64 Reports
Inspection Report — May 16, 2026
Complaint Investigation
Date: May 16, 2026
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On-site complaint investigation at a Nursing Care Institution conducted 16 May 2026.
Complaint Details
An offsite follow up survey was conducted on May 16, 2026. There were no deficiencies cited.
Findings
No deficiencies were cited during this inspection.
Inspection Report — Mar 20, 2026
Complaint Investigation
Date: Mar 20, 2026
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On-site complaint investigation of multiple complaints including intake numbers 2794501, 00161158, 0016127600162370, 00162386, and 2805113 at a Nursing Care Institution, conducted 20 March 2026.
Complaint Details
An onsite complaint survey was conducted on March 20, 2026 for the investigation of intake # 2794501, 00161158, 0016127600162370, 00162386, 2805113. Federal comments also referenced intake # 2794501, 2795906, 2797185, 2805113, 2806530, 2807701.
Findings
The inspection found two deficiencies related to failure to protect a resident from abuse by another resident. One deficiency lacked evidence text, but both had plans of correction provided.
Deficiencies (2)
§483.12 — The facility failed to protect the rights of one resident to be free from abuse by another resident, which could result in other residents being abused.
R9-10-410 — No evidence text provided for this deficiency related to abuse.
Report Facts
Deficiencies cited: 2
Inspection Report — Feb 25, 2026
Complaint Investigation
Date: Feb 25, 2026
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On-site complaint investigation of intakes 00159955 and 2787054 at a Nursing Care Institution, conducted 25 February 2026.
Complaint Details
Investigation of intakes #00159955 and 2787054 was conducted on February 25, 2026. No deficiencies were cited.
Findings
No deficiencies were cited during this complaint investigation.
Inspection Report — Dec 3, 2025
Complaint Investigation
Date: Dec 3, 2025
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On-site complaint investigation of complaints 2679341, 00151282, 00151631, 2669127, 2670857, 00150829, 00150574, and 00146485 at a Nursing Care Institution, conducted 3 December 2025.
Complaint Details
The investigation of complaints 2679341, 00151282, 00151631, 2669127, 2670857, 00150829, 00150574, and 00146485 was conducted on December 3, 2025. Federal comments referenced additional complaints investigated on the same date with no deficiencies cited.
Findings
No deficiencies were cited during this complaint investigation.
Report Facts
Complaints investigated: 8
Inspection Report — Dec 2, 2025
Date: Dec 2, 2025
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The inspection was conducted to assess compliance with regulatory requirements related to resident injury notification and care following an unwitnessed fall and injury of resident #222.
Findings
The facility failed to ensure timely notification of the resident's representative regarding an injury sustained by resident #222 after an unwitnessed fall. Staff did not promptly report the incident to family or supervisors, which was a violation of facility policy and expectations.
Deficiencies (1)
Failure to notify resident's representative of injury following an unwitnessed fall.
Report Facts
Resident ID: 222
Date of fall: Oct 17, 2025
Date family notified: Oct 20, 2025
BIMS score: 0
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff #260 | Licensed Practical Nurse | Confirmed bruising on resident #222 and described skin assessments |
| Staff #250 | Certified Nursing Assistant | Reported bruising and described fall risk procedures |
| Staff #245 | Licensed Practical Nurse | Acknowledged error in not reporting fall incident promptly |
| RR #200 | Resident's Representative | Reported lack of notification from facility about resident injury |
| Staff #230 | Director of Nursing | Described facility policy and reeducation of staff regarding timely reporting |
Inspection Report — Dec 2, 2025
Complaint Investigation
Date: Dec 2, 2025
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On-site complaint investigation of complaints 2650464, 2651882, 2651921, 2649932 and 2649229 at a Nursing Care Institution, conducted 25 October 2025 through 27 October 2025.
Complaint Details
The onsite complaint survey was conducted on October 25, 2025 through October 27, 2025 and investigated complaints # 2650464, 2651882, 2651921, 2649932 & 2649229.
Findings
The inspection found two deficiencies related to failure to notify a resident's representative of an injury in a timely manner. Both deficiencies were cited based on closed record review, staff interviews, and policy review.
Deficiencies (2)
§483.10(g)(14) — The facility failed to ensure that the resident's representative was notified of an injury for one resident (#222), risking that representatives would not be informed of resident injuries.
R9-10-412 — The facility failed to ensure that the resident's representative was notified of an injury for one resident (#222) as soon as possible but no more than 24 hours after the event.
Report Facts
Deficiencies cited: 2
Complaints investigated: 5
Inspection Report — Nov 26, 2025
Complaint Investigation
Date: Nov 26, 2025
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On-site complaint investigation of multiple complaints at a Nursing Care Institution, conducted 24 to 26 November 2025.
Complaint Details
The state-compliance survey was conducted from November 24, 2025 through November 26, 2025, in conjunction with the investigation of complaints #2243498, 2243711, 2243736, 2243763, 2243764, 2243765, 2243766, 2243767, 2243769, 2243770, 2244359, 2243772, 2243771, 2243775, 2243778, 2243784, 2243302, 2243788, and 2243789.
Findings
Two deficiencies were cited related to failure to conduct thorough investigations of abuse and failure to protect residents from abuse by other residents.
Deficiencies (2)
R9-10-403 — The administrator failed to conduct a thorough investigation of abuse for multiple residents based on clinical record review, staff interviews, and facility investigation.
R9-10-410 — The facility failed to protect the rights of eight residents to be free from abuse by other residents, based on clinical record reviews, documentation, and interviews.
Report Facts
Deficiencies cited: 2
Inspection Report — Nov 19, 2025
Complaint Investigation
Date: Nov 19, 2025
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On-site complaint investigation of Intake #00147057 and Intake #2636660 at a Nursing Care Institution, conducted 19 November 2025.
Complaint Details
Investigation of Intake #00147057 and Intake #2636660 was conducted on October 9, 2025. No deficiencies were cited.
Findings
No deficiencies were cited during this complaint investigation.
Inspection Report — Sep 18, 2025
Complaint Investigation
Date: Sep 18, 2025
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On-site complaint investigation of complaints 00142480, 00142546, 2594415, 00141270, 2601705, 2601548, and 2592384 at a Nursing Care Institution, conducted 18 September 2025.
Complaint Details
The Complaint survey was conducted on September 18, 2025, for the investigation of the following complaints #00142480, 00142546, 2594415, 00141270, 2601705, 2601548, 2594415, 2592384. There were no deficiencies cited.
Findings
This inspection resulted in no deficiencies cited.
Report Facts
Complaints investigated: 8
Inspection Report — Aug 15, 2025
Complaint Investigation
Date: Aug 15, 2025
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On-site complaint investigation of multiple complaints including 00134008, AZ00212647, and 00140823 at a Nursing Care Institution, conducted 15 August 2025.
Complaint Details
The complaint survey was conducted 8/15/2025, with investigation of intakes: 00134008, 224368, 2244277, 2244278, 2243339, 2243325, 2243355, AZ00212647, AZ00212645, AZ00212816, AZ00212815, AZ00212647, 00140823, 2244284, AZ00212941, AZ00212940, 2244285, AZ00214807, AZ00214808, AZ00214807, 2244285, 2243752, 2243752, AZ00222082, AZ00222080, 2244354, AZ00224006. There were no deficiencies cited.
Findings
This inspection resulted in no deficiencies cited or findings.
Inspection Report — Aug 7, 2025
Complaint Investigation
Date: Aug 7, 2025
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On-site complaint investigation of intake #00138681, AZ00216997, AZ00214982, AZ00214902 at a Nursing Care Institution, conducted 7 August 2025.
Complaint Details
An onsite complaint survey was conducted on August 07, 2025 for the investigation of intake #00138681, AZ00216997, AZ00214982, AZ00214902. Federal comments also reference intake #2581283, AZ00216995, AZ00214982, AZ00214901 with no deficiencies cited.
Findings
No deficiencies were cited during this complaint investigation.
Report Facts
Complaints investigated: 4
Inspection Report — Jul 25, 2025
Complaint Investigation
Date: Jul 25, 2025
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On-site complaint investigation of complaints 2243368 and 2243339 at a Nursing Care Institution, conducted 25 July 2025.
Complaint Details
An Risk-Based Complaint survey was conducted on July 23 through July 25, 2025 for the investigation of #2243368, 2243339.
Findings
One deficiency was cited during this complaint investigation. No evidence text was provided for the cited deficiency.
Deficiencies (1)
R9-10-410 — The administrator failed to ensure that a resident was not subjected to abuse. No evidence text was provided.
Report Facts
Deficiencies cited: 1
Inspection Report — Jul 15, 2025
Complaint Investigation
Date: Jul 15, 2025
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The inspection was conducted due to a complaint investigation regarding an alleged abuse incident between two residents (Resident #16 and Resident #3) at the facility.
Complaint Details
The complaint involved Resident #16 reporting that Resident #3 struck him in the face and attempted to choke him. The incident occurred on July 3, 2025. Witnesses included a Life Enrichment Associate who saw the incident but was not interviewed. The facility failed to report the abuse to the State Agency and Adult Protective Services within the required two-hour timeframe and did not conduct a thorough investigation as required by policy.
