Deficiencies (last 3 years)
Deficiencies (over 3 years)
9.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
162% worse than Arizona average
Arizona average: 3.7 deficiencies/yearDeficiencies per year
20
15
10
5
0
Census
Latest occupancy rate
45% occupied
Based on a July 2025 inspection.
Occupancy over time
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
| Name | Title | Context |
|---|---|---|
| Kitchen Manager | Staff #101 | Interviewed regarding expired food items and food handling processes |
| Executive Chef Director | Staff #10 | Interviewed regarding food storage and safety policies |
| Cook | Staff #41 | Interviewed regarding leftover food labeling and storage |
| Certified Nursing Assistant | Staff #37 | Interviewed regarding food safety perceptions |
| Director of Nursing | Staff #68 | Interviewed regarding expectations for food safety and preparation |
| Administrative Assistant | Staff #31 | Interviewed regarding arbitration agreement review with residents |
| Administrator | Staff #3 | Interviewed regarding arbitration process and PBJ staffing data |
| HUD Department Manager | Staff #100 | Interviewed regarding arbitration training and agreement 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
| Name | Title | Context |
|---|---|---|
| administrator | Interviewed regarding expired food items and facility food storage policies |
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
| Name | Title | Context |
|---|---|---|
| Staff #17 | Licensed Practical Nurse (LPN) | Interviewed regarding failure to document compression stocking application and visual confirmation process |
| Staff #2 | Director of Nursing (DON) | Interviewed regarding documentation deficiencies, medication reconciliation expectations, and risks |
| Staff #41 | MDS Nurse / Clinical Resource | Interviewed regarding documentation and medication reconciliation |
| Staff #11 | Certified Nursing Assistant (CNA) | Interviewed regarding transfer assistance and shower chair safety |
| Staff #6 | Executive Director (ED) | Interviewed regarding expectations for equipment safety inspections and removal of unsafe shower chair |
| Staff #103 | Licensed Practical Nurse (LPN) | Provided written statement regarding narcotic reconciliation process |
| Staff #27 | Registered Nurse (RN) | Provided written statement regarding narcotic reconciliation and was removed from schedule pending drug screen |
| Staff #104 | Registry Licensed Practical Nurse (LPN) | Provided written statement regarding narcotic reconciliation |
| Staff #102 | Registry Registered Nurse (RN) | Provided written statement regarding narcotic reconciliation |
| Staff #101 | Registry Licensed Practical Nurse (LPN) | Provided written statement regarding narcotic reconciliation |
| Staff #105 | Registry Licensed Practical Nurse (LPN) | Interviewed regarding narcotic count procedures and missing signatures |
| Staff #106 | Administrator | Interviewed 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
| Name | Title | Context |
|---|---|---|
| Staff #17 | Licensed Practical Nurse (LPN) | Interviewed regarding failure to document compression stocking application for resident #263 |
| Staff #2 | Director of Nursing (DON) | Interviewed regarding compression stocking documentation, narcotic reconciliation, and medication storage expectations |
| Staff #41 | MDS Nurse / Clinical Resource | Interviewed regarding compression stocking documentation and narcotic investigation |
| Staff #11 | Certified Nursing Assistant (CNA) | Interviewed regarding transfer assistance and shower chair incident for resident #113 |
| Staff #6 | Executive Director (ED) | Interviewed regarding shower chair safety and facility expectations |
| Staff #7 | Food Service Director | Interviewed regarding food storage and labeling deficiencies |
| Staff #106 | Administrator | Interviewed regarding QAPI process and narcotic log documentation issues |
| Staff #27 | Registered Nurse (RN) | Involved in narcotic count investigation and drug screening |
| Staff #103 | Licensed Practical Nurse (LPN) | Provided written statement regarding narcotic count process |
| Staff #104 | Registry Licensed Practical Nurse (LPN) | Provided written statement regarding narcotic count process |
| Staff #102 | Registry Registered Nurse (RN) | Provided written statement regarding narcotic count process |
| Staff #101 | Registry Licensed Practical Nurse (LPN) | Provided written statement regarding narcotic count process |
| Staff #105 | Registry Licensed Practical Nurse (LPN) | Interviewed regarding narcotic count process and missing signatures |
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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