Archie Hendricks Senior Skilled Nursing Facility
Federal Route 15 Mile Post 9, Sells, AZ 85634 · Non profit - Corporation · 60 certified beds · (520) 585-5500 Medicare & Medicaid certified
This home’s record is mixed — some reassuring signs, some worth asking about.
- a middle-of-the-pack inspection score (3/5)
- no federal fines or payment denials on record
- a high payroll-based staffing rating (4/5)
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- a high number of inspection citations overall (27) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- nursing-staff turnover (61%) runs well above the national median (45%)
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 | 3 of 5 |
| StaffingFrom payroll records (PBJ) | 4 of 5 |
| Quality measuresSelf-reported by the facility | 4 of 5 |
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 | 3 of 5 |
| Short-stay residentsrehab / post-hospital | 5 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 improved from 1 to 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 | 29.3% | 10.7% | 15.4% | worse |
| Long-stay residents who lose too much weight | 5.5% | 5.3% | 5.4% | typical |
| Long-stay residents with a catheter left in their bladder | 0.0% | 0.8% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 1.6% | 1.2% | 2.0% | better |
| Long-stay residents with depressive symptoms | 0.0% | 3.9% | 6.5% | check this* — see note marked star below the table |
| 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 | 1.6% | 2.1% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 26.7% | 12.8% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 6.0% | 21.0% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 93.3% | 94.6% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 6.3% | 4.4% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 27.2% | 20.6% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 7.0% | 10.6% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 0.0% | 1.2% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 61.3% | 87.3% | 79.4% | worse |
| Short-stay residents rehospitalized after admission | 14.7% | 23.7% | 22.6% | better |
| Short-stay residents with an outpatient ER visit | 18.8% | 10.4% | 12.0% | worse |
| Long-stay hospitalizations per 1,000 resident days | 2.66 | 1.47 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 0.89 | 1.42 | 1.80 | better |
* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. Weigh it against the inspection record above.
‡ 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.
70.4% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that better than the national rate. This is CMS’s risk-adjusted rate over 31 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Therapy staffing: this home’s payroll records show 0.36 therapist hours per resident per day in 2026Q1 — more than 61% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 26% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
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 | 70.4%CMS range 54.3–88.6 | 51.5% | Oct 2022–Sep 2024 | better than U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 11.9%CMS range 8.2–16.3 | 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 | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality 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 | 3.6% | 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 | 6.2%CMS range 3.6–12.2 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.97 | 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
How full it usually is: this home is certified for 60 beds and averages 50.7 residents a day — about 84% occupied, or roughly 9 beds typically open. It usually has some room. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 6.08 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.87 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 4.41 is at or above the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 5.48 hrs/resident/day on weekends vs 6.33 on weekdays — 13% thinner on weekends. RN hours go from 0.94 to 0.71 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 61% is well above the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are fewer than at the previous inspection — improving. 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.
27 citations, most serious first. The 10 most serious are shown; the remaining 17 are one tap away and print in full.
