16 Reports
Inspection Report — Apr 17, 2026
Complaint Investigation
Date: Apr 17, 2026
Visit Reason
On-site complaint investigation of complaints 00163266, 00163256, and 00143138 at a Nursing Care Institution, conducted 17 April 2026.
Complaint Details
An onsite complaint survey was conducted on April 17, 2026, for the investigation of intake (s) #00163266; 00163256, and 00143138. No deficiencies were cited.
Findings
No deficiencies were cited during this complaint investigation.
Report Facts
Complaints investigated: 3
Inspection Report — Oct 2, 2025
Complaint Investigation
Date: Oct 2, 2025
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On-site complaint investigation of complaints 00144929, 00144841, 2616414 and 2617378 at a Nursing Care Institution, conducted 2 October 2025.
Complaint Details
The onsite complaint survey was conducted on October 2, 2025 and investigated complaints #00144929, 00144841. The onsite complaint survey was conducted on October 2, 2025 and investigated complaints #2616414 and 2617378. There were no deficiencies noted.
Findings
This inspection resulted in no deficiencies or citations.
Report Facts
Complaints investigated: 4
Inspection Report — Sep 5, 2025
Complaint Investigation
Date: Sep 5, 2025
Visit Reason
The inspection was conducted due to complaints alleging verbal abuse by a staff member toward Resident #60, an allegation of physical abuse and lack of injury assessment for Resident #66, failure to encode and transmit Minimum Data Set (MDS) assessments for two residents (#3 and #12), and concerns about food safety and storage practices.
Complaint Details
The complaint investigation substantiated verbal abuse by Staff #99 toward Resident #60, including use of derogatory language and gestures. Staff #99 was suspended immediately and later terminated. The investigation also found failure to assess injury for Resident #66 after an abuse allegation. Multiple staff interviews and facility records supported these findings.
Findings
The facility substantiated the verbal abuse allegation against Staff #99 toward Resident #60, resulting in immediate suspension and eventual termination of the staff member. The facility failed to conduct a proper injury assessment for Resident #66 after an abuse allegation. The facility also failed to encode and transmit MDS assessments timely for two residents, impacting regulatory compliance. Additionally, the facility failed to maintain food at safe temperatures and did not properly label or date food items in storage, risking food safety violations.
Deficiencies (5)
Failed to protect Resident #60 from verbal abuse by a staff member who used derogatory language and gestures.
Failed to ensure a thorough investigation and injury assessment for Resident #66 after an allegation of abuse.
Failed to encode and transmit Minimum Data Set (MDS) assessments for Residents #3 and #12 according to regulatory requirements.
Failed to ensure food and drinks were palatable and maintained at safe and appetizing temperatures.
Failed to properly label, date, and monitor refrigerated and stored food items in the kitchen.
Report Facts
Deficiencies cited: 5
Food temperature: 48.3
Food temperature: 133.1
Food temperature: 51.1
Food temperature: 37.6
Food temperature: 173.8
Food temperature: 41.6
Food temperature: 126
Food temperature: 133
Food temperature: 154
Food temperature: 122
Food temperature: 57
Food temperature: 56
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff #99 | Licensed Practical Nurse (LPN) | Named in verbal abuse finding against Resident #60; suspended and terminated. |
| Staff #106 | Certified Nursing Assistant (CNA) | Reported verbal abuse incident involving Staff #99 and Resident #60. |
| Staff #57 | Director of Nursing (DON) | Interviewed regarding abuse investigations and MDS transmission failures. |
| Staff #65 | Administrator | Interviewed regarding abuse investigations and facility policies. |
| Staff #47 | Nutrition Care Manager | Interviewed and observed food temperature and storage practices. |
| Staff #200 | Licensed Practical Nurse (LPN) | Interviewed regarding verbal abuse incident involving Staff #99 and Resident #60. |
Inspection Report — Sep 5, 2025
Annual Inspection
Date: Sep 5, 2025
Visit Reason
Recertification survey and complaint investigation of multiple complaint intakes including 00138019, 2573394, 2246016, 2247911, 2248008, 2248002, 2247999, 2247909, 2247994, 2247989, 2247988, 2247987, 2247983, 2247975, 2247970, 2247969, 2249023, 2247998, 2247967, 2605929, and 2605837 at a Nursing Care Institution, conducted 2 through 5 September 2025.
