Caring House
510 South Ocotillo Road, Sacaton, AZ 85147 · Government - Federal · 100 certified beds · (520) 562-7400 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- it has an abuse, neglect, or exploitation citation (F0600), cited Sep 2025
- inspectors recorded 1 serious finding as past non-compliance — the problem was found, fixed, and verified before the survey closed, so it is history rather than a current condition, but it is still worth asking what changed
- a high number of inspection citations overall (16) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $28,695 in federal fines (most recent 2025-09-18)
- its facility-reported quality-measure score sits well above its independent inspection score
- its independent health-inspection rating is low (2/5)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 2 of 5 |
| StaffingFrom payroll records (PBJ) | Not rated |
| Quality measuresSelf-reported by the facility | 4 of 5 |
Worth a closer look. This home's quality-measure rating runs 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself — so a gap this large is worth reading the inspection record for.
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 4 of 5 |
| Long-stay residentspeople who live here | 5 of 5 |
| Short-stay residentsrehab / post-hospital | 3 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 3 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 15.6% | 10.7% | 15.4% | typical |
| Long-stay residents who lose too much weight | 3.5% | 5.3% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 0.8% | 0.8% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 0.7% | 1.2% | 2.0% | better |
| Long-stay residents with depressive symptoms | 2.5% | 3.9% | 6.5% | better |
| Long-stay residents who were physically restrained | 0.0% | 0.3% | 0.1% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with falls causing major injury | 3.8% | 2.1% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 9.5% | 12.8% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 2.7% | 21.0% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 98.9% | 94.6% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 2.5% | 4.4% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 13.0% | 20.6% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 14.6% | 10.6% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 3.6% | 1.2% | 1.4% | worse |
| Short-stay residents given the seasonal flu vaccine | 88.5% | 87.3% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 33.3% | 23.7% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 5.0% | 10.4% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 1.65 | 1.47 | 1.67 | typical |
| Long-stay outpatient ER visits per 1,000 resident days | 0.62 | 1.42 | 1.80 | better |
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
34.2% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that worse than the national rate. This is CMS’s risk-adjusted rate over 74 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 53.1% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 32 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 34.2%CMS range 26.1–44.2 | 51.5% | Oct 2022–Sep 2024 | worse than U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 11.0%CMS range 7.5–15.2 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 53.1% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 56.2% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 56.2% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 0.0% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 0.0% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 7.2%CMS range 4.2–11.7 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.23 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
CMS has not published payroll-based (PBJ) staffing hours for this facility yet — this can happen for newer, hospital-based, or recently-certified homes. It can also mean the home simply did not file, which CMS does not distinguish in this data, so treat the gap as unexplained rather than benign. Staffing is one of the three parts of the CMS star rating; where it’s missing, weigh the independent health-inspection score most, and ask the facility directly about its nurse-to-resident ratios and weekend RN coverage.
Inspection trend
Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
16 citations, most serious first. The 11 most serious are shown; the remaining 5 are one tap away and print in full.
- Immediate jeopardy · Jcited before2025-09-18 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, and record review, the facility failed to provide adequate supervision and follow its elopement policy for 1 of 1 resident (R1) reviewed for supervision. This failure resulted in R1 remaining alone outdoors for approximately 4 hours in extreme heat conditions (100 Fahrenheit (F) - 111 F, with a heat index of up to 114 F). (Heat index is defined as a measurement that combines air temperature and relative humidity to determine how hot the air actually feels to the human body.) The deficient practice placed the resident at risk for heat exhaustion, heat stroke, and/or death and resulted in a situation of immediate jeopardy.On [DATE] at 5:30 PM the Administrator and Assistant Administrator were notified of an Immediate Jeopardy determination for [DATE] for 42 CFR S483.25 (F689) related to the failed supervision and monitoring of one resident, leaving her outdoors in temperatures which reached 114 degrees Fahrenheit for 4 or more hours, placing her at risk for potentially…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-09-18 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, and review of records, the facility failed to protect one resident's (R4) right to be free from physical abuse by another resident (R3) for one resident-to-resident altercation reviewed when R3 hit R4.The deficient practice resulted in a violation of R4's right to be free from resident-to resident abuse.Findings include:For R4:Review of the Admissions Record revealed R4 was readmitted to the facility on [DATE] with diagnoses that included vascular dementia, moderate, with other behavioral