- Potential for harm · Ecited before2025-07-25 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to implement an effective infection control program in accordance with internal policies and procedures, nationally recognized infection control guidelines and regulations when:a. Glucometers (a device used to check the blood sugar) were not cleaned and disinfected after use.b. Staff did not perform hand hygiene before putting on gloves. Failure to implement infection prevention practices may contribute to cross contamination of infection that can jeopardize the health and safety of residents and staff. Findings:In an observation on 07/23/2025, at 11:04 AM, Licensed Practical Nurse (LPN) 1 entered the room of R7. LPN1 don on gloves without performing hand hygiene and proceed to check R7's blood sugar. After checking the blood sugar, LPN stored the glucometer in the black casing and did not clean and disinfect the equipment.In another observation on 07/23/2025 at 12:08 PM, LPN1 don on gloves without performing hand hygiene and checked…
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 before2025-07-25 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation interview, record review, manufacturer's manual review and facility policy review, the facility failed to ensure oxygen (O2) orders were in place for one of three sampled residents (Resident (R)32). In addition, maintain O2 concentrators filters free of dust and nasal cannulas were placed in bags while not in use for two of three sample residents (R32 and R33).This deficient practice had the potential to allow an increased chance of unnecessary respiratory treatment and infection. Findings include:Review of the facility's policy titled Medication Orders, revised 04/25/25 revealed, Purpose: The purpose of this procedure is to establish uniform guidelines in the receiving and recording of medication orders. Recording Orders. 3. Oxygen orders- When recording orders for oxygen, specify the rate of flow, route, and rationale.Review of the undated user manual for the concentrator page 23, revealed Cleaning the Cabinet Filter: Caution: DO NOT operate the concentrator without the filter installed. 1. Remove the filter and clean at least once a week depending on…
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 F0755 — failed to provide safe pharmacy services — isolatedProvide 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 observation, interview, and record review, the facility failed to provide pharmaceutical services that meet the needs of one of ten residents (Resident [R]5) observed for medication pass when Omeprazole (used to treat heartburn and indigestion) was administered after meal instead of before meal as ordered for R5.These failures could lead to decreased medication effectiveness and potential adverse health outcomes for R5.Findings:On 07/24/2025, at 08:51 AM, a medication administration observation to R5 was conducted with Registered Nurse (RN) 1. RN 1 administered medications to R5 including 1 tablet of Omeprazole 20 mg.Review of R5's physician's order dated 07/10/2025 indicated an order for Omeprazole Oral Tablet Delayed Release 20 milligram to give one tablet by mouth in the morning for GERD (Gastroesophageal Reflux Disease) to Administer 30-60 minutes prior to meals.In an interview on 07/24/2025, at 10:29 AM, R5 stated that he had eaten breakfast at 7 AM before R1 administer the medication. In an interview on 07/24/2025, at 10:31 AM, RN1 acknowledged that Omeprazole should…
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 · F2024-09-27 · tag F0801 — widespreadEmploy sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
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 observations, interview and record review the hospital failed to ensure a Registered Dietitian (RD) or qualified nutrition professional provided frequent oversight of food and nutrition services which resulted in deficient practices related to the competency of foodservice staff for the safe storage of refrigerated foods and ensuring sanitary condition of walk-in refrigerator (Refer to F812). These failures had the potential to lead to foodborne illness in a highly susceptible population of 45 residents who received food from the facility kitchen. Findings: In an interview on 09/24/24 at 10:00 AM, Acting Dietary Manager (ADM) explained that she assumed the position of Dietary Manager four months ago and the previous Dietary Manager (DM) is now assigned at the Assisted Living. ADM added, she is in the process of completing the required training for Dietary Manager certification (also known as CDM). The Dietary Manger Consultant stated that she is responsible to oversee (ADM) while she's in training.…
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 · F2024-09-27 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
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, facility failed to ensure food safety standards when 1) there was lack of consistent labeling of preparation date and use-by date for foods capable of foodborne illness 2) storage of food items outside the shelf life and 3) food storage practices that may promote cross contamination as evidence by presence of molds in the walk-in refrigerator. Failure to provide a food production environment that is safe and sanitary may result in foodborne illness, cross contamination of food and equipment and use of expired ingredients that may affect flavor and/or texture of food. Foodborne illness and cross contamination may result in gastrointestinal distress and in severe instances may result in death. The use of expired ingredients may result in a food product that is unpalatable, resulting in decreased meal intake. This had the potential to affect 45 residents who received meals from the facility. Findings: 1a.During initial tour of the kitchen on 09/24/24 at 10:04 AM,…
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 before2024-09-27 · tag F0578 — failed to honor advance directives / code status — isolatedHonor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
