Inspection Reports for
Christian Care Nursing Center

AZ, 85029

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Deficiencies (last 3 years)

Deficiencies (over 3 years) 5 deficiencies/year

Deficiencies are regulatory findings recorded during state inspections.

35% worse than Arizona average
Arizona average: 3.7 deficiencies/year

Deficiencies per year

12 9 6 3 0
2023
2024
2025

Inspection Report

Deficiencies: 3 Date: Aug 27, 2025

Visit Reason
The inspection was conducted to evaluate compliance with food safety standards, arbitration agreement procedures, and accuracy of Payroll Based Journal (PBJ) staffing data submissions at Christian Care Nursing Center.

Findings
The facility was found deficient in ensuring food items were not expired, failing to provide a neutral and fair arbitration process with agreed-upon arbitrator and venue, and inaccurately reporting direct care staffing information in PBJ submissions. These deficiencies posed risks of foodborne illness, inadequate resident understanding of arbitration rights, and inaccurate staffing data reporting.

Deficiencies (3)
Failed to ensure that food items were not expired, increasing risk of cross-contamination and foodborne illness.
Failed to ensure the binding arbitration agreement provided for selection of a neutral arbitrator and venue agreed upon by both parties.
Failed to report accurate Payroll Based Journal (PBJ) data regarding registered nurse hours and licensed nursing coverage.
Report Facts
Expired food items: 6 PBJ FY Quarter 2 2024 no RN hours reported: 8 PBJ FY Quarter 2 2024 no licensed nursing coverage 24 hours: 12 PBJ FY Quarter 1 2025 no RN hours reported: 5 PBJ FY Quarter 1 2025 no licensed nursing coverage 24 hours: 7 PBJ FY Quarter 2 2025 no licensed nursing coverage 24 hours: 6

Employees mentioned
NameTitleContext
Kitchen ManagerStaff #101Interviewed regarding expired food items and food handling processes
Executive Chef DirectorStaff #10Interviewed regarding food storage and safety policies
CookStaff #41Interviewed regarding leftover food labeling and storage
Certified Nursing AssistantStaff #37Interviewed regarding food safety perceptions
Director of NursingStaff #68Interviewed regarding expectations for food safety and preparation
Administrative AssistantStaff #31Interviewed regarding arbitration agreement review with residents
AdministratorStaff #3Interviewed regarding arbitration process and PBJ staffing data
HUD Department ManagerStaff #100Interviewed regarding arbitration training and agreement process

Inspection Report

Deficiencies: 1 Date: Aug 27, 2024

Visit Reason
The inspection was conducted to assess compliance with food procurement, storage, preparation, distribution, and serving standards to ensure resident safety.

Findings
The facility failed to ensure that no expired food items were available for resident use in the dining room refrigerator, posing a potential risk of foodborne illness. Specifically, expired orange juice and unlabeled peanut butter sandwich crackers were found accessible to residents.

Deficiencies (1)
Expired food items, including orange juice past expiration date and peanut butter sandwich crackers without use-by dates, were available for resident use in the dining room refrigerator.
Report Facts
Expired orange juice cartons: 5 Peanut butter sandwich crackers: 12

Employees mentioned
NameTitleContext
administratorInterviewed regarding expired food items and facility food storage policies

Inspection Report

Annual Inspection
Census: 9 Deficiencies: 3 Date: Jul 21, 2023

Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulatory standards related to resident care, safety, and medication management at Christian Care Nursing Center.

Findings
The facility was found deficient in documenting treatment and care for residents, ensuring a safe environment free from accident hazards, and maintaining proper pharmaceutical controls, including narcotic reconciliation. Deficiencies included failure to document compression stocking application, inadequate supervision and safety checks during resident transfers, and missing signatures on controlled medication logs.

