Below average — CMS composite of the measures below.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Resolve Harmony Center, Llc during CMS and state inspections, most recent first.
Two residents with known behavioral issues and cognitive/neurologic conditions were involved in a patio altercation where one resident struck another on the head after a verbal interaction and dispute over a book. Care plans for both residents already identified behavioral disturbances, including verbal and physical aggression, and outlined interventions such as providing a calm environment, diverting attention, and intervening to protect others. Despite these plans and prior documented episodes of verbal aggression and a previous physical altercation involving one of the residents, staff‑witness accounts and later review of video footage confirmed that one resident approached and hit another on the head, causing the victim to report pain and fear, demonstrating a failure to protect residents from physical abuse.
PASARR screenings were missing, incomplete, outdated, or not submitted for multiple residents with psychiatric diagnoses and related behaviors. Records showed absent or blank level I forms, outdated PASARRs from other facilities, and incomplete level II documentation for residents with schizoaffective disorder, schizophrenia, bipolar disorder, depression, anxiety, hallucinations, and psychotropic medication use. The SSW/DON interview confirmed that several screenings were not updated after stays exceeded 30 days and that some were not submitted for review.
Unsafe Smoking Supervision and Storage: A resident with schizoaffective disorder, anxiety, and multiple sclerosis was assessed as unable to smoke safely without assistance, yet staff observed the resident smoking with tremors, dropping ashes and a cigarette, and without a smoking protector. The record and staff interviews showed inconsistent practices about whether smoking materials could be kept on a resident’s person, while the resident had already received a smoking violation for having a lighter or matches.
Failure to Follow Smoking Policy for Multiple Residents: The facility did not consistently implement its smoking policy for multiple residents who smoked. A resident with COPD and nicotine dependence kept a lighter under her wheelchair cushion, another resident with serious mental health diagnoses kept cigarettes, lighters, matches, and e-vapes on her person and in her room, and a third resident with a history of TIA/CVA kept cigarettes and a lighter in her room and on her person despite a signed policy requiring secure storage. Staff interviews showed conflicting understanding of whether smoking materials could be kept by residents.
A resident with testicular dysfunction had a physician order for Testosterone Cypionate 200 mg IM every 14 days, but facility records showed the injection was given once and then not again until more than two weeks later, with no documentation that the scheduled intermediate dose was administered or that the provider was notified of the missed dose. Nursing staff and leadership acknowledged that the testosterone injection due on a specific date was not given and that required notifications and documentation were not completed, despite facility expectations and pharmacy services policy. The resident reported opting to resume injections at a urology clinic due to concerns about inconsistent administration by facility staff.
Delayed MDS Transmission: A resident admitted with chronic respiratory failure, atrial fibrillation, and bipolar disorder had an admission MDS completed by the RNAC, but it was not transmitted and accepted within the required timeframe. The MDS Coordinator said the delay was related to facility issues, including a prior MDS coordinator leaving, use of a third-party transmission service, and an incorrect CCN that had to be corrected before submission.
A resident with a history of alcohol dependence and SUD was prescribed Oxycodone HCl 10 mg PRN for pain levels 5-10, but the MAR showed the opioid was administered several times when pain scores were below the ordered range. The ADON and IDON confirmed the medication was given outside provider-ordered parameters, with no supporting documentation or provider authorization found, and the resident’s care plan and opioid consent identified opioid therapy risks and directions to give medications as ordered.
Unsecured Medication Cart Left Unattended: An LPN was observed preparing medications at a med cart on the South Wing, then walking into a resident room while the cart was left unattended, facing the hallway, and unlocked. The LPN confirmed the cart was unsecured when she returned, and the interim CNO/DON stated med carts should be locked whenever not in use or when a nurse is not in front of them. The facility policy required drugs and biologicals to be stored in locked compartments, including med carts.
