Below average — CMS composite of the measures below.
The next survey window likely opens around October 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Desert Cove Nursing Center during CMS and state inspections, most recent first.
An LPN signed out multiple doses of opioid medications for five residents on controlled substance records without corresponding entries on the MAR, including PRN oxycodone and hydromorphone orders and one discontinued oxycodone order. One resident reported not receiving narcotic medication despite a signed-out dose, and another had a discontinued narcotic documented as administered. A scheduled oxycodone ER dose was documented as wasted without a second nurse co-signature. Staff interviews confirmed that narcotics were sometimes not documented on the MAR and that required dual signatures for wasting were not consistently obtained, resulting in unresolved discrepancies between narcotic logs and medication records.
A resident with muscle weakness and neurological impairment did not receive a physician-ordered speech evaluation due to an order entry error that marked the order as completed before services were provided. The speech therapist was not notified of the order, and the resident confirmed never receiving speech therapy.
A resident with multiple health conditions, including bilateral below-the-knee amputations and a high risk for falls and skin breakdown, was left unattended in the shower room for about an hour after the assigned CNA became ill and left the facility. Although the CNA attempted to notify other staff, the information was not effectively communicated, resulting in the resident being left alone without a call light. Facility policy requiring staff to remain nearby during showers and check on residents every 5 to 10 minutes was not followed, and the resident was only discovered when they moved themselves to the door and were found by staff.
A CNA was observed emptying a resident's indwelling urinary catheter bag while wearing gloves but not a gown, contrary to facility policy and Enhanced Barrier Precautions (EBP). The CNA admitted to skipping the gown due to being in a hurry, despite having received infection control training. Interviews with an LPN and the DON confirmed that both gloves and a gown are required for catheter care, as outlined in facility policies.
Staff failed to follow IPCP practices when a CNA emptied a resident’s Foley bag without a gown, two CNAs delivered meal trays to multiple residents without sanitizing hands between rooms, and a resident with a suprapubic catheter had no EBP signage or PPE supplies at the door. The DON, Dietary Manager, and ADON/IP confirmed the expected use of gowns, gloves, hand hygiene, and door signage for catheter-related care and EBP.
Failure to Protect Residents from Abuse: A resident with impaired cognition and poor recall pinched and grabbed another resident on multiple occasions, leaving visible discoloration and scratch marks, while another resident with severe cognitive and decision-making impairment struck a resident with an action figure and had previously hit the same resident in the arm and neck. Staff notes, witness statements, and the DON’s review confirmed the acts were unprovoked resident-to-resident abuse.
Advance directives were not completed or maintained for two residents. One resident’s EHR lacked a physician-signed code status order even though the care plan listed full code, and the DON confirmed the order was missing after a recent hospital return. Another resident with intact cognition had no full code or DNR order, no advance directive document in the chart, and no evidence of the preference in the MDS or care plan; staff stated the resident was believed to be full code based on a provider note, but no order had been entered.
An LPN and a CNA did not have evidence of current CPR or first aid certification in their personnel files, despite signed job descriptions requiring CPR upon hire or during orientation and ongoing currency during employment. Facility staff and the Interim Administrator confirmed the missing documentation, and the facility policy required associates to maintain current CPR certification with proper documentation.
Inaccurate Nurse Staffing Postings: The facility failed to post accurate daily nurse staffing information reflecting actual hours worked by RNs, LPNs, and CNAs. Review of staffing postings found multiple mismatches between the posted numbers/hours and the actual hours worked, including incorrect LPN and CNA counts on several shifts. The Interim Administrator acknowledged the postings were incorrect, and the facility policy required posting the total number and actual hours worked by direct care nursing staff per shift.
A resident with paraplegia, chronic pain, HF, MDD, and anxiety reported that the facility often ran out of his scheduled pain medication, leaving him in extreme pain. The MAR showed multiple missed doses of ordered oxycodone because the medication was not available, and progress notes documented the same issue while the resident’s pain scores were 9 to 10 out of 10. The DON said delays could occur with signed prescriptions for controlled substances, but also stated the facility should not be running out of pain meds.
A resident with paraplegia, neurogenic bladder, DM, hypertensive heart disease, and bipolar disorder did not receive multiple 8:00 AM medications on time, including insulin glargine and several oral meds. During an observed dressing change, the resident reported not having received morning meds; an LPN later attempted to administer them after 11:00 AM, and the DON confirmed the meds were charted as given at 10:57 AM and acknowledged the late administration as a medication error.
Expired medications were found in the central med room, including unopened boxes of multivitamins, zinc, and vitamin B-12 past their expiration dates. The ADON, an LPN, and the DON stated that nurses are responsible for checking meds, that expired items should be returned or destroyed, and that expired meds should not remain in storage. The facility policy required outdated or expired meds and biologicals to be destroyed or returned per pharmacy guidelines.
Inaccurate MAR Documentation for Resident Medications: A resident with paraplegia, bladder dysfunction, DM, hypertensive heart disease, and bipolar disorder had multiple morning medications due at 8:00 AM, but during an observed dressing change the resident stated the meds had not yet been received. An LPN later said she had not actually administered the medications when she charted them as given, explaining she documented them because she knew what the resident would take; the DON confirmed the MAR showed the meds charted as administered before they were actually given.
A resident who was fully dependent on staff for bathing did not consistently receive scheduled showers as outlined in their care plan, with multiple missed or undocumented bathing events and no evidence of refusals. Staff interviews revealed confusion over assignments and improper documentation practices, including the use of another staff member's login credentials. Facility policies required regular assistance and documentation for ADLs, but these were not followed, resulting in unmet hygiene needs.