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 one of 12 sampled residents (R42) was provided assistance in formulating an advance healthcare directive when they expressed a desire to create one. This failure put the resident at risk for not having their wishes for treatment known and had the potential for the resident's decision regarding his healthcare and treatment options not being honored. Findings: Review of the electronic medical record (EMR) revealed R42 was admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS, a standardized assessment tool) with assessment reference date of 06/19/24, revealed a Brief Interview for Mental Status (BIMS) score of 14 out of 15 indicating R42 had no cognitive impairment. Review of the advance healthcare directive acknowledgment form signed by R42 upon admission indicated that R42 wished to complete a healthcare power of attorney. Review of the EMR failed to show a copy of R42's advance healthcare directive. On 09/26/24 at 10:57 AM, 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 · D2024-09-27 · tag F0623 — isolatedProvide 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 notify one of three residents (R31) reviewed for hospitalization, or their representatives in writing and send a copy of the notice to the ombudsman of the reason for the transfer. This had the potential for the resident and/or their representative to be unaware of their rights and posed the risk of the ombudsman not being aware of the circumstances should appeals be filed by the resident or their representative regarding the transfer/discharge. Findings: Review of the electronic medical record (EMR) revealed R31 was initially admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS, a standardized assessment tool) with assessment reference date of 03/02/24, revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicating R31 had no cognitive impairment. Review of a physician's order dated 02/17/24 revealed an order to send R31 to the acute care hospital for evaluation and treatment. Review of the Progress Notes…
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 · D2024-09-27 · tag F0625 — isolatedNotify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
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 one of three residents (R31), reviewed for hospitalization, and/or their representative were provided with written information regarding the facility's bed-hold policy when the resident was transferred to the acute care hospital. This failure had the potential for R31 or their representative to be unaware of their right to request a bed-hold and their right to return to the first available bed should the resident's hospital stay exceed the seven-day bed-hold period. Findings: Review of the electronic medical record (EMR) revealed R31 was initially admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS, a standardized assessment tool) with assessment reference date of 03/02/24, revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicating R31 had no cognitive impairment. Review of a physician's order dated 02/17/24 revealed an order to send R31 to the acute care hospital for evaluation and treatment. 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.
- Potential for harm · D2024-09-27 · tag F0641 — isolatedEnsure 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 interview and record review, the facility failed to ensure the Minimum Data Set (MDS) assessment for two of 12 sampled residents (R23 and R29) accurately reflected the residents' status. *R29's weight loss and anticoagulant use were coded incorrectly. *R23's active diagnosis of depression was not coded in the MDS. These failures had the potential for the residents to not receive an individualized plan of care based on their specific care needs. Findings: For R29: Review of the electronic medical record (EMR) revealed R29 was admitted to the facility on [DATE] with diagnoses including hypertension and coronary artery disease. Review of the MDS with assessment reference date of 07/26/24 revealed Section K, which addresses weight loss of 5% or more in the last month or 10% or more in the last 6 months, was marked as Yes, indicating R29 was not on a physician-prescribed weight loss regimen. However, a review of R29's weights showed that R29 did not experience a weight loss of 5% in the last month or 10% 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 · D2024-09-27 · tag F0757 — failed to avoid unnecessary drugs — isolatedEnsure each resident’s drug regimen must be free from unnecessary drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility did not ensure that the resident's drug regimen was free from unnecessary drugs when Midodrine HCL (used to treat low blood pressure) was administered outside the parameters for one of one sampled resident (Resident [R] 41). This failure resulted R41 receiving unnecessary medication that could negatively affect his health and well-being. Findings: R41 was admitted with diagnoses including Parkinson's Disease (chronic and progressive movement disorder), muscle weakness, and orthostatic hypotension (low blood pressure [BP] that happens when standing after sitting or lying down). Review of R41's physician order, dated 07/29/24, indicated an order for Midodrine HCl 10 milligram 1 tablet three times a day for Orthostatic Hypotension to Hold for Systolic Blood Pressure (SBP) less than 110. SBP is the measure of pressure within the arteries while the heart beats. Review of R41's August 2024 Medication Administration Record (MAR), indicated a Midodrine HCl Oral Tablet 10 MG was administered outside the parameters on the following dates:…
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 17 citations
- Potential for harm · D2024-09-27 · tag F0758 — failed to limit and justify psychotropic drugs — isolatedImplement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
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 the as needed order for psychotropic medications (drugs that affect brain activities with mental processes and behavior) for one of six residents (R) reviewed for unnecessary medications (R45) had the documented rationale from the physician for the appropriateness of extending the medication beyond 14 days. This failure had the potential for R45 to experience adverse effects or receive unnecessary psychotropic medications. Findings: Review of the electronic medical records (EMR) showed R45 was admitted to the facility on [DATE], and was receiving hospice services. Review of the Minimum Data Set (MDS, a standardized assessment tool) with assessment reference date of 08/28/24, revealed a Brief Interview for Mental Status (BIMS) score of 00 out of 15 indicating R45 had severe cognitive impairment. Review of the Order Summary Report showed the following physician's orders dated 09/09/24: - LORazepam [antianxiety medication] oral concentrate Oral…
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 · D2024-09-27 · tag F0759 — failed to keep medication error rate low — isolatedEnsure medication error rates are not 5 percent or greater.
