Average — CMS composite of the measures below.
The next survey window likely opens around January 2027
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 Diamondback Healthcare Center during CMS and state inspections, most recent first.
Surveyors identified a failure to follow food safety standards when multiple opened food items in the kitchen, including liquid eggs, frozen chicken tenders, frozen tilapia, and hot dog buns, were found without labels indicating when they were opened. The facility’s policy required all foods to be labeled and dated, and both the Dietary Manager and the RD confirmed that all products should be labeled upon delivery, storage, and opening so that staff know when items were received, stored, and opened.
A resident with C. difficile was on ordered single-room contact precautions with clear care plan interventions and posted signage requiring PPE use. Despite an isolation cart stocked with gowns, gloves, masks, and wipes, a CNA was observed exiting the resident’s contact isolation room after delivering a meal tray without performing hand hygiene, then handling another meal tray on the shared food cart, which continued to be used for meal service. In interviews, the CNA, an LPN, the Administrator, and the IP all acknowledged that PPE, hand hygiene, and other contact precaution measures are required for such residents, including during meal delivery. The facility’s IPCP policy required appropriate hand hygiene and PPE use, and the facility also failed to document community infection control surveillance mapping as part of its infection control program.
An unattended computer workstation was observed with a resident’s personal dietary information actively displayed on the monitor while no staff were present. A non-employee walked past the exposed screen without any staff attempt to shield or secure the information. The DON later returned to the workstation, logged off, and acknowledged that leaving PHI visible on an unattended workstation could violate HIPAA and did not meet facility expectations, despite existing policies and staff training on confidentiality and protection of resident records.
Two residents were transferred to the hospital for acute changes in condition, including unresponsiveness and hypotension, with documentation in nursing notes, physician visit notes, transfer forms, and discharge MDS assessments indicating hospital transfers with return anticipated, but no written transfer/discharge notices containing required elements were found in their records. One resident had multiple serious conditions including acute respiratory failure, heart failure, and pneumonia; the other had ventilator-associated pneumonia, sepsis, respiratory failure with hypercapnia, and severe cognitive impairment. Staff interviews revealed that Social Services was not involved in notifications, the Medical Records Director only began tracking notifications months after the events and was unsure how mailed notices were tracked, and the liaison who visited residents in the hospital did not provide any transfer/discharge forms. The Medical Records Director confirmed no transfer/discharge notices existed for the two residents and that the form in use contained incorrect appeal and ombudsman contact information, while the Administrator stated she was unaware that this version of the form was being used. Review of the facility’s discharge/transfer policy showed it addressed bed-hold review after emergent transfers but did not address providing written transfer/discharge notices or the required content.
A resident admitted on an antipsychotic (olanzapine 2.5 mg daily) with moderate cognitive impairment and no documented behavioral symptoms had the medication discontinued, as reflected on the MAR, but the discontinuation and rationale were not accurately documented in provider progress notes. A PA’s psychiatric note stated no medication changes were made and did not mention stopping olanzapine, while a telephone discontinue order was entered by an LPN and no further doses were given. Behavioral monitoring tied to the antipsychotic remained active with no recorded behaviors, and subsequent NP notes incorrectly documented that the resident would continue olanzapine, even though it was no longer administered and was not included on discharge prescriptions, resulting in inconsistent and inaccurate clinical documentation.
A resident with severe cognitive impairment and a history of bradycardia was repeatedly administered antihypertensive medications despite physician orders to hold these medications if the heart rate was below 60 bpm. Nursing staff and the DON confirmed awareness of the medication parameters, but the MAR showed multiple instances where medications were given outside of these parameters, contrary to facility policy and provider instructions.
A resident with severe cognitive loss and multiple diagnoses was found to have a bruise on the left foot, later confirmed as a fracture. Despite the spouse's request for an X-ray and hospital evaluation, the facility did not report the injury as required by their Abuse Policy. Staff interviews revealed that the facility did not consider the incident reportable, leading to a deficiency in reporting and investigating the injury.
A resident with multiple diagnoses, including anoxic brain damage, was found to have a bruise on the left foot, later revealed to be a fracture. The facility failed to report this injury of unknown origin within the required timeframe, as they did not consider it reportable. Interviews with staff indicated that unusual marks are typically reported and assessed, but the facility's policy on reporting was not followed in this case. The absence of a list of reportables and 5-day reports was noted by the new administrator.