The facility failed to prevent abuse when two residents with moderate cognitive impairment and complex medical/psychiatric histories engaged in a physical altercation on an outdoor patio during a nursing shift change. One resident, who used a wheelchair and had multiple serious medical conditions, verbally confronted another resident known to have a care plan for verbal/physical aggression and intrusive behaviors with behavior charting orders in place. The second resident admitted to instigating the fight and holding the first resident down until other residents intervened and called for help. When LPN staff arrived, the residents had already been separated, and assessment revealed multiple bruises, scrapes, and knots on the injured resident’s hands, knee, and leg. A cognitively intact resident witness corroborated that the aggressive resident stood up, grabbed the other resident, and fought until interrupted, and the Administrator later confirmed that this unwanted physical contact met the facility’s definition of physical abuse under its abuse-prevention policy.
Failure to Protect a Resident from Resident-to-Resident Abuse: A resident with severe cognitive impairment was involved in a physical altercation with another resident who had a history of hitting other residents. Staff documented that the other resident had a raised, clenched fist and that the resident reported being punched in the face, with slight redness noted on the cheek. The incident report said the residents were separated and the other resident was moved, but the move did not occur until the next day, and no skin assessment was documented for the resident on the day of the altercation.
Multiple incidents occurred in which residents engaged in physical altercations in unsupervised common areas, including the patio and smoking area. These altercations involved the use of wheelchairs as weapons, physical blows, and objects such as coffee mugs, resulting in injuries and emotional distress. Staff interviews and facility policy confirmed that such resident-to-resident interactions are considered abuse, and the lack of supervision contributed to the escalation of these events.
A deficiency was cited for not ensuring a resident's right to dignity, self-determination, communication, and the exercise of their rights. The report does not specify the exact circumstances or individuals involved.
A resident with a history of falls and cognitive impairment experienced multiple falls, including one resulting in a lumbar fracture. Despite these incidents, the fall care plan was not updated to include new interventions, as confirmed by the DON and ADON. Facility policy requiring timely care plan updates after significant events was not followed.
Two residents did not receive care that met professional standards when staff failed to promptly transfer a resident with severe back pain after a fall and did not consistently update or communicate fall risk assessments for another high-risk resident. Staff interviews revealed that CNAs and nurses were not reliably informed about residents' fall risk status or preventive measures, and there was no formal fall management program in place. Facility policies requiring timely assessment, communication, and individualized interventions were not followed.
The facility failed to protect residents from all forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, by any individual.
The facility did not promptly report suspected abuse, neglect, or theft, nor did it communicate the results of its investigation to the proper authorities as required.
Two cognitively intact residents with behavioral histories were involved in a physical altercation on the patio, resulting in one resident losing a tooth after being struck by another. The incident was documented, and both police and APS were notified. Facility policies prohibiting abuse were reviewed, and the administrator confirmed the injury and refusal of treatment.
Multiple residents were involved in physical altercations, including hitting and biting, after ongoing verbal disputes and behavioral issues were not effectively managed. Staff and witnesses reported escalating tensions and aggressive behaviors prior to the incidents, but interventions were insufficient to prevent injuries, resulting in minor wounds and the involvement of law enforcement.
A resident with respiratory issues was neglected when the facility failed to administer and monitor oxygen therapy as ordered. Despite experiencing symptoms of distress and having an oxygen saturation below 90%, the resident did not receive oxygen until reaching the hospital. The LPN could not find an oxygen concentrator and did not inform the DON, leading to a delay in care. The facility's policy requires daily monitoring of oxygen levels, which was not documented, resulting in a deficiency.