Findings
The facility failed to protect a resident from abuse by another resident, failed to timely investigate and report the alleged abuse within the mandatory two-hour timeframe, and did not follow proper procedures for interviewing witnesses and staff. The Executive Director confirmed gaps in the investigation and reporting process despite staff training on abuse reporting.
Deficiencies (3)
Failed to protect residents from abuse including physical and emotional harm.
Failed to develop and implement policies and procedures to prevent abuse, neglect, and theft.
Failed to timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Report Facts
Date of alleged incident: 2025
Date of survey completion: 2025
Number of staff interviews denying witnessing incident: 3
BIMS score Resident #16: 14
BIMS score Resident #3: 0
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff #7 | Life Enrichment Associate | Witnessed the incident where Resident #3 hit Resident #16 but was not interviewed during investigation |
| Staff #35 | Executive Director | Abuse officer who confirmed staff training and investigation procedures but acknowledged gaps in investigation and reporting |
| Staff #4 | Licensed Practical Nurse | Heard about the altercation from a case worker but did not witness it |
Inspection Report — Jul 15, 2025
Complaint Investigation
Date: Jul 15, 2025
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On-site complaint investigation of complaints 00135689, 00136012, 00136014, AZ00225111, AZ00225136, and AZ00225137 at a Nursing Care Institution, conducted 15 July 2025.
Complaint Details
The complaint survey was conducted on July 15, 2025 in conjunction with the investigation of the following complaints: 00135689, 00136012, 00136014, AZ00225111, AZ00225136, and AZ00225137. The census was 159.
Findings
Six deficiencies were cited related to abuse, neglect, and exploitation reporting and prevention. No specific evidence was provided in the report for these deficiencies.
Deficiencies (6)
R9-10-403 — No evidence text provided for the failure to report suspected abuse, neglect, or exploitation as required by the administrator.
R9-10-403 — No evidence text provided for the failure to maintain documentation of abuse, neglect, or exploitation reports for at least 12 months.
§483.12(a)(1) — No evidence text provided for failure to ensure the facility did not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion.
§483.12(b) — No evidence text provided for failure to develop and implement written policies and procedures to prohibit and prevent abuse, neglect, and exploitation of residents.
§483.12(c) — No evidence text provided for failure to report alleged violations involving abuse, neglect, exploitation, or mistreatment immediately or within required timeframes and to report investigation results timely.
R9-10-410 — No evidence text provided for failure to ensure residents were not subjected to abuse.
Report Facts
Deficiencies cited: 6
Complaints investigated: 6
Inspection Report — Jul 3, 2025
Complaint Investigation
Date: Jul 3, 2025
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On-site complaint investigation of complaints AZ00225062, SF00135196, AZ00209074, and AZ00210557 at a Nursing Care Institution, conducted 3 July 2025.
Complaint Details
The complaint survey was conducted on JULY 3, 2025, in conjunction with the investigation of complaints: AZ00225062, SF00135196, AZ00209074, AZ00210557.
Findings
The inspection found two deficiencies related to failure to protect a resident from abuse by another resident. Plans of correction were provided for both deficiencies.
Deficiencies (2)
§483.12 — The facility failed to protect the rights of one resident #222 to be free from abuse by another resident #333, which could result in further abuse.
R9-10-410 — The facility failed to protect the rights of one resident #222 to be free from abuse by another resident #333.
Report Facts
Deficiencies cited: 2
Inspection Report — Jun 13, 2025
Complaint Investigation
Date: Jun 13, 2025
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On-site complaint investigation of complaints 00133413 and AZ00224858 at a Nursing Care Institution, conducted 13 June 2025.
Complaint Details
The complaint investigation of intake # 00133413 and intake # AZ00224858 was conducted on June 13, 2025. No deficiencies were cited.
Findings
No deficiencies were cited during this complaint investigation.
Report Facts
Complaints investigated: 2
Inspection Report — May 27, 2025
Complaint Investigation
Date: May 27, 2025
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The inspection was conducted due to a complaint investigation regarding an incident of resident-to-resident abuse where one resident physically harmed another.
Complaint Details
The facility substantiated resident-to-resident abuse after an incident where Resident #32 grabbed Resident #121's leg and pulled him to the ground. The investigation included staff interviews and review of clinical records and policies.
Findings
The facility failed to prevent resident #32 from physically abusing resident #121, resulting in minimal harm or potential for actual harm. The investigation substantiated the abuse, and interventions included separating the residents, placing resident #32 on 1:1 supervision, and completing a unit change.
Deficiencies (1)
Failure to protect residents from physical abuse by another resident.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff#52 | Certified Nursing Assistant | Witnessed and reported the incident between Resident #32 and Resident #121. |
| Staff#170 | Licensed Practical Nurse | Witnessed the incident but was unavailable for telephonic interview. |
| Staff#43 | Administrator and Abuse Coordinator | Provided information about the incident, interventions, and facility policies. |
Inspection Report — May 13, 2025
Enforcement
Date: May 13, 2025
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Civil monetary penalty, action 00131011 (invoice INV-282967), assessed 13 May 2025.
Findings
A $500.00 penalty was assessed and paid in full on 26 June 2025.
Report Facts
Penalty amount: 500
Amount paid: 500
Amount remaining: 0
Inspection Report — Apr 25, 2025
Complaint Investigation
Date: Apr 25, 2025
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On-site complaint investigation of intakes 00127334, 00127556, 00128182, 00128109, 00128155, 00128009, 00127991, AZ00224232, AZ00224269, AZ00224262, AZ00224267, AZ00224258, AZ00224275, and AZ00224276 at a Nursing Care Institution, conducted 25 April 2025.
Complaint Details
A complaint investigation was conducted on April 25, 2025 through April 25, 2025 of intake # 00127334, 00127556, 00128182, 00128109, 00128155, 00128009, 00127991 and intake # AZ00224232, AZ00224269, AZ00224262, AZ00224267, AZ00224258, AZ00224275, AZ00224276. There were no deficiencies cited.
Findings
No deficiencies were cited during this complaint investigation.
Report Facts
Complaints investigated: 14
Inspection Report — Apr 17, 2025
Complaint Investigation
Date: Apr 17, 2025
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On-site complaint investigation of complaints 00126069, 00126142, 00127004, AZ00224102, AZ00224110, and AZ00224190 at a Nursing Care Institution, conducted 15 through 17 April 2025.
Complaint Details
Complaints 00126069, 00126142 and 00127004 were investigated from April 15, 2025 through April 17, 2025. Complaints AZ00224102, AZ00224110, and AZ00224190 were investigated from April 15, 2025 through April 17, 2025. There were no deficiencies.
Findings
This inspection resulted in no deficiencies or citations.
Report Facts
Complaints investigated: 6
Inspection Report — Mar 24, 2025
Complaint Investigation
Date: Mar 24, 2025
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The inspection was conducted due to a complaint investigation regarding a non-prescribed medication overdose involving Resident #12, suspected to have been caused by another resident sharing fentanyl.
Complaint Details
The investigation was complaint-driven, focusing on a suspected overdose incident involving Resident #12. The complaint was substantiated as the resident was found unresponsive due to fentanyl overdose, which was not prescribed and obtained from outside the facility. Resident #24 admitted to giving fentanyl to Resident #12.
Findings
The facility failed to ensure adequate supervision to prevent a non-prescribed medication overdose for Resident #12. Interviews and documentation revealed that Resident #24 gave fentanyl to Resident #12, resulting in an overdose and hospital admission. The facility's interventions to prevent illicit substances were insufficient.
Deficiencies (1)
Failure to ensure adequate supervision to prevent a non-prescribed medication overdose for Resident #12.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff #27 | Licensed Practical Nurse (LPN) | Interviewed regarding medication policies and awareness of the overdose incident. |
| Staff #3 | Licensed Practical Nurse (LPN) | Interviewed about unit assignments and knowledge of illicit substances in the facility. |
| Staff #42 | Assistant Director of Nursing (ADON) | Interviewed about interventions to prevent illicit substances and confirmed hospital records of overdose. |
Inspection Report — Mar 20, 2025
Complaint Investigation
Date: Mar 20, 2025
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The inspection was conducted due to allegations of staff to resident physical and verbal abuse involving two residents (#1 and #2) at the facility.
Complaint Details
The complaint investigation substantiated abuse allegations against CNA #5 for physical abuse of resident #1 and CNA #7 for verbal abuse of resident #2. Both staff were terminated and reported to the State Board of Nursing.
Findings
The facility failed to ensure residents #1 and #2 were free from physical and verbal abuse by staff. Staff #5 was found to have physically abused resident #1 and was terminated. Staff #7 was found to have verbally abused resident #2 and was also terminated. Both cases were substantiated by the facility.
Deficiencies (2)
Failure to protect resident #1 from physical abuse by CNA #5, including pushing the resident roughly and tipping a desk chair against the resident's wheelchair.
Failure to protect resident #2 from verbal abuse by CNA #7, including yelling and cursing at the resident.