disturbance (a stage of vascular dementia where cognitive decline significantly impacts daily life, requiring substantial assistance and exhibiting problematic behaviors like agitation, aggression, or mood changes) and displaced mid-cervical fracture of the left femur (fracture in the bone connecting the thigh bone to the hip joint), subsequent encounter for closed fracture with routine healing.The Significant Change Minimum Data Set (MDS) assessment dated [DATE] revealed the resident scored 7…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2025-07-25 · tag F0641 — patternEnsure each resident receives an accurate assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, records, and review of the RAI (Resident Assessment Instrument) manual, the facility failed to ensure that the MDS (Minimum Data Set) assessment accurately reflected the status of 1 out of 2 residents reviewed for falls (R12) and failed to reflect the PASARR (Preadmission Screening and Resident Review) status for 1 out of 2 residents reviewed for PASARR requirements (R8). Specifically, R12's MDS did not reflect a fall with major injury and R8's MDS did not reflect her PASARR Level II status for 3 consecutive years. The deficient practice may result in residents not receiving care appropriate to their individual needs.Findings include:For R12:Review of the admission Record revealed R12 was admitted to the facility on [DATE] with diagnoses which included repeated falls and Parkinson's Disease with dyskinesia (involuntary, uncontrollable movements that can develop as a side effect of long-term levodopa (dopamine agonists) treatment for Parkinson's disease), without mention of fluctuations.An…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2025-07-25 · tag F0644 — patternCoordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure Preadmission Screening and Resident Review (PASARR) screenings were coordinated and/or referred for Level II evaluations as required for newly evident Serious Mental Illness (SMI) diagnoses for two of two residents (Resident (R) 9 and R12) reviewed for PASARR requirements out of a total sample of 19 residents. The deficient practice may result in residents with Mental Disorders (MD) and/or Intellectual Disabilities (ID) not receiving specialized services to meet their needs. Findings: For R9: Review of R9's “admission Record, dated 07/25/25 and found in the electronic medical record (EMR) under the “Profile” tab, indicated the resident was admitted to the facility on [DATE] with diagnoses including Congestive Heart Failure (CHF), Adjustment Disorder and Other Specified Mental Disorders Due to Known Physiological Condition. Review of R9's “Psychiatric Provider Encounter Progress Note,” dated 11/08/24 and found in the EMR under the “Documents”…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2025-07-25 · tag F0755 — failed to provide safe pharmacy services — patternProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review the facility failed to provide pharmaceutical services to meet the needs of Resident (R) 2, one of five residents reviewed for unnecessary meds, when Staff held R2's long acting insulin 3 times in July unnecessarily, without an order or notifying the physician. This had the potential to cause R2 to experience hyperglycemia (elevated blood sugar). Hyperglycemia can lead to various short-term and long-term complications. Short-term effects include ketoacidosis (A complication of diabetes in which acids build up in the blood to levels that can be life-threatening), dehydration, and confusion. Long-term complications include diabetic retinopathy, nephropathy, neuropathy, cardiovascular disease, and increased risk of infections. Findings: Review of the admission Record revealed the facility admitted R2 most recently on 05/02/2025. Diagnoses included type 2 diabetes mellitus with other specified complications, and hypertensive end stage renal disease with dependence on dialysis. Review of physician orders revealed orders for both a long acting insulin…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-07-25 · tag F0558 — failed to accommodate residents' needs and preferences — isolatedReasonably accommodate the needs and preferences of each resident.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one of 19 residents sampled (R35), was able to call for assistance when their call bell was not within reach and R35 was not capable of retrieving and using it. As a result, R35 was not able to call for help until the surveyor alerted the staff. This had the potential for R35's needs to be unmet. FindingsReview of the admission Record revealed the facility admitted R35 most recently on 04/12/2023 with a primary diagnosis of acute posthemorrhagic anemia (a condition where the body experiences a sudden and significant drop in red blood cells and hemoglobin due to a rapid loss of blood). Other diagnoses included disorders of bone density, cerebral infarction (the death of brain tissue due to a prolonged decrease in blood flow, also known as stoke) with left sided hemiplegia and hemiparesis (weakness or paralysis on one side of the body), hearing loss, aphasia (a language disorder that affects a person's ability to communicate),…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-07-25 · tag F0582 — isolatedGive residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to ensure Resident (R) 38, one of three residents reviewed for beneficiary notices was provided a written Notice of Medicare Non-Coverage (NOMNC), and Advanced Beneficiary Notice of Non-coverage (ABN) when the facility identified R38's Part A benefit last covered day was due to end. This had the potential for R38 and/or their representative to be unaware of their appeal rights or how to activate an appeal. Findings: Review of the admission Record revealed the facility admitted R38 on 02/25/2025. R38 was their own responsible party. R38's spouse was listed as Emergency Contact #1 Review of the Beneficiary Protection Notification Review worksheet provided by the facility indicated R38's Medicare Part A benefit started on 02/25/2025 and the last covered day was 