A resident with a urinary catheter did not consistently receive care and monitoring as ordered by the physician, with multiple instances of missing documentation for catheter emptying and urine output. The resident reported that the catheter bag was sometimes not emptied for extended periods, and staff interviews confirmed lapses in following care protocols and documentation requirements.
The facility did not timely report suspected abuse, neglect, or theft, nor did it report the results of the investigation to the proper authorities as required.
A resident with multiple comorbidities, including diabetes and ulcers, did not receive wound care as ordered by the provider on several occasions, with no documentation to support that care was provided or refused. Interviews with staff and review of records confirmed that wound care was not consistently performed or recorded, contrary to facility policy and physician orders.
A resident with moderate cognitive impairment was inappropriately touched by another resident during a Christmas party, despite existing interventions for the latter's history of inappropriate behavior. The facility's policies on preventing abuse and ensuring consent were not effectively implemented, as no immediate psychiatric evaluation or care plan revision was conducted for the affected resident.
A facility failed to provide adequate supervision, resulting in multiple resident altercations. A resident with severe cognitive impairment and a history of aggression was involved in incidents where they hit other residents, despite care plan interventions requiring staff presence. Another resident with Alzheimer's exhibited aggression, striking a peer in the dining room. A third resident, with moderate cognitive impairment, was a victim of aggression due to lack of staff supervision during transitions. Staff interviews highlighted inconsistent adherence to care plans, contributing to these incidents.
The facility failed to provide necessary services for personal hygiene and meal assistance for two residents. One resident received fewer showers than required, and another did not receive consistent feeding assistance, as documented and confirmed by staff interviews.
The facility failed to ensure the environment remained free of accident hazards by leaving medications unattended. A medication cup with a red capsule was observed on a medication cart with no staff present. The DON disposed of the medication, and interviews confirmed that the RN had left it unattended after being called away.
The facility failed to ensure RN coverage for at least 8 consecutive hours a day, 7 days a week, as required. Staff schedules for January and March 2023 showed no RN coverage for 8 consecutive hours on at least 4 days each month, and in November and December 2023, there was no RN coverage for one day each month. Interviews with the staffing coordinator and DON confirmed awareness of the regulations but indicated inconsistent compliance. The census was 63 residents.
The facility failed to administer pain medication within the prescribed pain scale parameters for two residents, leading to potential overmedication. One resident was given 10 mg of oxycodone for pain levels 0 to 3, and another was given 5 mg of oxycodone for pain levels 0 to 6, contrary to physician orders. Staff interviews and the MAR confirmed these discrepancies, which did not meet the facility's policies and expectations.
The facility failed to ensure staff conducted appropriate hand hygiene during kitchen food preparation and dining services, and did not enforce the use of beard guards/nets for staff with facial hair. Observations revealed multiple instances of staff not washing hands after touching unsanitary surfaces and not wearing beard guards, which was confirmed by staff interviews and a review of facility policies.
The facility failed to ensure proper infection control practices, as an X-Ray Technician performed an ECG on a resident without PPE despite enhanced barrier precautions, and a nurse improperly sanitized a glucometer between uses. The Infection Preventionist and DON emphasized the importance of adhering to infection control policies.
A resident with multiple diagnoses was found with medications at the bedside without proper assessment or physician orders. Interviews with staff revealed a lack of adherence to the facility's policy on self-administration of medications, and the DON confirmed that the resident had not been assessed or authorized to self-administer medications.
A resident with ESRD and a dialysis shunt in the left arm had blood pressure measured from the shunt arm on seven occasions, contrary to the care plan and facility policy. Interviews revealed inconsistent understanding among RNs about the policy, potentially risking harm to the resident.
The facility failed to ensure unused medications were disposed of according to accepted professional standards. A red capsule was found unattended on a medication cart and was improperly disposed of in an uncovered bin by the DON. Interviews with staff confirmed that this practice was against facility policy and posed a risk to residents.
Unreconciled Narcotic Documentation and MAR Omissions Across Multiple Residents
Penalty
Summary
The deficiency involves the facility’s failure to ensure accurate and complete documentation of controlled substance administration on the Medication Administration Record (MAR) for five residents, despite entries on the Individual Resident Controlled Substance Records. For one resident with major depressive disorder, anemia, and sepsis, an order for PRN oxycodone 5 mg every 8 hours was in place, and the resident’s care plan included evaluation of pain medication effectiveness. The controlled substance record showed that an LPN (staff #777) documented administering oxycodone on a specific date, but the MAR for that month showed no administration recorded for that date. A second resident with muscle weakness, cardiomyopathy, and cellulitis had a care plan for pain relief and an order for PRN oxycodone 5 mg every 6 hours. The controlled substance record showed that staff #777 documented administering oxycodone on the same date as above, but the MAR did not show the medication as given on that date. A witness statement documented that this resident reported not having taken any narcotic pain medication since a date several weeks earlier. A third resident with chronic kidney disease, anxiety disorder, and heart failure had a care plan addressing pain and an order for PRN hydromorphone 1 mg/mL every hour. The controlled substance record showed staff #777 signed out oxycodone 5 mg for this resident on the same date, while the MAR for hydromorphone did not show administration on that date, and the hydromorphone order had been discontinued. A fourth resident, re-admitted with pneumonia, muscle weakness, and hyperlipidemia, had an order for PRN oxycodone 5 mg every 4 hours that had been discontinued weeks earlier. Despite this discontinuation, the controlled substance record showed that staff #777 signed out oxycodone for this resident on the same date in March. A fifth resident with depression, hyperlipidemia, and muscle falls had an order for scheduled oxycodone ER 10 mg twice daily for moderate to severe pain, and the controlled substance record showed that staff #777 documented wasting a 10 mg oxycodone dose at 2100 on that same date. Facility documents noted that this waste was recorded without a required second nurse co-signature. Interviews with staff and the alleged perpetrator confirmed that narcotics were signed out on controlled substance records without corresponding MAR documentation, that one narcotic dose was disposed of without a second nurse’s signature, and that the nurse acknowledged sometimes not documenting on the MAR, leading to discrepancies between the narcotic logs and the MAR for all five residents.
