No sales calls · nothing personal collected unless you ask us to · no facility pays to be here
Text size
Contrast

Devon Gables Rehabilitation Center

6150 East Grant Road, Tucson, AZ 85712 · For profit - Limited Liability company · 312 certified beds · (520) 296-6181 Medicare & Medicaid certified

Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Flagged for abuse1 actual-harm citation CMS recorded as corrected before the inspection ended (past non-compliance)
Insights

This home has serious findings on its record. Read them closely before you consider it.

In its favor
  • no federal fines or payment denials on record
  • a high payroll-based staffing rating (4/5)
  • lower-than-typical staff turnover (28% vs 45% nationally) — better care continuity
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • CMS has flagged it for abuse
  • it has an abuse, neglect, or exploitation citation (F0600), cited May 2026
  • 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 (21) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • its payroll-based staffing score sits well above its independent inspection score
  • its independent health-inspection rating is low (2/5)
  • its last standard health inspection was over 3 years ago — the star rating may not reflect current conditions

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.

2/5
CMS overall
2 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 2 of 5
StaffingFrom payroll records (PBJ) 4 of 5
Quality measuresSelf-reported by the facility 3 of 5

Worth a closer look. This home's staffing rating runs 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the staffing score rests on the facility's own payroll (PBJ) submissions — so a gap this large is worth reading the inspection record for.

Location & what’s nearby

Hospital
Urgent care / clinic
6274 E Grant Rd · (520) 296-8333 · Call to confirm hours
Pharmacy
6250 E Grant Rd · (520) 296-0317 · Call to confirm hours
Grocery
6600 E Grant Rd · (520) 885-6109 · Call to confirm hours
Park
1800 N Calle Serena · Typically dawn to dusk
Place of worship
6444 E Tanque Verde Rd

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 3 of 5
Long-stay residentspeople who live here 3 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 fell from 3 to 2 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.

Overall rating2★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased14.8%10.7%15.4%typical
Long-stay residents who lose too much weight0.0%5.3%5.4%check this — see note marked star below the table
Long-stay residents with a catheter left in their bladder2.1%0.8%0.9%worse
Long-stay residents with a urinary tract infection1.1%1.2%2.0%better
Long-stay residents with depressive symptoms0.0%3.9%6.5%check this — see note marked star below the table
Long-stay residents who were physically restrained0.0%0.3%0.1%better than state — see note marked double-dagger below the table
Long-stay residents with falls causing major injury1.9%2.1%3.3%better
Long-stay residents whose ability to walk worsened20.0%12.8%16.1%worse
Long-stay residents on antianxiety or hypnotic medication23.2%21.0%18.9%worse
Long-stay residents given the seasonal flu vaccine99.5%94.6%95.3%typical
Long-stay residents with pressure ulcers6.5%4.4%4.7%worse
Long-stay residents with worsening bladder/bowel control5.1%20.6%21.2%better
Long-stay residents who got an antipsychotic medication — see the note below the table18.0%10.6%17.1%typical
Short-stay residents who newly got an antipsychotic medication2.2%1.2%1.4%worse
Short-stay residents given the seasonal flu vaccine79.5%87.3%79.4%typical
Short-stay residents rehospitalized after admission17.3%23.7%22.6%better
Short-stay residents with an outpatient ER visit10.9%10.4%12.0%typical
Long-stay hospitalizations per 1,000 resident days1.461.471.67better
Long-stay outpatient ER visits per 1,000 resident days1.791.421.80typical

* 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.

48.9% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 58 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

48.9%U.S. median 51.5%
Got home and stayed home
12.3%U.S. median 10.7%
Went back to hospital
54.5%U.S. median 56.6%
Met the expected recovery
0.14U.S. median 0.31
Therapy hours / resident / day
0.07hours / resident / day
Physical therapy
0.04hours / resident / day
Occupational therapy
0.03hours / resident / day
Speech therapy

Met the expected recovery: 54.5% 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 33 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.