Failure to Prevent Resident-to-Resident Physical Abuse on Patio
Penalty
Summary
The deficiency involves the facility’s failure to protect two residents from physical abuse by another resident. One resident had multiple diagnoses including cirrhosis of the liver, Parkinsonism, hydrocephalus, bipolar disorder, and mild cognitive impairment, with a BIMS score indicating severe cognitive impairment. This resident had care plans addressing impaired cognitive function and behavioral disturbances, including verbal and physical abuse, with interventions such as providing a calm environment, diverting attention, and intervening as necessary to protect the rights and safety of others. Despite these identified needs and planned interventions, this resident was involved in a resident‑to‑resident altercation on the patio in which another resident struck him on the head after a verbal interaction. The second resident involved had diagnoses including metabolic encephalopathy and pain, and a care plan for behavioral disturbances such as refusal of care, refusal of medication, and verbal and physical abuse. This care plan also included interventions to document behaviors, reinforce why inappropriate behavior is unacceptable, and intervene as necessary to protect the rights and safety of others, including removing the resident from situations as needed. Prior to the incident on the patio, this resident had a documented history of involvement in a physical altercation with another resident, where he was described as the non‑aggressor, and had ongoing behavioral charting for verbal aggression and argumentative behavior. Behavior notes documented episodes of verbal aggression, cursing at staff, and yelling related to environmental changes. On the date of the incident leading to the deficiency, an internal incident report documented that the second resident slapped the first resident on the back of the head on the patio after a verbal confrontation. Witness accounts varied: the activities assistant reported hearing a loud slapping sound and seeing the second resident standing, then intervening, while another resident witness stated she saw the second resident hit the first resident on the head with a book because of a dispute over ownership of the book, and that there had been no argument beforehand. The DON reported that camera footage showed the two residents conversing about three feet apart on the smoking patio, then the second resident wheeled up to the first resident and hit him on the head, which the DON characterized as physical abuse. The administrator also acknowledged that video footage showed the second resident tapping the first resident’s head. The first resident later indicated he was in pain afterward and felt scared. These events occurred despite existing behavior care plans and interventions intended to prevent such incidents, resulting in a failure to ensure residents were free from physical abuse by another resident.
PASARR screenings were missing, outdated, or not submitted for multiple residents with mental health diagnoses
Penalty
Summary
The facility failed to ensure PASARR screenings were updated appropriately and accurately submitted, when applicable, for six sampled residents. The deficient practice involved residents with diagnoses and care plans reflecting serious mental health conditions, including schizoaffective disorder, schizophrenia, bipolar disorder, major depressive disorder, anxiety disorder, auditory hallucinations, and behavioral disturbances. Review of clinical records, MDS assessments, care plans, physician notes, and PASARR documents showed that required PASARR documentation was missing, incomplete, outdated, or not submitted for the residents reviewed. For one resident, the record contained a PASARR level 1 and level 2 dated after admission, but there was no PASARR document on admission and no updated PASARR after the stay exceeded 30 days. The Social Service Director stated she completed the level 2 and attempted to submit it, but said she was waiting for the guardian's signature even though the form reflected verbal consent from the guardian. For another resident, the only PASARR in the record was a level 1 from another facility completed for a 30-day convalescent stay, and it was not updated after the resident remained in the facility longer than 30 days. The form sections for mental illness, symptoms, psychiatric treatment history, psychotropic medications, ID/DD, referral determination, and consent were left blank. Additional residents also lacked proper PASARR processing. One resident had diagnoses including schizophrenia, bipolar disorder, major depressive disorder, and anxiety disorder, but no completed level 1 PASARR was found in the record; the Social Service Director stated PASARRs could not be submitted because the facility did not yet have an AHCCCS identification number. Another resident had diagnoses including schizoaffective disorder, depression, and anxiety disorder, and the record contained no PASARR on admission; the Social Service Director stated the PASARR was completed later but was not submitted because she had been told not to send paper PASARR documents. For two other residents, the records contained PASARRs from other facilities that were not updated after admission or after the stay exceeded 30 days, despite diagnoses and care plans showing psychotropic medication use, hallucinations, depression, anxiety, and behavioral concerns. The Social Service Director acknowledged that residents staying beyond 30 days should have updated PASARRs and that level 2 PASARRs should have been submitted for residents with diagnoses such as schizophrenia, bipolar disorder, major depressive disorder, and anxiety disorder.