Failure to Implement Physician-Ordered Speech Services Due to Order Entry Error
Penalty
Summary
The facility failed to ensure that professional standards of care were followed regarding the implementation of physician-ordered speech services for a resident. The resident was admitted with multiple diagnoses, including muscle weakness and a neurological disorder, and was assessed as cognitively intact. A physician order was entered for a one-time speech evaluation due to increased weakness in the resident's voice. However, the order was incorrectly entered with a one-day stop date, causing it to be automatically marked as completed in the system, even though the evaluation was never performed. The speech therapist did not receive notification of the order and therefore did not conduct the evaluation. The Director of Nursing confirmed that the speech evaluation was not completed and could not be located. The resident reported never receiving speech therapy, and the speech therapist stated he was unaware of any new orders for the resident. Facility documentation and interviews revealed that the failure to properly enter and communicate the physician's order resulted in the resident not receiving the required speech evaluation as ordered.
Resident Left Unattended in Shower Room Due to Staff Communication Failure
Penalty
Summary
A deficiency occurred when a resident with significant medical complexities, including bilateral below-the-knee amputations, chronic heart failure, diabetes, chronic respiratory failure, and muscle weakness, was left unattended in the shower room for an extended period. The resident's care plan identified them as being at risk for falls and impaired skin integrity, requiring maximal assistance with bathing and toileting, and the use of a motorized wheelchair with orthotics/prosthetics. During a bathing session, the assigned CNA became ill and was sent home by the DON, who instructed the CNA to notify other staff about the resident. The CNA reported informing an LPN and another CNA, but the information was not effectively communicated, resulting in the resident being left alone in the shower room without a call light nearby. The resident reported being left in the shower room for approximately an hour, during which time they were seated in a shower chair and eventually had to pull themselves toward the door to seek assistance. Facility policy required staff to stay nearby during showers and check on residents every 5 to 10 minutes, but this protocol was not followed. Interviews with staff confirmed that residents should not be left unattended in shower chairs due to the risk of injury, yet the resident was left alone, and the incident was only discovered when a staff member found the resident after they had moved themselves to the door.
Failure to Follow Enhanced Barrier Precautions During Catheter Care
Penalty
Summary
A Certified Nursing Assistant (CNA) was observed entering a resident's room and emptying the resident's indwelling urinary catheter bag while wearing gloves but not a gown, as required by the facility's infection control policies. The resident had a medical history that included infection and inflammatory reaction due to an indwelling urethral catheter, urinary tract infection, and obstructive and reflux uropathy. The CNA acknowledged during an interview that she should have worn a gown in addition to gloves but failed to do so because she was in a hurry, despite having received infection control training and having access to personal protective equipment. Further interviews with an LPN and the Director of Nursing confirmed that Enhanced Barrier Precautions (EBP), including the use of gloves and a gown, are required when providing catheter care or emptying a catheter, in accordance with facility policy. Review of the facility's policies on indwelling urinary catheter management and transmission-based precautions also specified the need for gloves and gowns during manipulation of the catheter or high-contact resident care activities. The failure to follow these infection control practices was identified through clinical record review, observation, and staff interviews.
