Citations in Arizona
Statistics, citations and compliance trends for long-term care facilities in Arizona.
Statistics for Arizona (Last 12 Months)
Financial Impact (Last 12 Months)
Latest citations in Arizona
The facility failed to maintain sufficient nursing staff to meet resident needs and its own staffing plan. PBJ data showed repeated low weekend staffing, and review of staffing postings, assignment sheets, and punch-in records found frequent call-offs and staff leaving early, resulting in staffing levels that often did not match the facility assessment. Staff interviews described CNA/LNA shortages on every shift, especially weekends, and residents reported concerns that there were not enough CNAs to assist with meals and other needs. The DON acknowledged higher turnover and that staffing depended on census and acuity.
A facility failed to protect two residents from resident-to-resident physical abuse. In one incident, a resident with dementia and cognitive impairment was struck during a dispute over TV volume and responded by scratching the other resident. In another, a resident with dementia and physically aggressive behaviors scratched a roommate’s face, leaving superficial marks. Staff interviews and clinical records confirmed both altercations and the resulting injuries.
Failure to follow abuse policy after a resident-on-resident assault. A resident with dementia and physically aggressive behaviors scratched another resident’s face, causing superficial marks to the chin and cheek. The injured resident had significant cognitive impairment and later reported that the other resident ran fingernails across her face. Staff confirmed the incident was abuse, but the clinical record contained inconsistent documentation and the behavior note did not include details of the assault.
A resident with dysphagia, esophageal obstruction, AFib, and other cardiac diagnoses had apixaban ordered by mouth BID, but the MAR documented the drug as U-SA for 17 administrations even though the record had no self-administration assessment, order, or care plan. An LPN, RN MDS Coordinator, DOR, and DON all stated that self-administration required those elements and that they were not present in the chart; facility policy also required IDT and physician determination that self-administration was safe and appropriate.
A resident with dementia, schizoaffective disorder, and a history of verbal and physical aggression was involved in a care encounter with two CNAs when he struck one CNA and the other blocked him. During the interaction, the second CNA used insulting and profane language toward the resident, including calling him a “sissy” and “fucking pussy,” while staff later described the exchange as de-escalation and the facility concluded the abuse allegation was not verified.
Failure to Follow Behavioral Care Plan During Transfer and Personal Care: A resident with dementia and psychiatric diagnoses became verbally and physically aggressive during a sling transfer and personal care. The care plan called for paired care, calm and non-threatening approaches, reduced stimulation, simple choices, reassurance, and space when safe, but staff instead engaged in a back-and-forth interaction, used rough handling, and one CNA made a joking remark to the resident during the episode.
Insufficient Nursing Staffing and Weekend Coverage
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet residents’ needs and to maintain the staffing levels identified in its own facility assessment. Review of PBJ staffing data showed the facility repeatedly triggered for excessively low weekend staffing during three reporting quarters in 2025. The facility assessment stated the building was licensed for 106 residents, had an average daily census of 70 to 80 residents, and included 65 residents who required at least two-person assistance. The staffing plan called for a full-time DON, full-time ADON, full-time MDS RN, full-time wound care RN, five RN/LPNs on the 6:00 AM to 6:00 PM shift, two RN/LPNs on the 6:00 PM to 6:00 AM shift, six CNAs on days, and four CNAs on nights. Review of assignment sheets, Daily Staffing Postings, and punch-in records for selected dates from January through September 2025 showed that scheduled staffing often appeared adequate on paper, but actual staffing was affected by frequent call-offs and staff leaving before completing 12-hour shifts. Across multiple three-day periods, the census ranged from 68 to 84 residents, while the punch-in records reflected varying RN/LPN and CNA hours that did not consistently match the staffing structure in the facility assessment. The records showed repeated shortages involving RNs, LPNs, CNAs, LNAs, and CMAs, with some staff clocking out early and some shifts left uncovered when call-offs occurred. Interviews confirmed the staffing problems. An LNA stated there were CNA/LNA shortages on every shift, especially weekends, and that some days tasks could not be completed on time because of staffing shortages. The staffing schedule coordinator stated call-offs occurred mostly on weekends, staff had two hours to report call-offs, and if coverage could not be found he had to cover the shift himself. A resident council meeting reflected resident concern that there were not enough nursing staff, particularly on PM and nocturnal shifts, and that only two CNAs were available to assist residents eating in the dining hall even though several residents needed help. An RN also stated there were days when CNA shortages occurred on the floor and that numerous CNA call-offs had been observed in the preceding weeks. The DON stated staffing depended on census and acuity and acknowledged higher turnover during 2025 and 2026. The facility policy required sufficient staff with the skills and competencies necessary to provide care and services to all residents in accordance with care plans and the facility assessment.