Unsafe Smoking Supervision and Storage
Penalty
Summary
The facility failed to ensure that one sampled resident was free from accidents and hazards related to safe smoking. Resident #37 had diagnoses including schizoaffective disorder, bipolar type; mood disorder due to a known physiological condition; generalized anxiety disorder; multiple sclerosis; and other muscle spasm. A safe smoking assessment documented that the resident was not able to smoke a cigarette or use a smoking device with safe technique, including lighting matches or a lighter, holding the cigarette or device while smoking, disposing of ashes appropriately, or extinguishing and disposing of the cigarette before it became dangerously short. The care plan identified the resident as a smoker who required supervision during smoking. The resident’s smoking policy form stated that smoking materials were to be stored in a secure area and that having cigarettes or combustible material on the resident’s person was a direct violation of the policy. A smoking violation document showed the resident received a verbal education offense for having a lighter or matches, and the materials were confiscated with a room search completed. During an observation, the resident was seen smoking in the designated supervised smoking area while staff noted tremors, ashes dropping onto the resident, and no smoking protector in place. Staff stated the resident had dropped ashes and a cigarette on her person and had dropped a cigarette on the ground. Interviews with staff showed inconsistent understanding of the smoking process and storage of smoking materials. Some staff stated residents could keep smoking materials on their person if they were unsupervised, while others stated residents were not allowed to keep cigarettes, lighters, matches, or electronic vapes on their person and that smoking materials were stored by staff. The interim DON stated the policy did not state where unsupervised residents could keep smoking materials, and that both supervised and unsupervised residents were not allowed to keep smoking materials on their person. The facility policy titled Resident Smoking stated that residents who smoke are assessed to determine whether supervision is required and that smoking materials for residents requiring supervision are maintained by nursing staff.
Failure to Follow Smoking Policy for Multiple Residents
Penalty
Summary
The facility failed to implement its smoking policy for three residents who were identified as smokers. Resident #12 had diagnoses including type 2 diabetes mellitus, nicotine dependence, COPD, depression, anxiety, and seizures, and had a BIMS score of 15. Although a safe smoking assessment and smoking evaluation were documented, the resident stated that she kept cigarettes and an orange lighter under the cushion of her wheelchair in her room, and an observation confirmed the lighter was stored there. The resident also stated that she smoked in the designated smoking area and that the Activity Director purchased and supplied cigarettes and lighters for residents. Resident #26 was admitted with diagnoses including paraplegia, major depressive disorder, anxiety disorder, bipolar disorder, and schizoaffective disorder, and had a BIMS score of 15. The record showed a progress note identifying her as a smoker and orienting her to the smoking areas, but there was no evidence of a smoking assessment or signed smoking policy in the record at that time. During interviews and observation, Resident #26 stated that she kept cigarettes, lighters, matches, and electronic vapes on her person and in her room, and she showed six electronic vapes, a box of cigarettes, and a lighter. The interim DON observed the items and confiscated them during the interview. Resident #41 had diagnoses including a history of TIA and cerebral infarction without residual deficits, major depressive disorder, and polyneuropathy, and had a BIMS score of 15. The record included a smoking assessment and a signed smoking policy stating that smoking materials were to be stored in a secure area and not kept on the resident’s person. However, interviews and observation showed that Resident #41 kept smoking materials on her person and in her room, including two boxes of cigarettes and a lighter. Staff interviews showed conflicting understanding of the smoking policy, with some staff stating residents were not allowed to keep smoking materials in their rooms or on their persons, while others stated unsupervised smokers could keep them on their person.
Failure to Administer Ordered Testosterone Injections as Scheduled
Penalty
Summary
The deficiency involves the facility’s failure to administer physician-ordered testosterone therapy as prescribed for Resident #2 and to document appropriate follow-up when a dose was missed. Resident #2, who had testicular dysfunction and was cognitively intact with a BIMS score of 15, was re-admitted with an order for Testosterone Cypionate 200 mg IM every 14 days in the afternoon for supplementation. The January Medication Administration Record showed the resident received the injection on January 15, 2026, but there was no documentation that the scheduled dose on January 29, 2026, was given. A nursing note documented that the next testosterone injection was administered on February 8, 2026, which exceeded the 14-day interval specified in the order, and the clinical record did not contain documentation supporting administration outside the ordered schedule. Interviews with staff confirmed that the ordered testosterone injection was not administered on January 29, 2026, and that there was no documentation that the provider was notified of the missed dose. The RN stated that testosterone therapy is important for maintaining the resident’s mood and overall well-being and that if a medication is not available, staff should notify the provider and pharmacy, document the notifications, and inform the resident. The ADON and Interim DON both stated that facility expectations are for staff to follow physician orders as written and to promptly notify the provider when medications are unavailable or cannot be administered as ordered, which did not occur in this case. The resident reported changing back to receiving injections at the urology clinic due to concerns that the facility had not reliably administered the injections as scheduled.