Report Facts
BIMS score: 0
BIMS score: 12
Length of employment: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #5 | Certified Nursing Assistant | Named in physical abuse finding involving resident #1; admitted to incident and was terminated |
| CNA #7 | Certified Nursing Assistant | Named in verbal abuse finding involving resident #2; denied inappropriate language but was terminated |
| Licensed Practical Nurse Staff #11 | Licensed Practical Nurse | Witnessed physical abuse of resident #1 and reported concerns |
| Registered Nurse Staff #32 | Registered Nurse | Provided information on resident #2 and staff #7 behavior and facility context |
| Director of Nursing Staff #15 | Director of Nursing | Discussed facility policies and substantiation of abuse investigations |
| CNA Staff #22 | Certified Nursing Assistant | Witnessed verbal abuse incident involving resident #2 and staff #7 |
Inspection Report — Feb 27, 2025
Complaint Investigation
Date: Feb 27, 2025
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On-site complaint investigation of intakes 0108930, 00115727, 00120738, AZ00223445, AZ00223539, and AZ00223609 at a Nursing Care Institution, conducted 27 February 2025.
Complaint Details
A complaint survey was conducted on 2/27/25 for the investigation of intakes #0108930, 00115727, 00120738 and #AZ00223445, AZ00223539, AZ00223609. There were no deficiencies cited.
Findings
This inspection resulted in no deficiencies cited.
Report Facts
Complaints investigated: 6
Inspection Report — Feb 10, 2025
Date: Feb 10, 2025
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On-site inspection of a Nursing Care Institution classified as 'Other' type, conducted 10 February 2025 at Immanuel Campus of Care.
Findings
The inspection identified five deficiencies related to fire safety and emergency systems, including missing fire extinguishers, poorly maintained corridor doors, unsealed smoke barrier penetrations, lack of emergency lighting at the generator, and absence of a remote stop switch for the generator.
Deficiencies (5)
Portable Fire Extinguishers — The facility failed to provide a fire extinguisher near the generator, which could result in harm during an emergency.
R9-10-403.E — The facility failed to maintain several corridor doors, including gaps, missing latches, and improper hardware, which could allow heat and smoke to transfer and harm patients and staff.
Subdivision of Building Spaces - Smoke Barrier Construction — The facility failed to properly seal penetrations in multiple fire/smoke barrier areas, allowing smoke and heat to penetrate other wings and potentially harm patients during a fire.
Electrical Systems - Other — The facility did not provide battery-powered emergency lighting for the emergency generator, potentially affecting all 152 residents.
Electrical Systems - Essential Electric System Maintenance and Testing — The facility failed to ensure a remote stop or kill switch was installed for the generator, risking loss of power or fire during an emergency.
Report Facts
Deficiencies cited: 5
Inspection Report — Jan 31, 2025
Annual Inspection
Date: Jan 31, 2025
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On-site complaint investigation and annual recertification survey conducted January 28 through January 31, 2025, at a Nursing Care Institution, including investigation of complaints AZ00222524, AZ00222616, AZ00219154, AZ00212847, AZ00212137, AZ00212282, AZ00215819, AZ00222617, AZ00213412, and AZ00222759.
Complaint Details
The recertification survey was conducted January 28, 2025 through January 31, 2025, in conjunction with the investigation of complaints # AZ00222524, AZ00222616, AZ00219154, AZ00212847, AZ00212137, AZ00212282, AZ00215819, AZ00222617, AZ00213412, AZ00222759. Federal comments also referenced investigation of complaints #AZ00222254, AZ00222613, AZ00219154, AZ00212847, AZ00212568, AZ00215815, AZ00222617, AZ00222679, AZ00213400, AZ00222757, AZ00212137.
Findings
Three deficiencies were cited during this inspection. No evidence was provided in the report to detail the specific violations.
Deficiencies (3)
R9-10-410 — No evidence was provided to support a finding related to resident abuse.
R9-10-410 — No evidence was provided to support a finding related to residents' rights to retain personal possessions.
R9-10-412 — No evidence was provided to support a finding related to administration of unnecessary drugs to residents.
Report Facts
Deficiencies cited: 3
Inspection Report — Jan 31, 2025
Complaint Investigation
Date: Jan 31, 2025
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The inspection was conducted based on complaints and allegations related to resident dignity, abuse, and medication administration practices at Immanuel Campus of Care.
Complaint Details
The complaint investigation substantiated multiple incidents including resident #64 exposing herself in public areas, resident-to-resident physical abuse involving residents #12 and #400, and residents #137 and #105. The facility failed to report and manage these incidents timely and appropriately. The allegation of resident-to-resident abuse was substantiated based on staff witnessing and resident admissions.
Findings
The facility failed to ensure residents were treated with dignity and respect, failed to protect residents from abuse including resident-to-resident physical altercations, and failed to properly monitor behaviors as specified in psychotropic medication orders. Several residents were involved in incidents of exposure and physical abuse with minimal harm noted. Medication administration records did not reflect required behavior monitoring for certain residents.
Deficiencies (4)
Failure to honor resident's right to be treated with respect and dignity, including incidents of resident #64 exposing herself in public areas.
Failure to protect residents (#12 and #400) from physical abuse by another resident, including a physical altercation resulting in punches to the face.
Failure to protect residents (#137 and #105) from resident-to-resident abuse, including physical aggression and hitting.
Failure to ensure medication administration records accurately reflected targeted behavior monitoring as specified within physician orders for residents (#118, #123).
Report Facts
Residents affected: 1
Residents affected: 2
Residents affected: 2
Medication administration monitoring failures: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant (CNA) Staff #736 | Reported resident #64 exposing herself and failure to report incidents | |
| Licensed Practical Nurse (LPN) Staff #723 | Expressed concerns about resident #64 dignity and exposure incidents | |
| Director of Nursing (DON) Staff #405 | Provided expectations for reporting exposure incidents and abuse; described facility abuse reporting procedures | |
| Licensed Practical Nurse (LPN) Staff #95 | Witnessed and intervened in physical altercation between residents #12 and #400 | |
| Certified Nursing Assistant (CNA) Staff #150 | Reported awareness of physical fight between residents #12 and #400 | |
| Licensed Practical Nurse (LPN) Staff #854 | Heard about physical altercation between residents #12 and #400 | |
| Administrator Staff #28 | Confirmed role as abuse coordinator and substantiated resident-to-resident abuse | |
| Certified Nursing Assistant (CNA) Staff #762 | Described procedures for monitoring and reporting resident-to-resident altercations | |
| Certified Nursing Assistant (CNA) Staff #315 | Reviewed training for resident-to-resident altercation reporting | |
| Licensed Practical Nurse (LPN) Staff #30 | Described resident behaviors and unit transfers related to resident-to-resident abuse | |
| Licensed Practical Nurse (LPN) Staff #768 | Confirmed medication administration practices and behavior monitoring requirements | |
| Licensed Practical Nurse (LPN) Staff #111 | Reviewed medication administration records and confirmed lack of behavior monitoring for residents #118 and #123 |
Inspection Report — Jan 23, 2025
Complaint Investigation
Date: Jan 23, 2025
Visit Reason
On-site complaint investigation of intakes AZ00222522, AZ00221827, AZ00221789, AZ00222400 at a Nursing Care Institution, conducted 23 January 2025.
Complaint Details
A complaint survey was conducted on January 23, 2025 for the investigation of intake # AZ00222522, AZ00221827, AZ00221789, AZ00222400. Federal comments also note investigation of intakes AZ00221789, AZ00222400, AZ00222521, AZ00221826. There were no deficiencies cited.
Findings
This inspection resulted in no deficiencies cited.
Report Facts
Complaints investigated: 7
Inspection Report — Jan 3, 2025
Complaint Investigation
Date: Jan 3, 2025
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On-site complaint investigation of intake AZ00221159 and AZ00221158 at a Nursing Care Institution, conducted 3 January 2025.
Complaint Details
A complaint survey was conducted on January 03, 2024 for the investigation of intake # AZ00221159. A complaint survey was conducted on January 03, 2024 for the investigation of intake # AZ00221158. There were no deficiencies cited.
Findings
This inspection found no deficiencies.
Inspection Report — Dec 20, 2024
Complaint Investigation
Date: Dec 20, 2024
Visit Reason
The inspection was conducted due to complaints regarding residents not being allowed to leave their rooms during a COVID-19 outbreak, failure to provide activities to COVID-19 positive residents, and inadequate supervision of a resident with suicidal behavior.
Complaint Details
The complaint investigation was substantiated, revealing that residents were improperly restricted to their rooms during COVID-19 quarantine and that one resident was inadequately supervised leading to a suicide attempt.
Findings
The facility failed to ensure residents (#55 and #33) were allowed to leave their rooms during COVID-19 quarantine, resulting in dignity and respect violations. Activities were not offered to COVID-19 positive residents, impacting their psychosocial well-being. Additionally, the facility failed to provide adequate supervision to resident #77, who attempted self-harm when left unsupervised.
Deficiencies (3)
Residents #55 and #33 were not allowed to leave their rooms during COVID-19 quarantine, violating their rights to dignity and respect.
Residents #55 and #33 were not offered activities during their COVID-19 positive quarantine period, impacting psychosocial well-being.
Resident #77 was left unsupervised despite a one-to-one supervision order, resulting in a suicide attempt.