Deficiencies (3)
Failed to document treatment and care regarding implementation of compression stockings for resident #263.
Failed to ensure resident environment was free from accident hazards; shower chair had sharp knobs causing skin tear to resident #113 and inadequate transfer assistance.
Failed to ensure prompt identification of loss or potential diversion of controlled medications; missing narcotics and multiple missing signatures on narcotic count logs.
Report Facts
Resident census: 9 Missing narcotic count signatures: 139 Missing narcotic count signatures: 15 Missing narcotic count signatures: 14 Missing narcotic count signatures: 2 Missing narcotic count signatures: 13 Missing narcotic count signatures: 21 Missing narcotic count signatures: 9 Missing narcotic count signatures: 20 Missing narcotic count signatures: 12 Missing narcotic count signatures: 15 Missing narcotic count signatures: 3 Missing narcotic count signatures: 7 Missing narcotic count signatures: 8

Employees mentioned
NameTitleContext
Staff #17Licensed Practical Nurse (LPN)Interviewed regarding failure to document compression stocking application and visual confirmation process
Staff #2Director of Nursing (DON)Interviewed regarding documentation deficiencies, medication reconciliation expectations, and risks
Staff #41MDS Nurse / Clinical ResourceInterviewed regarding documentation and medication reconciliation
Staff #11Certified Nursing Assistant (CNA)Interviewed regarding transfer assistance and shower chair safety
Staff #6Executive Director (ED)Interviewed regarding expectations for equipment safety inspections and removal of unsafe shower chair
Staff #103Licensed Practical Nurse (LPN)Provided written statement regarding narcotic reconciliation process
Staff #27Registered Nurse (RN)Provided written statement regarding narcotic reconciliation and was removed from schedule pending drug screen
Staff #104Registry Licensed Practical Nurse (LPN)Provided written statement regarding narcotic reconciliation
Staff #102Registry Registered Nurse (RN)Provided written statement regarding narcotic reconciliation
Staff #101Registry Licensed Practical Nurse (LPN)Provided written statement regarding narcotic reconciliation
Staff #105Registry Licensed Practical Nurse (LPN)Interviewed regarding narcotic count procedures and missing signatures
Staff #106AdministratorInterviewed regarding medication count compliance, audits, and performance improvement efforts

Inspection Report

Routine
Census: 9 Deficiencies: 5 Date: Jul 21, 2023

Visit Reason
The inspection was conducted to evaluate compliance with regulatory standards related to resident care, medication management, safety, food storage, and quality assurance at Christian Care Nursing Center.

Findings
The facility was found deficient in documenting treatment and care for residents, ensuring a safe environment free from hazards, maintaining proper pharmaceutical controls including narcotic reconciliation, storing food safely and hygienically, and implementing effective quality assurance processes. Multiple minimal harm deficiencies were cited affecting a few to some residents.

Deficiencies (5)
Failed to document treatment and care regarding implementation of compression stockings for one resident (#263).
Failed to ensure resident environment was free from accident hazards; shower chair was unsafe and resident (#113) did not receive appropriate transfer assistance.
Failed to ensure prompt identification of loss or potential diversion of controlled medications; multiple missing narcotic count signatures and a missing vial of Ativan.
Failed to ensure food was properly stored, labeled, and dated; multiple food items were exposed, undated, or spoiled.
Failed to implement and review an appropriate plan of action to correct incomplete narcotic count documentation in the Quality Assurance and Performance Improvement (QAPI) committee.
Report Facts
Resident census: 9 Missing narcotic log signatures: 139 Missing narcotic log signatures: 15 Missing narcotic log signatures: 14 Missing narcotic log signatures: 2 Missing narcotic log signatures: 13 Missing narcotic log signatures: 21 Missing narcotic log signatures: 9 Missing narcotic log signatures: 20 Missing narcotic log signatures: 12 Missing narcotic log signatures: 15 Missing narcotic log signatures: 3 Missing narcotic log signatures: 7 Missing narcotic log signatures: 8