Complaint Details
The recertification survey was conducted along with investigation of complaint intakes # 00138019, 2573394, 2246016, 2247911, 2248008, 2248002, 2247999, 2247909, 2247994, 2247989, 2247988, 2247987, 2247983, 2247975, 2247970, 2247969, 2249023, 2247998, 2247967, 2605929, and 2605837. Federal comments referenced complaint intakes # 257587, 2573394, 2248015, 2247911, 2248007, 2248001, 2248000, 2247909, 2247994, 2247989, 2247988, 2247987, 2247983, 2247975, 2247970, 2247969, 2249023, 2247998, 2247968, 2605929, and 2605837.
Findings
The inspection found eight deficiencies related to resident abuse protections, investigation procedures, resident assessment data transmission, and food safety practices including food palatability, temperature, and storage. Plans of correction were provided for all deficiencies.
Deficiencies (8)
§483.12 — The facility failed to protect the rights of one resident (#60) to be free from verbal abuse by a staff member, risking psychosocial harm.
§483.12(c) — The facility failed to ensure a thorough investigation was conducted and recorded, and that a resident (#66) was assessed for injury regarding an allegation of abuse, risking continued harm or delayed care.
§483.20(f) — The facility failed to ensure resident assessments for two residents were encoded and transmitted according to regulatory requirements, impacting monitoring of health data changes.
§483.60(d) — The facility failed to ensure food and drinks were palatable and maintained at an appetizing temperature, risking bacterial growth in susceptible conditions.
§483.60(i) — The facility failed to ensure prepared food was stored in accordance with professional food safety standards, risking bacterial growth in susceptible conditions.
R9-10-410 — The facility failed to protect the rights of one resident (#60) to be free from verbal abuse by a staff member, risking psychosocial harm.
R9-10-423 — The facility failed to ensure that prepared food was stored in accordance with professional food safety standards, risking bacterial growth in susceptible conditions.
R9-10-423 — The facility failed to ensure food and drinks were palatable and maintained at an appetizing temperature, risking bacterial growth in susceptible conditions.
Report Facts
Deficiencies cited: 8
Complaints investigated: 21
Inspection Report — Jul 4, 2025
Complaint Investigation
Date: Jul 4, 2025
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On-site complaint investigation of intakes SF00135131, AZ00225048 and AZ00225053 at a Nursing Care Institution, conducted 3 July 2025.
Complaint Details
A complaint survey was conducted on July 3, 2025 for the investigation of intakes SF00135131, AZ00225048 and AZ00225053. No deficiencies were cited.
Findings
This inspection resulted in no deficiencies or citations.
Report Facts
Complaints investigated: 3
Inspection Report — May 20, 2025
Complaint Investigation
Date: May 20, 2025
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On-site complaint investigation of intakes 00130983 and 00131064 at a Nursing Care Institution, conducted 19-20 May 2025.
Complaint Details
A complaint survey was conducted on May 19, 2025 through May 20, 2025 for the investigation of intakes #00130983, 00131064 and #AZ00224555, AZ00224568.
Findings
Two deficiencies were cited related to reporting suspected abuse, neglect, or exploitation. No evidence text was provided for either deficiency.
Deficiencies (2)
R9-10-403.F.2.a — The administrator failed to report suspected abuse, neglect, or exploitation of residents as required by state law.
§483.12(c)(1) — The facility failed to ensure alleged violations involving abuse, neglect, exploitation, or mistreatment were reported immediately or within required timeframes.
Report Facts
Deficiencies cited: 2
Complaints investigated: 4
Inspection Report — Dec 10, 2024
Complaint Investigation
Date: Dec 10, 2024
Visit Reason
On-site complaint investigation of intakes AZ00219613, AZ00209245, AZ00209065, AZ00208961, AZ00207035, AZ00206564, AZ00206367, and AZ00201281 at a Nursing Care Institution, conducted 10 December 2024.
Complaint Details
A complaint survey was conducted on December 10, 2024 for the investigation of intake #AZ00219613, AZ00209245, AZ00209065, AZ00208961, AZ00207035, AZ00206564, AZ00206367, AZ00201281. Federal comments noted investigation of intakes #AZ00219613, AZ00209407, AZ00220021, AZ00209065, AZ0020734, AZ00206367, AZ00206564. There were no deficiencies cited.
Findings
This inspection found no deficiencies.
Inspection Report — Sep 11, 2024
Complaint Investigation
Date: Sep 11, 2024
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On-site complaint investigation of intake numbers AZ00215642 and AZ00215641 at a Nursing Care Institution, conducted 11 September 2024.