Report Facts
Quarantine duration: 18
COVID-19 positive test date: Dec 2, 2024
Vital signs: 127
Vital signs: 104
Vital signs: 155
Vital signs: 99
Vital signs: 98
Vital signs: 24
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant (CNA/staff #6) | Observed telling resident #33 to get back in her room in an unwelcoming tone. | |
| Nursing Administrator Staff (LPN/staff 17) | Reviewed COVID-19 line list and stated residents #55 and #33 should have been allowed out of rooms after quarantine. | |
| Quality Assurance and Performance Improvement (QAPI) nurse / Infection Control Preventionist (staff #20) | Stated quarantine time and staff notification procedures; emphasized dignity and respect. | |
| Licensed Practical Nurse (LPN/staff #14) | Reported being told no residents were allowed out of rooms due to ongoing illness. | |
| Activity Assistant/Life Enrichment Associate (staff #26) | Reported not offering activities to COVID-19 positive residents during outbreak. | |
| Life Enrichment Director (staff #35) | Discussed purpose of activities and lack of documentation. | |
| Director of Nursing (DON/staff #1) | Discussed expectations for activities and supervision; involved in resident #77 incident. | |
| Licensed Practical Nurse (LPN/staff #12) | Reported resident #77 was left unsupervised due to staff assisting another emergency. |
Inspection Report — Nov 7, 2024
Complaint Investigation
Date: Nov 7, 2024
Visit Reason
On-site complaint investigation of complaints AZ00218429, AZ00218433, AZ00218220, AZ00218166, AZ00210494, AZ00218229, AZ00210504, AZ00217686, AZ00218314, AZ00218478, and AZ00218291 at a Nursing Care Institution, conducted 7 November 2024.
Complaint Details
The onsite complaint survey was conducted November 4 through November 7, 2024, investigating complaints AZ00218429, AZ00218433, AZ00218220, AZ00218166, AZ00210494, AZ00218229, AZ00210504, AZ00217686, AZ00218314, AZ00218478, and AZ00218291. No deficiencies were cited.
Findings
No deficiencies were cited during this complaint investigation.
Report Facts
Complaints investigated: 11
Inspection Report — Oct 29, 2024
Complaint Investigation
Date: Oct 29, 2024
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On-site complaint investigation of intakes AZ00217784, AZ00217843, AZ00217975, AZ00210040, and AZ0017636 at a Nursing Care Institution, conducted 29 October 2024.
Complaint Details
An onsite complaint survey was conducted on October 29, 2024 of intake # AZ00217784, AZ00217843, AZ00217975, AZ00210040, AZ0017636. The following deficiencies were cited: An onsite complaint survey was conducted on October 9, 2024 of intake #AZ00217780, AZ00217843, AZ00217974, AZ00210040. There were no deficiencies cited.
Findings
The inspection found one deficiency related to failure to provide timely written notification of a resident's self-inflicted injury requiring emergency medical services. The facility failed to notify the Department within two working days after the incident involving resident #36.
Deficiencies (1)
R9-10-403.H.2 — The facility failed to provide written notification within two working days after a self-inflicted injury requiring emergency medical services for resident #36. This failure could result in the state agency being uninformed of residents with such injuries.
Report Facts
Deficiencies cited: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff #18 | Unit Manager | Interview regarding facility procedures for suicide attempts and reporting. |
| Staff #10 | Certified Nursing Assistant | Interview regarding implementation of 1:1 supervision and notification procedures. |
| Staff #23 | Director of Nursing | Interview regarding facility process for monitoring and reporting self-harm threats or attempts. |
Inspection Report — Oct 25, 2024
Complaint Investigation
Date: Oct 25, 2024
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On-site complaint investigation of multiple complaints including AZ00217755, AZ00217627, AZ00217088, AZ00212225, AZ00212216, AZ00211116, AZ00210359, and AZ00217614 at a Nursing Care Institution, conducted 22 October 2024.
Complaint Details
A complaint survey was conducted on October 22, 2024, for the investigation of intake #s:AZ00217755, AZ00217627, AZ00217088, AZ00212225, AZ00212216, AZ00211116, AZ00210359, AZ00217614. No deficiencies were cited. Federal comments noted a similar complaint survey with overlapping intake numbers and no deficiencies cited.
Findings
No deficiencies were cited during this complaint investigation.
Inspection Report — Sep 30, 2024
Complaint Investigation
Date: Sep 30, 2024
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On-site complaint investigation of intakes AZ00216193 and AZ00216204 at a Nursing Care Institution, conducted 30 September 2024.
Complaint Details
An onsite investigation was conducted on September 30, 2024 on intakes # AZ00216193, AZ00216204. There were no deficiencies cited. Federal Comments also note an onsite investigation on September 30, 2024 on intakes # AZ00216193, AZ00216203 with no deficiencies cited.
Findings
No deficiencies were cited during this complaint investigation.
Report Facts
Complaints investigated: 2
Inspection Report — Sep 5, 2024
Complaint Investigation
Date: Sep 5, 2024
Visit Reason
The inspection was conducted following a complaint regarding verbal abuse by a staff member towards a resident.
Complaint Details
The complaint was substantiated based on clinical record reviews, staff interviews, and facility documentation. Staff member #4 admitted to verbal abuse and was terminated following investigation.
Findings
The facility failed to ensure a resident was free from verbal abuse by a staff member, who used inappropriate language and was subsequently terminated. The investigation confirmed unprofessional conduct and lack of behavior documentation in the resident's records.
Deficiencies (1)
Failure to protect a resident from verbal abuse by staff members.
Report Facts
Date of reported incident: Aug 29, 2024
Date of staff in-service abuse training: Jul 19, 2024
Date of staff #4 prior orientation abuse training: May 1, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Confirmed termination of staff member #4 during entrance conference | |
| Staff member #4 admitted to verbal abuse and was suspended pending investigation and later terminated |
Inspection Report — Jul 10, 2024
Annual Inspection
Date: Jul 10, 2024
Visit Reason
The inspection was conducted as part of an annual survey to assess compliance with professional standards, specifically focusing on the completeness and accuracy of skin assessments and documentation for residents.
Findings
The facility failed to ensure that skin assessments were complete and accurately documented for resident #43, who had multiple bruises and discolorations that were not properly recorded in weekly skin checks. Interviews with staff confirmed that bruising was noted but not documented as required by facility policy.
Deficiencies (1)
Failure to ensure that the skin assessment was complete and accurately documented in the clinical record for resident #43.
Report Facts
Number of discolorations noted: 4
Dates of weekly skin checks missing bruise documentation: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant (CNA) | Staff #224 noted discolorations and bruises on resident #43 during care and observation | |
| Licensed Practical Nurse (LPN) | Staff #40 familiar with resident #43 and confirmed bruising was reported but not documented | |
| Director of Nursing (DON) | Staff #83 stated weekly skin assessments should be completed accurately and include all skin alterations |
Inspection Report — Jul 10, 2024
Complaint Investigation
Date: Jul 10, 2024
Visit Reason
On-site complaint investigation of complaints AZ00212775, AZ00212454, AZ00212772, and AZ00212705 at a Nursing Care Institution, conducted 9 and 10 July 2024.
Complaint Details
The complaint survey was conducted on July 9 and 10, 2024 for the investigation of intake numbers AZ00212775, AZ00212454, AZ00212772, and AZ00212705. Deficiencies related to incomplete and inaccurate skin assessment documentation were cited.
Findings
The inspection found two deficiencies related to incomplete and inaccurate documentation of skin assessments for one resident (#43). The facility failed to document bruising and discolorations accurately in the clinical record and weekly skin checks.
Deficiencies (2)
R9-10-403.C — The facility failed to ensure that the skin assessment was complete and accurately documented in the clinical record for resident #43, missing documentation of bruising and discolorations noted during observations and progress notes.
§483.20(f)(5), §483.70(i) — The facility failed to maintain complete, accurate, and confidential medical records for resident #43, resulting in incomplete documentation of skin conditions that could affect care.
Report Facts
Deficiencies cited: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff #224 | Certified Nursing Assistant | Observed resident #43 and interviewed regarding skin bruising and bedrail padding. |
| Staff #40 | Licensed Practical Nurse | Interviewed about resident #43's bruising and clinical record documentation. |
| Staff #83 | Director of Nursing | Interviewed about skin assessment policies and documentation requirements. |
Inspection Report — Jun 11, 2024
Enforcement
Date: Jun 11, 2024
Visit Reason
Civil monetary penalty, action 00111082 (invoice INV-257918), assessed 11 June 2024.
Findings
A $500.00 penalty was assessed and paid in full on 8 August 2025.
Report Facts
Penalty amount: 500
Amount paid: 500
Amount remaining: 0
Inspection Report — Jun 4, 2024
Complaint Investigation
Date: Jun 4, 2024
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On-site complaint investigation of intakes AZ00211145, AZ00210669 and AZ00210731 at a Nursing Care Institution, conducted 31 May 2024 to 4 June 2024.
Complaint Details
The complaint survey was conducted on May 31, 2024 and June 4, 2024 for the investigation of intake #s:AZ00211145, AZ00210669 and AZ00210731. There were no deficiencies cited.
Findings
No deficiencies were found during this complaint investigation.
Inspection Report — Apr 19, 2024
Complaint Investigation
Date: Apr 19, 2024
Visit Reason
On-site complaint investigation conducted from April 5 through April 19, 2024 at Immanuel Campus of Care, a Nursing Care Institution, for multiple complaint intake numbers including AZ00190719, AZ00191557, AZ00191552, and others.
