyor. Further interviews with the resident and staff revealed that the mobile tray was placed in the hallway to accommodate the use of a Hoyer lift during transfers. A registered nurse (RN) and the Director of Nursing (DON) both confirmed that razors should be immediately disposed of in a sharps container after use to prevent potential injuries. The facility's policy on providing a safe environment, as outlined in their Elopement/Unsafe Wandering policy, emphasizes the importance of removing such hazards to ensure resident safety.
Deficiency in Bed Rail Assessment and Documentation
Penalty
Summary
The facility failed to ensure that a resident was properly assessed for the risk of entrapment when using full-size bed rails on both sides of the bed. The resident, who was admitted with diagnoses including quadriplegia and muscle spasms, had a care plan that included the use of bed rails for safety due to muscle spasms. However, the facility did not consistently document informed consent for the use of these bed rails, nor did they conduct ongoing assessments to evaluate the necessity and safety of the bed rails. The resident's care plan and evaluations over several years indicated the use of full-size bed rails for muscle spasms, yet there was a lack of documentation tracking these spasms. Despite orders and evaluations suggesting the need for bed rails, the facility's records did not consistently reflect assessments or consents for their use. Observations and interviews with staff revealed that the resident used the bed rails for balancing a communication board and accessing a remote and call-light, but there was no recent assessment to confirm the continued need for the bed rails. Interviews with facility staff, including a CNA, RN, and the Director of Nursing, highlighted the absence of proper assessments and documentation regarding the resident's muscle spasms and the use of bed rails. The facility's policy prohibits the use of side rails as restraints unless necessary for medical symptoms, which must be documented. The lack of consistent documentation and assessment for the use of bed rails represents a deficiency in the facility's adherence to its policies and procedures.
Failure to Provide Required RN Coverage
Penalty
Summary
The facility failed to ensure that a registered nurse (RN) provided eight hours of coverage in a 24-hour period, as required by their policy. On December 24, 2023, the daily staff posting indicated that the census was 82, but there was no RN scheduled for the required eight hours. Instead, the staffing consisted of four licensed practical nurses (LPNs) from 6:00 a.m. to 6:00 p.m. and from 6:00 p.m. to 6:00 a.m., along with certified nursing assistants (CNAs) covering various shifts. During an interview, the Staffing Coordinator confirmed the absence of an RN on that day and mentioned that the Director of Nursing (DON) was informed about the unavailability of an RN from the registry. The DON acknowledged that it was her responsibility to ensure RN coverage and that an RN must be scheduled for eight consecutive hours daily, especially with a census of 82.
Failure to Update Daily Staff Posting
Penalty
Summary
The facility failed to ensure that the daily staff posting reflected the correct information, as required by their policy and procedures. On April 21, 2024, an observation revealed that the daily staff posting was outdated, displaying information from April 19, 2024, with an incorrect census number. Interviews with staff members, including an LPN and the receptionist, indicated confusion about who was responsible for updating the posting. The LPN believed the charge nurse updated it at 10:00 a.m., while the receptionist stated that the Staffing Coordinator usually handled it by 8:00 a.m. However, there was no posting present when the receptionist arrived that morning. Further investigation revealed that the Staffing Coordinator, who is responsible for updating the daily staff posting, had not designated another staff member to update the posting on weekends. The Director of Nursing confirmed that it was expected for the Staffing Coordinator to prepare postings for the weekend in advance. The facility's policy, dated May 2022, requires the posting of staffing numbers, including hours worked by registered nurses, LPNs, and nursing assistants, in a public area. However, the policy did not specify the need for the correct date and census, contributing to the deficiency.
Deficiency in Documentation for AMA Discharge
Penalty
Summary
The facility failed to ensure that a resident's clinical record included the required information for transfer or discharge, specifically when the resident left against medical advice (AMA). The resident, who had multiple complex medical conditions including an unspecified fracture of the right femur, end-stage renal disease, and type II diabetes mellitus with diabetic polyneuropathy, left the facility AMA. The electronic health record did not document the arrival of emergency medical services (EMS) on the day the resident left, nor was there evidence that the necessary discharge or transfer documentation was provided to EMS. Interviews with various staff members revealed inconsistencies in the discharge process. A certified nursing assistant (CNA) stated that she would notify a nurse if a resident wanted to leave AMA and assist in collecting the resident's belongings. A registered nurse (RN) mentioned that they would discuss the consequences with the resident, notify the emergency contact and doctor, and provide documentation to EMS if present. However, EMS staff reported that they were not given any verbal or written report regarding the resident's condition upon their arrival. The facility's policy on discharge against medical advice requires that appropriate instructions be given to the resident and documented, and that a safe discharge is coordinated. However, the medical record lacked documentation of instructions given to either the EMS or the resident, and there was no evidence of a report being provided to EMS. The director of nursing (DON) confirmed that there was no documentation of EMS arrival or report in the medical record, which could result in a lack of continuation of care for the resident.
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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) |
|---|---|---|---|---|
| Maryland Gardens Post Acute | 2.2 mi | ★★★★★ | 0 | 0 |
| Desert Terrace Healthcare Center | 2.3 mi | ★★★★★ | 7 | 0 |
| Desert Haven Care Center | 2.4 mi | ★★★★★ | 10 | 0 |
| The Terraces Of Phoenix | 2.9 mi | ★★★★★ | 0 | 0 |
| Haven Of Phoenix | 2.9 mi | ★★★★★ | 12 | 0 |
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