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 Report and Document Alleged Neglect: A Nursing Student reported that a CNA did not provide cares to residents, including residents being left soaking wet and unchanged. The concern was relayed to facility leadership, but the allegation was not reported to the SA within the required timeframe and the investigation was not documented, despite the facility’s abuse/neglect policy requiring prompt reporting and a written investigation record.
Failure to timely report an allegation of neglect: a Nursing Student reported that a CNA had not provided cares and residents were left wet and unchanged, and the RN relayed the complaint to facility leadership. The DON and SSD acknowledged the complaint was shared internally, but the former Administrator denied receiving it and did not report it to the SA within the required 24-hour timeframe. The facility’s policy required prompt reporting of suspected neglect and a follow-up investigation report within 5 working days.
Failure to investigate and document an allegation of neglect: an RN received a Nursing Student’s report that a CNA was not providing cares and residents were left soaking wet and unchanged, and the complaint/grievance form was texted to the former ADM, DON, and SSD. The facility did not make its initial report to the SA until weeks later, the original grievance form could not be located, and no written investigation record was produced even though policy required prompt interviews of residents and staff and a written record.
A resident with brain metastasis and other serious diagnoses was ordered dexamethasone 2 mg PO BID, but the resident missed scheduled doses when the medication was documented as not available and then pending delivery. The MAR and e-MAR showed the missed doses, but there was no evidence the provider was notified or that a refill was placed at the time. The family member said the steroid was important for brain swelling, and the RN and DON stated missed doses should be communicated to the provider and documented.
Daily staff postings were not accurately updated to show the actual number of RN, LPN, and CNA staff who worked each shift or the actual hours worked. Review of multiple postings showed only scheduled hours, while the actual hours from punch details were left blank. The staffing coordinator, receptionist, DON, and executive director each stated they were not responsible for or were unaware of the need to update the postings with actual staffing information.
Medication Administration Outside Ordered Pain Parameters: The facility failed to administer pain medications according to provider orders for two residents. One resident received Oxycodone and Acetaminophen outside the ordered pain-scale parameters, and another resident received Dilaudid for pain ratings below the prescribed threshold. Nursing staff stated that giving medications outside ordered parameters is a medication error, and the record contained no documentation or provider authorization for the out-of-parameter doses.
Failure to Report and Document Alleged Neglect
Penalty
Summary
The facility failed to implement its Abuse, Neglect, & Exploitation Policy after an allegation of neglect was made by a Nursing Student and relayed to RN/Staff #2. The allegation stated that a CNA did not provide cares to residents on the unit, including residents being left soaking wet and not changed. Staff #2 reported the concern to the former Administrator, and a complaint/grievance form was completed and texted to facility leadership, but the original form later could not be located in the abuse binder. The facility did not report the allegation of neglect to the State Agency within the required timeframe. The report indicates the initial allegation was made on March 27, 2026, but the facility’s first report to the SA was not made until April 17, 2026, approximately 21 days later. Staff #41 stated allegations of neglect are to be reported to the SA within 24 hours, and Staff #44 confirmed the allegation was not reported until after corporate office became involved. The investigation of the alleged neglect was also not documented. Staff #9 reportedly told Staff #44 that he had investigated by speaking with residents and staff and concluded the neglect had not occurred, but no written documentation of that investigation was produced. Staff #44 stated the standard process requires the investigation to be documented. The facility policy required the administrator or supervisor to protect residents from continued neglect, investigate the incident as soon as practicable, maintain a written record of the investigation, and report the allegation externally to the SA.