Failure to Protect Residents from Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to ensure two sampled residents were free from physical abuse by other residents. One resident with dementia, anxiety, chronic pain, visual hallucinations, and moderate cognitive impairment was involved in an altercation with a roommate after a disagreement about TV volume. The incident escalated when the roommate attempted to take the TV remote and struck the resident with an open hand, and the resident responded by scratching the roommate. The record also documented a new scratch on the resident’s left hand and later noted that the resident no longer wanted to share a room with the other resident. The other incident involved a resident with dementia and significant cognitive impairment who had a behavior care plan for impaired safety awareness and physically aggressive behaviors. The record stated that the resident clawed a roommate in the face, leaving superficial scratches and red marks on the roommate’s chin and cheek. The roommate’s record reflected ongoing monitoring for scratches to the chin and neck, and the roommate stated that the other resident reached up and ran fingernails across her face while they were getting up for breakfast. Facility documentation and staff interviews confirmed both resident-to-resident incidents. Staff described the first event as a physical altercation triggered by conflict over TV volume, and the second as an incident in which one resident scratched another resident’s face. The DON stated the facility investigated and reported the incidents, and also acknowledged that the documentation surrounding the second event was inconsistent and did not meet expectations or policy. The cited deficiency was based on the facility’s failure to ensure the residents were protected from physical abuse by other residents.
Failure to Follow Abuse Policy After Resident-on-Resident Assault
Penalty
Summary
The facility failed to follow its abuse policy for one resident involved in an incident with another resident who had dementia, anxiety, impaired safety awareness, verbal behavior, and physically aggressive behaviors. The perpetrating resident was documented as having a BIMS score of 07 and a care plan that included interventions to protect the rights and safety of others, such as intervening as necessary, speaking calmly, diverting attention, and removing the resident from the situation when needed. On July 26, 2026, a CNA reported that the resident clawed a roommate in the face while the nurse was on break. The injured resident was assessed and found to have superficial scratches under the right side of the chin and red marks on the cheek, with no active bleeding. The perpetrating resident was also observed kicking another resident’s wheelchair in an apparent attempt to get that resident to move out of the way. A behavior note entered shortly afterward documented increased escalated behaviors and redirection, but it did not include details of the incident described in the struck-out progress note, and no additional details about the incident were found in the clinical record. The injured resident had significant cognitive impairment with a BIMS score of 08 and subsequent documentation showed ongoing monitoring for scratches to the chin and neck area, including skin assessments and change-of-condition notes. During interview, the injured resident stated another resident ran fingernails across her face and that she cried because she did not know why the other resident was being mean to her. Staff interviews confirmed the perpetrator was the other resident and described the event as abuse, while the DON stated the struck-out note and inconsistent documentation were unfortunate and did not meet expectations or policy.
