Below average — CMS composite of the measures below.
A standard survey is most likely before around October 2026
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Caring House during CMS and state inspections, most recent first.
MDS assessments were inaccurate for two residents. One resident with repeated falls, Parkinson's disease, and a witnessed fall with skin tears later developed increased LLE pain and was found to have a broken L hip, but the re-entry MDS was coded so fall history and a major injury were not reflected. Another resident had a PASARR Level II determination, yet three annual MDS assessments marked A1500 as No, and an MDS Level I screening also failed to reflect the Level II status. MDS staff and the DON acknowledged the assessments were not accurate.
PASARR screenings and Level II referrals were not properly coordinated for two residents with newly evident SMI. One resident had a new personality disorder diagnosis added to the chart, but the Level 1 PASARR was not updated to reflect it. Another resident had schizophrenia, worsening psychosis, hallucinations, aggression, and ongoing behavioral symptoms, yet annual MDSs still indicated no PASARR SMI status and a later Level 1 PASARR incorrectly found no Level II referral was needed despite documented hallucinations or delusions.
An LPN held a resident’s daily insulin glargine three times without an order and without notifying the provider. The resident had DM2 and ESRD on dialysis, and the MAR showed code 5 entries with progress notes documenting blood sugar readings of 77, 80, and 88, but no documentation of symptoms or provider contact. The Unit Manager reviewed the record and stated the holds were medication errors and that the nurse was not following orders.
A resident with a prior stroke, left-sided weakness, dementia, aphasia, and a recent right humerus fracture was observed in bed with the call bell hanging below the bed and out of reach. The resident called out for help repeatedly while staff in the hallway did not respond right away, and an LPN later confirmed the resident could not use the call light unless it was placed in his hand. Staff also stated the resident’s right arm function had recently declined and he now needed more assistance with daily care.
A resident’s Medicare Part A coverage was ending, but the facility did not ensure the resident received signed written NOMNC and ABN forms. The forms in the chart were unsigned and did not show the resident was given the notices or aware of the appeal rights and potential non-covered charges; the DoF confirmed the forms were not sent and there was no process to verify receipt or obtain a signature.
A resident with multiple chronic pain conditions did not receive timely or effective pain management, as staff failed to follow facility policy and professional standards for pain assessment, documentation, and provider notification. Pain reassessments after PRN opioid administration were frequently delayed or incomplete, and the resident experienced prolonged severe pain, including an episode of crying and distress lasting over two hours before hospital transfer. Staff interviews confirmed inconsistent and sometimes inaccurate pain documentation, contributing to inadequate pain control.
A resident with a documented DNR order and preference for Comfort Care Only was provided CPR after being found unresponsive, due to staff miscommunication about code status. CPR was performed for two minutes before the error was recognized and resuscitation efforts were stopped, contrary to the resident's advance directive.
A resident with significant cognitive impairment and a history of behavioral disturbances entered another resident's room and scratched her face, resulting in physical injury. Both residents were dependent on staff for care, and the aggressor had a known pattern of entering others' rooms and displaying physical behaviors toward others. Despite interventions such as staff awareness and redirection, the incident was not prevented.
A resident with multiple chronic conditions, including dementia, experienced a significant decline in ADL function and required increased assistance from staff after a COVID-19 infection. Despite clear documentation of these changes and staff observations of increased care needs, an SCSA was not completed, and the MDS RN was unaware of the resident's status change due to communication gaps.
Two residents were not adequately supervised, resulting in one resident falling in the shower after being left alone by a CNA, and another resident becoming agitated and striking a peer during a community outing. In both cases, staff did not follow individualized care plans or provide the required level of supervision, leading to preventable incidents.
A resident with multiple chronic pain conditions did not receive a timely or accurate pain reassessment after being given PRN oxycodone, as required by physician orders. The RN failed to document the effectiveness of the pain medication within the expected timeframe and later entered an inaccurate pain score in the EMR, which was not consistent with the resident's report. The DON confirmed that this documentation did not meet professional standards.
An LPN failed to perform hand hygiene after removing contaminated gloves and before donning new gloves while administering IV medication to a resident with a PICC line. This action was observed during medication administration, and both the LPN and the facility's Infection Preventionist confirmed that hand hygiene should have occurred between glove changes, as required by facility policy.