Infection Control Lapses With PPE, Hand Hygiene, and EBP Signage
Penalty
Summary
The facility failed to provide and implement its infection prevention and control program when staff did not consistently use PPE and did not sanitize hands during resident care and resident-to-resident interactions. During initial pool screening, a CNA was observed emptying Resident #2’s Foley catheter bag into a plastic container while wearing gloves but not a gown. The CNA stated she only wears a gown when performing catheter care, not when emptying the catheter bag. The DON stated staff were expected to wear a gown and gloves when performing care involving catheters, and the facility’s Foley management policy stated staff should wear gloves and gowns during any manipulation of the catheter or collecting system. Staff were also observed delivering lunch trays to multiple residents without sanitizing their hands between rooms. Two CNAs delivered trays to several residents, and neither was observed sanitizing hands between room entries. The Dietary Manager stated staff were expected to sanitize their hands between delivering meals to different residents. In addition, Resident #44, who had diagnoses including hereditary spastic paraplegia, epilepsy, neuromuscular dysfunction of the bladder, and a suprapubic catheter, had an order for Enhanced Barrier Precautions related to the catheter. Staff observed that the resident’s room lacked EBP signage and PPE supplies at the door, and staff stated they relied on door signage to indicate when EBP was in place. The ADON/IP and DON confirmed the absence of signage and supplies at the room.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to ensure that residents were protected from abuse when resident #100 physically assaulted resident #66 on more than one occasion. Resident #100 had diagnoses including major depressive disorder and hemiplegia/hemiparesis following cerebral infarction, with moderately impaired cognition, impaired insight, poor recall, and use of a wheelchair. Resident #66 had diagnoses including major depressive disorder and dementia, was severely cognitively impaired, had episodes of inattention and wandering, and also used a wheelchair. Resident #100’s care plan included cueing, reorientation, and supervision because of impaired cognitive ability and poor recall. Clinical notes documented multiple aggressive incidents involving resident #100 and resident #66. On one occasion, resident #100 was witnessed pulling on resident #66’s shirt while resident #66 was propelling herself in a wheelchair, causing resident #66 to yell before staff intervened. Another note documented resident #100 propelling herself toward another resident in an aggressive manner in the dining room before staff stopped and redirected her. On April 10, 2024, a kitchen aide reported that while resident #100 was being pushed in a wheelchair, she reached out and grabbed resident #66’s left upper arm and pinched it, leaving discoloration and scratch marks; the note stated the act was unprovoked and that resident #66 was not looking in resident #100’s direction before it occurred. The record also showed that resident #120 physically struck resident #6 on separate occasions. Resident #120 had diagnoses including bipolar disorder, sequelae of cerebral infarction, chronic pain syndrome, memory problems, severe impairment in decision-making, impairment in all extremities, and wheelchair use. One event note stated that resident #120 struck resident #6 on the right upper arm with an action figure while resident #6 was in the hallway. Another note from a prior incident documented resident #120 hitting resident #6 in the left arm and neck while both were in the lobby. Interviews with staff and a family witness confirmed that resident #120 hit resident #6 with a toy and that resident #6 said it hurt. The DON reviewed both incidents and stated that pinching and hitting another resident constituted abuse.
Advance Directives Not Completed or Maintained for Two Residents
Penalty
Summary
The facility failed to ensure advance directives were completed and maintained for two residents, including one resident with paraplegia, hypertension, major depressive disorder, chronic pain, anxiety disorder, and heart failure, and another resident with COPD, asthma, type 2 diabetes, acute kidney failure, hypertension, anemia, UTI, major depressive disorder, infection and inflammatory reaction due to an indwelling urethral catheter, and hyperlipidemia. For the resident with paraplegia, the electronic record did not contain the code status order in the physician orders or miscellaneous tab, although the care plan identified the resident as full code. A paper chart notation indicated full code, but it was not signed by a physician. The LPN and DON both reviewed the record and could not locate the code status order in the EHR. For the resident with intact cognition, the admission MDS did not show an advance directive for full code or DNR, and there was no order for full code or DNR in the record. There was also no advance directive document in the clinical record and no evidence of an advance directive in the care plan. A CNA stated code status would be found on the tablet at the nurses’ station, while an LPN stated advance directives should be signed on paper, entered as a physician order, uploaded to the EHR, and stored in the paper chart. When the LPN reviewed the resident’s record, she could not find any completed advance directive worksheet or order. The FNP stated she understood the resident was full code based on a provider note, but there was no order in the chart and she was entering one at that time. The DON stated there should always be an advance directive in the hard chart and EHR, and that an order should be entered so it appears on the banner and profile. The DON confirmed the resident had an order pending, meaning there had been no order in the record before that. Facility policy stated the physician must give an order for changes in advance directives, Social Services must obtain a copy for the medical record and verify a physician order, and CPR/First Aid policy required verification and immediate documentation of advance directives and CPR wishes upon admission.
Missing CPR and First Aid Certifications for Direct-Care Staff
Penalty
Summary
The facility failed to ensure that 2 of 3 sampled direct-care staff members, an LPN and a CNA, maintained valid CPR and first aid certifications as required by their job descriptions. Review of the LPN’s personnel file showed no evidence of CPR or first aid certification, even though the signed job description stated that an LPN must have CPR certification upon hire or obtain it during orientation and keep it current during employment. Review of the CNA’s personnel file also showed no evidence of CPR or first aid certification, despite a signed job description stating that a CNA must have CPR certification upon hire or obtain it during orientation and keep it current during employment. During interviews, the admissions assistant and fill-in staffing coordinator stated that the facility did not have CPR and first aid certification for either staff member. The Interim Administrator also confirmed that the facility did not have CPR or first aid certification for the CNA or the LPN and stated that she would have expected the personnel files to be complete and accurate. The administrator stated that it was the facility’s expectation that all direct-care staff, including CNAs and LPNs, obtain and maintain CPR and first aid certification, and that it was the company’s practice for them to have a CPR card. Facility policy stated that associates must maintain current CPR certifications for Healthcare Providers, and the Arizona Revised Statutes cited in the report required policies and procedures covering CPR and first aid training, including required personnel, training content, renewal time frames, and documentation.
Inaccurate Nurse Staffing Postings
Penalty
Summary
The facility failed to ensure that the daily nurse staffing information posted for residents and visitors accurately reflected the actual hours worked by licensed direct care nursing staff. A review of August and September 2025 staffing postings compared with actual hours worked found that 3 of 7 postings did not match the records. On August 26, 2025, the posting showed 6 CNAs worked 48 hours on the night shift, but the actual hours worked showed 5 CNAs worked 60 hours. On September 7, 2025, the posting showed 3 LPNs worked the day shift, but the actual hours worked showed 2 LPNs; it also showed 4 LPNs worked the night shift for 42 hours, when the actual hours worked should have been 48, and showed 6 CNAs worked 48 hours on the night shift, while the actual hours worked showed 5 CNAs worked 60 hours. On September 16, 2025, the posting showed 3 LPNs worked the night shift, but the actual hours worked showed 2 LPNs. During an interview on September 23, 2025, the Interim Administrator stated the postings for August 26, September 7, and September 16 were incorrect and that it was her expectation that the postings be correct and accurate. The facility policy stated that the total number and actual hours worked by RNs, LPNs, and CNAs directly responsible for resident care must be posted per shift.