Complaint Details
A complaint survey was conducted from April 5 through April 19, 2024 for the investigation of multiple intake numbers including AZ00190719, AZ00191557, AZ00191552, AZ00191629, AZ00191698, AZ00191953, AZ00192115, AZ00192160, AZ00192149, AZ00192139, AZ00192453, AZ00192581, AZ00192636, AZ00192663, AZ00192654, AZ00192706, AZ00192572, AZ00193142, AZ00193476, AZ00193577, AZ00193925, AZ00194273, AZ00194583, AZ00194570, AZ00194706, AZ00195006, AZ00195791, AZ00195906, AZ00195959, AZ00196276, AZ00196305, AZ00196466, AZ00196526, AZ00196952, AZ00196937, AZ00197034, AZ00197001, AZ00197149, AZ00197246, AZ00197468, AZ00197475, AZ00197441, AZ00197631, AZ00197620, AZ00197737, AZ00197920, AZ001978002, AZ00198030, AZ00198047, AZ00198104, AZ00198153, AZ00198491, AZ00198603, AZ00198642, AZ00198785, AZ00198847, AZ00198927, AZ00198936, AZ00199388, AZ00199366, AZ00199243, AZ00199635, AZ00199670, AZ00199640, AZ00199746, AZ00199705, AZ00199809, AZ00199870, AZ00199924, AZ00200089, AZ00200272, AZ00202545, AZ00202657, AZ00202799, AZ00202813, AZ00202884, AZ00203223, AZ00203398, AZ00203458, AZ00203740, AZ00203763, AZ00204393, AZ00204476, AZ00204579, AZ00204684, AZ00205359, AZ00205430, AZ00205533, AZ00206315, AZ00206408, AZ00206574, AZ00206524, AZ00207303, AZ00207345, AZ00207552, AZ00207706, AZ00207076, AZ00208558, AZ00208610, AZ00208782, AZ00208784, AZ00208841, AZ00208838, AZ00208901, AZ00208938 and AZ00209246.
Findings
The inspection found two deficiencies related to failure to protect residents from abuse by other residents, including incidents resulting in physical injuries and aggressive behaviors. The facility submitted plans of correction for both deficiencies.
Deficiencies (2)
§483.12 — The facility failed to protect the rights of 21 residents to be free from abuse by another resident, resulting in injuries including lacerations and fractures. Incidents involved aggressive behaviors by residents leading to physical harm and hospitalizations.
R9-10-410 — The administrator failed to ensure residents were not subjected to abuse, as evidenced by incidents where residents pushed and physically harmed each other, resulting in injuries and hospital evaluations. Investigations confirmed substantiated resident-to-resident abuse.
Report Facts
Deficiencies cited: 2
Complaints investigated: 90
Inspection Report — Mar 20, 2024
Complaint Investigation
Date: Mar 20, 2024
Visit Reason
On-site complaint investigation of complaints AZ00207666, AZ00207251, AZ00206452, AZ00206449, AZ00207247, and AZ00207663 at a Nursing Care Institution, conducted 20 March 2024.
Complaint Details
An investigation of complaint #'s AZ00207666, AZ00207251, AZ00206452, AZ00206449, AZ00207247, and AZ00207663 was conducted on March 20, 2024. There were no deficiencies cited.
Findings
This inspection resulted in no deficiencies or citations.
Inspection Report — Mar 8, 2024
Complaint Investigation
Date: Mar 8, 2024
Visit Reason
On-site complaint investigation conducted from February 26 through March 8, 2024, for multiple intake numbers including AZ00207011, AZ00206787, AZ00206893, and others at a Nursing Care Institution.
Complaint Details
A complaint survey was conducted from February 26 through March 8, 2024, investigating intake numbers AZ00207011, AZ00206787, AZ00206893, AZ00206899, AZ00206907, AZ00206840, AZ00206861, AZ00206845, AZ00206524, AZ0019031, and AZ00190017. Federal comments referenced similar intake numbers including AZ00207010, AZ00206783, AZ00206892, AZ00206898, AZ00206905, AZ00206840, AZ00206860, AZ00206844, AZ00206524, AZ00190313, and AZ00190017.
Findings
The inspection found three deficiencies related to failure to provide care consistent with professional standards, failure to prevent resident elopement, and failure to ensure a comprehensive care plan addressing resident needs. Plans of correction were provided for all deficiencies.
Deficiencies (3)
§483.21(b)(3) — The facility failed to ensure that resident #90 was provided care consistent with professional standards, including inappropriate staff behavior violating professional boundaries and jeopardizing resident safety and dignity.
§483.25(d) — The facility failed to ensure that resident #90 did not elope, lacking a care plan for elopement risk despite orders restricting resident passes and documented incidents of elopement.
R9-10-414 — The facility failed to ensure that resident #90 was provided nursing care that assisted in maintaining the resident's highest practicable well-being, including failure to prevent elopement and inappropriate staff conduct.
Report Facts
Deficiencies cited: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff #323 | Social Worker | Terminated for inappropriate behavior with resident #90 involving crossing professional boundaries. |
| Staff #300 | Social Services Assistant | Reported observations of inappropriate interactions between staff #323 and resident #90. |
| Staff #1 | Licensed Practical Nurse | Observed inappropriate situation involving staff #323 and resident #90 and reported to DON. |
| Staff #65 | Licensed Practical Nurse | Provided information about elopement procedures and incidents involving resident #90. |
| Staff #186 | Director of Nursing | Provided information about elopement policies and incidents involving resident #90. |
| Staff #106 | Administrator | Provided facility employee handbook sections related to professional conduct and relationships. |
Inspection Report — Mar 7, 2024
Complaint Investigation
Date: Mar 7, 2024
Visit Reason
On-site complaint investigation of complaints AZ00207307 and AZ00207306 at a Nursing Care Institution, conducted 7 March 2024.
Complaint Details
An investigation of complaints AZ00207307 and AZ00207306 was conducted March 7, 2024. There were no deficiencies cited.
Findings
This inspection resulted in no deficiencies cited.
Inspection Report — Feb 1, 2024
Complaint Investigation
Date: Feb 1, 2024
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On-site complaint investigation of intakes AZ00205376, AZ00205401, and AZ00205375 at a Nursing Care Institution, conducted 31 January through 1 February 2024.
Complaint Details
A complaint survey was conducted on January 31, through February 1, 2024 for the investigations of intake #s: AZ00205376, AZ00205401, and AZ00205375. There were no deficiencies cited.
Findings
This inspection resulted in no deficiencies cited or findings.
Inspection Report — Dec 22, 2023
Complaint Investigation
Date: Dec 22, 2023
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On-site complaint investigation of complaints AZ00204442 and AZ00204166 at a Nursing Care Institution, conducted 21 December 2023.
Complaint Details
The state compliance survey was conducted on 12/21/23 in conjunction with the investigation of the following complaints, AZ00204442, AZ00204166. There were no deficiencies cited. The Complaint survey was conducted on 12/21/22 in conjunction with the investigation of the following complaints , AZ00204442 AZ00204166, There were no deficiencies cited.
Findings
This inspection resulted in no deficiencies or citations.
Inspection Report — Dec 1, 2023
Complaint Investigation
Date: Dec 1, 2023
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On-site complaint investigation of intakes AZ00203721, AZ00203421, AZ00202519, AZ00198154, AZ00198186, AZ00203720, AZ00203420, AZ00202516, AZ00198154 and AZ00198184 at a Nursing Care Institution, conducted 1 December 2023.
Complaint Details
A complaint survey was conducted on December 1, 2023 for the investigation of the following intake #s: AZ00203721, AZ00203421, AZ00202519, AZ00198154 and AZ00198186. Federal comments also note investigation of intakes AZ00203720, AZ00203420, AZ00202516, AZ00198154 and AZ00198184. There were no deficiencies cited.
Findings
This inspection resulted in no deficiencies cited.
Report Facts
Complaints investigated: 10
Inspection Report — Nov 20, 2023
Complaint Investigation
Date: Nov 20, 2023
Visit Reason
On-site complaint investigation of intake numbers AZ00203221, AZ00188539, AZ00189069, AZ00189166, AZ00189147, AZ00189431, AZ00189477, AZ00189467 and AZ00188335 at a Nursing Care Institution, conducted 20 November 2023.
Complaint Details
The complaint survey was conducted on November 20, 2023 for the investigation of intake numbers AZ00203221, AZ00188539, AZ00189069, AZ00189166, AZ00189147, AZ00189431, AZ00189477, AZ00189467 and AZ00188335. Federal comments list similar intake numbers with no deficiencies cited.
Findings
This inspection resulted in no deficiencies cited.
Inspection Report — Nov 3, 2023
Annual Inspection
Date: Nov 3, 2023
Visit Reason
On-site complaint investigation and annual recertification survey conducted October 30, 2023 through November 3, 2023, in conjunction with the investigation of complaints AZ00201316, AZ00201314, AZ00201319, AZ00202207, AZ00201114, AZ00201140, AZ00200912, AZ00200930, AZ00200935, AZ00200835, AZ00200775, and AZ00200346 at a Nursing Care Institution.