A resident with multiple diagnoses, including Alzheimer's and dysphagia, experienced a worsening pressure wound due to repeated loose stools. Despite physician orders for Imodium, it was only administered once, and the facility failed to manage the resident's condition effectively. Inadequate communication between CNAs and nursing staff contributed to the deficiency, as the facility did not adhere to its policies on resident condition changes and incontinence care.
The facility failed to ensure adequate staffing for residents requiring ventilator and tracheostomy care, leaving LPNs to manage care beyond their scope. The absence of a scheduled RT for the night shift resulted in residents not receiving necessary trach care, vent checks, or suctioning. Interviews revealed that LPNs were not comfortable or trained to handle ventilator settings or emergent situations, posing a significant risk to resident safety.
Failure to Label and Date Opened Food Items in Kitchen Storage
Penalty
Summary
The deficiency involves the facility’s failure to ensure that opened food items were labeled and dated in accordance with professional food safety standards and the facility’s own policy. During a kitchen observation conducted with the Dietary Manager, surveyors found two liquid egg cartons in the refrigerator without an opened date label, as well as one bag of chicken tenders and one bag of tilapia in the freezer without opened date labels. In addition, one bag of hot dog buns was found without an opened date label. The facility’s written policy, titled “Food Safety Requirements,” stated that all foods will be labeled, dated, and monitored, including refrigerated foods and leftovers, so that they are used by their use‑by date. In interviews, the Dietary Manager stated that food should be labeled with the date it is opened and the expiration date, and that if food has no opened date or expiration date label, kitchen staff should dispose of it immediately because eating from open, undated food could pose a risk to residents. The registered dietitian stated that the expectation was that all food products are properly labeled and dated upon delivery and storage, and again once items are opened, noting that the risk included not knowing when the food was received, stored, or opened. These observations and statements show that staff did not consistently follow the facility’s established food safety requirements for labeling and dating opened food items.
Failure to Follow Contact Precautions and Document Infection Surveillance
Penalty
Summary
The deficiency involves the facility’s failure to implement proper infection prevention and control practices for a resident on contact precautions and to document community infection control surveillance mapping. A resident admitted with diagnoses including C. difficile enterocolitis, urinary tract infection, and psychoactive substance abuse had a comprehensive care plan and physician order requiring single-room contact precautions, including use of gowns and gloves for high-contact care, gowns and masks when changing contaminated linens, and conducting all care, therapies, and activities in the room. Signage outside the resident’s room indicated contact precautions and the need for PPE, and an isolation cart with gowns, gloves, masks, and sanitizing wipes was present. Surveyors observed a CNA exiting this contact isolation room after delivering a meal tray without performing hand hygiene. After exiting, the CNA handled another meal tray on the food cart and pushed it back into the cart, and there was no evidence that this tray was discarded while staff continued to pass meal trays from the same cart. In interviews, the CNA acknowledged exiting the room without hand hygiene and stated that staff are required to don gowns and gloves when entering, doff them before exiting, use disposable meal trays, perform hand hygiene, and disinfect reusable items for residents on contact precautions. An LPN and the Administrator, along with the Infection Preventionist, confirmed that proper PPE use and adherence to contact precautions are required, including when delivering meal trays. The facility’s IPCP policy required hand hygiene per facility procedures and use of PPE according to policy, but these practices were not followed in this instance, and the facility also failed to document community infection control surveillance mapping as part of its infection prevention and control program.
Unattended Computer Screen Exposes Resident PHI
Penalty
Summary
Surveyors identified a deficiency related to failure to maintain confidentiality of resident-identifiable information when an unattended computer workstation displayed personal records for Resident #29. On January 29, 2026, at 10:45 a.m., the workstation was observed with resident records actively visible on the monitor and no staff present or monitoring the area. The information on the screen included personal and identifiable dietary information for Resident #29. At 10:46 a.m., a non-employee walked down the hallway and passed directly by the monitor with the resident’s information visible, and no staff intervened to shield or secure the information. At 10:47 a.m., the DON (Staff #85) approached the unattended workstation and immediately logged off the computer. In an interview at that time, the DON confirmed that the computer contained private resident information and acknowledged that leaving resident information visible on an unattended workstation could constitute a HIPAA violation and did not meet facility expectations for confidentiality. Review of facility documentation showed staff training on PHI, closing screens, not leaving information exposed, confidentiality, HIPAA, and resident and family notification, with 31 staff members having signed acknowledgment. A review of the facility’s Resident Rights policy, revised January 1, 2025, stated that residents have the right to secure and confidential personal and medical records and that the facility is responsible for safeguarding resident information from unauthorized access or disclosure.