Failure to Timely Report Allegation of Neglect
Penalty
Summary
The facility failed to ensure an allegation of neglect was reported to the State Agency within the required timeframe. A Nursing Student reported to an RN that several nursing students were upset because a CNA had not changed residents on her unit and that residents were soaking wet and remained unchanged. The RN notified the former Administrator, took a picture of the completed complaint/grievance form, and texted it to him after the initial report was made to her. The RN stated she later received a call from the former Administrator that same night and relayed what had been reported by the Nursing Student. The Social Services Director and the DON both acknowledged that the complaint/grievance form was sent by text message to facility leadership in March 2026 and that the allegation involved residents not being provided cares. The DON stated she did not follow up after returning to the facility, and the Social Services Director stated she was not assigned to investigate because the former Administrator said he would handle it. The former Administrator denied receiving the texted complaint/grievance form and denied being notified of the allegation in March 2026, although he acknowledged that if the statement on the form was read aloud, it sounded like an allegation of neglect and would need to be reported to the SA. The facility’s policy required allegations of suspected neglect to be reported to the SA within 24 hours and the follow-up investigation report within 5 working days, but the initial report to the SA was not made until approximately 21 days after the allegation was first made.
Failure to Investigate and Document Allegation of Neglect
Penalty
Summary
The facility failed to ensure an allegation of neglect was thoroughly investigated and documented after a Nursing Student reported that a CNA had not provided cares to residents on her unit. The allegation was first made to an RN, who described neglect as delayed care, staff isolation of residents, not giving medications, or not implementing interventions. The RN stated she notified the former Administrator, instructed the Nursing Student to complete a complaint/grievance form, took a picture of it, and texted it to the former Administrator. The RN also stated she later spoke with him by phone and relayed what had been reported, but she did not receive any status updates on the outcome of the investigation. The facility’s records showed the allegation was initially made on March 27, 2026, but the facility did not make its initial report of neglect to the State Agency until April 17, 2026, about 21 days later, and then initiated an investigation. Review of the State Agency complaint portal found no other self-report or 5-day investigation report for the alleged timeframe. The SSD stated that suspected neglect is reported to her as the abuse coordinator, that the grievance form was completed and sent by text to her, the DON, and the former Administrator, but she was unable to locate the specific form in the binder and said she was not assigned to investigate because the former Administrator said he would conduct the investigation. The DON acknowledged receiving the texted grievance form stating that residents were soaking wet all day and remained unchanged. She recalled speaking with the former Administrator and said he assumed responsibility for follow-up, but when asked to produce the original complaint/grievance form, it was missing. The former Administrator denied being notified of the allegation and denied receiving the texted form, though he acknowledged he was the abuse coordinator and expected to be available while traveling. A senior corporate clinical leader stated the former Administrator said he investigated by speaking with residents and staff, but no documentation of that investigation was provided. The facility policy required suspected neglect to be investigated as soon as practicable by interviewing residents and staff and maintaining a written record of the investigation.
Missed Dexamethasone Doses Not Administered or Reported
Penalty
Summary
The facility failed to ensure that a resident with secondary malignant neoplasm of the brain, malignant melanoma of the skin, cognitive, social, or emotional deficit following nontraumatic intracerebral hemorrhage, visual disturbance, headache, COPD, and a personal history of venous thrombosis and embolism received dexamethasone according to physician orders. The resident had been started on dexamethasone for brain metastasis, and the physician ordered dexamethasone 2 mg by mouth twice daily, with doses scheduled for 8:00 a.m. and 10:00 p.m. The April 2026 MAR showed the resident received the morning dose on April 5, but did not receive the evening dose on April 5 or the morning dose on April 6. The e-MAR documented that the April 5 dose was not given because the medication was not available, and the April 6 dose was not given because it was pending delivery. There was no evidence that the physician was notified of either missed dose, and there was no evidence that a pharmacy refill order was placed when the medication was reported unavailable. The resident’s family member stated the resident had missed the steroid because the facility ran out of it, and that the medication was important because it controlled swelling in the brain due to the brain tumor. The RN stated that when a dose is missed because a medication is out of stock, the nurse should notify the provider and document the provider’s recommendation. The contracted pharmacy technician stated the pharmacy stocked dexamethasone 2 mg tablets and found no evidence that the medication was out of stock during April 2026. The DON stated the medication should have been available to administer and confirmed there was no evidence the provider was notified for either missed dose.