Complaint Details
The recertification survey was conducted October 30, 2023 through November 3, 2023, in conjunction with the investigation of complaints AZ00201316, AZ00201314, AZ00201319, AZ00202207, AZ00201114, AZ00201140, AZ00200912, AZ00200930, AZ00200935, AZ00200835, AZ00200775, and AZ00200346. Federal comments referenced complaints AZ00201315, AZ00201313, AZ00201317, AZ00202207, AZ00201114, AZ00201140, AZ00200911, AZ00200929, AZ00200934, AZ00200834, AZ00200775, and AZ00200344.
Findings
The inspection found multiple deficiencies including failure to complete required PASARR Level 2 referral for a resident, restrictions on residents' access to personal cell phones without clinical justification, lack of private phone use areas, failure to address resident medical needs in care plans, and incidents of verbal abuse by staff. Plans of correction were provided for all deficiencies.
Deficiencies (11)
R9-10-403 — The facility failed to ensure a Pre-Admission Screening and Resident Review (PASARR) Level 2 referral was completed for resident #48 after readmission with a new diagnosis, risking inadequate care.
The facility restricted residents #31 and #100 from accessing their personal cell phones except during limited times without documented clinical justification or care plan support.
The facility failed to address resident #160's medical needs related to breast lump, malignant neoplasm, liver cirrhosis, and Hepatitis C in the care plan and admission process, risking unmet health needs.
The facility failed to provide reasonable access to a telephone and a private place for calls for resident #418, resulting in lack of privacy and restricted phone use.
R9-10-410 — The facility failed to provide resident #418 reasonable access to telephone use and a private place for calls, with unsecured personal electronic items observed at the nurse's station.
The facility failed to ensure residents #27 and #53 were free from verbal abuse by staff, including a housekeeper who was terminated for calling a resident's mother a derogatory name.
The facility failed to complete a PASARR Level 2 referral for resident #48 with a new diagnosis, risking residents not receiving needed care and services.
The facility restricted residents' access to personal cell phones and limited phone use times without individual clinical justification or care plan documentation.
R9-10-410 — The facility failed to protect resident #27 and #53 from abuse, with documented verbal abuse by staff resulting in termination of the responsible employee.
R9-10-410 — The facility failed to support and respect resident #31's individuality and choices by restricting personal cell phone use without clinical basis or care plan documentation.
R9-10-414 — The facility failed to include diagnoses impacting nursing care for resident #160 in the comprehensive assessment and care plan, risking unmet health needs.
Report Facts
Deficiencies cited: 11
Complaints investigated: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff #115 | Social Services Assistant | Interviewed regarding PASARR Level I and II referral process for resident #48. |
| Staff #15 | Social Services Director | Interviewed regarding PASARR Level I and II referral process for resident #48. |
| Staff #69 | Director of Nursing | Interviewed regarding PASARR referral process and phone use policies. |
| Staff #225 | Certified Nursing Assistant | Interviewed regarding phone use restrictions for residents. |
| Staff #92 | Licensed Practical Nurse | Interviewed regarding phone use restrictions and policies. |
| Staff #39 | Director of Behavior Services | Interviewed regarding phone use policy rationale. |
| Staff #165 | Administrator | Interviewed regarding phone use policy and care plan documentation. |
| Staff #802 | Housekeeper | Involved in verbal abuse incident with resident #27. |
| Staff #206 | Housekeeper | Provided statement regarding verbal altercation involving resident #27 and staff #802. |
| Staff #253 | Registered Nurse | Provided statement regarding verbal altercation involving resident #27 and staff #802. |
| Staff #226 | Registered Nurse | Interviewed regarding phone use restrictions and resident privacy. |
Inspection Report — Nov 3, 2023
Date: Nov 3, 2023
Visit Reason
On-site inspection of a Nursing Care Institution classified as 'Other' conducted 3 November 2023, including a recertification survey for Medicare under the Life Safety Code 2012 Edition.
Findings
The inspection found six deficiencies related to fire protection, emergency lighting, sprinkler system installation, door maintenance, smoke barrier penetrations, and HVAC fire/smoke damper inspections. The facility acknowledged all findings during the exit conference.
Deficiencies (6)
Based on observation the facility failed to provide adequate fire protection and separation between a new outpatient treatment center and the nursing home, including absence of a fire wall above ceiling tiles. Failing to have proper extinguishing systems could harm patients and staff during a fire emergency.
Based on observation the facility failed to maintain two emergency lights within the building, which could cause harm to patients during an emergency power outage.
R9-10-403.E — A linen closet in Desert Cove was missing a required fire sprinkler head, risking harm to patients and staff during an emergency.
Based on observation the facility failed to maintain several doors, including missing closers, doors failing to latch securely, damaged doors, and excessive gaps, which could allow heat and smoke transfer causing harm to patients and staff.
Based on observation the facility failed to fill penetrations in smoke barriers and fire walls, allowing smoke and heat to penetrate other wings or the whole facility, risking patient safety during a fire.
Based on staff interview and record review the facility failed to inspect and maintain fire/smoke dampers or fusible links, with the last documented inspection dated January 30, 2019, risking harm during an emergency.
Report Facts
Deficiencies cited: 6
Inspection Report — Nov 3, 2023
Complaint Investigation
Date: Nov 3, 2023
Visit Reason
The inspection was conducted due to complaints and allegations of abuse involving residents and staff at the facility, including verbal and physical abuse and resident-to-resident altercations.
Complaint Details
The complaint investigation substantiated staff physical abuse by CNA staff #305 against resident #53, verbal abuse by housekeeper staff #802 against resident #27, and resident-to-resident abuse between residents #72 and #79. Staff #305 and staff #802 were terminated. Resident-to-resident altercation was substantiated with injuries noted.
Findings
The facility failed to ensure residents were free from abuse, including verbal abuse by staff, physical abuse by staff, and resident-to-resident altercations. Several incidents were substantiated, resulting in staff termination and implementation of monitoring and corrective actions.
Deficiencies (3)
Failure to protect residents from verbal abuse by staff, including a housekeeper calling a resident's mother a derogatory name.
Failure to protect a resident from staff physical abuse where a CNA hit a resident twice on the head.
Failure to prevent resident-to-resident abuse, including physical altercations resulting in injury.
Report Facts
Date of survey completion: Nov 3, 2023
Staff termination date: Oct 1, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff #802 | Housekeeper | Named in verbal abuse finding and terminated |
| Staff #305 | CNA | Named in physical abuse finding and terminated |
| Staff #133 | CNA | Witnessed physical abuse by staff #305 |
| Staff #92 | LPN | Heard resident yelling and reported abuse |
| Staff #165 | Administrator | Witnessed resident-to-resident altercation and substantiated it |
| Staff #69 | Director of Nursing | Interviewed regarding verbal abuse incident |
Inspection Report — Nov 3, 2023
Complaint Investigation
Date: Nov 3, 2023
Visit Reason
The inspection was conducted due to complaints regarding residents' access to personal phones, privacy during phone calls, and concerns about care planning and PASARR referrals.
Complaint Details
The investigation was complaint-driven, focusing on residents' rights to phone access and privacy, adequacy of care planning for medical conditions, and compliance with PASARR requirements.
Findings
The facility failed to ensure reasonable access to personal phones and privacy for phone calls for multiple residents, imposed broad and non-individualized restrictions on phone use, and did not document or justify these restrictions in care plans. Additionally, the facility failed to address a resident's significant medical diagnoses in the care plan and did not complete a required PASARR Level II referral for a resident with a new mental health diagnosis.
Deficiencies (3)
Failed to ensure residents had access to personal phones and privacy during phone calls, with restricted phone times and lack of private areas for calls.
Failed to address significant medical diagnoses in a resident's care plan, including left breast lump and other serious conditions.
Failed to complete required PASARR Level II referral for a resident with a new diagnosis of schizoaffective disorder, bipolar type.
Report Facts
Phone use time restriction: 15
Phone use allowed times: 4
PASARR referral timeframe: 28
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant (CNA/staff #41) | Interviewed regarding phone access restrictions and rationale | |
| Licensed Practical Nurse (LPN/staff #235) | Interviewed about phone access and privacy at nurse's station | |
| Certified Nursing Assistant (CNA/staff #85) | Interviewed about phone and tablet access policies | |
| Licensed Practical Nurse (LPN/staff #135) | Interviewed about phone and electronic device restrictions | |
| Certified Nursing Assistant (CNA/staff #225) | Interviewed about phone use times and restrictions | |
| Licensed Practical Nurse (LPN/staff #92) | Interviewed about phone use policies and rationale | |
| Director of Behavior Services (Staff #39) | Interviewed about phone use policy rationale and structure | |
| Director of Nursing (Staff #69) | Interviewed about phone use policies and care plan documentation | |
| Administrator (Staff #165) | Interviewed about phone use policies and care plan documentation | |
| Social Services Director (Staff #15) | Interviewed about PASARR process and resident services | |
| Social Services Assistant (Staff #115) | Interviewed about PASARR process and resident services | |
| Registered Nurse (RN #226) | Interviewed about phone use restrictions and resident complaints |
Inspection Report — Oct 20, 2023
Complaint Investigation
Date: Oct 20, 2023
Visit Reason
On-site complaint investigation of complaints AZ00201811, AZ00201640, AZ002016487, AZ00201642, AZ00201810, AZ00201641, AZ002016484, and AZ00201639 at a Nursing Care Institution, conducted 19-20 October 2023.
