13 Reports
Inspection Report — Aug 27, 2025
CMS
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 — Aug 27, 2025
Annual Inspection State
Date: Aug 27, 2025
Visit Reason
On-site complaint investigation of complaints 2268119, 2268120, 2268124, 2268123, 2268111, 2268110, 2268107, 2268115, 2268106, 2268050, and 2268051, conducted in conjunction with the annual compliance survey at a Nursing Care Institution on 26-27 August 2025.
Complaint Details
The State Compliance Survey was conducted on August 26, 2025 through August 27, 2025, in conjunction with the investigation of Complaint(s) # 2268119, 2268120, 2268124, 2268123, 2268111, 2268110, 2268107, 2268115, 2268106, 2268050, 2268051.
Findings
The inspection found four deficiencies related to food safety, binding arbitration agreements, payroll-based journal staffing data, and food storage practices. Plans of correction were provided for all deficiencies.
Deficiencies (4)
§483.60(i) — The facility failed to ensure that food items were not expired, increasing the risk of cross-contamination and foodborne illness.
§483.70(m) — The facility failed to ensure the binding arbitration agreement provided for the selection of a neutral arbitrator and a venue agreed upon by both parties.
§483.70(p) — The facility failed to report accurate Payroll Based Journal (PBJ) staffing data as required.
R9-10-423 — The facility failed to ensure that food items were not expired, which could increase the risk of cross-contamination and foodborne illness.
Report Facts
Deficiencies cited: 4
Complaints investigated: 11
Inspection Report — Aug 26, 2025
State
Date: Aug 26, 2025
Visit Reason
On-site inspection of Christian Care Nursing Center conducted 26 August 2025 with a Nursing Care Institution worksheet type, classified as Other inspection type.
Findings
The inspection found three deficiencies related to facility maintenance including door smoke seals, unsealed smoke barrier penetrations, and exposed electrical wires. The facility was found not in substantial compliance with 42 CFR 483.73 Emergency Preparedness requirements.
Deficiencies (3)
Patient Sleeping Room Doors Locks — The facility failed to maintain several doors, including missing smoke seals with gaps from handle to top of door, which could allow heat or smoke transfer causing harm to patients and staff.
Subdivision of Building Spaces - Smoke Barrier Construction — The facility failed to seal multiple penetrations and holes in smoke barriers, allowing potential smoke and heat penetration that could harm patients during a fire.
Utilities - Gas and Electric Equipment — The facility failed to ensure a protected covering over exposed wires in an open junction box above the ceiling near room 135, posing a hazard to staff and patients.
Report Facts
Deficiencies cited: 3
Inspection Report — Jul 21, 2025
Complaint Investigation State
Date: Jul 21, 2025
Visit Reason
On-site complaint investigation of complaints 00137000, 00136994, 2567223, and 2567687 at a Nursing Care Institution, conducted 21 July 2025.
Complaint Details
The complaint survey was conducted on July 21, 2025 of the following complaint #s 00137000, 00136994. The complaint survey was conducted on July 21, 2025 of the following complaint #s 2567223, 2567687. There were no deficiencies cited.
Findings
This inspection resulted in no deficiencies cited or citations.
Report Facts
Complaints investigated: 4
Inspection Report — Jun 11, 2025
Complaint Investigation State
Date: Jun 11, 2025
Visit Reason
On-site complaint investigation of intake numbers 00133163, AZ00214374, AZ00214561, AZ00224843, and AZ00214560 at a Nursing Care Institution, conducted 11 June 2025.
Complaint Details
The complaint survey was conducted on June 11, 2025, investigating intake numbers 00133163, AZ00214374, AZ00214561, AZ00224843, AZ00214374, and AZ00214560. No deficiencies were cited.
Findings
No deficiencies were found during this complaint investigation.