A resident with diabetes was incorrectly coded as having received insulin on the MDS assessment after staff misidentified Ozempic, a non-insulin diabetes medication, as insulin. Both the MDS nurse and DON initially classified Ozempic as insulin before later confirming it was not, leading to an inaccurate assessment.
MDS Assessments Did Not Accurately Reflect Fall History or PASARR Status
Penalty
Summary
The facility failed to ensure that MDS assessments accurately reflected resident status for two residents. For one resident admitted with repeated falls and Parkinson's disease with dyskinesia, the record showed a witnessed fall on 04/28/25 when the resident fell to the floor, landed on the left side, and sustained skin tears to the right forearm and left knee. The resident later reported increased left lower extremity pain, required additional pain medication, and was found on 05/19/25 to have a broken left hip after returning from a CT scan, with transfer to the hospital ordered the same day. For that resident, the first assessment following re-entry was coded so that A0310E was answered No, which disabled Section J1700 and prevented fall history questions from being completed. Section J1800 was also coded No, indicating no falls since admission/entry or re-entry. During interview, the MDS Coordinator stated she coded the assessment as No for J1800 because the resident had not had any falls since readmission and that she combined the Significant Change with the 5-Day MDS; when asked if the assessment accurately reflected the resident's fall with major injury, she stated No. The RAI manual instructions for A0310E were reviewed during the investigation. For the second resident, the record included a PASARR Level II determination letter dated 08/18/21 showing the resident qualified for specialized services, but three Annual MDS assessments each answered A1500 No, indicating the resident was not currently considered by the state Level II PASARR process to have serious mental illness and/or intellectual disability or a related condition. A later PASARR Level I screening completed by the MDS Coordinator listed schizophrenia and other mental health diagnoses, yet still indicated no referral was necessary for Level II services. During interviews, the MDS Coordinator and another MDS Coordinator acknowledged that the annual assessments were not an accurate reflection of the resident's PASARR Level II status, and the DON stated that all MDS assessments were expected to be accurate.
PASARR screenings and Level II referrals were not coordinated for residents with newly evident SMI
Penalty
Summary
The facility failed to coordinate PASARR screenings and referrals for Level II evaluation when newly evident serious mental illness diagnoses were identified for two residents reviewed for PASARR requirements. The report states that the deficient practice involved one resident whose record showed a new personality disorder diagnosis added to the chart after the most recent Level 1 PASARR, but no updated and accurate Level 1 PASARR could be located to reflect that diagnosis. Facility staff confirmed that a new Level 1 PASARR should have been completed and submitted after the diagnosis was added, but they could not find evidence that this occurred. For the first resident, the record showed admission with diagnoses including CHF, adjustment disorder, and other specified mental disorders due to a known physiological condition. A psychiatric provider note later added personality disorder to the diagnosis list. The resident’s significant change MDS showed a BIMS score of 15, no psychotropic medication, and frequent depressive symptoms, but no behaviors during the assessment period. The most recent Level 1 PASARR in the record did not include the added personality disorder diagnosis, and an updated PASARR could not be found. The MDS nurse, DON, and Administrator all confirmed that the PASARR should have been updated and resubmitted when the mental health diagnosis changed. For the second resident, the record showed a prior Level II PASARR determination that instructed the facility to notify the PASARR Coordinator of significant medical or psychiatric changes or newly suspected SMI. The resident’s record included schizophrenia in a hospital history and physical, later ED documentation of worsening psychosis with hallucinations and aggression toward peers and staff, and ongoing behaviors on MAR review including auditory hallucinations and skin picking. Despite this, annual MDS assessments indicated the resident was not currently considered by the state Level II PASARR process to have SMI or ID. A Level I PASARR completed by the MDS coordinator on 07/17/25 listed schizophrenia but incorrectly indicated no referral was necessary for Level II services, even though the screening also documented symptoms related to hallucinations or delusions. During interviews, the MDS coordinators acknowledged the screening was not accurate and stated that the resident should have triggered a Level II referral based on the evidence.