Daily Staff Postings Not Updated With Actual Staffing Hours
Penalty
Summary
The facility failed to ensure that daily staff postings were posted accurately to reflect the actual number of licensed and unlicensed staff who worked each shift and the actual hours worked by RN, LPN, and CNA staff. Review of 17 randomly selected daily staff postings and corresponding punch details showed that the postings did not include updated actual staffing information for any of the days reviewed. The census during the review period was 43 residents. For the daily staff posting dated October 26, 2024, the posting showed a census of 44 residents and listed scheduled staffing hours of 40 RN hours, 16 LPN hours, and 64 CNA hours, but the column for actual hours worked was left blank. Punch details for that day showed 23.75 RN hours, 30.87 LPN hours, and 69.36 CNA hours. Similar omissions were identified on the other reviewed dates, including November 2, 2024; November 30, 2024; December 14, 2024; December 28, 2024; April 5, 2025; April 19, 2025; May 17, 2025; May 25, 2025; June 7, 2025; June 22, 2025; July 5, 2025; July 19, 2025; August 16, 2025; August 23, 2025; September 13, 2025; and September 21, 2025. In each instance, the posting included scheduled staffing hours, but the actual hours worked were not entered. Interviews showed that the staffing coordinator created the schedule and provided it to the receptionist, who completed the daily staff posting. The receptionist stated she had not been trained to update the posting throughout the day and had never been informed that the posting needed to include the actual number of staff who worked and the actual hours worked. The DON stated she was not responsible for overseeing the daily staff posting but said the actual hours should be updated and reviewed one posting with punch details, stating there may not have been enough staff on that day to meet resident needs. The executive director stated she was unaware that the actual number of staff and hours worked needed to be updated on the posting and had never seen an updated daily staff posting.
Medication Administration Outside Ordered Pain Parameters
Penalty
Summary
The facility failed to ensure medications were administered according to physician orders for two residents. One resident had diagnoses including essential hypertension, type 2 diabetes mellitus, anxiety disorder, depression, pneumonia, and muscle weakness, and had a care plan for Oxycodone therapy for chronic pain with an intervention to administer medications as ordered. The resident’s orders specified Oxycodone 10 mg every 6 hours as needed for pain rated 6-10/10 and Acetaminophen 325 mg, 2 tablets every 6 hours as needed for pain rated 1-5/10. The MAR showed Oxycodone was administered for pain rated 5/10 on multiple occasions, and Acetaminophen was administered for pain rated 10/10. Another resident was admitted with diagnoses including a fracture of the lower end of the right tibia, displaced fracture of the lateral malleolus of the right fibula, anxiety, essential hypertension, and difficulty walking. The resident had a care plan for alteration in comfort/pain with an intervention to administer analgesics as ordered. Physician orders included Dilaudid 4 mg, 0.5 tablet every 3 hours as needed for pain rated 6-10/10 and Dilaudid 4 mg, 1 tablet every 4 hours as needed for pain rated 6-10/10. The MAR showed Dilaudid was administered for pain rated 5/10 on several occasions. Interviews with nursing staff confirmed that giving pain medication outside ordered parameters was considered a medication error, and review of the record found no documentation explaining why the medications were given outside the ordered parameters or any physician authorization for doing so.
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Compliance trends in Arizona
Data through Apr 2026Comparisons below measure the most recent period May 2025 – Apr 2026 against the prior period May 2024 – Apr 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): May 2025 – Apr 2026 vs the prior period May 2024 – Apr 2025. Only tags with at least 20 citations in both periods are shown.
Severity movers
Tags whose average scope/severity shifted the most: May 2025 – Apr 2026 vs the prior period May 2024 – Apr 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: May 2025 – Apr 2026 vs the prior period May 2024 – Apr 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 May 2025 – Apr 2026 vs the prior period May 2024 – Apr 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. May 2025 – Apr 2026 vs the prior period May 2024 – Apr 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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