Complaint Details
The complaint survey was conducted on September 11, 2024, with the investigation of intake #: AZ00215642. The complaint survey was conducted on September 11, 2024, with the investigation of intake #: AZ00215641.
Findings
This inspection resulted in no deficiencies or citations.
Inspection Report — Sep 4, 2024
Date: Sep 4, 2024
Visit Reason
On-site inspection of a Nursing Care Institution using the Nursing Care Institution worksheet, conducted 4 September 2024. The inspection type was Other, and this was a recertification survey for Medicare under the Life Safety Code 2012.
Findings
The inspection found eight deficiencies related to emergency preparedness, fire safety, sprinkler system coverage and maintenance, smoke barrier penetrations, fire door inspections, and emergency call light systems. The facility failed to maintain and update emergency plans and communication, had locked egress doors without proper arrangements, blocked sprinkler heads, missing sprinkler riser hydraulic plate, unsealed smoke barrier penetrations, lacked documentation of fire door inspections, and had disabled or improperly maintained emergency call systems.
Deficiencies (8)
The facility failed to maintain, review, and update the Emergency Preparedness Plan annually, resulting in outdated information and inaccurate documentation regarding staff and residents.
The facility failed to develop and maintain an emergency preparedness communication plan that includes current contact information for staff, entities providing services, next of kin, and others, resulting in outdated and inaccurate contact details.
NFPA 101 2012 Life Safety Code Chapter 19.2.2.2.5.1 — The facility failed to provide appropriate emergency egress arrangements; an exit door was locked with a key-activated cylinder, impeding rapid occupant removal during emergencies.
NFPA 101 Life Safety Code, 2012, Chapter 19.3.5.3 — The facility failed to assure sprinkler system coverage in all areas, with storage within eighteen inches of sprinkler heads and an exterior area not sprinklered, risking ineffective fire control.
NFPA 25 2011 — The facility failed to display a current hydraulic design information sign on the sprinkler riser, which could lead to errors during system modifications and failures.
The facility failed to fill two softball-sized penetrations in a smoke barrier, allowing smoke and heat to penetrate other areas, which could harm patients during a fire.
The facility failed to provide written documentation of the annual inspection and testing of fire door assemblies as required by NFPA 80, risking unverified door functionality.
NFPA 99: Health Care Facilities Code, 2012 Edition - Chapter 7 — The facility failed to properly maintain emergency call light systems and emergency pull cords in resident rooms and bathrooms, including disabled systems and missing or improperly placed pull cords.
Report Facts
Deficiencies cited: 8
Inspection Report — Aug 30, 2024
Annual Inspection
Date: Aug 30, 2024
Visit Reason
On-site annual compliance inspection of a Nursing Care Institution at Beatitudes Campus conducted from August 26 to August 30, 2024.
Findings
The inspection identified 10 deficiencies related to infection control, staff training, resident privacy and notification, restraint assessments, care planning for oxygen use, food storage safety, and facility maintenance issues.
Deficiencies (10)
R9-10-403 — The facility failed to keep a resident's indwelling catheter bag off the floor, posing a risk of infection.
R9-10-406 — The facility failed to maintain an effective annual training program for two staff members, lacking evidence of required training after their hire dates.
R9-10-406 — The facility failed to ensure two staff members received ongoing education on resident rights, abuse, neglect, exploitation, and infection control after their initial training.
R9-10-410 — The facility failed to notify one resident or their representative prior to a room change and did not obtain consent as required.
R9-10-410 — The facility failed to assess and care plan for the use of a power wheelchair seatbelt and bed rails/mobility bars for one resident.
R9-10-412 — The facility failed to ensure daily staff postings were current and posted at the beginning of each shift on the 4th floor.
R9-10-414 — The facility failed to develop a comprehensive care plan with oxygen-related interventions for one resident until more than four months after admission.
R9-10-414 — The facility failed to administer oxygen as ordered for one resident and lacked a physician order for oxygen use for another resident.
R9-10-423 — The facility failed to store food properly in the third-floor nourishment refrigerator, with undated and partially uncovered fruit plates present.
R9-10-425 — The facility failed to maintain a safe and comfortable environment, with water stains, brown splatters, and leaking temperature probe observed without documented work orders.