Medication Not Available for Scheduled Pain Management
Penalty
Summary
The facility failed to ensure that medications were accurately acquired and administered to meet the needs of one resident with paraplegia, hypertension, chronic pain, heart failure, major depressive disorder, and anxiety disorder. The resident reported during initial pool screening that the facility oftentimes ran out of his scheduled pain medication, leaving him in extreme pain. His care plan identified him as being at risk for pain related to neuropathy, chronic pain, and generalized pain, and one intervention was to administer pain medications as ordered. A review of the provider orders showed an order for Oxycodone 15 mg, one tablet every four hours. The MAR for April 2025 through September 2025 showed missed scheduled doses on multiple dates because the medication was not available, and progress notes documented that the medication was not available on those dates. The resident’s pain scores on those occasions were documented between 9 and 10 on a 0-10 scale. The DON stated that controlled substances require a signed prescription from the physician and that there were sometimes delays in obtaining signatures and sending prescriptions to the pharmacy, but also stated the physician comes into the building regularly and is willing to sign prescriptions. The DON stated the facility should not be running out of residents’ pain medications and expected staff to order refills sooner.
Late Administration of Scheduled Morning Medications
Penalty
Summary
Resident #8, who was admitted with paraplegia, neuromuscular dysfunction of the bladder, diabetes mellitus, hypertensive heart disease, and bipolar disorder, was found to have missed morning medications that were scheduled for 8:00 AM. The medication administration record showed multiple medications due at that time, including dapagliflozin, aspirin, baclofen, famotidine, fluticasone, gabapentin, insulin glargine, methocarbamol, a multivitamin, progesterone, propranolol, simethicone, and Vitron-C. During an observed dressing change, the resident told the wound nurse that she had not received her morning medications. At 11:00 AM, an LPN entered the room to assess blood glucose and administer the morning medications, but was asked to return after the dressing change. In interview, the LPN stated she had not administered the medications and acknowledged they were due at 8:00 AM; she also stated she had tried earlier to assess the resident's blood glucose, but the resident had refused. The DON reviewed the MAR and confirmed the medications were charted as administered at 10:57 AM, acknowledged that the 8:00 AM medications were given late, and stated this was a medication error. The facility policy stated medications should be given at the time specified by the provider's order.
Expired Medications Left in Medication Room
Penalty
Summary
The facility failed to ensure that expired medications were properly discarded and kept out of available stock in the central medication room. During an observation with the ADON, surveyors identified five unopened boxes of one-daily multivitamin dietary supplement with an expiration date of April 2025, one unopened box of zinc 50 mg with an expiration date of March 2025, and four unopened boxes of vitamin B-12 100 mcs with an expiration date of July 2025. During interviews, the ADON stated that nurses are responsible for checking and disposing of expired medications, that she performs weekly checks, and that the pharmacy reviews medications monthly, with expired items either returned to the pharmacy or destroyed using the Drug Buster system. An LPN stated that all nurses are responsible for checking medications and that expired medications should never be administered or left in storage. The DON stated that medications should be checked regularly, ideally monthly, and destroyed using the Drug Buster if expired, and that the recently found expired medications were unacceptable. The facility policy required discontinued, outdated, expired, or deteriorated medications or biologicals to be destroyed or returned in accordance with pharmacy return/destruction guidelines and applicable law.
Inaccurate MAR Documentation for Resident Medications
Penalty
Summary
The facility failed to ensure that Resident #8’s medication administration record (MAR) was accurately documented. Resident #8 was admitted with diagnoses including paraplegia, neuromuscular dysfunction of the bladder, diabetes mellitus, hypertensive heart disease, and bipolar disorder. The MAR showed multiple medications due at 8:00 AM, including dapagliflozin propanediol, aspirin, baclofen, famotidine, fluticasone propionate nasal suspension, gabapentin, insulin glargine, methocarbamol, a multivitamin, progesterone, propranolol, simethicone, and Vitron-C. During an observed dressing change, the resident stated that morning medications had not yet been received. An LPN later entered the room to assess blood glucose and administer the morning medications, but stated in interview that she had not actually administered them at that time and had not attempted to give them when due. Review of the MAR showed the medications were charted as already administered, and the LPN stated she documented them that way because she knew which medications the resident would take, acknowledging it was a charting error. The DON reviewed the MAR and stated the medications were charted as administered at 10:57 AM, and expected medications to be charted after the resident took them.
Failure to Provide and Document Scheduled Showers for Dependent Resident
Penalty
Summary
A deficiency was identified when a resident with paraplegia and a history of chronic pain, hypertension, and recent infection was not provided assistance with bathing or showering according to their care plan and preferences. The resident was assessed as cognitively intact and fully dependent on staff for bathing, with a care plan specifying two showers per week. Facility records and shower schedules indicated multiple missed or undocumented showers over a period of several weeks, with no evidence of resident refusal or proper documentation in the clinical record for those dates. Interviews with the resident and various staff members revealed inconsistencies in the assignment and documentation of bathing tasks. The resident reported not receiving scheduled showers and recounted a previous period of four weeks without a shower. Staff interviews confirmed that showers were to be documented on shower sheets and in the electronic record, with refusals also to be documented. However, several staff members either did not offer showers as scheduled or were not assigned to the resident, and one staff member's electronic documentation was found to be completed by someone else using their login credentials while they were not present in the facility. Review of facility policies confirmed that residents are to receive assistance with ADLs, including bathing, in accordance with their care plan and professional standards. Documentation of showers, including skin condition and refusals, was required but not consistently completed. The lack of proper documentation and failure to provide scheduled showers as per the resident's care plan constituted a failure to meet the resident's needs and preferences for personal hygiene.
