Inspection Reports for
Christian Care Nursing Center

AZ, 85029

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Deficiencies (last 3 years)

Deficiencies (over 3 years) 13.7 deficiencies/year

Deficiencies are regulatory violations found during state inspections.

270% worse than Arizona average
Arizona average: 3.7 deficiencies/year

Deficiencies per year

28 21 14 7 0
2023
2024
2025

Occupancy

Latest occupancy rate 45% occupied

Based on a July 2025 inspection.

Occupancy rate over time

40% 60% 80% 100% Jul 2023 Aug 2024 Apr 2025 Jul 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: 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 food handling practices with expired food items stored improperly, failure to ensure a neutral arbitration process with agreed-upon arbitrator and venue, and inaccurate reporting of direct care staffing data to CMS, including missing registered nurse hours and licensed nursing coverage on multiple dates.

Deficiencies (3)
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards; expired food items found in storage.
Provide a neutral and fair arbitration process and agree to arbitrator and venue; facility failed to ensure binding arbitration agreement included selection of a neutral arbitrator agreed upon by both parties and venue agreement.
Electronically submit to CMS complete and accurate direct care staffing information based on payroll and other verifiable data; facility failed to report accurate PBJ data including missing RN hours and licensed nursing coverage on multiple dates.
Report Facts
Expired food items: 6 PBJ missing RN hours: 8 PBJ missing licensed nursing coverage dates: 12 PBJ missing licensed nursing coverage dates: 6

Employees mentioned
NameTitleContext
Kitchen ManagerInterviewed regarding expired food items and food handling practices.
Executive Chef DirectorInterviewed regarding food storage inventory and food safety expectations.
CookInterviewed regarding leftover food labeling and storage.
Certified Nursing Assistant (CNA)Interviewed regarding attitudes toward expired food.
Director of Nursing (DON)Interviewed regarding food safety guidelines and expectations.
Administrative AssistantInterviewed regarding arbitration agreement process and understanding.
AdministratorInterviewed regarding arbitration agreement and PBJ staffing data submission.
HUD Department ManagerInterviewed regarding arbitration agreement training and process.

Inspection Report

Complaint Investigation
Census: 9 Capacity: 20 Deficiencies: 0 Date: Jul 21, 2025

Visit Reason
Complaint survey conducted with no deficiencies cited.

Findings
Complaint survey conducted with no deficiencies cited.

Inspection Report

Complaint Investigation
Census: 9 Capacity: 20 Deficiencies: 0 Date: Jun 11, 2025

Visit Reason
Complaint survey conducted with no deficiencies cited.

Findings
Complaint survey conducted with no deficiencies cited.

Inspection Report

Complaint Investigation
Census: 9 Capacity: 20 Deficiencies: 0 Date: Apr 23, 2025

Visit Reason
Risk based complaint survey conducted with no deficiencies cited.

Findings
Risk based complaint survey conducted with no deficiencies cited.

Inspection Report

Census: 9 Capacity: 20 Deficiencies: 5 Date: Sep 10, 2024

Visit Reason
Recertification survey for Medicare under Life Safety Code 2012. Facility meets standards based on acceptance of plan of correction.

Findings
Recertification survey for Medicare under Life Safety Code 2012. Facility meets standards based on acceptance of plan of correction.

Deficiencies (5)
Multiple Occupancies - Construction Type Where separated occupancies are in accordance with 18/19.1.3.2 or 18/19.1.3.4, the most stringent constructio...
Spinkler System - Installation 2012 EXISTING Nursing homes, and hospitals where required by construction type, are protected throughout by an approved...
Subdivision of Building Spaces - Smoke Barrier Construction 2012 EXISTING Smoke barriers shall be constructed to a 1/2-hour fire resistance rating per...
Maintenance, Inspection & Testing - Doors Fire doors assemblies are inspected and tested annually in accordance with NFPA 80, Standard for Fire Do...
Electrical Systems - Maintenance and Testing Hospital-grade receptacles at patient bed locations and where deep sedation or general anesthesia is admi...

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

Deficiencies: 1 Date: Aug 27, 2024

Visit Reason
The inspection was conducted to evaluate compliance with food procurement, storage, preparation, distribution, and serving standards in the facility.

Findings
The facility failed to ensure that expired food items were not readily available for resident use in the dining room refrigerator, posing a potential risk for foodborne illness. Specifically, expired orange juice and peanut butter sandwich crackers without expiration dates were found accessible to residents.

Deficiencies (1)
Expired food items, including orange juice and peanut butter sandwich crackers without expiration 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
Administrator (staff #10) interviewed regarding expired food items

Inspection Report

Annual Inspection
Census: 9 Capacity: 20 Deficiencies: 2 Date: Aug 26, 2024

Visit Reason
State compliance survey conducted with two deficiencies cited related to personnel records and expired food items.