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 the medication error rate was below 5%. The medication error rate was 12%. Three medication administration errors were identified out of 25 opportunities during medication administration observation on 09/26/24 as follows: *RN 2 administered a medication to Resident (R) 20 that was ordered to be administered before a meal, but instead, it was administered after R20 had already eaten breakfast. *RN 2 administered two different eye drops to R20 without allowing the required 3-5 minute wait between drops, as outlined in their policy and standard of practice. These failures could lead to decreased medication effectiveness and potential adverse health outcomes for R20. Findings: On 09/26/24 at 08:43 AM, a medication pass observation to R20 was conducted with Registered Nurse (RN) 2. RN 2 was observed preparing medications for R20 which included calcium acetate (medication used to lower high phosphate levels in patients with kidney…
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 · Ecited before2023-09-14 · tag F0695 — failed to provide proper breathing / tracheostomy care — patternProvide safe and appropriate respiratory care for a resident when 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 observation, interview, and record review, the facility failed to provide safe respiratory care to meet the needs of two of 12 sampled residents (R16 and R28). * The facility failed to ensure the licensed nurses documented the administration of supplemental oxygen to R16 according to the physician's order. In addition, the facility failed to notify R16's physician when he was refusing to wear his CPAP (continuous positive airway pressure, is a non-invasive ventilation machine that involves the administration of air usually through the nose by an external device at a predetermined level of pressure) according to the physician's order. * The facility failed to ensure R28 was administered oxygen in accordance with the physician's order. These failures posed the risk of the residents not being provided the appropriate respiratory care and treatment. Findings: 1. On 09/12/23 at 08:47 AM, an observation and concurrent interview was conducted with R16 in his room. R16 was observed receiving oxygen at 2 liters…
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 · E2023-09-14 · tag F0698 — failed to provide proper dialysis care — patternProvide safe, appropriate dialysis care/services for a resident who requires such services.
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 12 sampled residents (R38), who required dialysis (a treatment to rid the body of toxins when the kidneys no longer function), received care and services consistent with professional standards of practice. The facility failed to assess and document care of R38's dialysis access site. This failure posed the risk of not detecting problems such as bleeding or other complications that would require immediate notification of the physician. Findings: On 09/11/23 at 10:10 AM, an observation and interview was conducted with R38 in his room. R38 was observed sitting on his wheelchair. R38 stated he was waiting for his transport to dialysis. When asked where his dialysis access site was, R38 stated he had a fistula (arterio-venous fistula, access is created by surgically connecting an artery and a vein) on the left upper arm. Review of the electronic medical record (EMR) showed R38 was admitted to the facility on [DATE]. Review of the…
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 · E2023-09-14 · tag F0883 — failed to offer flu and pneumonia vaccines — patternDevelop and implement policies and procedures for flu and pneumonia vaccinations.