Failure to Provide Required Written Transfer/Discharge Notices and Accurate Information
Penalty
Summary
The deficiency involves the facility’s failure to provide required written transfer/discharge notifications to residents and/or their representatives when residents were transferred to the hospital. For one resident with acute respiratory failure with hypoxia, a left femur fracture, pulmonary hypertension, heart failure, and pneumonia, the record showed admission on a specified date and a subsequent transfer to the hospital on a later date due to unresponsiveness and rapid decline in mental status. The face sheet identified the husband as responsible party and the daughter as emergency contact, with phone numbers listed, and documented that the resident was discharged to the hospital. A physician visit note confirmed the emergent transfer, and a discharge MDS coded as a discharge-return anticipated indicated the resident was sent to the hospital. However, there was no order in the Order Summary Report for the hospital transfer and no documentation in the clinical record of a written transfer notice containing the required elements being provided to the resident or resident representative. For another resident originally admitted with ventilator-associated pneumonia, sepsis, respiratory failure with hypercapnia, type II neurofibromatosis, respirator dependence, visual loss, and pleural effusion, the face sheet listed the resident’s mother as emergency contact with a phone number. An eINTERACT transfer form documented a hospital transfer for hypotension, and a nursing note recorded a blood pressure of 84/65, that the POA was at bedside, the provider was notified, and 911 was called for transport per physician’s orders. The Order Summary Report contained a physician’s order to transfer the resident to the ER for hypotension, and a discharge MDS coded as discharge-return anticipated documented that the resident, who had severe cognitive impairment, was sent to the hospital. Despite this, the clinical record contained no documentation that a written transfer notice with the required information was provided to the resident or resident representative. Interviews and policy review further described gaps in the facility’s process for transfer/discharge notifications. The social worker reported that Social Services/Case Management was not involved in transfer/discharge notifications and identified Medical Records as responsible. The Medical Records Director stated she began tracking transfer/discharge notifications around October 2025, that a transfer/discharge form was created at that time, and that completed forms were to be scanned into the clinical record if provided to her, but she was unsure how mailed notifications were tracked. She confirmed there were no transfer/discharge notifications in the records of the two residents and acknowledged that the form in use contained incorrect appeal and ombudsman contact information. The Admissions Coordinator/Clinical Liaison stated he visited residents in the hospital but did not provide any transfer/discharge form or packet and was unfamiliar with the form. The Administrator stated that transfer notices are provided three days prior to discharge and that there is a notification for each level with a checklist, but when shown the facility’s transfer/discharge notification form, she said it did not look like the one she approved and she was unaware her team was using it. Review of the facility’s Discharge/Transfer policy showed it addressed reviewing the bed-hold policy with the POA within 24 hours of an unplanned emergent transfer but did not address providing transfer/discharge notifications to residents or representatives or specify the required information, despite State Operations Manual requirements for written notice including reasons, effective date, destination, appeal rights, and advocacy contact information.