03/26/2025. The Beneficiary Notice worksheet indicated R38 remained in the facility after their last Medicare A covered day. Review of the NOMOC filed in R38's medical record revealed the form included that coverage for physical/occupational/speech therapy, and nursing…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-07-29 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one of one sampled resident (Resident [R] 1) received adequate assistance during transfer when transfer equipment was not utilized based on resident's plan of care. The deficient practice resulted R1 experienced right knee and left shoulder pain after the assisted fall during transfer on 05/07/24 at 10:52 AM. Findings: R1 was admitted to the facility with diagnoses including obesity, cerebrovascular disease (also known as stroke), hemiparesis and hemiplegia (partial paralysis of one side of the body). Review of R1's Quarterly Minimum Data Set (MDS) assessment, dated 04/29/24 indicated R1's cognition was moderately impaired. R1's functional limitation in range of motion was impaired on one side of his lower and upper extremities. Review of the FRI detail reported by the facility on 05/13/24 indicated, [R1] had a fall on May 7th . Two CNA failed to follow the care planned assistance to transfer with Hoyer lift [a lift used to safely…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-09-15 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure a resident-centered care and treatment were provided in accordance with professional standards of practice and resident's comprehensive care plan when facility staff failed to ensure 1 of 5 sampled residents (R)(R78) reviewed for pressure injuries/skin conditions had documented evidence of weekly wound measurements to ensure the wound was objectively monitored and evaluated. In addition, R78 was observed with incorrect weight settings on their pressure relieving low air loss mattresses (LAL). These failures increased the resident's risks for pressure injuries, delayed care and less than optimal treatment. Findings include: Resident 78 Review of R78's medical record documented R78 was admitted to the facility on [DATE] with diagnoses including diabetes, repair of left femur fracture, past left knee surgery with delayed wound healing resulting in left above the knee amputation with readmission on [DATE] after amputation. Review of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-09-15 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, record review, the facility failed to ensure the residents environment was free of accident hazards for one (Resident (R)36) of three residents reviewed for accidents when staff failed to gather all necessary equipment prior to preparing the resident for a transfer from the bed to the wheelchair which resulted in R36 standing up on her own without the assistance of the CNA. Findings include: Review of R36's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) date of 04/11/23, located in the MDS tab of the electronic medication record (EMR), revealed an admission date of 03/23/23, a Brief Interview for Mental Status (BIMS) score of 14 out of 15 indicating R36's cognition was intact, diagnoses of encounter for orthopedic aftercare following surgical amputation of left leg above the knee, and that R36 required extensive assistance for transfers with two person physical assist and activity did not occur for walk in room and corridor. Review of R36's 04/03/23 Fall Risk Evaluation, located in the EMR under the Assessment tab, revealed…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-09-15 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolatedProvide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure 1 of 1 sampled resident (R) 42 reviewed for bladder incontinence was comprehensively assessed for the type of urinary incontinence to ensure the development of individualized interventions to restore or maintain continence to the extent possible. This failure increased the resident's risk for ongoing and increased urinary incontinence. Findings include: Review of Resident 42's (R42) medical record documented resident was admitted to the facility on [DATE] with diagnoses including personal history of transient ischemic attack and cerebral infarction without residual effects (stroke, blood flow to the brain is blocked or there is sudden bleeding in the brain) and encephalopathy (decrease in blood flow or oxygen to the brain). R42's Minimum Data Set (MDS-assessment tool) dated 7/25/23 documented resident had some moderate cognitive impairment with brief mental status interview score of 10 out of 15. R42 required supervision for…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 5 citations
- Potential for harm · D2023-09-15 · tag F0808 — failed to follow doctor-ordered diets — isolatedEnsure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, and record review, the facility failed to ensure 1 of 1 resident (R24) observed for thickened liquids received liquids in the appropriate honey thick form as prescribed by a physician. This failed practice increased the resident's risk for aspiration. Findings include: Review of Resident 24's (R24) medical record documented resident was admitted to the facility on [DATE] with diagnoses including dementia and Alzheimer's disease. R24's Minimum Data Set (MDS-assessment tool) dated 8/29/23 documented resident had some moderate cognitive impairment with a brief mental status interview score of 10 out of 15. Observation on 9/11/23 at about 12:00 PM showed Certified Nursing Assistant (CNA) 40 wheeling R24 from her room to the dining room and placed resident at the first table in front of the TV. A cup containing light brown liquid was on the table, CNA40 stirred the liquid with a spoon and resident drank from the cup. Observation on 9/11/23 at 12:21 PM showed R24 eating her lunch in…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2022-08-12 · tag F0576 — patternEnsure residents have reasonable access to and privacy in their use of communication methods.