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 educate and offer influenza and pneumococcal vaccines the residents were eligible to receive in accordance with the current Centers for Disease Control and Prevention (CDC) guidelines to 3 of 5 residents (R28, R14, and R15) reviewed for immunizations. This failure posed the risk of the residents contracting influenza or pneumonia and its associated complications. Findings: On 09/14/23 at 11:48 AM, an interview and concurrent review of the facility's immunization program was conducted with the Registered Nurse (RN) Supervisor. The RN Supervisor stated the facility followed the current CDC guidelines for vaccinations, including pneumococcal vaccines. For R28: Review of the Electronic Medical Record (EMR) showed R28 was admitted to the facility on [DATE], was [AGE] years old, with diagnoses including diabetes and chronic respiratory failure with hypoxia. Review of the Immunization tab of the EMR showed R28 historically received the influenza vaccine on…
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 before2023-09-14 · tag F0578 — failed to honor advance directives / code status — isolatedHonor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
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 offer assistance to formulate an advance directive to one of 12 sampled residents (R38). This failure placed R38 at risk of not having his wishes for treatment known and had the potential for the resident's decision regarding his healthcare and treatment options not being honored. Findings: Review of the electronic medical record (EMR) showed R38 was admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS, a standardized assessment tool) with assessment reference date of 08/07/23, showed a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating R38 had no cognitive impairment. Review of the Advanced Directive Statement dated 08/01/23, showed R38 wished to complete/designate a Health Care Power of Attorney. A copy of an advance directive was not located in R38's medical record. On 09/12/23 at 11:52 AM, an interview was conducted with R38. R38 stated he remembered signing the form upon admission that he wished to…
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 · D2023-09-14 · tag F0610 — failed to investigate and act on abuse reports — isolatedRespond appropriately to all alleged violations.
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, record review, and policy review, the facility failed to complete a thorough investigation for one (Resident (R) 23) reviewed for a facility reported incident of neglect, out of a survey sample of 12 residents. There was no evidence the facility interviewed other current residents regarding the allegation of potential neglect associated with a staff member (Certified Nursing Assistant (CNA) 109). The timeline of the report of the incident does not match the statement from the perpetrator CNA 109. Findings include: Review of the facility policy titled Abuse, Neglect and Exploitation, dated 03/22, revealed .When suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur, an investigation is immediately warranted. Interview the involved resident, if possible, and document all responses. If the resident is cognitively impaired, interview the resident several times to compare response. If there is no discernible response from the resident, interview the…
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 · D2023-09-14 · tag F0622 — isolatedNot transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
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 record review, staff interviews, and facility policies and procedures, the facility failed to provide documentation of one resident's (Resident 40) discharge summary at the time of transfer to a hospital. The deficient practice could result in receiving facilities not having the necessary information for continuing care of residents. Findings include: Review of the facility policy and procedure titled Discharge Planning Process revised 7/21/22 included a Discharge Summary will include a recapitulation of the resident's stay including but not limited to: -Diagnoses --Course of Illness --Treatments or therapies --Pertinent Labs --Radiology -All Consultations -A final summary to include resident's discharge status, that will be made available to authorized persons but consent of the resident or the resident's representative. Resident 40 (R) admitted on [DATE], readmitted on [DATE] had diagnoses that included end stage renal disease, gastro-esophageal reflux disease without esophagitis, essential (primary)…
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 · D2023-09-14 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
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 develop comprehensive plans of care to reflect the individual care needs of two of 12 sampled residents (R38 and R28). * The facility failed to develop a comprehensive care plan to address R38's dialysis (a treatment to rid the body of toxins when the kidneys no longer function) and care of his dialysis access site. * The facility failed to develop a comprehensive care plan for R28, who was receiving oxygen therapy. These failures posed the risk of not providing appropriate, consistent, and individualized care to the residents. Findings: 1. On 09/11/23 at 10:10 AM, an observation and interview was conducted with R38 in his room. R38 was observed sitting on his wheelchair. R38 stated he was waiting for his transport to dialysis. When asked where his dialysis access site was, R38 stated he had a fistula (arterio-venous fistula, access is created by surgically connecting an artery and a vein) on the left upper arm. Review of the electronic…