Report Facts
Complaints investigated: 6
Inspection Report — Apr 24, 2025
Complaint Investigation State
Date: Apr 24, 2025
Visit Reason
On-site complaint investigation of complaints AZ00169728, AZ00171743, AZ00182740, AZ00182356, AZ00178713, AZ00176178, AZ00175048, AZ00173528, AZ00173041, and AZ00171762 at a Nursing Care Institution, conducted 24 April 2025.
Complaint Details
The Risk Based Complaint Survey was conducted April 23, 2025 through April 24, 2025 in conjunction with the following Complaints: AZ00169728, AZ00171743, AZ00182740, AZ00182356, AZ00178713, AZ00176178, AZ00175048, AZ00173528, AZ00173041, and AZ00171762. There were no deficiencies cited.
Findings
This inspection resulted in no deficiencies cited.
Inspection Report — Sep 10, 2024
State
Date: Sep 10, 2024
Visit Reason
On-site other inspection of a Nursing Care Institution conducted 10 September 2024, including a recertification survey for Medicare under the Life Safety Code 2012 Edition.
Findings
The inspection found five deficiencies related to fire protection, sprinkler system coverage, smoke barrier penetrations, door inspection documentation, and electrical receptacle testing documentation. The facility failed to meet several Life Safety Code requirements but provided plans of correction for all deficiencies.
Deficiencies (5)
Based on observations, the facility failed to provide adequate fire protection and separation between the skilled nursing center and assisted living facility, including missing firewalls and doors without the required two-hour fire rating at key junctions.
NFPA 101 2012 Edition 19.3.5.3 — The facility failed to provide automatic sprinkler protection for the roof overhang at the entrance to the Skilled Nursing Center, which is over four feet in width and constructed of combustible materials.
Based on observation, the facility failed to properly seal penetrations, holes, and openings in multiple smoke barriers, including unsealed drywall patches in the laundry room and a hole above the kitchen doorway, risking smoke and heat penetration.
NFPA 80 Section 5.2 — The facility failed to have written documentation of the annual inspection and testing of fire door openings as required, lacking records for compliance with NFPA 80 standards.
NFPA 99 Chapter 6, Section 6.3.4.1.3 — The facility failed to conduct, maintain, and document electrical receptacle testing in patient care areas, including patient rooms, risking ignition hazards.
Report Facts
Deficiencies cited: 5
Inspection Report — Aug 27, 2024
CMS
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 — Aug 27, 2024
Annual Inspection State
Date: Aug 27, 2024
Visit Reason
Annual compliance inspection of Christian Care Nursing Center conducted 26-27 August 2024 using the Nursing Care Institution worksheet.
Findings
Two deficiencies were cited related to personnel fingerprint clearance and expired food items in the dining room refrigerator.
Deficiencies (2)
R9-10-406 — The facility failed to ensure that staff #7 had a valid fingerprint clearance card while working, as multiple fingerprint applications were rejected and no hearing date was provided. This posed a potential risk to residents due to inadequate background checks.
R9-10-423 — The facility failed to ensure no expired food items were available for resident use; five cartons of orange juice expired three days prior were found in the dining room refrigerator. Additionally, peanut butter sandwich crackers without any expiration or use-by dates were stored, risking resident illness.
Report Facts
Deficiencies cited: 2
Inspection Report — Jul 21, 2023
Routine CMS
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
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 — Jul 21, 2023
CMS
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
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
| Name | Title | Context |
|---|---|---|
| Staff #17 | Licensed Practical Nurse (LPN) | Interviewed regarding compression stocking documentation and visual confirmation |
| 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 reconciliation |
| Staff #11 | Certified Nursing Assistant (CNA) | Interviewed regarding transfer assistance and shower chair use |
| Staff #6 | Executive Director (ED) | Interviewed regarding expectations for durable medical equipment safety inspections |
| Staff #105 | Licensed Practical Nurse (Registry LPN) | Interviewed regarding narcotic counts and medication storage observations |
| Staff #27 | Registered Nurse (RN) | Involved in narcotic reconciliation investigation |
| Staff #106 | Administrator | Interviewed regarding narcotic count audits and performance improvement |
Inspection Report — Jul 21, 2023
Annual Inspection State
Date: Jul 21, 2023
Visit Reason
On-site complaint investigation and annual compliance survey conducted July 17-21, 2023, at Christian Care Nursing Center, including investigation of multiple complaints (e.g., AZ00196329, AZ00194190, AZ00193425) with a Nursing Care Institution worksheet.