Delayed MDS Transmission
Penalty
Summary
The facility failed to transmit the admission MDS for one resident within the required regulatory timeframe after admission. The resident was admitted with diagnoses including chronic respiratory failure, atrial fibrillation, and bipolar disorder, and the admission MDS showed an ARD of October 26, 2025. The RN Assessment Coordinator signed the assessment as complete on November 3, 2025, and the resident’s BIMS score was 14, indicating cognitive intactness. Review of the CMS QIES Third-Party Service Bureau User Request form showed the facility authorized an outside entity to submit PBJ and/or assessment data, but the MDS submission option was not selected. The resident’s MDS Summary showed the assessment was not accepted until December 23, 2025. During interviews, the MDS Coordinator stated the assessment process began on October 20, 2025 and was completed on November 3, 2025, but transmission was delayed because of facility issues, including the prior MDS coordinator quitting unexpectedly, the decision to use a third-party transmission service, and an incorrect CCN that had to be corrected before successful submission.
Unnecessary Drug Administration Outside Ordered Pain Parameters
Penalty
Summary
The facility failed to ensure that one resident with a history of substance use disorder was not administered pain medication outside of provider-ordered parameters. The resident was re-admitted with diagnoses including aftercare following surgical amputation, paraplegia, cirrhosis of the liver, and alcohol dependence. The resident’s opioid consent form identified dependence and addiction as risks of opioid therapy, and care plans directed staff to administer medications as ordered and provide pain management as needed. The quarterly MDS showed the resident was cognitively intact with a BIMS score of 15 and that he received PRN pain medication and was on opioid therapy. The resident had an order for Oxycodone HCl 10 mg every four hours as needed for pain levels between 5 and 10, but the MAR showed the medication was given outside those parameters on multiple occasions. In January 2026, Oxycodone HCl was administered at pain levels of 1 on two dates; in February 2026, it was administered at a pain level of 2; and in March 2026, it was administered at a pain level of 1. During interview, the ADON confirmed the order and stated that if medication must be given outside ordered parameters, the provider must be notified. The IDON also reviewed the record, identified the out-of-parameter administrations, stated there was no supporting documentation or provider authorization for those doses, and noted the nurses involved were no longer employed by the facility.
Unsecured Medication Cart Left Unattended
Penalty
Summary
The facility failed to ensure one medication cart was secured when left unattended. During an observation on March 10, 2026 at 09:32 a.m. on the South Wing, a staff member was seen preparing medications at the medication cart, collecting a medication cup with medications, and then walking around the cart and into a resident room next to the cart. At that time, the medication cart was left facing out into the hallway and was unattended and unlocked. An interview at 09:33 a.m. with the LPN who had been using the cart confirmed that the medication cart was unlocked when she returned from passing medications to a resident. The LPN stated that leaving a medication cart unlocked and unattended could result in unauthorized staff or residents/visitors accessing the medications. An interview on March 11, 2026 with the interim CNO/DON also confirmed that medication carts should be locked at all times when not in use or when a nurse is not in front of the cart. The facility policy titled Medication Storage, reviewed/revised October 1, 2025, stated that all drugs and biologicals will be stored in locked compartments, including medication carts.
