Citations in Arizona
Comprehensive analysis of citations, statistics, 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
Multiple residents with cognitive and behavioral impairments were involved in physical altercations, including biting, hitting, and striking, resulting in injuries such as a hand bite, head injury, and lip laceration. Staff and facility documentation confirmed that these incidents were witnessed, reported, and investigated, but the facility did not prevent the abuse despite existing policies and staff awareness.
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.
A deficiency was cited when a resident's care plan did not address all assessed needs and failed to include measurable timetables and specific actions, as observed in the care planning documentation.
The facility did not have effective policies and procedures in place to prevent abuse, neglect, and theft. Surveyors found that staff were not consistently trained or monitored, and there was a lack of regular review or updating of procedures to protect residents.
The facility failed to protect residents from various forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, by any individual.
Two residents with cognitive and behavioral impairments were involved in an altercation where one threatened to harm the other, requiring CNA intervention. Although the incident was documented by an LPN and later verified, it was not reported to state agencies or investigated immediately as required by facility policy. Staff interviews confirmed the delay in reporting and lack of prompt action.
A resident with diabetes and vascular disease did not receive consistent monitoring and documentation of negative pressure wound therapy (NPWT) as ordered. When the wound vac was removed due to a broken seal and peri-wound maceration, required wound care and dressing changes were not completed or documented for several days. Staff interviews confirmed lapses in monitoring and documentation, contrary to physician orders and facility policy.
A deficiency was cited when a facility area was found to contain accident hazards and lacked adequate supervision to prevent accidents, compromising resident safety.
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.
Nurses and nurse aides lacked the appropriate competencies to provide care that maximizes each resident's well-being, resulting in care that did not fully support residents' highest practicable physical, mental, and psychosocial well-being.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect multiple residents from abuse by other residents, as evidenced by several documented incidents of physical altercations. In one case, a resident with severe cognitive impairment and a history of wandering and aggression was bitten on the hand by another resident known to be territorial and prone to agitation when her personal space was invaded. Staff witnessed the incident and intervened to separate the residents, but not before an injury occurred. Both residents had documented behavioral issues and cognitive impairments, and the incident was reported and investigated by the facility. Another incident involved a resident with severe cognitive impairment and a history of physical aggression who was punched in the head by another resident with moderate cognitive impairment and behavioral symptoms. Staff observed the aftermath, noting a visible injury, and interviews revealed ongoing tension between the two residents, with one being protective of his belongings and the other prone to wandering into others' rooms. Staff confirmed witnessing the altercation and described the residents' history of conflict. Additional altercations were documented, including one where a resident was struck in the face during a wheelchair entanglement, resulting in a lip laceration, and another where two residents became verbally and physically aggressive in the dining room, leading to mutual physical contact. Staff interviews confirmed that such incidents were considered abuse and should be reported, and facility policy affirmed residents' rights to be free from abuse. Despite these policies and staff awareness, the facility did not prevent these resident-to-resident altercations, resulting in physical and emotional harm.
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 notes 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.
Incomplete Care Plan Lacking Measurable Actions
Penalty
Summary
A deficiency was identified due to the failure to develop and implement a complete care plan that addresses all of a resident's needs. The care plan lacked measurable timetables and specific actions, resulting in incomplete documentation and planning for the resident's care requirements. This omission was observed during the review of resident records and care planning documentation, where it was found that the care plan did not comprehensively cover the resident's assessed needs or include clear, measurable objectives and interventions.
Failure to Implement Policies Preventing Abuse, Neglect, and Theft
Penalty
Summary
The facility failed to develop and implement effective policies and procedures to prevent abuse, neglect, and theft. This deficiency was identified through surveyor observations and review of facility documentation, which revealed that the required safeguards and protocols were either not in place or not consistently followed. The lack of comprehensive and enforced policies contributed to an environment where incidents of abuse, neglect, or theft could occur without adequate prevention or timely detection. Surveyors noted that staff were not consistently trained or monitored regarding the prevention of these incidents, and there was insufficient evidence of regular review or updating of the facility's procedures related to resident protection.
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 notes 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 Resident-to-Resident Abuse Allegation
Penalty
Summary
The facility failed to ensure that all allegations of abuse were reported to the state agency and other mandated entities within the required timeframe for two residents. On August 21, 2025, two residents with significant cognitive and behavioral diagnoses were involved in a resident-to-resident altercation in their shared room. One resident threatened to physically harm the other, and a CNA intervened to prevent escalation. Documentation by an LPN confirmed the incident, and the facility's own investigation later verified the allegation. Despite the altercation and the facility's policy requiring immediate reporting and investigation of suspected abuse, there was no evidence that the incident was reported to the appropriate state agencies or that an investigation was initiated immediately after the event. Interviews with staff revealed that the incident was only brought to the attention of facility leadership the following day through a 24-hour report, and staff acknowledged the importance of timely reporting. The clinical records and interviews confirmed the lack of immediate action in accordance with facility policy and federal guidelines.
Failure to Monitor and Document Wound Vac Therapy
Penalty
Summary
The facility failed to ensure appropriate monitoring and documentation of negative pressure wound therapy (NPWT) for a resident with a history of Parkinson's disease, type 2 diabetes mellitus, and peripheral vascular disease, who was at risk for pressure ulcers and had existing wounds on the left lateral foot and ankle. Physician orders required wound vac monitoring every shift for functioning and placement, with specific instructions to follow if the wound vac malfunctioned or was off for more than two hours, including cleansing the wound and changing the dressing every 12 hours until the wound vac was replaced. However, review of clinical records revealed that wound vac monitoring was not documented as completed for the overnight shift on one occasion, and when the wound vac was removed due to a broken seal and peri-wound maceration, the required wound cleansing and dressing changes were not completed on multiple subsequent days. The resident reported discomfort and worsening of the wound after the wound vac was applied, and interviews with staff confirmed that the wound vac was removed due to a leak in the seal. The Director of Nursing stated that it was expected for nurses to monitor the wound vac every shift and notify the physician of any issues, but acknowledged that monitoring was not documented as completed. Facility policy required that all wound treatments be administered and documented as per physician orders. The failure to monitor and document wound vac therapy and to perform required wound care when the vac was off constituted the deficiency.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
A deficiency was identified due to the failure to ensure that a specific area within the facility was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment did not meet safety standards, which resulted in the presence of accident hazards and insufficient oversight to protect residents from potential harm. No additional details regarding the specific hazards, the number of residents affected, or their medical conditions 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.
Lack of Staff Competency in Resident Care
Penalty
Summary
Nurses and nurse aides did not demonstrate the necessary competencies to provide care that maximizes each resident's well-being. The deficiency was identified due to a lack of evidence that staff possessed or applied the required skills and knowledge to meet the individualized needs of all residents. This failure resulted in care that did not fully support the highest practicable physical, mental, and psychosocial well-being of residents, as required.
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