Report Facts
Deficiencies cited: 10
Inspection Report — Aug 30, 2024
Routine
Date: Aug 30, 2024
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements including resident rights, use of restraints, care planning, oxygen therapy, infection control, staff training, and facility environment.
Findings
The facility was found deficient in multiple areas including failure to notify a resident of a room change, inadequate assessment and care planning for restraints and oxygen use, lack of physician orders for oxygen administration, improper infection control practices, missing daily staff postings, unsafe food storage, environmental maintenance issues, and incomplete staff training on resident rights, abuse prevention, and infection control.
Deficiencies (12)
Failed to notify resident #37 prior to room change and obtain consent.
Failed to assess and care plan for use of power wheelchair seatbelt and bed rails for resident #44.
Failed to develop timely care plan for oxygen use for resident #38.
Failed to ensure physician order for oxygen administration for resident #50 and failed to document oxygen administration.
Failed to post daily nurse staffing information on 4th floor.
Stored undated and partially uncovered food in nourishment refrigerator on 3rd floor.
Indwelling catheter bag found on floor increasing risk of infection.
Failed to disinfect blood pressure cuffs between resident use.
Enhanced Barrier Precautions signs were missing on 4th floor resident rooms.
Staff failed to perform hand hygiene between resident contacts and upon leaving rooms.
Facility environment had water stains on ceiling tiles, brown stains on door frames, and leaking temperature probe.
Two staff (#70 RN and #19 housekeeper) lacked annual training on abuse, neglect, exploitation, resident rights, dementia management, and infection control.
Report Facts
Power outage timeframe: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff #38 | Social Worker | Involved in room change notification issue for resident #37 |
| Staff #76 | Licensed Practical Nurse | Interviewed regarding restraint assessment and oxygen administration |
| Staff #12 | Director of Nursing | Interviewed regarding restraint policy, oxygen administration, and hand hygiene |
| Staff #60 | Licensed Practical Nurse | Interviewed regarding oxygen therapy for resident #38 |
| Staff #68 | Assistant Director of Nursing | Interviewed regarding oxygen therapy and infection control |
| Staff #29 | Licensed Practical Nurse | Observed and interviewed regarding oxygen administration and infection control |
| Staff #35 | Registered Dietician | Interviewed regarding food storage issues |
| Staff #11 | Certified Nursing Assistant | Interviewed regarding catheter bag placement |
| Staff #1 | Certified Nursing Assistant | Interviewed regarding catheter bag placement |
| Staff #49 | Registered Nurse | Interviewed regarding daily staff posting |
| Staff #22 | Certified Nursing Assistant | Observed failing to perform hand hygiene |
| Staff #16 | Certified Nursing Assistant | Observed failing to perform hand hygiene |
| Staff #205 | Senior Maintenance Engineer | Interviewed regarding facility maintenance issues |
| Staff #110 | Administrator | Interviewed regarding facility environment and staff training |
| Staff #59 | Administrator | Interviewed regarding staff training and infection control |
| Staff #90 | Human Resources Assistant | Interviewed regarding staff training requirements |
| Staff #40 | VP of Human Resources and Risk Management | Interviewed regarding staff training policies and updates |
Inspection Report — Jul 30, 2024
Complaint Investigation
Date: Jul 30, 2024
Visit Reason
On-site complaint investigation of complaints AZ00163266, AZ00164047, AZ00164565, AZ00164578, AZ00173633 and AZ00174247 at a Nursing Care Institution, conducted 30 July 2024.
Complaint Details
An onsite complaint survey was conducted on July 30, 2024 for the investigation of intake #s AZ00163266, AZ00164047, AZ00164565, AZ00164578, AZ00173633 and AZ00174247.
Findings
The inspection found one deficiency related to failure to ensure residents were free from abuse by other residents. The facility failed to prevent multiple incidents of resident-to-resident abuse involving three residents.
Deficiencies (1)
R9-10-410 — The facility failed to ensure that three residents were free from abuse by another resident, including incidents where one resident pushed another causing a fall, and altercations involving hitting and unauthorized entry into a resident's room.
Report Facts
Deficiencies cited: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff #37 | Licensed Practical Nurse | Incident report entered by LPN/staff #37 dated March 7, 2020, regarding resident #54 pushing resident #56. |
| Staff #36 | Certified Nurse Assistant | Witnessed resident #54 push resident #56 on March 7, 2020. |
| Staff #38 | Licensed Practical Nurse | Incident report entered by LPN/staff #38 on April 12, 2020, regarding resident #54 hitting resident #55. |
Inspection Report — Dec 7, 2023
Complaint Investigation
Date: Dec 7, 2023
Visit Reason
On-site complaint investigation of intake numbers AZ00203462, AZ00203610, AZ00196997, AZ00197510, AZ00197938 and AZ00198953 at a Nursing Care Institution, conducted 7 December 2023.