Employees mentioned
NameTitleContext
Staff #17Licensed Practical Nurse (LPN)Interviewed regarding failure to document compression stocking application for resident #263
Staff #2Director of Nursing (DON)Interviewed regarding compression stocking documentation, narcotic reconciliation, and medication storage expectations
Staff #41MDS Nurse / Clinical ResourceInterviewed regarding compression stocking documentation and narcotic investigation
Staff #11Certified Nursing Assistant (CNA)Interviewed regarding transfer assistance and shower chair incident for resident #113
Staff #6Executive Director (ED)Interviewed regarding shower chair safety and facility expectations
Staff #7Food Service DirectorInterviewed regarding food storage and labeling deficiencies
Staff #106AdministratorInterviewed regarding QAPI process and narcotic log documentation issues
Staff #27Registered Nurse (RN)Involved in narcotic count investigation and drug screening
Staff #103Licensed Practical Nurse (LPN)Provided written statement regarding narcotic count process
Staff #104Registry Licensed Practical Nurse (LPN)Provided written statement regarding narcotic count process
Staff #102Registry Registered Nurse (RN)Provided written statement regarding narcotic count process
Staff #101Registry Licensed Practical Nurse (LPN)Provided written statement regarding narcotic count process
Staff #105Registry Licensed Practical Nurse (LPN)Interviewed regarding narcotic count process and missing signatures

Inspection Report

Census: 9 Deficiencies: 3 Date: Jul 21, 2023

Visit Reason
The inspection was conducted to evaluate compliance with regulatory standards related to treatment documentation, resident safety, and medication management at Christian Care Nursing Center.

Findings
The facility failed to document treatment and care regarding compression stockings for one resident, failed to ensure a safe environment by not inspecting a shower chair leading to a resident injury, and failed to implement a system for prompt identification of loss or diversion of controlled medications, with multiple missing narcotic count signatures.

Deficiencies (3)
Failed to document treatment and care in accordance with professional standards regarding implementation of compression stockings for resident #263.
Failed to ensure the resident environment was free from accident hazards by not inspecting a shower chair before use, resulting in a skin tear injury to resident #113.
Failed to ensure prompt identification of loss or potential diversion of controlled medications; multiple missing narcotic count signatures and a missing vial of Ativan.
Report Facts
Resident census: 9 Missing narcotic count signatures: 139 Length of resident laceration: 12 Number of missing narcotic signatures by month and cart: 15 Number of missing narcotic signatures by month and cart: 14 Number of missing narcotic signatures by month and cart: 2 Number of missing narcotic signatures by month and cart: 13 Number of missing narcotic signatures by month and cart: 21 Number of missing narcotic signatures by month and cart: 9 Number of missing narcotic signatures by month and cart: 20 Number of missing narcotic signatures by month and cart: 12 Number of missing narcotic signatures by month and cart: 15 Number of missing narcotic signatures by month and cart: 3 Number of missing narcotic signatures by month and cart: 7 Number of missing narcotic signatures by month and cart: 8

Employees mentioned
NameTitleContext
Staff #17Licensed Practical Nurse (LPN)Interviewed regarding compression stocking documentation and visual confirmation
Staff #2Director of Nursing (DON)Interviewed regarding compression stocking documentation, narcotic reconciliation, and medication storage expectations
Staff #41MDS Nurse / Clinical ResourceInterviewed regarding compression stocking documentation and narcotic reconciliation
Staff #11Certified Nursing Assistant (CNA)Interviewed regarding transfer assistance and shower chair use
Staff #6Executive Director (ED)Interviewed regarding expectations for durable medical equipment safety inspections
Staff #105Licensed Practical Nurse (Registry LPN)Interviewed regarding narcotic counts and medication storage observations
Staff #27Registered Nurse (RN)Involved in narcotic reconciliation investigation
Staff #106AdministratorInterviewed regarding narcotic count audits and performance improvement

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