Failure to Provide Catheter Care and Output Monitoring per Physician Orders
Penalty
Summary
The facility failed to provide care and services for a urinary catheter according to physician orders for a resident with paraplegia, neurogenic bladder, and a history of sepsis and catheter-related infection. The resident had physician orders to have the catheter emptied and urine output recorded three times daily, with documentation required in the electronic clinical record. Review of the Medication and Treatment Administration Record (MAR/TAR) revealed multiple instances across several months where the required documentation was missing, indicating that the catheter may not have been emptied or the output recorded as ordered. There was no evidence in the clinical record that the resident refused care on these occasions. Interviews with the resident confirmed that the catheter bag was not always emptied as scheduled, with reports of the bag not being emptied for 12-14 hours at times, and the resident having to empty the bag himself. Staff interviews corroborated that both CNAs and nurses are responsible for catheter care and output monitoring, and that failure to empty the catheter bag as ordered could lead to complications. The Assistant Director of Nursing and the Director of Nursing both acknowledged the importance of adhering to physician orders for catheter care and recognized that the lack of documentation meant there was no way to confirm if care was provided as required. Facility policy required regular emptying of catheter bags and documentation to prevent infection and ensure proper care. The policy also specified the use of clean containers and ongoing monitoring for signs of infection. The review of records and staff interviews demonstrated that the facility did not consistently follow these protocols, resulting in a failure to provide care and services in accordance with physician orders and established standards.
Failure to Timely Report Suspected Abuse, Neglect, or Theft
Penalty
Summary
The facility failed to timely report suspected abuse, neglect, or theft and did not report the results of the investigation to the proper authorities. This deficiency was identified based on a review of facility practices and documentation, which showed that when an incident of suspected abuse, neglect, or theft occurred, the required notifications and reporting to authorities were not completed within the mandated timeframe. The report does not provide specific details about the individuals involved or the nature of the incident, but it clearly states that the reporting and communication requirements were not met.
Failure to Provide and Document Wound Care per Physician Orders
Penalty
Summary
The facility failed to ensure that a resident received wound care in accordance with physician orders. The resident, who had diagnoses including heart failure, cellulitis, diabetes with ulcers, obesity, and muscle weakness, was admitted with a care plan requiring treatment as ordered and weekly skin checks. Physician orders specified detailed wound care steps for ulcers on the left lower extremity and right inner calf, to be performed daily or twice daily. However, clinical record review showed that wound care for both areas was not documented as performed or refused on multiple identified dates. Interviews with facility staff confirmed that wound care was the responsibility of licensed nurses, and that refusals or missed treatments were to be documented and reported. The Director of Nursing acknowledged that there was no evidence in the Treatment Administration Record to support that wound care was provided or refused on the specified dates, and that facility expectations for documentation and care were not met. Facility policies required accurate documentation of care and resident condition, as well as resident participation in care planning.
Failure to Prevent Resident-to-Resident Sexual Abuse
Penalty
Summary
The facility failed to protect a resident from sexual abuse, resulting in an incident where one resident was inappropriately touched by another resident. Resident #26, who has moderate cognitive impairment due to dementia, was involved in an incident at a Christmas party where Resident #13, also with moderate cognitive impairment, was observed with his hand down Resident #26's pants. This incident was witnessed by the Admissions Assistant, who noted that Resident #26 did not appear distressed at the time. Resident #13 has a history of inappropriate sexual behavior, including making inappropriate comments and touching staff. His care plan included interventions for these behaviors, such as monitoring and supervision. Despite these measures, the incident with Resident #26 occurred, indicating a failure in the facility's ability to prevent such interactions between residents. The facility's policies on intimacy and abuse prevention were not effectively implemented, as evidenced by the lack of immediate psychiatric evaluation or care plan revision for Resident #26 following the incident. The Director of Nursing acknowledged that both residents lacked the capacity to consent to sexual activity, yet the facility did not take adequate steps to prevent the abuse or address the aftermath appropriately.
Inadequate Supervision Leads to Resident Altercations
Penalty
Summary
The facility failed to provide adequate supervision to prevent resident abuse, as evidenced by incidents involving three residents. Resident #1, who has severe cognitive impairment and a history of physical aggression, was involved in multiple altercations. Despite care plan interventions requiring staff presence and maintaining distance from other residents, Resident #1 was observed hitting another resident in the hallway. This incident occurred without staff escorting Resident #1, contrary to the care plan requirements. Resident #2, diagnosed with Alzheimer's Disease and severe cognitive impairment, exhibited physical aggression towards peers. An incident was documented where Resident #2 struck another resident in the dining room. The care plan for Resident #2 included interventions to manage aggression, such as allowing extra time for responses and maintaining a consistent routine, but these measures were not effectively implemented to prevent the altercation. Resident #3, with moderate cognitive impairment, was a victim of physical aggression by Resident #1. Despite being aware of Resident #1's aggressive tendencies, the facility did not ensure staff supervision during transitions in and out of the dining room, leading to Resident #3 being hit. Interviews with staff revealed a lack of consistent supervision and adherence to care plan interventions, contributing to the incidents of resident-to-resident aggression.