Apixaban Documented as Self-Administered Without Required Assessment or Care Plan
Penalty
Summary
The facility failed to ensure that Resident #25 received apixaban in accordance with the physician’s order and professional standards of practice when the medication was documented as unsupervised self-administration without evidence of a required assessment, order, or care plan for self-administration. Resident #25 was readmitted with diagnoses including esophageal obstruction, dysphagia, pulmonary hypertension, chronic systolic heart failure, paroxysmal atrial fibrillation, atherosclerotic heart disease, and cardiac and vascular implants and grafts. The hospital’s post-acute orders and the facility physician’s order both included apixaban 2.5 mg by mouth twice daily, but the clinical record contained no evidence that the resident had been evaluated to determine whether she could safely self-administer medications. The June 2026 MAR documented apixaban as U-SA, meaning unsupervised self-administration, for 17 administrations from June 14 through June 22, 2026. The record also contained no care plan addressing medication self-administration. A Medicare 5-Day MDS showed a BIMS score of 14, and also listed active diagnoses of dysphagia, esophageal obstruction, and cognitive communication deficit. On June 23, 2026, the apixaban order was revised to change the administration status from unsupervised self-administration to clinician administration. During interviews, an LPN, the RN MDS Coordinator, the DOR, and the DON each stated that self-administration required an order, assessment, and care plan, and that they did not find those elements in Resident #25’s record. The DON stated that the resident was not evaluated to self-administer medications, there was no order for self-administration, and it was not in the care plan. The facility policies reviewed stated that residents could self-administer medications only if the interdisciplinary team and attending physician determined it was clinically appropriate and safe, and that medications were to be administered as prescribed.
Verbal Abuse During Resident Care Encounter
Penalty
Summary
The facility failed to protect a resident from verbal abuse by staff during a care encounter involving two CNAs. The resident had diagnoses including hemiplegia, chronic kidney disease, schizoaffective disorder, type 2 diabetes mellitus, major depressive disorder, and dementia. The care plan described the resident as being in a secured unit for dementia with behavioral disturbance, with verbal and physical aggression toward staff, refusal of care from people of different ethnicities, fluctuating mood, impulsivity, and emotional dysregulation. The resident’s care plan also directed staff to provide care in pairs, approach calmly and consistently, minimize stimulation, allow time for processing, and use clear, concise communication. During the incident, one CNA was assisting with placing a sling under the resident when the resident punched that CNA in the stomach. The other CNA blocked the resident’s fist and then held the resident’s hand while the resident squeezed it. Staff interviews and the facility’s investigation documented that the second CNA made comments including “stop being a sissy,” and another interview from the first CNA reported the second CNA said, “fucking pussy, how dare you put hand on a woman, I should put my hands on you.” The first CNA also reported that the second CNA repeated the resident’s statement back to him and that the interaction continued while the resident was being cared for and later wheeled back to his room. The facility’s investigation concluded that the allegation of abuse was not verified, despite staff statements acknowledging the use of derogatory language. The second CNA stated he was trying to protect the other CNA from being hit and said he did not feel he did anything wrong, while also acknowledging that his comments could have been seen as verbal abuse and that he could have used better judgment and professionalism. The DON, ADON, administrator, behavioral health consultant, and other staff interviewed described the resident as combative at baseline and discussed de-escalation and care in pairs, but the report documents that the resident was verbally addressed with insulting language during the encounter.