Therapy staffing: this home’s payroll records show 0.14 therapist hours per resident per day in 2026Q1 — more than 10% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 14% 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
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF48.9%CMS range 37.7–58.951.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF12.3%CMS range 7.8–18.110.7%Oct 2022–Sep 2024no 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 discharge54.5%56.6%Oct 2024–Sep 2025CMS 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 discharge51.5%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge57.6%50.0%Oct 2024–Sep 2025CMS 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 identified100.0%98.7%Oct 2024–Sep 2025CMS 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 settingnot 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 discharge100.0%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay0.0%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened4.2%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization9.5%CMS range 5.9–15.47.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.081.02Oct 2022–Sep 2024CMS 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

0.51
RN hours/ resident / day
0.87
LPN hours/ resident / day
2.26
Aide hours/ resident / day
3.64
Total nurse hours/ resident / day
0.45
RN hoursweekends
28.2%
Total nursing turnover
30.4%
RN turnover

How full it usually is: this home is certified for 312 beds and averages 183.3 residents a day — about 59% occupied, or roughly 129 beds typically open. It often has substantial empty capacity — worth asking why, since low census can reflect either a new or shrinking home or one families are avoiding. 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 3.64 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.51 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.26 is below 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 3.35 hrs/resident/day on weekends vs 3.76 on weekdays — 11% thinner on weekends. RN hours go from 0.54 to 0.45 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 28% is below 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

1
deficiencies at the latest standard inspection (2023-07-14)
7
at the previous standard inspection (2022-04-29)

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.

This trend is not current. The most recent of these two inspections was over 3 years ago; the arrow describes what inspectors found then, not what the home is like now.

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.

ABCDEFGHIJKL

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.

21 citations, most serious first. The 11 most serious are shown; the remaining 10 are one tap away and print in full.

  • Actual harm · Gcited before2025-06-10 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure 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 clinical record review, staff interviews and review of facility protocol and policies the facility failed to ensure one resident (#5) was free from accidents during a hoyer transfer. The deficient practice could lead to major injury. Findings include: Resident #5 was admitted originally on October 5, 2020 and readmitted on [DATE] with diagnosis that included epilepsy, transient cerebral ischemic attach, other mechanical complication of internal fixation device of right femur, bipolar disorder, acute respiratory failure, non-ST elevation myocardial infraction. A significant change in status Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) summary score of 02. indicating severe cognitive impairment. Further review of the MDS assessment revealed the resident was dependent and needed the assistance of 2 or more helpers to complete any activities dealing with transfers. A care plan created May 26, 2025 revealed an approach that the resident is a hoyer lift…

    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.

    Quality of Life and Care Deficiencies · Past Non-Compliance
  • Potential for harm · Dcited before2026-05-19 · tag F0600 — failed to protect residents from abuse and neglect — isolated
    Protect 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 clinical record review, staff interviews, facility documentation, and review of facility policies and procedures, the facility failed to protect the rights of one three resident's (#20) to be free from abuse by another resident. The deficient practice had the potential to result in further abuse of residents.-Regarding Resident # 35:Resident #35 (alleged perpetrator) was admitted to the facility on [DATE], with diagnoses including unspecified dementia, altered mental status, and brief psychotic disorder.A quarterly Minimum Data Set (MDS) assessment, dated February 11, 2026, revealed Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition, no behaviors of wandering were exhibited during the assessment period.A psychosocial well-being care plan, initiated on November 18, 2025, revealed the following problem area: Adjustment to living in a secure environment related to dementia, memory impairment and history of attempts to elope and wandering. The goal was for the resident 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2025-06-26 · tag F0600 — failed to protect residents from abuse and neglect — pattern
    Protect 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 interviews, review of clinical record, and review of facility policy and procedure, the facility failed to ensure three residents (#22, #26 and #27) were not abused by other residents (#125, #50 and#145). The deficient practice could lead to physical and psychosocial harm of residents.-Regarding Resident #22 (alleged victim):Resident #22 was re-admitted to the facility September 20, 2023, with diagnoses that included dysphagia, catatonic schizophrenia, cerebral infarction, hyperlipidemia, vascular dementia with behavioral disturbance, schizoaffective disorder, major depressive disorder with severe psychotic symptoms, and restlessness and agitation. A quarterly minimum data set (MDS) assessment dated [DATE], revealed Resident #22 had a Brief Interview for Mental Status (BIMS) score of 00, indicating severe cognitive impairment.A care plan dated November 8, 2017, revealed Resident #22 has socially inappropriate / disruptive behavioral symptoms as evidenced by making verbal unwanted statements and reaching…