Deficiencies in Personal Hygiene and Meal Assistance
Penalty
Summary
The facility failed to provide necessary services to maintain good grooming and personal hygiene for one resident and assistance with meals for another resident. Resident #39, who has multiple diagnoses including paraplegia and chronic pain, was documented to have received only one shower during the week of January 24, 2024, despite the care plan indicating a need for two showers per week. Interviews with staff revealed that the facility had been short-staffed for the past 3 to 4 weeks, leading to delays in providing showers. The Director of Nursing confirmed that a 6-day gap between showers did not meet the facility's expectations and acknowledged the potential risk of infection due to lack of hygiene. Resident #10, diagnosed with quadriplegia and other conditions, required assistance with feeding as per the care plan. However, documentation revealed inconsistencies in the assistance provided, with several instances where the resident did not receive the necessary help during meal times. An interview with the resident confirmed that she did not receive assistance with her meal on the morning of February 5, 2024. Staff interviews indicated that the resident required extensive assistance with all meals, and the Director of Nursing acknowledged that the documentation did not meet expectations, suggesting a possible documentation error. The facility's ADL policy, reviewed in August 2023, mandates that residents receive assistance with activities of daily living, including bathing and feeding. The failure to adhere to this policy for residents #39 and #10 highlights deficiencies in the facility's ability to provide consistent and necessary care, potentially compromising the residents' health and well-being.
Unattended Medication on Cart
Penalty
Summary
The facility failed to ensure the environment remained free of accident hazards by leaving medications unattended. On February 08, 2024, at 9:34 A.M., a small clear plastic measuring cup with a red capsule was observed on top of a medication cart with no staff present. The Director of Nursing (DON) also observed the unattended medication on the cart and disposed of it in an uncovered bin located at the bottom end of the medication cart. The medication was identified as docusate belonging to a resident. Interviews conducted with a registered nurse (RN) and the DON confirmed that the medication was left unattended. The RN stated that they were called away and it slipped their mind to secure the medication. The administrator confirmed that medications should always be within view and not left unattended on carts, as they can be picked up by unauthorized individuals.
Failure to Maintain RN Coverage for 8 Consecutive Hours Daily
Penalty
Summary
The facility failed to use the services of a registered nurse (RN) for at least 8 consecutive hours a day, 7 days a week, as required by regulations. Review of staff schedules for January and March 2023 revealed that there were no RNs on duty for 8 consecutive hours for at least 4 days each month. Additionally, in November and December 2023, there were no RNs for 8 consecutive hours for one day in each month. Interviews with the staffing coordinator and the Director of Nursing (DON) confirmed awareness of the regulations but indicated that the facility did not consistently meet the requirement. The staffing coordinator mentioned that typically an RN, such as the Infection Preventionist or the DON, would be present, and the DON stated that she would cover if no licensed nurse was available within a 24-hour period. The census at the time was 63 residents, and this deficiency has the potential to affect resident care.
Failure to Administer Pain Medication Within Prescribed Parameters
Penalty
Summary
The facility failed to administer pain medication within the prescribed pain scale parameters for two residents, leading to potential overmedication. Resident #39, who has diagnoses including paraplegia, chronic pain, and anxiety disorder, was administered 10 mg of oxycodone for pain levels ranging from 0 to 3, despite the physician's order specifying it should only be given for pain levels 4 to 10. This occurred at least seven times, as confirmed by the Director of Nursing (DON) and the Medication Administration Record (MAR). Interviews with staff revealed that the medication was administered outside the prescribed parameters, which did not meet the facility's expectations and policies. Similarly, Resident #17, with diagnoses including a displaced intertrochanteric fracture of the right femur and chronic back pain, was given 5 mg of oxycodone for pain levels 0 to 6, contrary to the physician's order for administration only for pain levels 7 to 10. This occurred on at least eleven occasions, as confirmed by the DON and the MAR. Staff interviews indicated that the medication was not administered according to the prescribed parameters, which could lead to serious health risks. The facility's policy on the administration of medications, reviewed in August 2023, mandates that medications be administered safely and appropriately per physician orders. The policy also emphasizes adherence to the 10 rights of medication administration. The DON acknowledged that the administration of oxycodone outside the prescribed parameters did not meet the facility's standards and posed potential risks to the residents.
Failure to Ensure Proper Hand Hygiene and Beard Guard Use
Penalty
Summary
The facility failed to ensure staff conducted appropriate hand hygiene during kitchen food preparation and dining services, as well as donning beard guards/nets in the presence of facial hair. During a kitchen observation, a dietary aide was seen with facial hair and not wearing a beard guard/net. Additionally, a cook was observed answering the kitchen phone and returning to puree preparation without conducting hand hygiene. In the dining room, the activities director was seen pulling up his pants, scratching his face, and then passing out dining trays without washing his hands. Similarly, the staffing coordinator was observed cutting up food for multiple residents without performing hand hygiene between each resident's utensils. The activities director was also seen wiping under his eyes and then delivering a food tray without washing his hands first. Interviews with staff confirmed that the expected hand hygiene practices were not followed. The dietary director and the executive director both acknowledged that the failure to adhere to proper hand hygiene and beard guard policies could lead to contamination of food and potential infection. A review of the facility's policies on Associate Conduct and Dress Code, as well as Handwashing and Glove Use, revealed that these practices were required to prevent contamination and ensure sanitary conditions in the kitchen and dining areas.
