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
Failure to Protect Residents from Resident-to-Resident Abuse: Multiple residents with cognitive impairment, dementia, schizophrenia, bipolar disorder, PTSD, and other behavioral diagnoses were involved in physical and verbal altercations. One resident with aphasia and dementia was punched in the jaw by another resident after a confrontation on the patio, and another resident was punched in the arm during a dining room incident that also involved a third resident pushing the aggressor away. A separate event involved a resident with severe cognitive impairment standing over a roommate in bed and hitting him, resulting in a bruise and skin tear. Staff described limited observation in the dining area and the facility’s investigations were documented as inconclusive.
Resident verbally abused by staff member: A cognitively intact resident with multiple chronic conditions reported that an LPN bullied, yelled, and cursed at him and threw him to the floor, leaving him scared. Multiple CNAs and residents described hearing the LPN use disrespectful language, including racial slurs, and seeing the resident pushed back into his room and later found on the floor crying. The DON stated APS later notified the facility of an allegation of physical and verbal abuse by the same LPN.
Failure to Report and Investigate Abuse Allegations: The DON, ADON, and Administrator did not treat a resident’s reported fight with a CNA and a separate resident-to-resident assault as reportable abuse events. Records showed conflicting resident statements, visible injuries, and staff accounts describing physical aggression, yet the incidents were not promptly reported to State agencies under the facility’s abuse policy. The Administrator stated the events were not considered abuse because of the residents’ statements and lack of willful intent.
Failure to Timely Report Suspected Abuse Allegations: The facility did not timely report suspected abuse involving a resident and CNA, and did not report a resident-to-resident altercation until the state agency brought it to its attention. Records showed one resident with mood disorder, SI, anxiety, and depression reported a physical fight with a CNA and had scratches, while two other residents were involved in an incident where one resident was found over the other and the injured resident had a bruise and skin tear. Staff and the DON discussed the events internally, but the administrator determined one allegation was not reportable and the other was not abuse, despite policy requiring immediate reporting of suspected abuse.
A resident with moderate cognitive impairment and multiple chronic conditions was involved in a transfer when staff observed her stiffening and slipping from her wheelchair. During the assist, an LPN was reported to have hit, smacked, or jabbed the resident’s leg while telling her to relax and bend her knees. The resident later said the nurse hit her leg, a roommate heard yelling, and written statements described the resident as crying and reporting that she had been struck during care.
Abuse Allegation Not Thoroughly Investigated: A resident with moderate cognitive impairment and multiple medical conditions was involved in a transfer incident in which staff described her legs as rigid and locked. Witnesses and the resident reported that an LPN hit or smacked the resident’s leg while telling her to relax and bend her knees, and the resident became tearful and said she had been hit. The facility’s abuse investigation was inconsistent and incomplete, with omitted written witness statements and a conclusion that the allegation was unsubstantiated despite accounts describing physical contact.
Failure to Protect Residents from Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect residents from physical and verbal abuse during multiple resident-to-resident incidents involving residents with significant behavioral and cognitive impairments. The report identified seven sampled residents involved in altercations, including residents who were both victims and aggressors. The facility’s abuse prevention policy stated that residents have the right to be free from abuse, including verbal and physical abuse by other residents. One incident involved two residents on the patio smoking area, where one resident with expressive aphasia, vascular dementia, and behavioral disturbances was struck in the mouth by another resident with schizophrenia, bipolar disorder, and a history of aggression. The assaulted resident was documented as having jaw pain rated 6 out of 10 and received Tylenol. The other resident admitted punching him and stated he did so because he felt threatened after the first resident was yelling and pointing a finger at him. The facility’s follow-up investigation concluded the allegation was inconclusive because it did not obtain a complete history from the individuals involved and witnesses could not corroborate the event. Another incident involved two residents in the dining room, one with bipolar disorder and PTSD and another with schizoaffective disorder, along with a third resident with dementia and behavioral disturbances who intervened. The resident with schizoaffective disorder punched the resident with bipolar disorder in the arm after a verbal exchange, and the third resident pushed him away. Staff later stated that the dining room area lacked direct observation before the altercation and that staffing was adjusted afterward so one staff member could watch the residents while others prepared meals. A separate incident involved a resident with severe cognitive impairment and behavioral problems who was found standing over a roommate and hitting him while the roommate was in bed; the roommate reported being hit, fighting back, and later having a bruise and skin tear on his left hand. Staff and leadership described the event as resident-to-resident contact, but the facility still concluded the allegation was inconclusive, and the administrator stated he did not feel it was abuse because there was no willful intent.