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 · D2023-09-14 · tag F0657 — failed to keep the care plan current — isolatedDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
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 the comprehensive plan of care for one of 12 sampled residents (R7) was revised to reflect current needs and interventions. R7 sustained an unwitnessed fall in the bathroom on 07/24/23. R7's care plan was not revised to reflect the post fall interventions to apply grab bar covers to optimize grip and to consider support bar options in the bathroom. This failure posed the risk of not providing R7 with individualized person-centered care. Findings: Review of the electronic medical record (EMR) showed R7 was admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS, a standardized assessment tool) with assessment reference date of 06/07/23, showed a Brief Interview for Mental Status (BIMS) score of 14 out of 15, indicating R7 had no cognitive impairment. R7 was independent and did not require staff assistance for transfers and locomotion on unit. Review of the Fall Charting dated 07/24/23, showed R7 was found lying supine with head…
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 · D2023-09-14 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
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 record review and interviews, the facility failed to ensure a resident with a pressure injury received necessary monitoring and treatments to promote healing for one of three residents (R40) sampled for closed record review. R40 did not receive thorough weekly wound monitoring, a pressure reducing chair cushion, or changes in wound care after documented changes in wound drainage. R40's sacral wound increased 317% in area, developed malodorous drainage and increased pain requiring transfer to a hospital on 8/4/23. Findings include: Review of the electronic Health Record (e-HR) R40 admitted on [DATE], readmitted on [DATE], had diagnoses that included end stage renal disease, hypertension, and moderate protein-calorie malnutrition. Review of the admission Minimum Data Set (MDS) dated [DATE] showed R40 had a BIMS (Brief Interview for Mental Status) score of 9 indicating the resident had moderately impaired cognition. R40 required extensive two-person assistance with bed mobility, dressing, toilet use, and…
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 · D2023-09-14 · 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 provide the necessary care and services to ensure one of 12 sampled residents (R7) was free from accident hazards. The facility failed to ensure the post fall interventions were in place for R7, who sustained a fall on 7/24/23, creating a risk for further falls and injuries. Findings: Review of the electronic medical record (EMR) showed R7 was admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS, a standardized assessment tool) with assessment reference date of 06/07/23, showed a Brief Interview for Mental Status (BIMS) score of 14 out of 15, indicating R7 had no cognitive impairment. R7 was independent and did not require staff assistance for transfers and locomotion on unit. Review of the Fall Charting dated 07/24/23, showed R7 was found lying supine with head facing the wall and feet/legs by the commode. Wheelchair was in front of commode with one wheel locked and the other one unlocked. Resident was heard saying…
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 · D2023-09-14 · tag F0697 — failed to manage pain — isolatedProvide safe, appropriate pain management for a resident who requires such services.
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 record review and interviews, the facility failed to ensure that one resident's pain from an unstageable pressure ulcer was managed according to the standards of practice and the resident's goal and preferences for 1 of 3 closed record sampled residents (Resident 40). Findings include: Review of the electronic health record (e-HR) revealed R40 admitted on [DATE], readmitted on [DATE] had diagnoses that included end stage renal disease, hypertension, and moderate protein-calorie malnutrition. Review of the admission Minimum Data Set (MDS) dated [DATE] showed R40 had a BIMS (Brief Interview for Mental Status) score of 9 indicating the resident had moderately impaired cognition. Review of the e-HR revealed the following provider orders entered on 7/7/23: -Vital and Pain evaluation every day and night shift. -Pain level documentation 0-10 every day and night shift for assessment of pain. -Acetaminophen (Tylenol) tablet, 650 mg (milligram), give 1 tablet by mouth every 4 hours as needed for general…
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 · D2023-09-14 · tag F0699 — isolatedProvide care or services that was trauma informed and/or culturally competent.