Complaint Details
An investigation of complaints AZ00201811, AZ00201640, AZ002016487, and AZ00201642 was conducted October 18 through October 20, 2023. An investigation of complaints AZ00201810, AZ00201641, AZ002016484, and AZ00201639 was conducted October 18 through October 20, 2023.
Findings
The inspection found two deficiencies related to failure to provide adequate bowel care for one resident, which could result in constipation and bowel obstructions.
Deficiencies (2)
§483.25(e) — The facility failed to provide bowel care for one resident in accordance with standards of practice, risking constipation and bowel obstructions.
R9-10-414 — The administrator failed to ensure the care plan assisted the resident in maintaining the highest practicable well-being, specifically regarding bowel care.
Report Facts
Deficiencies cited: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Resident #1 | Resident | Resident #1 was the subject of the bowel care deficiencies. |
| Staff #8 | Certified Nursing Assistant | CNA/staff #8 reported on bowel movement monitoring and communication with nursing. |
| Staff #203 | Licensed Practical Nurse | LPN/staff #203 described CNA responsibilities and nursing follow-up for bowel care. |
Inspection Report — Oct 6, 2023
Complaint Investigation
Date: Oct 6, 2023
Visit Reason
On-site complaint investigation of intake numbers AZ00201418 and AZ00201417 at a Nursing Care Institution, conducted 5-6 October 2023.
Complaint Details
A complaint survey was conducted on October 5, 2023 through October 6, 2023 for the investigation of intake #AZ00201418 and intake #AZ00201417. There were no deficiencies cited.
Findings
This inspection found no deficiencies.
Inspection Report — Sep 14, 2023
Complaint Investigation
Date: Sep 14, 2023
Visit Reason
On-site complaint investigation of multiple complaints including AZ00188687, AZ00189886, AZ00189922, AZ00190806, AZ00190987, AZ00191007, AZ00191005, AZ00191019, AZ00191034, AZ00191057, AZ00191153 and AZ00191148 at a Nursing Care Institution, conducted 12 through 14 September 2023.
Complaint Details
A complaint survey was conducted on September 12 through September 14, 2023 for the investigation intake #s: AZ00188687, AZ00189886, AZ00189922, AZ00190806, AZ00190987, AZ00191007, AZ00190987, AZ00191005, AZ00191019, AZ00191034, AZ00191057, AZ00191153 and AZ00191148. Federal comments noted similar complaint intake numbers investigated during the same period.
Findings
The inspection substantiated two deficiencies related to resident-to-resident physical abuse involving residents #176 and #70. The facility failed to ensure residents were free from physical abuse, resulting in one resident sustaining injuries and requiring transfer to another unit.
Deficiencies (2)
§483.12 — The facility failed to ensure that resident #176 was free from physical abuse by resident #70, who punched resident #176's arms causing redness and discoloration. The facility substantiated the allegation and placed the residents on one-on-one monitoring and transferred resident #176 to another unit.
R9-10-410 — The administrator failed to ensure that resident #176 was not subjected to abuse by resident #70, who punched resident #176's arms. The facility policy requires monitoring and prompt reporting of aggressive behavior, but the abuse occurred and was substantiated.
Report Facts
Deficiencies cited: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff #241 | Certified Nursing Assistant | Witnessed resident #70 punching resident #176 and yelled for help during the incident. |
Inspection Report — Sep 6, 2023
Complaint Investigation
Date: Sep 6, 2023
Visit Reason
On-site complaint investigation of intake #AZ00199674 and #AZ00199673 at a Nursing Care Institution, conducted 6 September 2023.
Complaint Details
A complaint survey was conducted on September 6, 2023 for the investigation of intake #AZ00199674 and intake #AZ00199673. There were no deficiencies cited.
Findings
This inspection resulted in no deficiencies cited or citations.
Inspection Report — Aug 28, 2023
Complaint Investigation
Date: Aug 28, 2023
Visit Reason
On-site complaint investigation of complaints AZ00199282 and AZ00199545 at a Nursing Care Institution, conducted 28 August 2023.
Complaint Details
The complaint survey was conducted on August 28, 2023 for the investigation of intake numbers AZ00199282, AZ00199545, and AZ00199541. Deficiencies were cited related to resident elopement and supervision.
Findings
The inspection found two deficiencies related to inadequate supervision that resulted in a resident eloping multiple times. The facility failed to prevent elopement and ensure the resident was free from conditions that could cause physical injury.
Deficiencies (2)
§483.25(d) — The facility failed to ensure adequate supervision was provided to prevent elopement for one resident, resulting in multiple incidents of the resident leaving the facility through a window without staff awareness.
R9-10-425 — The facility failed to ensure one resident was free from a condition or situation that may cause physical injury by not providing adequate supervision to prevent elopement, despite the resident's known risk and multiple elopement incidents.
Report Facts
Deficiencies cited: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff #31 | Director of Behavioral Services | Interviewed regarding secured behavioral units and elopement incidents. |
| Staff #61 | Certified Nurse Assistant | Interviewed about resident supervision and elopement history. |
| Staff #91 | Licensed Practical Nurse | Interviewed about monitoring behaviors and interventions for elopement. |
| Staff #11 | Social Services Director | Interviewed about reporting elopement incidents to Adult Protective Services. |
| Staff #71 | Social Services Assistant | Interviewed alongside Social Services Director regarding elopement reporting. |
Inspection Report — Jul 27, 2023
Complaint Investigation
Date: Jul 27, 2023
Visit Reason
On-site complaint investigation of multiple complaints including AZ00196263, AZ00190620, AZ00186857, AZ00190691, AZ00186882, AZ00186049, AZ00187688, AZ00189392, AZ00199332, AZ00186559, AZ00186843, AZ00186698, AZ00186680, AZ00186651, AZ00186653, AZ00186189, AZ00186118, AZ00186029, AZ00186024, AZ00185866, AZ00185720, AZ00181016, AZ00186944, AZ00187080, AZ00187215, AZ00187420 and AZ00188345 at a Nursing Care Institution, conducted 24-27 July 2023.
Complaint Details
An onsite survey was conducted from July 24 through July 27, 2023 for the investigation of intake numbers AZ00196263, AZ00190620, AZ00186857, AZ00190691, AZ00186882, AZ00186049, AZ00187688, AZ00189392, AZ00199332, AZ00186559, AZ00186843, AZ00186698, AZ00186680, AZ00186651, AZ00186653, AZ00186189, AZ00186118, AZ00186029, AZ00186024, AZ00185866, AZ00185720, AZ00181016, AZ00186944, AZ00187080, AZ00187215, AZ00187420 and AZ00188345. A complaint survey was also conducted for intake numbers AZ00186843, AZ00196262, AZ00186698, AZ00186680, AZ00186651, AZ00190619, AZ00186653, AZ00186855, AZ00186558, AZ00186569, AZ00186189, AZ00190690, AZ00186118, AZ00186029, AZ00186024, AZ00186881, AZ00185866, AZ00185720, AZ00186048, AZ00142740, AZ00186883, AZ00186882, AZ00181016, AZ00186944, AZ00187687, AZ00187080, AZ00187215, AZ00187420, AZ00188345, AZ00189391 and AZ00188331.
Findings
The inspection found two deficiencies related to failure to ensure residents were free from abuse, including resident-to-resident abuse incidents involving multiple residents. The facility had plans of correction in place.
Deficiencies (2)
§483.12 — The facility failed to ensure four residents (#1, #28, #5, #11) were free from abuse, including physical and sexual abuse by other residents, despite interventions and monitoring. Multiple incidents were documented involving resident altercations and inappropriate contact.
R9-10-410 — The administrator failed to ensure residents were not subjected to abuse, as evidenced by incidents involving residents #10 and #11 with biting and pushing behaviors, and residents #5 and #6 with physical aggression. Staff monitoring and interventions were insufficient to prevent these occurrences.
Report Facts
Deficiencies cited: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff #22 | Licensed Practical Nurse | Interviewed regarding staff presence and procedures to prevent resident altercations and abuse. |
| Staff #191 | Certified Nursing Assistant | Interviewed about monitoring residents and preventing incidents. |
| Staff #193 | Director of Nursing | Interviewed about abuse reporting procedures and staff training. |
| Staff #229 | Certified Nursing Assistant | Interviewed regarding an incident involving residents #5 and #6. |
Inspection Report — Jun 27, 2023
Complaint Investigation
Date: Jun 27, 2023
Visit Reason
On-site complaint investigation of intakes AZ00196618, AZ00196791, AZ00196801, and AZ00196912 at a Nursing Care Institution, conducted 26-27 June 2023.
Complaint Details
An onsite survey was conducted on June 26, 2023 through June 27, 2023 for the investigation of intake #s: AZ00196618, AZ00196791 and AZ00196801. No deficiencies were cited. A complaint survey was conducted on June 26, 2023 through June 27, 2023 for the investigation of intake #s: AZ00196618, AZ00196912 and AZ00196791. No deficiencies were cited.
Findings
No deficiencies were cited during this complaint investigation.
Report Facts
Complaints investigated: 4
Inspection Report — Jun 14, 2023
Complaint Investigation
Date: Jun 14, 2023
Visit Reason
On-site complaint investigation of complaints AZ00196564 and AZ00196518 at a Nursing Care Institution, conducted 14 June 2023.