Resident verbally abused by staff member
Penalty
Summary
The facility failed to protect a resident from verbal abuse by a staff member. Resident #2 was admitted with diagnoses including hemiplegia and hemiparesis following cerebral infarction, anxiety disorder, depression, type 2 diabetes mellitus, chronic kidney disease, and epilepsy. A quarterly MDS showed a BIMS score of 14, indicating intact cognition, and the resident’s care plan addressed verbal behaviors related to ineffective coping skills. A psychiatric note documented a history of impulsivity, yelling, and aggression, but stated there had not been increased behavioral disturbance since the prior visit. On June 28, 2026, Resident #2 was documented as refusing personal care and assistance before breakfast, yelling while staff passed trays, coming out of the room with no pants on, cursing at staff, threatening to hit staff, and making false accusations. The record also included a change in condition note stating there were no verbal aggression behaviors that shift and that the resident was compliant with medications and care. A later physician order and change in condition note referenced monitoring for mood behavior pattern and fear of other patients and staff, and the note stated the resident was not observed to be afraid of other patients and staff. The clinical record did not show evidence of a fall or that the resident intentionally placed himself on the floor. Multiple interviews described conflicting accounts of what occurred between Resident #2 and Staff #66. Resident #2 stated that the nurse bullied him, yelled and cursed at him, got him alone in his room, and threw him onto the floor, leaving him scared. Another resident stated Staff #66 had cursed at him before and witnessed Staff #66 verbally assault Resident #2 and drag him to his room by his wheelchair. A CNA stated she heard Staff #66 yell and curse at Resident #2, use racial slurs, and push him aggressively in his wheelchair back into his room, then later found him sitting on the floor crying. Another CNA stated she heard Resident #2 scream for Staff #66 to get her hands off of him and later saw him sitting on the floor in his room. Other residents reported hearing disrespectful or rude comments from Staff #66 toward Resident #2. The DON stated that staff are expected to report allegations of abuse immediately, and that on June 29, 2026, APS informed the facility of an allegation of physical and verbal abuse by Staff #66 toward Resident #2.
Failure to Report and Investigate Abuse Allegations
Penalty
Summary
The facility failed to implement its abuse policy for allegations involving resident-to-staff and resident-to-resident abuse. The report states that the facility did not notify the appropriate State Agencies and did not thoroughly investigate allegations involving three residents. The deficiency was based on clinical record review, facility documentation, staff interviews, and policy review. For one resident, who had diagnoses including unspecified mood disorder, suicidal ideations, anxiety disorder, and depression, a nurse documented that the resident reported being in a physical altercation with a CNA and had visible scratches to the arms. The DON and NP were notified, and later documentation reflected conflicting accounts from the resident, including statements that the scratches were self-inflicted and that the resident had slapped and choked the CNA. The resident’s record showed a BIMS of 14 and behaviors including delusions, physical and verbal behavior, and rejection of care. Staff interviews reflected that the resident was known for making false accusations, and the Administrator stated the allegation was not considered reportable because the resident said she was the aggressor. The report also noted that the CNA involved continued to work shifts after the initial allegation and was not placed on administrative leave until several days later. For two other residents, one resident was found standing over the other while the other resident stated that the roommate had walked up and started hitting him. The record documented that the residents were separated, one resident was placed on 1:1, and the injured resident had a bruise and later a skin tear and discoloration on the left hand. The resident who was alleged to have caused the injury had diagnoses including anoxic brain damage, hydrocephalus, PTSD, major depressive disorder, unspecified dementia, and unspecified mood disorder, with a BIMS of 1 and documented physical behaviors and aggression. Staff interviews described the incident as resident-to-resident abuse, with one CNA stating the resident was over the other resident in bed and another stating the residents were fighting when staff arrived. However, the Administrator stated the event was not considered abuse because there was no willful intent and therefore was not reported. The facility policy required suspected abuse to be reported immediately to the administrator and other officials according to state law, with immediate defined as within 2 hours for allegations involving serious bodily injury or within 24 hours for allegations not involving serious bodily injury.
Failure to Timely Report Suspected Abuse Allegations
Penalty
Summary
The facility failed to report suspected abuse allegations to the applicable state agencies within the required timeframe for three residents. The report states that an allegation involving a resident and CNA #12 was not reported because the administrator determined it was not reportable after the resident said she was the aggressor. The facility policy required suspected abuse to be reported immediately, with “immediately” defined as within 2 hours for allegations involving abuse resulting in serious bodily injury or within 24 hours for allegations that do not involve serious bodily injury. For one resident, the clinical record documented that she reported being in a physical altercation with CNA #12 and had visible scratches to her arms. The DON and NP were notified, and later documentation included the resident stating she slapped and choked the CNA. The resident had diagnoses including mood disorder, suicidal ideation, anxiety disorder, and depression, and the MDS showed a BIMS of 14, indicating cognitive intactness. Staff interviews reflected that the allegation was discussed internally, but the administrator stated it was not considered reportable because the resident said she was the aggressor. For two other residents, staff documentation showed a resident-to-resident altercation in which one resident was found standing over the other and the injured resident stated the other resident walked up and began hitting him. The injured resident had a bruise and skin tear to the left hand, and the other resident had diagnoses including anoxic brain damage, hydrocephalus, PTSD, major depressive disorder, unspecified dementia, and unspecified mood disorder, with a BIMS of 1 and documented physical aggression. Staff interviews confirmed that the residents had to be separated and that the incident was discussed with leadership, but the facility did not report the allegation until the state agency brought it to their attention. The facility later concluded the allegation was inconclusive even though it acknowledged witnessed contact occurred when one resident was attempting to climb into the other resident’s bed.