Failure to Prevent Resident-to-Resident Physical Abuse on Patio
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from abuse by another resident, resulting in a physical altercation with documented injuries. One resident, identified as having severe to moderate cognitive impairment, multiple serious medical conditions, and using a manual wheelchair, was involved in an incident on the facility patio with another resident. The resident’s clinical record showed a history of rejecting care on some days and being at risk for falls due to decreased mobility and strength. On the date of the incident, nursing documentation reflected that the resident’s primary physician and nurse practitioner were notified about an event involving another resident. The other resident involved in the altercation had a history of diffuse traumatic brain injury, schizoaffective disorder, major depressive disorder, seizures, hemiplegia, and other conditions, with a BIMS score indicating moderate cognitive impairment. This resident’s care plan, initiated months before the incident, identified verbal and physical aggression, intrusive behaviors, and outbursts, and included the January altercation as part of the behavioral focus. Orders in place required behavior charting on day and evening shifts. A nursing progress note documented behavior issues for this resident around the time of the incident, noting that he was redirected to his room. On the day of the event, during a nursing shift change, staff heard residents on the patio calling for help. When LPN staff responded, the two residents had already stopped fighting and were back in their wheelchairs, with other residents present who had witnessed the altercation. One cognitively intact resident witness reported that the alleged victim verbally confronted the other resident, who then stood up from his wheelchair, grabbed the resident, and engaged in a physical fight until other residents intervened and called for help. The resident identified as the aggressor admitted that he instigated the physical altercation, held the other resident down, and continued fighting until separated. Subsequent assessment documented that the victim had a knot on his left hand, a bruise and scrape on his right hand, a scrape on his right knee, and a bruise with two knots on his left leg. The facility Administrator and Abuse Coordinator stated that unwanted physical contact met the definition of physical abuse and that this incident constituted abuse and did not meet facility expectations, despite a written policy requiring an environment free from abuse.
Failure to Protect a Resident from Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect one resident from abuse by another resident. Resident #4 had diagnoses including schizophrenia, unspecified dementia with severe cognitive impairment, major depressive disorder, and anxiety, and his care plan noted wandering into other residents’ rooms and a later altercation with another resident. Resident #6 had diagnoses including hemiplegia and hemiparesis following cerebrovascular disease, cerebral infarction, pain, hypertension, aphasia, and dementia-related conditions, with a prior care plan problem related to hitting another resident in the past. On September 21, 2025, staff documented a physical altercation between the two residents in the hallway near their rooms. A nurse reported hearing a loud verbal outburst and seeing Resident #4 at the entrance of the other resident’s room while the other resident had an arm raised, drawn back, and a clenched fist. Resident #4 stated that he had been punched in the face and pointed to the left side of his face. The nurse documented no visible bruising, swelling, or open injury, while the facility incident report described slight redness to the left cheek. The record also showed that no skin assessment was documented for that date. The incident documentation stated that the residents were separated and that Resident #6 was moved to another room, but the census showed the move did not occur until the following day. Interviews with residents and staff described that Resident #6 struck Resident #4 in the face with a closed fist, attempted to hit him again, and had a history of hitting or bumping other residents. Resident #4 later stated that he had been punched in the face and that it hurt, and he said he felt safe after the other resident was moved the next day.
Failure to Prevent Resident-to-Resident Abuse in Unsupervised Common Areas
Penalty
Summary
The facility failed to protect residents from abuse, as evidenced by multiple resident-to-resident altercations that resulted in physical and emotional harm. In one incident, a resident with schizoaffective disorder and moderate cognitive impairment was involved in an altercation with another resident, during which both used their wheelchairs as weapons and physical blows were exchanged. The altercation began as a verbal dispute inside the building and escalated on the patio, where there was no staff supervision. Witnesses confirmed the physical nature of the altercation, and the facility's investigation determined that both residents were active participants. Staff interviews revealed that residents were allowed to access the patio and smoke without supervision, and staff typically became aware of incidents only when informed by other residents. Another incident involved two residents in the designated smoking area, where one resident was observed throwing rocks at cats. When confronted by another resident, the situation escalated to physical violence, with one resident hitting the other in the face and tearing their shirt. Security footage confirmed the sequence of events, and the injured resident exhibited physical signs of distress, including redness on the face and anxiety. Staff interviews consistently identified such resident-to-resident altercations as abuse according to facility policy, which defines abuse as the willful infliction of injury or pain. A third altercation occurred between two residents following a verbal disagreement, which escalated to both residents throwing coffee at each other, and one resident being struck in the face with a mug. Staff and resident interviews confirmed the altercation and described ongoing behavioral issues between the involved residents. Facility policy and staff statements consistently recognized these interactions as abuse. In all cases, the lack of supervision in common areas such as the patio and smoking area contributed to the occurrence and escalation of these incidents.