Complaint Details
The complaint survey was conducted on December 7, 2023 for the investigation of intake numbers AZ00203462, AZ00203610, AZ00196997, AZ00197510, AZ00197938 and AZ00198953. No deficiencies were cited.
Findings
No deficiencies were cited during this complaint investigation.
Report Facts
Complaints investigated: 6
Inspection Report — Nov 17, 2023
Complaint Investigation
Date: Nov 17, 2023
Visit Reason
On-site complaint investigation of intake AZ00202955 at a Nursing Care Institution, conducted 17 November 2023.
Complaint Details
A complaint survey was conducted on November 17, 2023 for the investigation of intake #AZ00202955. There were no deficiencies cited.
Findings
No deficiencies were cited during this complaint investigation.
Inspection Report — Jul 11, 2023
Complaint Investigation
Date: Jul 11, 2023
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On-site complaint investigation of complaints AZ00197219 and AZ00197218 at a Nursing Care Institution, conducted 11 July 2023.
Complaint Details
The investigation of complaint AZ00197219 was conducted on July 11, 2023. There were no deficiencies found, complaint was forwarded to appropriate agency. The investigation of complaint AZ00197218 was conducted on July 11, 2023. There were no deficiencies found, complaint was forwarded to appropriate agency.
Findings
No deficiencies were found during this inspection. Both complaints were forwarded to the appropriate agency.
Report Facts
Complaints investigated: 2
Inspection Report — Jan 20, 2023
Complaint Investigation
Date: Jan 20, 2023
Visit Reason
The inspection was conducted based on complaint investigations related to failure to obtain informed consent for psychotropic medication, failure to timely report and respond to abuse allegations, failure to complete PASARR screening, failure to follow physician orders for insulin administration, failure to maintain RN coverage, inaccurate nurse staffing postings, and failure to monitor refrigerator temperatures.
Complaint Details
The complaint investigation included failure to obtain informed consent for psychotropic medication for resident #18, failure to timely report and respond to abuse allegations involving resident #39, failure to complete PASARR screening for resident #25, failure to follow insulin orders for resident #14, failure to maintain RN coverage, inaccurate nurse staffing postings, and failure to monitor refrigerator temperatures.
Findings
The facility failed to ensure informed consent for psychotropic medication, timely reporting and response to abuse allegations, completion of PASARR screening, adherence to insulin administration orders, RN coverage for at least 8 hours daily, accurate daily nurse staffing postings, and consistent monitoring and documentation of refrigerator temperatures.
Deficiencies (8)
Failed to ensure resident or representative was informed and consented to psychotropic medication use prior to administration.
Failed to timely report suspected abuse and report investigation results to proper authorities.
Failed to respond appropriately to alleged violations, allowing potential further abuse by staff.
Failed to complete PASARR Level 1 screening as required for one resident.
Failed to follow physician orders regarding insulin administration for one resident.
Failed to have a registered nurse on duty for at least 8 consecutive hours daily.
Failed to post accurate daily nurse staffing information reflecting actual hours worked.
Failed to consistently monitor, maintain, and document refrigerator temperatures.
Report Facts
Resident: 18
Resident: 39
Resident: 25
Resident: 14
Staff sample: 15
Dates: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator/Director of Nursing | Interviewed regarding psychotropic medication consent, abuse reporting, insulin administration, RN coverage, and staffing postings | |
| Licensed Practical Nurse (LPN) | Interviewed regarding psychotropic medication consent and abuse reporting | |
| Certified Nursing Assistant (CNA) | Involved in abuse allegation and reporting | |
| Registered Nurse (RN) | Interviewed regarding insulin administration and staffing | |
| Executive Chef | Interviewed regarding refrigerator temperature monitoring | |
| Staffing Coordinator | Interviewed regarding nurse staffing postings accuracy |
4 CMS Surveys
CMS Survey — May 20, 2025
May 20, 2025
CMS Survey — Jan 20, 2023
Jan 20, 2023
CMS Survey — Aug 30, 2024
Aug 30, 2024
CMS Survey — Sep 5, 2025
Sep 5, 2025
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