Failure to Accurately Document Discontinuation of Antipsychotic Medication
Penalty
Summary
The deficiency involves the facility’s failure to accurately document the discontinuation of an antipsychotic medication and the rationale for that change in a resident’s clinical record. The resident was admitted from the hospital with an order for olanzapine 2.5 mg daily and had moderate cognitive impairment with no documented behavioral symptoms during the MDS assessment period. Facility physician orders showed olanzapine was started with an indefinite end date, and the MAR reflected administration for several days, with the medication discontinued on November 11, 2025, at 11:41 a.m. A behavioral monitoring order related to olanzapine, initiated the day before, remained active through the resident’s discharge, and no behavioral symptoms were documented during that time. On the same day olanzapine was discontinued, a psychiatry progress note by a PA documented that this was the initial psychiatric visit and stated that no medication changes were recommended, without noting the discontinuation of olanzapine and directing staff to refer to the MAR for non-pharmacologic interventions. A telephone discontinue order for olanzapine was entered by an LPN as a telephone order from the same PA, and the MAR confirmed no further doses were given after that date. Subsequent nurse practitioner notes on two later dates documented that the resident would continue olanzapine and benztropine for psychosis, despite the medication having been discontinued and not provided, and the resident was ultimately discharged without a prescription for olanzapine. Interviews with nursing and pharmacy staff, as well as the PA, confirmed that the discontinuation was not documented in the progress note and that behavioral monitoring and alert charting were not updated, contrary to facility policies requiring accurate documentation of physician-ordered services and nursing documentation of treatment and order changes.
Failure to Follow Medication Administration Parameters for Resident with Bradycardia
Penalty
Summary
The facility failed to ensure that medications were administered within the physician-ordered parameters for a resident with multiple diagnoses, including acute and chronic respiratory failure, hypotension, dependence on a ventilator, and bradycardia. The resident had severely impaired cognition and was prescribed several antihypertensive medications, all with specific instructions to hold administration if the systolic blood pressure was less than 110 mmHg or if the heart rate was less than 60 beats per minute. Despite these clear parameters, the medical records and Medication Administration Records (MAR) showed that nursing staff repeatedly administered Amlodipine, Carvedilol, Clonidine, Doxazosin, and Hydralazine on multiple occasions when the resident's heart rate was below 60 bpm. Interviews with staff confirmed that they were aware of the medication parameters and the risks associated with administering these medications outside of those parameters. A CNA stated that staff are instructed to notify a nurse if a resident's pulse falls below 60 bpm, and an LPN confirmed that medication orders with parameters are to be followed as written. The LPN also reviewed the MAR and acknowledged that medications were given when the resident's pulse was below the required threshold, stating that they should have been held on those days. The Director of Nursing (DON) stated that the facility's expectation is for nursing staff to follow provider orders when administering medications and recognized that bradycardia can be dangerous. The DON also noted that episodes of bradycardia should be reported to the provider and that such events qualify as a change of condition. The facility's Medication Administration policy directs staff to review medication records and adhere to the five rights of medication administration, but this was not followed in the case of this resident.
Failure to Report and Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to report an injury of unknown origin and complete a 5-day written investigation as required by their Abuse Policy for a resident. The resident, who had severe cognitive loss due to anoxic brain damage, was found to have a bruise on the left dorsal foot below the second toe, which was later confirmed to be a fracture. The incident was not reported as the facility did not consider it a reportable incident, despite the resident's spouse requesting an X-ray and subsequent hospital evaluation. The resident was admitted with multiple diagnoses, including anoxic brain damage, respiratory failure, and epilepsy, and was always incontinent of bladder and bowel. The care plan indicated the resident had communication problems and potential skin integrity issues. On a specific date, the resident's spouse noticed a bruise and requested an X-ray, which led to the discovery of a fracture. The facility's staff, including a CNA and LPN, followed procedures to notify relevant parties and document the incident, but the facility did not report the injury as required. Interviews with staff revealed that the facility's Director of Nursing and Administrator did not believe the incident was reportable, citing the resident's condition and lack of an open wound. The facility's policy on abuse prevention and reporting was reviewed, which mandates reporting all alleged violations within specified timeframes. However, the facility did not adhere to these requirements, resulting in a deficiency in reporting and investigating the injury of unknown origin.
Failure to Report Injury of Unknown Origin
Penalty
Summary
The facility failed to report an injury of unknown origin within the required timeframe for a resident, which may result in residents being abused or receiving untimely treatment and care. The resident, who was admitted with multiple diagnoses including anoxic brain damage and respiratory failure, was found to have a bruise on the left dorsal foot below the second toe. The resident's spouse informed the nurse of the bruise, and an X-ray was ordered, revealing a fracture. The resident was then transported to the hospital for evaluation and treatment. Interviews with staff revealed that unusual marks are typically reported to the nurse, who then observes the mark, notifies the DON, ADON, the doctor, and family members, and performs any orders received. However, in this case, the facility did not report the incident as they did not consider it reportable, understanding the patient's condition. The DON later acknowledged that in hindsight, the incident should have been reported. The facility's policy on abuse prevention and reporting was reviewed, which requires reporting of all alleged violations within specified timeframes. The report highlights that the facility did not have a list of reportables or 5-day reports available, as shared files were wiped from the system. The new administrator, who started on January 1, noted the absence of these files. The facility's failure to report the injury of unknown origin within the required timeframe constitutes a deficiency, as it may result in residents being abused or receiving untimely treatment and care.