Failure to Honor Resident Rights
Penalty
Summary
A deficiency was identified regarding the failure to honor the resident's right to a dignified existence, self-determination, communication, and the exercise of their rights. The report notes that the facility did not ensure these resident rights were upheld, but does not provide specific details about the actions or inactions that led to this deficiency, nor does it mention any particular events or residents involved.
Failure to Update Fall Care Plan After Resident Falls
Penalty
Summary
The facility failed to update the fall care plan for a resident who had a history of falls and multiple medical conditions, including abnormal gait, generalized muscle weakness, dorsalgia, and a previous lumbar vertebra fracture. The resident experienced at least two falls during their stay, as documented in nursing progress notes. After one fall, the resident reported sliding from a chair due to a cushion, resulting in a bruise, and later complained of severe back pain, which led to an emergency room visit and diagnosis of a lumbar spine fracture. Despite these incidents, there was no documentation that the fall care plan was updated to reflect new interventions following the falls. Interviews with the DON and ADON confirmed that the care plan was not revised after each fall, and that standard interventions such as moving the resident closer to the nurse's station or providing non-skid socks were not documented as added to the care plan. The facility's policy requires the care plan to be updated within seven days of the comprehensive assessment and after significant changes, but this was not followed in the resident's case. The lack of timely updates to the care plan was acknowledged by facility leadership during the survey.
Failure to Meet Professional Standards in Fall Management and Response
Penalty
Summary
The facility failed to ensure that two residents received services that met professional standards of quality, as evidenced by documentation, staff interviews, and review of facility policies. One resident was admitted with multiple diagnoses including abnormal gait, muscle weakness, and a history of falls and fractures. After experiencing a fall, the resident complained of severe back pain and requested to be sent to the emergency room. Despite the complaint of severe pain following a fall and a history of lumbar fracture, the resident was sent to the hospital via non-emergent transportation, resulting in a significant delay. Staff interviews revealed that both the DON and ADON acknowledged that severe back pain after a fall should have prompted an emergent transfer, and the nurse involved stated that an emergency call would be appropriate if a resident had severe pain, indicating a possible fracture. The facility's policy required prompt assessment and following emergency personnel orders, which was not adhered to in this case. Another resident with diagnoses including cardiomyopathy, cerebral infarction, and hemiplegia was identified as a high fall risk upon admission and had a history of multiple falls with injuries. Despite physician orders for fall risk assessments every three months and after falls, there was no evidence of updated fall risk assessments following subsequent falls. Interviews with CNAs and LPNs revealed that direct care staff were not consistently informed of residents' fall risk status or specific preventative measures. New staff reported not receiving written or verbal information about which residents were at risk for falls, and there was no formal system in place to communicate this information. Observations confirmed that a resident's bed was kept in a high position, contrary to best practices for fall prevention, and staff were unaware of the resident's fall risk status. The DON stated that fall risk and preventative measures were supposed to be communicated verbally and through a CNA sheet, but both new and existing staff reported not receiving this information. The DON also admitted uncertainty about the existence of a formal fall management program. Facility policy required individualized interventions and regular fall risk assessments, but these were not consistently implemented or communicated to staff. The lack of updated assessments, failure to communicate fall risk status, and improper response to acute pain after a fall contributed to the facility's failure to meet professional standards of quality care for these residents.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report documents that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's responsibility to ensure resident safety and well-being. No specific details about the residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
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 the facility's lack of prompt action in notifying the appropriate agencies when an incident of suspected abuse, neglect, or theft occurred. The report indicates that the required notifications and investigation results were not communicated as mandated.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to prevent one resident from physically abusing another resident, resulting in physical harm. Resident #2, who was cognitively intact and had a history of behavioral issues including outbursts of anger and exposing himself, was involved in an altercation with Resident #4 on the facility patio. During this incident, Resident #2 knocked out Resident #4's tooth, while Resident #4 struck Resident #2 with a stick. The altercation was documented in progress notes, and both the police and Adult Protective Services were notified immediately after the event. Resident #4, also cognitively intact and with a history of behavioral problems such as making false accusations and interfering with facility protocols, lost newly cemented dental bridges as a result of the altercation. Interviews confirmed that Resident #4 had been involved in previous altercations at the facility. The facility's policies on abuse and resident rights, which prohibit physical abuse and guarantee freedom from abuse and neglect, were reviewed as part of the investigation. The administrator confirmed the loss of the tooth and noted that the resident refused treatment.