Findings
State compliance survey conducted with two deficiencies cited related to personnel records and expired food items.

Deficiencies (2)
R9-10-406.F. An administrator shall ensure that a personnel record is maintained for each personnel member, employee, volunteer, or student that inclu...
R9-10-423.A. An administrator shall ensure that: R9-10-423.A.3. If a nursing care institution contracts with a food establishment, as defined in 9 A.A...

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

Inspection Report

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

Visit Reason
The inspection was conducted to assess compliance with regulatory standards including treatment documentation, resident safety, medication management, food storage, and quality assurance processes.

Findings
The facility was found deficient in documenting treatment implementation for compression stockings, ensuring resident safety during transfers, controlling and documenting narcotic medications, proper food storage and labeling, and maintaining effective quality assurance processes related to narcotic count documentation.

Deficiencies (5)
Failed to document treatment and care regarding implementation of compression stockings for one resident.
Failed to ensure resident environment was free from accident hazards; shower chair had sharp knobs causing skin tear during transfer.
Failed to ensure prompt identification of loss or potential diversion of controlled medications; missing narcotics and incomplete narcotic count documentation.
Failed to ensure food was properly stored, labeled, and dated; multiple food items were exposed, unlabeled, or spoiled.
Failed to implement and review an appropriate plan of action to correct incomplete narcotic count documentation.
Report Facts
Resident census: 9 Missing narcotic log signatures: 139 Missing narcotic log signatures by month and cart: 15 Missing narcotic log signatures by month and cart: 14 Missing narcotic log signatures by month and cart: 2 Missing narcotic log signatures by month and cart: 13 Missing narcotic log signatures by month and cart: 21 Missing narcotic log signatures by month and cart: 9 Missing narcotic log signatures by month and cart: 20 Missing narcotic log signatures by month and cart: 12 Missing narcotic log signatures by month and cart: 15 Missing narcotic log signatures by month and cart: 3 Missing narcotic log signatures by month and cart: 7 Missing narcotic log signatures by month and cart: 8

Employees mentioned
NameTitleContext
Staff #2Director of Nursing (DON)Interviewed regarding treatment documentation, narcotic reconciliation, and medication storage expectations
Staff #17Licensed Practical Nurse (LPN)Interviewed regarding compression stocking application and transfer assistance
Staff #41MDS Nurse / Clinical ResourceInterviewed regarding treatment documentation and narcotic reconciliation
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 meetings, narcotic log documentation, and performance improvement plans
Staff #27Registered Nurse (RN)Involved in narcotic reconciliation investigation

Inspection Report

Complaint Investigation
Census: 9 Capacity: 20 Deficiencies: 10 Date: Jul 17, 2023

Visit Reason
State compliance survey conducted with multiple deficiencies cited related to quality of care, medication management, food safety, and facility maintenance.

Findings
State compliance survey conducted with multiple deficiencies cited related to quality of care, medication management, food safety, and facility maintenance.

Deficiencies (10)
R9-10-403.C. An administrator shall ensure that: R9-10-403.C.2. Policies and procedures for physical health services and behavioral health services ar...
R9-10-404. An administrator shall ensure that: R9-10-404.1. A plan is established, documented, and implemented for an ongoing quality management progr...
§ 483.25 Quality of care Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on t...
§483.25(d) Accidents. The facility must ensure that - §483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and...
§483.45 Pharmacy Services The facility must provide routine and emergency drugs and biologicals to its residents, or obtain them under an agreement d...
§483.60(i) Food safety requirements. The facility must - §483.60(i)(1) - Procure food from sources approved or considered satisfactory by federal, s...
§483.75(c) Program feedback, data systems and monitoring. A facility must establish and implement written policies and procedures for feedback, data ...
R9-10-421.D. When medication is stored at a nursing care institution, an administrator shall ensure that: R9-10-421.D.3. Policies and procedures are e...
R9-10-423.A. An administrator shall ensure that: R9-10-423.A.3. If a nursing care institution contracts with a food establishment, as defined in 9 A.A...
R9-10-425.A. An administrator shall ensure that: R9-10-425.A.1. A nursing care institution's premises and equipment are: R9-10-425.A.1.b. Free from a ...

Inspection Report

Census: 9 Capacity: 20 Deficiencies: 0 Date: Jul 17, 2023

Visit Reason
Recertification survey for Medicare under Life Safety Code 2012. Facility meets standards with no deficiencies cited.

Findings
Recertification survey for Medicare under Life Safety Code 2012. Facility meets standards with no deficiencies cited.

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