    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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-06-26 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure 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 the clinical record, staff interviews, facility policy and facility records, the facility failed to ensure that 1 resident (#33) was safe. Failure to ensure the resident's safety could lead to resident harm. Findings include: Resident #33 was admitted on [DATE] with diagnoses of dementia, Major Depressive Disorder, and macular degeneration. A hospital history and physical dated October 7, 2023 included that this resident has chronic dementia and was unable to recall events of what happened. An admission assessment dated [DATE] included that this resident was attentive, disoriented, memory impaired, and had disorganized thinking. A care plan dated October 18, 2023 included that this resident is oriented to self and that this resident had Cognitive loss/dementia or alteration in thought processes related to diagnosis of dementia with behavioral disturbance as evidenced by impaired decision making, short and/or long term memory loss, and/or neurological symptoms. A treatment consent dated October 19, 2023…

    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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-10-25 · tag F0600 — failed to protect residents from abuse and neglect — pattern
    Protect 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 staff interviews, clinical record review, facility documents and facility policy, the facility failed to ensure that three residents (#33, #24, #11) were not abused. This deficient practice could result in further incidents of abuse. Findings include: Regarding resident #33 and resident #24 A facility reported incident was made on May 14, 2024. This report included Staff responded to visitor calling for help, stating those two men are fighting. She states that she heard raised voices coming from the room across the hallway. She looked across the hallway and observed (residents #24 and #33) in the bathroom doorway and appeared to be fighting. A 5 day report dated May 17, 2024 included Per staff report (resident #24) had been having increased behavioral episodes the prior day and night. He was seen packing his belongings, pushing at doors and very difficult for the staff to re-direct. Per night staff he had slept very little the previous night. (resident #33 can be very territorial about his room 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-10-25 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure 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 clinical record review, staff and resident interviews, facility records and facility policy the facility failed to ensure that one resident (#24) is free from preventable falls. This deficient practice could result in increased morbidity and mortality. Findings include: Resident #24 was admitted on [DATE] with diagnoses of Alzheimer's disease, Mood disorder due to known physiological condition with depressive features and Vascular dementia A 5-day Minimum Data Set (MDS) dated [DATE] included that this resident was unable to answer questions for cognition and that the resident had a fall prior to entry. A care plan dated December 19, 2022 included this resident is at risk for falls related to diagnosis and history of falls. A progress note dated July 27, 2023 included Upon entering pts room he was noted laying on back in front of closet. pt stated I fell. Body check done, no new injuries. Denies hitting head, no red, raised or open areas.Neuro check done due to unwitness fall. Passive ROM to upper 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-07-14 · tag F0584 — failed to keep a safe, clean, comfortable home — pattern
    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
    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, resident and staff interviews and review of policy, the facility failed to maintain a safe, comfortable homelike environment related to ambient temperatures. The facility census was 227. The deficient practice may result in uncomfortable ambient temperature levels. Findings include: During a survey of the facility conducted 07/11/23 through 07/14/23, temperature findings were identified in common areas to include the following: -On 07/11/23 at 09:43 AM the fire door outside of room [ROOM NUMBER] measured 83.5 degrees Fahrenheit (F). -On 07/12/23 at 09:55 AM the Saguaro Room curtain temperatures ranged from 82-83 degrees F. -On 07/12/23 at 09:56 AM the air conditioner units in the hall by room [ROOM NUMBER] measured 82 degrees F. An observation of room [ROOM NUMBER] was conducted on 07/13/23 at 11:05 AM. Two fans were observed to be running in the room. The temperature of the room ranged from 78-80 degrees F. The two residents of the room stated that they were comfortable at that time, but…

    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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2022-04-29 · tag F0688 — failed to keep residents mobile / prevent decline — pattern
    Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY -Resident #109 was admitted [DATE] with diagnoses that included a tear of the medial meniscus, age related physical debility, hemiplegia and hemiparesis of the left side. Review of the clinical record revealed an order dated January 7, 2019 for restorative nursing (RNA) 3 to 5 times per week to prevent a decrease in range of motion. A care plan dated March 12, 2019 revealed that the resident is receiving restorative nursing services to maintain functional ability. The goal is that the resident will maintain joint function. Approaches including AROM (Active Range of Motion) to the lower extremity as tolerated 3- 5 times per week. Review of the care plan dated July 17, 2020 revealed the resident is at high risk for falls related to limited function. Approaches included implementing an exercise program that targeted strength, gait and balance. The significant change in status minimum data set (MDS) assessment dated [DATE] revealed a score of 15 on the brief interview for mental status (BIMS) indicating the resident…