Failure to Prevent Resident-to-Resident Abuse Resulting in Physical Injuries
Penalty
Summary
The facility failed to protect multiple residents from resident-to-resident abuse, resulting in several altercations that led to physical injuries. In one incident, two cognitively intact residents with significant medical histories, including hemiplegia, diabetes, and dementia, engaged in a physical altercation in their shared room. The altercation escalated from verbal disputes over environmental factors, such as a smell in the room, to physical violence, including hitting and biting. Both residents sustained minor injuries, including a bite mark and contusions, and the police were notified. Staff and witness statements confirmed that the altercation was preceded by ongoing arguments and that staff were aware of escalating tensions but were unable to prevent the physical confrontation. In another event, a resident with severe cognitive impairment and a history of aggressive behavior struck another resident multiple times in the head and face in a common area. The aggressor had a documented pattern of combative and violent behavior towards both staff and peers, with multiple nursing notes describing ongoing agitation, attempts to strike staff, and threats of violence. Despite these documented behaviors and ongoing medication adjustments, the resident was able to physically assault another resident, resulting in a contusion and a small open wound. Multiple staff and resident witnesses observed the unprovoked attack, and the aggressor continued to display aggressive behavior throughout the day. The facility's documentation and witness statements indicate that staff were aware of behavioral issues and prior verbal disputes among residents but did not implement effective interventions to prevent physical altercations. The care plans for the involved residents included goals to prevent altercations and manage behaviors, but these measures were insufficient to ensure resident safety. The facility's failure to anticipate and address escalating behaviors directly resulted in residents sustaining injuries from peer-to-peer abuse.
Failure to Administer and Monitor Oxygen Therapy
Penalty
Summary
The facility failed to ensure that a resident was not neglected, as evidenced by the lack of proper oxygen administration and monitoring. The resident, who was admitted with acute respiratory disease, pneumonia due to coronavirus, wheezing, and spinal stenosis, had an order for oxygen therapy to be applied as needed for oxygen saturation below 90%. However, the care plan did not include a plan for oxygen therapy, and there was no documentation of oxygen saturation rates on a specific date when the resident experienced symptoms of distress. On the day of the incident, the resident complained of chest pain, shortness of breath, numbness, and anxiety, with an oxygen saturation of 87%. Despite the need for oxygen, the medication and treatment administration records did not show that oxygen was administered. Interviews revealed that the LPN responsible for the resident's care was unable to find an oxygen concentrator and did not inform the DON of this issue. The resident was eventually sent to the emergency room, where it was noted that oxygen was not provided until arrival at the hospital. Interviews with staff indicated that vital signs, including oxygen levels, should have been checked daily, especially given the resident's condition and medication orders. The DON acknowledged that there was no documentation of oxygen levels on multiple days and that the resident's oxygen level should have been monitored daily. The facility's policy on respiratory care and oxygen administration requires that residents receive necessary care and be transferred to the hospital if interventions do not work, highlighting a failure in following these procedures.
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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 266 citations issued within 25 miles in the last 12 months — including the 2 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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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.
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Phoenix
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| South Mountain Post Acute | 2.6 mi | ★★★★★ | 1 | 0 |
| Desert Peak Care Center | 3 mi | ★★★★★ | 9 | 0 |
| Haven Health Sky Harbor, Llc | 4.1 mi | ★★★★★ | 9 | 0 |
| Mirabella At Asu | 5.6 mi | ★★★★★ | 11 | 0 |
| Desert Terrace Healthcare Center | 5.7 mi | ★★★★★ | 7 | 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 June 2026) and official state health department websites.