Complaint Details
The State compliance survey was conducted July 17-21, 2023, in conjunction with investigation of complaints: #AZ00196329, AZ00194190, AZ00193425, AZ00186861, AZ00185834, AZ00185118, AZ00170704, AZ00168018, AZ00163394, AZ00158628, AZ00153607, AZ00197814, AZ00197084, AZ00196862, AZ00195392, AZ00194096, AZ00190942, AZ00189520, AZ00187619, AZ00186785, AZ00186716, AZ00184943, AZ00169486 and AZ00164358. The Recertification survey was conducted July 17-21, 2023, in conjunction with investigation of complaints: #AZ00196324, AZ00194189, AZ00193422, AZ00186860, AZ00185833, AZ00185117, AZ00170702, AZ00168016, AZ00163391, AZ00158628, AZ00153607, AZ00197814, AZ00197084, AZ00196862, AZ00195392, AZ00194096, AZ00190942, AZ00189520, AZ00187619, AZ00186785, AZ00186716, AZ00184943, AZ00169486 and AZ00164358.
Findings
The inspection found ten deficiencies including failures in policy implementation for physical and behavioral health services, incomplete narcotic log documentation, unsafe resident environment conditions, and improper food storage. The facility also failed to ensure adequate supervision and safety measures during resident transfers, increasing risk of injury.
Deficiencies (10)
R9-10-403 — The administrator failed to ensure policies and procedures for physical and behavioral health services were established, documented, and implemented, resulting in lack of documentation for compression stocking application for resident #263.
R9-10-404 — The administrator failed to establish and implement a quality management program that included methods to address concerns about resident care, evidenced by 139 missing signatures on narcotic count logs from January to June 2023.
Quality of care — The facility failed to document treatment and care according to professional standards for resident #263, specifically regarding the implementation of compression stockings, risking inadequate treatment.
§483.25(d) Accidents — The facility failed to ensure the resident environment was free of accident hazards by not inspecting a shower chair for safety and providing appropriate transfer assistance for resident #113, increasing risk of injury.
§483.45 Pharmacy Services — The facility failed to ensure accurate acquiring, receiving, dispensing, and administering of drugs, demonstrated by multiple missing signatures on narcotic logs and inconsistent medication count audits.
§483.60(i) Food safety requirements — The facility failed to properly store, label, and date food items, including expired and exposed foods, risking foodborne illness for residents. The census was 9.
§483.75(c) Program feedback, data systems and monitoring — The QAPI committee failed to implement and review an effective plan to correct incomplete narcotic count documentation, risking inaccurate medication accounting.
R9-10-421 — The administrator failed to ensure policies and procedures protected residents by maintaining proper storage, inventory, and dispensing of controlled substances, evidenced by missing narcotic log signatures.
R9-10-423 — The administrator failed to ensure the nursing care institution could store, refrigerate, and reheat food to meet residents' dietary needs, with multiple food items improperly stored or undated. The census was 9.
R9-10-425 — The administrator failed to ensure the premises and equipment were free from conditions causing physical injury, related to unsafe shower chair knobs and inadequate transfer assistance for resident #113.
Report Facts
Deficiencies cited: 10
Complaints investigated: 24
Complaints investigated: 24
Deficiencies cited: 139
Inspection Report — Jul 21, 2023
State
Date: Jul 21, 2023
Visit Reason
Recertification survey for Medicare under the Life Safety Code 2012, Chapter 19 existing nursing home, conducted 21 July 2023 at Christian Care Nursing Center.
Findings
No deficiencies were found during this inspection. The facility met all applicable federal, state, and local standards.
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