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure residents' right to mail delivery on Saturdays. Four of 4 residents (R24, R18, R8 and R51) who receive mail and attended Resident Council stated that they did not receive mail on Saturdays. This failure had the potential to affect all residents who received mail and denied the residents timely access to their mail over the weekend, and placed residents at risk for diminished quality of life. Findings include: During a Resident Council meeting on 08/09/22 at 01:58 PM residents were asked if mail was delivered on Saturdays. Four residents (R24, R18, R8 and R51) who received mail stated that they had not received mail on Saturdays. These four residents were identified by the facility as alert and interviewable. Review of R24's Minimum Data Set (MDS-assessment tool) dated 05/31/22 documented resident had a brief interview for mental status of 14, indicating no cognitive impairment. Review of R18's Minimum Data Set (MDS-assessment tool) dated…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2022-08-12 · tag F0623 — patternProvide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure that transfer/discharge notices provided to residents (R) and their responsible parties (RP) included information on their right to appeal including the name and contact information of the entity(ies) and information on how to obtain an appeal form for 3 of 3 sampled residents (R71, R61, R65) reviewed for hospitalizations. These failures did not afford residents and/or their RPs the opportunity to make informed decisions about transfers or discharges and prohibited access to an advocate who could inform residents and their RPs of their options and rights. Findings include: Resident 71 Review of Resident 71's (R71) record indicated the facility admitted the resident on 06/14/21 with diagnoses including dementia and type 2 diabetes (disease that makes the person more susceptible to developing infections, as high blood sugar levels can weaken the person's immune system defenses. In addition, some diabetes-related health issues, such as nerve damage…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2022-08-12 · tag F0880 — failed to prevent and control infections — patternProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review the facility did not assure that staff followed infection prevention and control protocols for three of 18 sampled residents (R), when staff did not 1. sanitize their hands during and after the provision of incontinence care for two residents (R) (R38 and R15) and 2. did not sanitize surfaces and wound care equipment with Environmental Protection Agency (EPA) registered sanitizer after the provision of wound treatment for resident (R65). This deficient practice had the potential for staff to cross contaminate surfaces and spread contagious infections to other residents, staff or the public. Findings: 1. Incontinence care Facility policy Infection Prevention Hand Hygiene Program, revised date 2/2020, documented Indication for hand hygiene with either alcohol-based hand rub or wash with soap and water for the following clinical indications b. Before donning [putting on] gloves, d. Before moving from work on a soiled body site to a clean body site on the same patient, f. After contact with blood, body fluids, or contaminated surfaces,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2022-08-12 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolatedProvide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review the facility failed to ensure that one of one resident (R) R17 sampled for urinary catheters received appropriate treatment and services based on standards of practice when the facility failed to ensure that the urinary collection bag was kept in a dignity bag and did not touch the floor. This failure was a breach in infection control and had the potential to lead to a urinary tract infection. Findings: Review of R17's Electronic Health Records (EHR) revealed he was admitted to the facility with the following pertinent diagnoses. Benign Prostatic Hyperplasia (a noncancerous enlargement of the prostate gland, and is the most common benign tumor found in men), and dementia with behavioral disturbances. Review of R17's most recent Minimum Data Set (MDS), an assessment tool, dated 05/13/22 revealed that R17 had a Brief Interview for Mental Status score of 15 which indicates he is cognitively intact. Also, under Section H which is used to assess the bladder and bowel function of the residents revealed R17 had an external catheter. Review…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
$28,695 in federal fines across 2 penalties. 1 Medicare payment denial on record.
- $13,260 — penalty dated 2025-09-18
- $15,435 — penalty dated 2024-11-08
- Medicare payment denial — starting 2024-12-12 for 8 days
Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.
Who owns this facility
| Owner / manager | Type | Role | Since |
|---|---|---|---|
| GILA RIVER HEALTH CARE CORPORATION | Organization | DIRECT OWNERSHIP INTEREST | since 08/05/2015 |
| HORTON, ROBERT | Individual | CORPORATE DIRECTOR | since 05/25/2015 |
| HAAKE, MAX | Individual | CORPORATE OFFICER | since 07/11/2016 |
| CHANDRAN, SAI | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 04/01/2022 |
| GODDARD, RUSSELL | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 08/01/2025 |
| KRAMER, DARCY | Individual | OPERATIONAL/MANAGERIAL CONTROL | since 01/19/2019 |
| MCFARLAND, KIMBERLY | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 03/09/2026 |
| SOTO, LINDA | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 04/24/2022 |
CMS files one row per role, so the 12 rows in the source record cover these 8 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.
1 organizational owner listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in AZ
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Arizona Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 035216. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-07-25, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →
Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →
Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.