Complaint Details
The Complaint survey was conducted on June 14, 2023 with investigations of complaints AZ00196564 and AZ00196518. The deficiencies cited relate to failure to report and investigate abuse allegations and failure to prevent resident-to-resident abuse.
Findings
The inspection found multiple deficiencies related to failure to report and investigate allegations of abuse between residents, and failure to prevent resident-to-resident abuse. Six deficiencies were cited.
Deficiencies (6)
R9-10-403 — The administrator failed to ensure allegations of abuse involving two residents were reported to the State Agency within the required timeframe.
R9-10-403 — The administrator failed to ensure allegations of abuse involving two residents were thoroughly investigated and documented within five working days.
§483.12 — The facility failed to ensure one resident was not abused by another, risking further resident-to-resident abuse.
§483.12(c) — The facility failed to report an allegation of abuse to the State Agency within the required timeframe, risking unreported abuse.
§483.12(c) — The facility failed to ensure an allegation of resident-to-resident abuse was thoroughly investigated, risking incomplete investigations.
R9-10-410 — The administrator failed to ensure residents do not abuse one another, involving two residents and risking further abuse.
Report Facts
Deficiencies cited: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff #30 | Administrator | Failed to report and investigate allegations of abuse involving residents #1 and #2. |
| Staff #60 | Social Services Director | Interviewed and involved in resident care and abuse investigation. |
| Staff #50 | Social Services Assistant | Received abuse report from resident #1 and communicated concerns. |
Inspection Report — Jun 12, 2023
Complaint Investigation
Date: Jun 12, 2023
Visit Reason
On-site complaint investigation of complaint AZ00195997 at a Nursing Care Institution, conducted 12 June 2023.
Complaint Details
An onsite survey was conducted on June 12, 2023 for the investigation of #AZ00195997. There were no deficiencies cited. A complaint survey was conducted on June 12, 2023 for the investigation of #AZ00195997. There were no deficiencies cited.
Findings
No deficiencies were cited during this inspection.
Inspection Report — Apr 11, 2023
Complaint Investigation
Date: Apr 11, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding an incident of resident-to-resident abuse involving residents #34 and #50.
Complaint Details
The facility was able to substantiate the allegation of resident-to-resident abuse. Resident #50 hit resident #34 with a remote control causing a small scratch. Resident #50 was separated and transferred to another unit. Staff interviews confirmed the incident and the facility's response.
Findings
The facility substantiated the allegation that resident #50 struck resident #34 in the face causing a small scratch. Resident #50 was separated and transferred to another unit due to physical aggression and medication adjustments were made. Staff interviews and documentation confirmed the incident and the facility's policy on abuse was reviewed.
Deficiencies (1)
Failure to ensure that one resident (#34) was free from abuse by another resident (#50).
Report Facts
BIMS score: 5
BIMS score: 3
Incident time: 1620
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN) staff #207 | Provided information about resident #50's transfer and medication compliance | |
| Licensed Practical Nurse (LPN) staff #100 | Reported witnessing the incident and described resident #50's behavior | |
| Registered Nurse (RN) staff #40 | Provided information on resident #50's behavior and facility policy on abuse |
Inspection Report — Sep 2, 2022
Routine
Date: Sep 2, 2022
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, abuse prevention, medication administration, and residents' rights at Immanuel Campus of Care.
Findings
The facility was found deficient in several areas including failure to timely address a resident's need for a specialized wheelchair, failure to ensure residents' access to personal trust funds, failure to protect a resident from abuse by another resident, failure to thoroughly investigate an abuse allegation, and failure to ensure medications were administered as ordered and by qualified personnel.
Deficiencies (6)
Failure to timely address resident #134's need for a specialized wheelchair, resulting in the resident being bedridden and unable to ambulate.
Failure to ensure three sampled residents (#17, #35, and #51) had access to their personal trust funds as required.
Failure to protect resident #64 from abuse by resident #161 during a group activity in the dining room.
Failure to thoroughly investigate an allegation of abuse involving residents #64 and #161, including not interviewing the activity assistant who was supervising at the time.
Failure to ensure resident #174 was administered medications as ordered, including missed doses of Metoprolol and Morphine without proper documentation or physician notification.
Failure to ensure resident #85 was administered medications only by qualified personnel; a housekeeping employee was found to have given a resident a pill.
Report Facts
Deficiencies cited: 6
Medication doses missed: 3
Trust fund withdrawal limit: 50
Weekend trust fund hours: 10 a.m. to 4 p.m. on Saturday and Sunday
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Social Services Director | Social Services Director (#108) | Interviewed regarding missing wheelchair for resident #134 |
| Certified Nursing Assistant | CNA (#155) | Interviewed about resident #134's wheelchair and mobility |
| Registered Nurse | RN (#78) | Interviewed about resident #134's bedridden status and wheelchair |
| Director of Nursing | DON (#58) | Interviewed about wheelchair policy, abuse supervision, and medication administration |
| Business Office Manager | Business Office Manager (#27) | Interviewed about residents' access to personal trust funds |
| Activity Assistant | Activity Assistant (#86) | Interviewed regarding supervision during abuse incident involving residents #64 and #161 |
| Licensed Practical Nurse | LPN (#196) | Interviewed about supervision during activities |
| Registered Nurse | RN (#245) | Interviewed about supervision and medication administration |
| Certified Nursing Assistant | CNA (#171) | Interviewed about supervision during abuse incident |
| Certified Nursing Assistant | CNA (#147) | Interviewed about charting and supervision during abuse incident |
| Administrator | Administrator (#208) | Interviewed about abuse investigation and medication incident |
| Housekeeping Employee | Staff #259 | Involved in medication administration incident with resident #85 |
Inspection Report — Sep 2, 2022
Complaint Investigation
Date: Sep 2, 2022
Visit Reason
The inspection was conducted based on complaints alleging multiple deficiencies including failure to accommodate resident needs, improper management of resident trust funds, resident abuse, inadequate investigation of abuse allegations, and medication administration errors.
Complaint Details
The complaint investigation was triggered by allegations including failure to provide a specialized wheelchair, restricted access to personal trust funds, resident-to-resident abuse, inadequate abuse investigation, and medication administration errors. The investigation included interviews with residents, staff, and review of policies and records. The abuse allegation was substantiated with findings of inadequate supervision and investigation.
Findings
The facility was found deficient in several areas including failure to timely provide a specialized wheelchair to a resident, restricting resident access to personal trust funds on weekends, failure to protect a resident from abuse by another resident, inadequate investigation of abuse allegations, and failure to administer medications as ordered or by qualified personnel.
Deficiencies (6)
Failure to reasonably accommodate the needs and preferences of resident #134 regarding a specialized wheelchair.
Failure to honor residents' rights to manage their personal trust funds for residents #17, #35, and #51, restricting access on weekends.
Failure to protect resident #64 from abuse by resident #161 during an activity in the dining room.
Failure to thoroughly investigate an allegation of abuse involving residents #64 and #161, including omission of interviewing the activity assistant who was supervising at the time.
Failure to ensure resident #85 was administered medication only by qualified personnel; a housekeeping staff gave a resident a pill.
Failure to administer medications as ordered for resident #174, including missed doses of Metoprolol and Morphine without proper documentation or physician notification.
Report Facts
Residents affected: 1
Residents affected: 3
Residents affected: 2
Staff involved: 1
Medication doses missed: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Social Services Director | Social Services Director | Interviewed regarding missing wheelchair for resident #134 |
| Director of Nursing | Director of Nursing | Interviewed regarding wheelchair issue, abuse supervision, and medication administration |
| Administrator | Administrator | Interviewed regarding abuse investigation and medication administration incidents |
| Staff #259 | Housekeeping Staff | Involved in unauthorized medication administration to resident #85; terminated |
| Registered Nurse RN #245 | Registered Nurse | Interviewed regarding medication administration errors for resident #174 |
Report
Report
22 CMS Surveys
CMS Survey — Apr 11, 2023
Apr 11, 2023
CMS Survey — Jun 14, 2023
Jun 14, 2023
CMS Survey — Jul 27, 2023
Jul 27, 2023
CMS Survey — Aug 28, 2023
Aug 28, 2023
CMS Survey — Sep 14, 2023
Sep 14, 2023
CMS Survey — Oct 20, 2023
Oct 20, 2023
CMS Survey — Nov 3, 2023
Nov 3, 2023
CMS Survey — Mar 8, 2024
Mar 8, 2024
CMS Survey — Apr 19, 2024
Apr 19, 2024
CMS Survey — Jul 10, 2024
Jul 10, 2024
CMS Survey — Sep 5, 2024
Sep 5, 2024
CMS Survey — Dec 20, 2024
Dec 20, 2024
CMS Survey — Jan 31, 2025
Jan 31, 2025
CMS Survey — Mar 20, 2025
Mar 20, 2025
CMS Survey — Mar 24, 2025
Mar 24, 2025
CMS Survey — May 27, 2025
May 27, 2025
CMS Survey — Jul 3, 2025
Jul 3, 2025
CMS Survey — Jul 15, 2025
Jul 15, 2025
CMS Survey — Dec 2, 2025
Dec 2, 2025
CMS Survey — Sep 2, 2022
Sep 2, 2022
CMS Survey — Nov 3, 2023
Nov 3, 2023
CMS Survey — Jan 31, 2025
Jan 31, 2025
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