Failure to Protect Resident from Staff Physical Abuse
Penalty
Summary
The facility failed to protect a resident with moderate cognitive impairment and multiple medical conditions, including palliative care needs, muscle spasms, diabetes, hypertension, urinary incontinence, a sacral pressure ulcer, polyneuropathy, and generalized anxiety disorder, from staff-to-resident physical abuse. The resident had been admitted with significant medical diagnoses and was documented as having a BIMS score of 11. During an evening transfer from a wheelchair, staff observed the resident slipping from the chair with both knees locked and her body rigid while staff attempted to reposition her safely. According to the resident’s progress note and the facility’s investigation materials, a CNA and an LPN were assisting the resident when the resident remained stiff and could not bend her legs. The CNA reported that the LPN tapped or smacked the resident’s leg in an attempt to get her to bend her knees. Other statements in the investigation described the LPN as yelling at the resident to relax her legs and hitting or punching her legs until they relaxed. The resident later told staff that the nurse had hit her leg and that she could not help the stiffness. A roommate also reported hearing a nurse yelling at the resident. The facility’s investigation included interviews with staff and the resident’s family, and the written statements collected by the facility contained conflicting descriptions of the event, including that the nurse struck, smacked, jabbed, or touched the resident’s leg during the transfer. The resident was later found to have bruising on both knees and red spots on her arms, with notes indicating she believed she had bumped into things. The facility ultimately documented the allegation as unsubstantiated, despite the resident’s report, the witness account, and the additional statements describing the nurse striking the resident during care.
Abuse Allegation Not Thoroughly Investigated
Penalty
Summary
The facility failed to implement its abuse policy after an incident involving a staff member and Resident #96. Resident #96 was admitted with multiple diagnoses including palliative care, muscle spasms, atherosclerotic heart disease, cervical cancer, type 2 diabetes, hypertension, urinary incontinence, a sacral pressure ulcer, polyneuropathy, and generalized anxiety disorder. A Medicare 5-Day MDS showed a BIMS score of 11, indicating moderate cognitive impairment. During the incident, the resident was found slipping from her wheelchair with both knees locked and her body rigid while staff attempted to reposition her. The resident was repeatedly instructed to relax and bend her knees, and she was later assisted to bed for safety. The clinical record and investigation documents showed conflicting accounts of what occurred during the transfer. One staff witness reported that the LPN tapped or smacked the resident’s leg to get her to bend her knees, while the resident later told staff that the nurse hit her leg until it relaxed. Another staff member documented that the resident said the nurse was yelling and hitting her legs, and the resident became tearful and stated that the incident made her feel like no one cared about her and that she was not wanted at the facility. The resident’s family members also reported that they were told the nurse had hit or jabbed the resident’s leg during the transfer. The facility’s investigation was incomplete and inconsistent with its own policy. The investigation was initially determined to be unsubstantiated, with the conclusion that no policies were broken, despite witness statements and resident interviews describing physical contact to the resident’s leg during the transfer. The investigation also omitted written witness statements that were later requested and obtained, including statements from staff who reported that the resident said she had been hit and that the nurse had struck or smacked her leg. The facility policy required all allegations of abuse to be thoroughly investigated, including interviews with staff who had contact with the resident, witnesses, the reporting person, and the resident or representative, and required written, signed, and dated witness statements.
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Compliance trends in Arizona
Data through May 2026Comparisons below measure the most recent period Jun 2025 – May 2026 against the prior period Jun 2024 – May 2025 (two equal 12-month windows). The most recent 2 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 2-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): Jun 2025 – May 2026 vs the prior period Jun 2024 – May 2025. Only tags with at least 20 citations in both periods are shown.
Severity movers
Tags whose average scope/severity shifted the most: Jun 2025 – May 2026 vs the prior period Jun 2024 – May 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: Jun 2025 – May 2026 vs the prior period Jun 2024 – May 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 Jun 2025 – May 2026 vs the prior period Jun 2024 – May 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 2 months are still being reported.
Deficiency-free survey rate
Share of health surveys that found zero deficiencies — the odds of a clean survey. Jun 2025 – May 2026 vs the prior period Jun 2024 – May 2025; the most recent 2 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 2 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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