Failure to Follow Behavioral Care Plan During Transfer and Personal Care
Penalty
Summary
The facility failed to follow a resident’s care plan during a behavioral episode involving care provided by two CNAs. The resident was admitted with hemiplegia, chronic kidney disease, schizoaffective disorder, type 2 diabetes mellitus, major depressive disorder, and dementia. The resident’s care plan, revised in November 2025, identified behavior problems including verbal and physical aggression with staff and refusal of care from people of different ethnicities, and it also identified risk for altered mood state and impaired psychosocial well-being related to psychiatric diagnoses, impulsivity, emotional dysregulation, and overstimulation during personal care. The care plan interventions directed staff to provide cares in pairs, approach the resident in a calm, consistent, and non-threatening manner, minimize environmental stimulation during care, allow adequate time for processing, offer simple choices, use clear and concise communication, provide positive redirection and reassurance, support a sense of safety and well-being, and allow personal space if safe. The resident’s MDS showed a BIMS score of 10, indicating moderate cognitive impairment, and also documented physical and verbal behavioral symptoms and rejection of care. During the incident, the resident became verbally and physically aggressive while staff were assisting with a sling transfer and changing care. One CNA reported that the resident punched her in the stomach, and the other CNA blocked the punch. Staff interviews and the facility’s investigation summary documented that the resident grabbed the CNA’s hand, that the CNA held the resident’s hand tightly, and that the CNA jokingly told the resident to stop being a sissy. The resident later attempted to strike the CNA again while being wheeled back to his room. Interviews with nursing leadership and the behavioral health consultant confirmed that the resident’s plan of care called for de-escalation, space, and re-approaching when calm, and the DON stated that the plan should be followed to assure care was provided appropriately.
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Compliance trends in Arizona
Data through Jul 2026Comparisons below measure the most recent period Aug 2025 – Jul 2026 against the prior period Aug 2024 – Jul 2025 (two equal 12-month windows). The most recent 1 months are excluded because CMS is still publishing them.
Top tags by month · last 24 months
dashed = still reportingMonthly citation counts for the 5 most-cited tags. The dashed tail is the 1-month reporting lag.
Frequency movers
Biggest change in how often each tag is cited, as a rate per 100 inspections (so it isn't skewed by survey volume): Aug 2025 – Jul 2026 vs the prior period Aug 2024 – Jul 2025. Only tags with at least 20 citations in both periods are shown.
Severity movers
Tags whose average scope/severity shifted the most: Aug 2025 – Jul 2026 vs the prior period Aug 2024 – Jul 2025. The number is the average severity on the A–L scale (A=0…L=11); the letter is the band it falls in. A rise means the same tag is being cited at a more serious level — note the average can move enough to rank here while staying within the same letter. Same 20-citation minimum applies.
Care domain movers
Citations grouped into CFR care domains — F-tags by their §483 regulatory section (CMS State Operations Manual, Appendix PP) — measured as a rate per 100 inspections: Aug 2025 – Jul 2026 vs the prior period Aug 2024 – Jul 2025. Share is the domain's portion of citations this period; avg severity is the mean scope/severity letter and immediate jeopardy the percentage cited at J–L, both over the current period. Domains with at least 20 citations in both periods are shown; the sparkline tracks the last 12 months (left = oldest).
Immediate jeopardies · this period
Citations at the most serious scope/severity — J–L, immediate jeopardy, residents placed at risk of serious harm or death — over Aug 2025 – Jul 2026 vs the prior period Aug 2024 – Jul 2025. "Surveys with an IJ" counts distinct health inspections that had at least one.
Survey activity · by month
faded/dashed = still reportingCitations each month split into complaint-driven (unscheduled, triggered by grievances) vs standard surveys — bars, left axis — with the number of inspections as a line on the right axis. Rising inspections signal more scrutiny; a rising complaint share means more off-cycle surveys. The most recent 1 months are still being reported.
Deficiency-free survey rate
Share of health surveys that found zero deficiencies — the odds of a clean survey. Aug 2025 – Jul 2026 vs the prior period Aug 2024 – Jul 2025; the most recent 1 months are still being reported (dashed).
Penalties · by month
faded = still reportingTotal civil money penalty dollars imposed on the state's facilities each month — how hard the state is enforcing. The most recent 1 months are still being reported, and penalties often lag citations by several months.
Emerging tags
Tags that weren't established last period but surged — an early warning, distinct from movers (which track already-common tags). Criteria: fewer than 20 citations in the prior period, but at least 10 this period and 2.5× their prior volume. The sparkline shows monthly counts over the last 12 months (left = oldest).
Trusted data from CMS and state health departments
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