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 trauma survivors receive trauma-informed, culturally competent care accounting for residents' experiences and preferences to avoid triggers leading to re-traumatization for one resident (Resident (R) R19) of 12 residents in the sample. Findings include: Review of R19's Face Sheet located in the electronic medical record (EMR) under the Face Sheet tab revealed that R19 was admitted to the facility on [DATE] with an admitting diagnosis of toxic encephalopathy, infective endocarditis, post-traumatic stress disorder (PTSD) chronic. Review of R19's Quarterly Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 06/07/23 located under the MDS tab of the EMR revealed a Brief Interview for Mental Status (BIMS) score of 07 out of 15, which is indicative of severe cognitive impairment. Review of R19's Care Plan located in the EMR under the Care Plan tab revealed that there was no care plan for PTSD and triggers had not been…
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 · D2023-09-14 · tag F0756 — failed to review each resident's drug regimen — isolatedEnsure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
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 the Consultant Pharmacist's medication recommendation was addressed for one of five residents (R38) reviewed for unnecessary medications. The facility failed to ensure the Consultant Pharmacist's recommendation for R38 was acted upon by the physician. This failure had the potential for R38 to receive unnecessary medications. Findings: Review of the electronic medical record (EMR) showed R38 was admitted to the facility on [DATE]. Review of the Consultant Pharmacist's Medication Regimen Review dated 08/01/23, showed a note to R38's attending physician to Please write an analgesic order clarification to include specific parameters for the following orders: Acetaminophen 500mg po [per orem, by mouth] Q6hrs PRN [as needed] pain . suggest clarify Acetaminophen 500mg [sic] to PRN pain 1-3 Review of the Active Orders as of 09/12/23, showed acetaminophen oral tablet 500 mg (milligrams), give 500 mg by mouth every 6 hours as needed for pain. The…
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 · D2023-09-14 · tag F0760 — failed to prevent significant medication errors — isolatedEnsure that residents are free from significant medication errors.
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 one of 12 sampled residents (R25) was free from significant medication errors. R25 was not administered the extended-release medications according to the physician's order. The medications were crushed and dissolved in water and were administered via GT (gastrostomy tube, a tube inserted through the abdomen into the stomach used to administer nutritional formula and medications). This failure could cause in rapid release and absorption of the medications that could result in a potentially life-threatening fatal dose. Findings: On 09/13/23 at 08:17 AM, an interview was conducted with Registered Nurse (RN) 127. RN 127 was approached by the surveyor about medication pass observation. RN 127 stated there was only one resident (R25) in the facility with GT. RN 127 stated she had administered R25's medications scheduled to be administered at 08:00 and 09:00 AM .just now. RN 127 stated she administered the medications via GT. RN 127 stated she crushed…
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 before2023-09-14 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
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, record review, interviews, and review of facility policy and procedure, the facility failed to ensure infection control practices were maintained during observation of medication administration for one of three residents (Resident 34). The deficient practice puts residents at risk for illness from infection. Findings include: Review of the facility policy and procedure titled Infection Prevention/Control: Infection Surveillance revised 7/19/23 included Its purpose is to identify infections and to monitor adherence to recommended infection prevention and control practices to reduce infections and prevent the spread of infections. Review of the facility policy and procedure titled Medication Administration revised 7/21/22 included Medications are administered by licensed nurses, or other staff legally authorized in this state, as ordered by the physician and in accordance with professional standards of practice, to prevent contamination or infection .Remove medication from source, taking care…
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
No federal fines in the current CMS record.
Who owns this facility
| Owner / manager | Type | Role | Since |
|---|---|---|---|
| ABAD, ROSIE | Individual | W-2 MANAGING EMPLOYEE | since 04/02/2018 |
| CASILLAS, JUANA | Individual | CORPORATE DIRECTOR | since 06/01/2014 |
| LOPEZ, CHERYL | Individual | CORPORATE DIRECTOR | since 03/18/2013 |
| STOUT, FRANCES | Individual | CORPORATE DIRECTOR | since 02/16/2006 |
The source lists no ownership percentage for any party here — PECOS records a share only for equity interests, not for board or management roles.
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.
About 73% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself.
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 035263. 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 →
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