Insulin Glargine Held Without Order or Provider Notification
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of Resident 2 when staff held the resident’s long-acting insulin glargine three times in July 2025 without an order and without notifying the physician. Resident 2 was admitted on 05/02/2025 with diagnoses including type 2 diabetes mellitus with other specified complications and hypertensive end stage renal disease with dependence on dialysis. Physician orders included insulin glargine 15 units subcutaneously once daily and insulin lispro twice daily per sliding scale, with instructions to hold insulin only for blood sugar less than 100 mg/dL and call the provider. The July 2025 MAR showed LPN1 entered code 5, meaning hold/see progress notes, for insulin glargine on 07/11/2025, 07/16/2025, and 07/21/2025. The corresponding progress notes documented blood sugar readings of 77, 80, and 88, but did not indicate whether the resident had signs or symptoms of low blood sugar or whether the physician was contacted. During interview, the Unit Manager reviewed the MAR and progress notes and stated that holding the insulin glargine on those days was a medication error and that the nurse was not following orders. Facility policy on insulin administration stated that insulin glargine has an onset of 3-4 hours, does not peak, and lasts 24 hours.
Call Bell Not Within Reach of Resident With Limited Mobility
Penalty
Summary
The facility failed to ensure that one resident with significant functional limitations could call for assistance when the call bell was not within reach. The resident was admitted with multiple diagnoses including a prior cerebral infarction with left-sided hemiplegia and hemiparesis, hearing loss, aphasia, reduced mobility, end stage renal disease on dialysis, ischemic cardiomyopathy, coronary artery disease, mild neurocognitive disorder, dementia, diabetes, and acute posthemorrhagic anemia. During observation, the resident was in bed with hands motionless under the covers, and the call bell was attached to the side of the bed hanging below the bed, out of reach. While the surveyor observed from the hallway, the resident called out for help nine times over a 10-minute period, and staff in the hallway did not immediately respond. The surveyor notified an LPN, who then entered the room and observed that the resident wanted to get up and that the call light was hanging off the side of the bed. The LPN stated the resident could not reach the call bell when it was over the side and needed it placed near or in his hand to operate it, especially since he had a right shoulder injury and relied on his right side after a stroke with left-sided weakness. Record review showed the resident also had a fractured right humerus, and staff interviews confirmed his right arm function had recently declined and he now needed assistance with feeding and transfers.
Failure to Provide Written Medicare Non-Coverage Notices
Penalty
Summary
The facility failed to ensure a resident was provided a written Notice of Medicare Non-Coverage (NOMNC) and an Advanced Beneficiary Notice of Non-coverage (ABN) when the resident’s Medicare Part A benefit was identified as ending. The resident was admitted on 02/25/2025, was their own responsible party, and their spouse was listed as an emergency contact. The facility’s beneficiary notice worksheet showed the resident’s Medicare Part A benefit started on admission and the last covered day was 03/26/2025, with the resident remaining in the facility after that date. The NOMNC in the medical record stated that coverage for therapy and nursing services would end on 03/26/2025 and included appeal rights, but it was unsigned and did not indicate it was provided to the resident or that the resident was aware of it. The ABN stated that beginning 03/27/2025 the estimated cost for therapy and daily skilled nursing care would be $1,500 per day/item or service, but it was also unsigned and did not indicate it was provided to the resident or that the resident was aware of the notice. The Director of Finance stated the facility’s process was to send the forms electronically for signatures, but after review confirmed the forms for this resident were not sent and there was no process to verify whether the resident received them or to obtain a signature after the fact. The Administrator stated staff were expected to go over the form and explain it, and acknowledged the written notice could be important because it included who to call to make an appeal.
Failure to Provide Timely and Effective Pain Management
Penalty
Summary
Facility staff failed to provide safe and appropriate pain management for a resident with multiple chronic pain conditions, including thoracic spine pain, systemic lupus erythematosus, Sjogren syndrome, ankylosing spondylitis, chronic pain syndrome, osteoporosis, and a history of spinal fusion and fractures. Despite physician orders and a care plan requiring regular pain assessments and timely reassessment after administration of as-needed (PRN) opioid pain medication, staff did not consistently assess or document the location, intensity, frequency, pattern, and severity of the resident's pain for each occurrence. Pain reassessments were frequently delayed, often occurring several hours after medication administration instead of within the required one-hour timeframe, and were sometimes documented as "unknown" or inaccurately recorded. There was also no evidence that staff notified the provider when pain medication was ineffective or that additional interventions were offered when the resident continued to experience high pain levels. The resident experienced prolonged and severe pain episodes, including an incident where she was observed crying and tearful for over two hours before being transferred to the hospital for severe back pain. Documentation showed repeated instances where the resident reported pain levels of 8/10 or 9/10, with PRN opioid medication administered but with little to no relief, and no timely follow-up or escalation of care. Staff interviews revealed a lack of adherence to facility policy and professional standards regarding pain assessment and documentation, with some staff admitting to making assumptions about pain location and intensity, and others acknowledging that pain assessments were not completed as required. Inaccurate documentation of pain levels was also noted, with one nurse admitting to recording a pain level of zero when the resident was still experiencing significant pain. The facility's own policies required comprehensive pain assessments and timely reassessment after PRN pain medication, as well as provider notification when pain management was ineffective. However, these procedures were not followed, resulting in inadequate pain management for the resident. The failure to properly assess, document, and respond to the resident's pain led to prolonged suffering and ultimately necessitated hospital transfer for pain control.