Failure to Manage Resident's Loose Stools and Pressure Wound
Penalty
Summary
The facility failed to provide care and services according to professional standards for a resident who was admitted with multiple diagnoses, including a traumatic hemorrhage of the cerebrum, Alzheimer's disease, dysphagia, and protein-calorie malnutrition. Upon admission, the resident was noted to have an unstageable pressure wound and moisture-associated skin damage (MASD) to the sacrum. Despite a physician's order for wound care, there was no evidence of proper wound measurements or consistent assessments for the risk of developing pressure ulcers. The resident experienced repeated episodes of loose stools, which were documented by CNAs but not effectively communicated to nursing staff, leading to inadequate management of the resident's condition. The resident's condition deteriorated as the pressure wound increased in size, attributed to the ongoing loose stools. Although Imodium was ordered to manage the loose stools, it was only administered once, despite the resident experiencing multiple episodes of diarrhea. The lack of communication between CNAs and nursing staff resulted in a failure to address the resident's loose stools promptly, contributing to the worsening of the pressure wound. The facility's policies on change in resident condition and incontinence care were not followed, as there was insufficient documentation and monitoring of the resident's medical status and interventions. Interviews with staff revealed inconsistencies in the awareness and management of the resident's condition. Some staff members were unaware of the resident's ongoing diarrhea, while others noted the need for frequent changes due to loose stools. The Director of Nursing acknowledged the importance of effective communication and the need for daily assessments of residents with loose stools. However, the facility's failure to adhere to its policies and ensure proper communication and intervention led to the deficiency in care for the resident.
Inadequate Respiratory Care Staffing
Penalty
Summary
The facility failed to ensure that staff had the necessary competencies or skills to provide care for eight residents who required ventilator and tracheostomy care. The facility's census was 75, and the deficiency was identified through personnel record reviews, facility documentation, staff interviews, and policy review. The absence of a scheduled Respiratory Therapist (RT) for the night shift on the ventilator/tracheostomy unit led to Licensed Practical Nurses (LPNs) being responsible for care beyond their scope of practice. This situation resulted in residents not receiving the required tracheostomy care, ventilator checks, or suctioning. The staff schedule revealed that no RT was scheduled for the night shift, leaving LPNs to manage the care of residents on ventilators and tracheostomies. Interviews with staff indicated that LPNs were not comfortable or adequately trained to handle ventilator settings, alarms, or emergent situations. The Director of Nursing acknowledged that LPNs were not able to assess trach or vent residents independently and were only able to assist RTs or RNs. The facility's policy stated that respiratory care should be provided consistent with professional standards, but the lack of trained personnel on the night shift contradicted this policy. Interviews with RTs and LPNs highlighted concerns about the risks associated with LPNs providing care without proper supervision or training. The RTs expressed that airway management is a high-risk task that should not be left to LPNs alone. The facility's failure to staff RTs or RNs for the night shift on the ventilator/tracheostomy unit resulted in inadequate care for residents, as evidenced by the state of the trach and vent patients when the daytime RT arrived. The deficiency posed a significant risk to the health and safety of the residents requiring specialized respiratory care.
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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) |
|---|---|---|---|---|
| Northpark Health And Rehabilitation Of Cascadia | 0.8 mi | ★★★★★ | 3 | 0 |
| Bella Vita Health And Rehabilitation Center | 5.1 mi | ★★★★★ | 3 | 0 |
| Palm Valley Post Acute | 5.3 mi | ★★★★★ | 4 | 0 |
| Estrella Health And Rehabilitation Center | 5.7 mi | ★★★★★ | 8 | 0 |
| Az - Rio Vista Post Acute And Rehabilitation | 6 mi | ★★★★★ | 0 | 0 |
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