Infection Control Deficiencies
Penalty
Summary
The facility failed to ensure proper infection control practices were observed, leading to potential spread of infections. Resident #60, who was cognitively intact and had a foley catheter, was placed under enhanced barrier precautions to prevent urinary infections. However, an X-Ray Technician entered the resident's room and performed an ECG without donning appropriate PPE, despite the presence of CDC signage indicating the need for enhanced barrier precautions. The technician admitted to not seeing the signage and acknowledged the risk involved in performing high-contact procedures without PPE. The Infection Preventionist expressed uncertainty about the necessity of PPE for an ECG, but emphasized the importance of adhering to posted signage and inquiring when unsure about precautions. Additionally, during a medication pass observation, a registered nurse was seen returning a glucometer to the medication cart without properly sanitizing it between uses. The nurse was unsure of the policy regarding glucometer sanitization and used an alcohol pad instead of the required bleach wipes. The Director of Nursing later provided the correct policy for cleaning and disinfecting the glucometer, which mandates the use of EPA-registered bleach wipes to prevent the transmission of bloodborne pathogens. The DON stated that the nurse was reeducated on the proper cleaning procedures and emphasized the importance of following infection control policies. The facility's policies for standard precautions, handwashing, and glove use were reviewed, revealing that the infection prevention and control program includes systems for preventing, identifying, reporting, investigating, and controlling infections. The policies also specify the appropriate use of PPE, hand hygiene, and cleaning and disinfecting procedures. Despite these policies, the observed deficiencies in infection control practices highlight lapses in adherence to established protocols, potentially jeopardizing the health and safety of residents and staff.
Failure to Assess Resident for Self-Administration of Medication
Penalty
Summary
The facility failed to ensure that a resident was assessed for self-administration of medication. Resident #6, who was admitted with diagnoses including type 2 diabetes, spinal stenosis, heart failure, and essential hypertension, was observed with hydrocortisone ointment and Vicks Vaporub at the bedside without any staff present. The resident confirmed that staff were aware of the medications. Interviews with a CNA and an LPN revealed that there was no consistent understanding or adherence to the policy regarding self-administration of medications. The CNA was unaware of any policy and stated that medications found at the bedside were typically disposed of by the nurse. The LPN confirmed that all medications should be stored in the wound or medication cart and administered by a nurse, and acknowledged the existence of a policy for self-administration but noted it was not commonly practiced. The DON confirmed that the resident had not been assessed for self-administration, and there were no physician orders or care plan entries to support self-administration for this resident. The facility's policy, dated August 29, 2023, requires an interdisciplinary team assessment and a physician's order for residents to self-administer medications. However, this policy was not followed for Resident #6, as there was no evidence of an assessment or physician's order in the resident's records. The DON verified that the resident was not authorized to self-administer medications, highlighting a failure to adhere to the established policy and procedure, which could result in residents self-administering medications without proper assessment and authorization.
Failure to Follow Dialysis Care Policy for Blood Pressure Monitoring
Penalty
Summary
The facility failed to ensure that a resident with end stage renal disease (ESRD) and a dialysis shunt in the left arm received safe monitoring of vital signs. Despite the care plan and facility policy explicitly stating that blood pressure should not be taken from the arm with the shunt, the resident's blood pressure was measured from the left arm on seven occasions between January 25, 2024, and February 7, 2024. This practice was contrary to the facility's Hemodialysis Offsite Policy, which was last reviewed on August 23, 2023, and could potentially lead to complications such as damage to the access site, clotting, or circulatory problems. Interviews with multiple registered nurses revealed a lack of consistent understanding and adherence to the policy. One RN incorrectly stated that it did not matter which arm was used for blood pressure measurements, while two other RNs correctly identified that using the arm with the shunt was inappropriate and could cause harm. The resident involved was cognitively intact, with a Brief Interview for Mental Status (BIMS) score of 15, and had no documented issues with the right arm that would necessitate using the left arm for blood pressure readings.
Improper Disposal of Unused Medications
Penalty
Summary
The facility failed to ensure unused medications were disposed of according to accepted professional standards. On February 08, 2024, at 9:34 A.M., a small clear plastic measuring cup with a red capsule was observed on top of a medication cart with no staff present. The Director of Nursing (DON) also observed the unattended medication on the cart and disposed of it in an uncovered rectangular bin located at the bottom end of the medication cart. This action was contrary to the facility's policy and professional standards for medication disposal. An interview with a Registered Nurse (RN) revealed that unused medications should be disposed of in a sharps container to prevent access by unauthorized personnel or residents. The RN emphasized that discarding medications in an uncovered trashcan poses a risk, especially for residents who are not cognitively aware. The facility's administrator confirmed that the trashcan is not an approved method for medication disposal and that the facility's policy requires medications to be disposed of in a manner that limits access and complies with applicable laws and environmental regulations.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 240 citations issued within 25 miles in the last 12 months — including the 1 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 Chandler
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Chandler Post Acute And Rehabilitation | 0.6 mi | ★★★★★ | 9 | 0 |
| Sante Of Chandler | 0.7 mi | ★★★★★ | 3 | 0 |
| Archstone Care Center | 0.8 mi | ★★★★★ | 4 | 0 |
| River Park Post Acute | 3.3 mi | ★★★★★ | 0 | 0 |
| Tempe Post Acute | 5.9 mi | ★★★★★ | 6 | 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.