Failure to Honor Resident's DNR Order Resulting in Unwanted CPR
Penalty
Summary
A resident with chronic kidney disease, atrial fibrillation, and hypertension was admitted to the facility and had a signed Living Will Instruction Form indicating a preference for Comfort Care Only and a Do Not Resuscitate (DNR) order. The resident's advance directive clearly stated that in the event of a terminal condition, cardiopulmonary resuscitation (CPR) should not be performed. Despite these documented wishes, when the resident was found unresponsive, facility staff initiated CPR after someone incorrectly called out that the resident was a Full Code. Two minutes of CPR were performed before it was clarified that the resident was DNR, at which point resuscitation efforts ceased and the resident was pronounced dead. The facility's policy on advance directives, which aligns with Arizona state law, requires that residents' wishes regarding treatment and resuscitation be honored. In this case, the resident's documented refusal of CPR was not followed, resulting in the administration of unwanted life-saving measures. The Assistant Administrator acknowledged upon review that the resident was indeed DNR and that providing CPR was a mistake.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect a resident's right to be free from physical abuse when one resident entered another's room and scratched her face. Both residents involved were significantly cognitively impaired, with documented histories of dementia and dependence on staff for all care. The resident who committed the abuse had a known pattern of entering other residents' rooms, taking their belongings, and displaying physical behavioral symptoms toward others, including a prior attempt to strike another resident. Despite these known behaviors, the interventions in place at the time included staff awareness, redirection, and maintaining a calm environment, but did not prevent the incident from occurring. On the evening of the incident, staff had just assisted the victim to bed and left the room when, within two minutes, a scream was heard. The aggressor was observed leaving the victim's room, and the victim was found with a one-inch scratch on her face. The aggressor had no recall of the event. The care plan for the aggressor had previously identified the risk for conflict with other residents, but the measures in place were insufficient to prevent the physical abuse that occurred.
Failure to Complete Significant Change Assessment for Resident with Declining ADL Function
Penalty
Summary
A significant change in status assessment (SCSA) was not completed for a resident who experienced a notable decline in her ability to perform activities of daily living (ADLs). The resident, admitted with diagnoses including hypertension, diabetes mellitus, and dementia, was observed to have increased care needs following a COVID-19 infection. Staff interviews revealed that the resident, who previously required only supervision or limited assistance, became dependent on two staff members for bed mobility, transfers, toileting, and bathing. She also became more confused, spent more time in bed, became incontinent, and was no longer able to express her needs as before. Review of the resident's electronic medical records showed a documented increase in the level of assistance required, as reflected in monthly summaries. However, the MDS Registered Nurse confirmed that an SCSA was not completed and was unaware of the resident's increased care needs until after the fact. The facility's policy requires that significant changes in a resident's status be consistently reflected in assessments, progress notes, and care plans, but this was not done in this case due to a communication gap among staff.
Failure to Provide Adequate Supervision and Accident Prevention
Penalty
Summary
Staff failed to provide adequate supervision to two residents, resulting in separate incidents that compromised resident safety. In the first incident, a resident with a history of dementia, behavioral disturbances, and physical impairments participated in a community outing to a ball game. During the process of seating residents in a small, crowded suite, the resident became agitated and struck another resident on the leg while attempting to transfer. Staff present at the outing were not fully familiar with the resident's care plan, which included multiple interventions for managing agitation and aggression, and did not have the necessary transfer equipment (slide board) available. The environment was noisy and overstimulating, which contributed to the resident's agitation and subsequent physical outburst. In the second incident, a resident with a history of cerebral infarction, memory deficit, neuromuscular dysfunction of the bladder, and dementia was left unsupervised in the shower by a CNA. The resident, who required substantial to maximum assistance for bathing, attempted to reach for a washcloth and fell from the shower chair, which also tipped over. The resident was found on the floor by another CNA after the call light was activated. The care plan for this resident specifically required that at least one staff member remain with the resident during showering, but this intervention was not followed, resulting in the fall. Both incidents involved lapses in staff adherence to individualized care plans and supervision requirements. In the first case, staff did not anticipate or adequately manage the resident's behavioral triggers in a group setting, and in the second, a staff member left a dependent resident unattended in a high-risk situation. These failures led to preventable accidents and minor injuries, as documented in the facility's investigations and resident interviews.
Inaccurate Pain Assessment and Documentation in Resident Medical Record
Penalty
Summary
The facility failed to ensure the accuracy of medical records for a resident with multiple chronic pain-related diagnoses, including thoracic spine pain, systemic lupus erythematosus, Sjogren syndrome, ankylosing spondylitis, chronic pain syndrome, and osteoporosis. Physician orders required pain assessments every shift using a 0-10 scale, with documentation of pain location, non-medication interventions, and the effectiveness of PRN pain medication. On the day in question, a registered nurse administered PRN oxycodone for severe pain but did not perform a timely or complete reassessment of the resident's pain as required. During medication administration, the nurse asked the resident about their pain level, which remained at 9/10 after receiving oxycodone earlier that morning. The nurse did not inquire further about the pain's location, intensity, or duration, nor did she document a reassessment within the expected 30-60 minute window. The Medication Administration Record (MAR) initially lacked documentation of the pain medication's effectiveness, and a later entry indicated the medication was effective, but this was not supported by the resident's report or timely assessment. A progress note created by the nurse later that day inaccurately documented the resident's pain level as 0/10, which the nurse later admitted was incorrect and attributed to rushing and attempting to match expected documentation times. The Director of Nursing confirmed that pain reassessments should be documented in real time and within one hour of administration, and that inaccurate or delayed documentation does not meet professional standards. Facility policy supports the use of electronic medical records but requires accurate and timely documentation.
Failure to Perform Hand Hygiene Between Glove Changes During IV Medication Administration
Penalty
Summary
During a medication administration observation, a licensed nurse prepared and administered an intravenous (IV) antibiotic to a resident with a peripherally inserted central catheter (PICC) line. The nurse followed aseptic technique while flushing the PICC line prior to medication administration. However, after moving the IV pump and reconnecting a dislodged electrical cord, the nurse removed her gloves and immediately donned a new pair without performing hand hygiene in between glove changes. The nurse acknowledged during the observation that she had skipped the required hand hygiene step after removing contaminated gloves. The facility's Infection Preventionist confirmed that the expectation is for staff to perform hand hygiene between glove changes. Review of the facility's infection prevention and control policy also indicated that hand hygiene must be performed after removing gloves, even if gloves are used during resident care.
Inaccurate MDS Assessment Due to Misclassification of Diabetes Medication
Penalty
Summary
The facility failed to accurately assess a resident for the Minimum Data Set (MDS) assessment by incorrectly coding the administration of insulin. The resident was admitted with diagnoses including type 2 diabetes mellitus with hyperglycemia and was prescribed Ozempic, a medication for diabetes, but not an insulin. During the quarterly MDS assessment, the nurse responsible for completing the assessment coded that the resident had received insulin during the lookback period, based on the administration of Ozempic. Interviews with the MDS nurse and the Director of Nursing revealed a lack of understanding regarding the classification of Ozempic, with both initially identifying it as insulin. Upon further review using a drug guide, it was clarified that Ozempic is not insulin. The facility's policy requires comprehensive and accurate assessments to inform person-centered care plans, but this process was not followed, resulting in an inaccurate MDS assessment 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.
Illustrative
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Nursing homes near Sacaton
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Oasis Pavilion Nursing & Rehabilitation Center | 12.5 mi | ★★★★★ | 3 | 0 |
| The Center At Val Vista, Llc | 14.3 mi | ★★★★★ | 0 | 0 |
| Wellsprings Of Gilbert | 15 mi | ★★★★★ | 0 | 0 |
| Archstone Care Center | 16.8 mi | ★★★★★ | 7 | 0 |
| Sante Of Chandler | 16.8 mi | ★★★★★ | 3 | 0 |
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