    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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2022-04-29 · tag F0761 — failed to label and store drugs safely — pattern
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, staff interviews, and review of the policy and procedures, the facility failed to ensure that medications were dated according to the standard of practice, and failed to ensure that expired medications were not available for administration. The deficient practice could result in expired medications being administered to residents. Findings include: -An observation was conducted on April 28, 2022 at 1:30 p.m. of the medication cart on hall 209-228, sub-acute unit. An insulin box with a pharmacy label Aspart Insulin contained two opened vials of insulin inside. The first vial with a maroon top was labeled Insulin Lispro, and the second vial with a silver top was labeled insulin Aspart. The insulin vials had no resident's name, or open dates. An interview was conducted on April 28, 2022 at 1:33 p.m. with an RN (Registered Nurse/staff #204). Staff #204 stated each insulin is usually in an individual box with the resident's name and opened date. Staff #204 looked at the insulin vials and stated the maroon top is insulin Lispro, and the silver top is insulin Aspart.…

    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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-04-29 · tag F0582 — isolated
    Give 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interviews, policy review and the Form Instructions for the Facility Advanced Beneficiary Notice (SNFABN), the facility failed to provide evidence that the Skilled Nursing Advanced Beneficiary Notice (SNFABN) was issued to one (#108) of three sampled residents. The deficient practice could result in residents not being informed of their potential liability for payment. Findings include: Resident #108 was admitted [DATE] with diagnoses that included atrial fibrillation, major depressive disorder, chronic obstructive pulmonary disease, altered mental status, anxiety disorder and type 2 diabetes mellitus. Review of the admission Record face sheet revealed the resident was their own responsible party. The admission Minimum Data Set assessment dated [DATE] revealed a score of 15 on the Brief Interview for Mental Status which indicated the resident had intact cognition. Review of the Notice of Medicare Non-Coverage (NOMNC) revealed the last day of coverage was on March 31, 2022.…

    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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-04-29 · tag F0644 — isolated
    Coordinate 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 clinical record review, staff interview, and policy and procedure, the facility failed to ensure that one resident (#43) with a diagnosis of a serious mental illness was referred to the appropriate State-designated mental health or intellectual disability authority for review once the resident's stay exceeded 30 days. The sample size was 3. The deficient practice could result in necessary specialized services not being provided for residents that need it. Findings include: Resident #43 was admitted to the facility on [DATE] with the following diagnoses: Unspecified dementia with behavioral disturbance; Bipolar disorder, current episode hypomanic; Other personality and behavioral disorders due to known physiological condition. Review of a Level I PASRR (Preadmission Screening and Resident Review) signed November 28, 2020 revealed the resident was for convalescent care and required 30 days or less nursing facility services. The section for Identification of Potential Mental Illness did not have anything…

    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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
Show the remaining 10 citations
  • Potential for harm · D2022-04-29 · tag F0645 — isolated
    PASARR screening for Mental disorders or Intellectual Disabilities
    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 clinical record review, staff interviews, and review of policy, the facility failed to ensure that one resident (#71) received a Level I Pre-admission Screening and Resident Review (PASRR) after remaining in the facility for longer than the predetermined 30-day convalescent stay. The deficient practice increases the risk that individuals identified with mental disorders may not be evaluated to receive care and services in the most integrated setting appropriate to their needs. Findings include: Resident #71 was admitted to the facility on [DATE] with diagnoses that included multiple fractures of the ribs left side, subsequent encounter for fracture with routine healing, nondisplaced intertrochanteric fracture of left femur, subsequent encounter for closed fracture with routine healing, and schizoaffective disorder, unspecified. A Level I PASRR screening document dated 07/30/21 revealed the physician had certified the resident required 30 days or less of convalescent care after receiving acute inpatient…

    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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-04-29 · tag F0658 — failed to meet professional standards of care — isolated
    Ensure services provided by the nursing facility meet professional standards of quality.
    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, staff interviews, and review of policy, the facility failed to ensure medications were not left in the room of one resident (#95). The deficient practice could negatively impact residents' care, and could result in residents not receiving medications as ordered by the physician. Findings include: Resident #95 was admitted to the facility on [DATE] with diagnoses that included vascular dementia without behavioral disturbance and major depressive disorder. Review of the clinical record revealed a Self-Administration of Medication Observation dated completed on December 22, 2021. The document stated the resident did not want to self-administer medications and that it was not appropriate for the resident to self-administer any medications. Review of the annual Minimum Data Set assessment dated [DATE] revealed a Brief Interview for Mental Status score of 14 which indicated the resident had intact cognition. During an observation conducted on April 25, 2022 between 10:21 AM, a white paper…

    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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-04-29 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    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 resident and staff interviews, clinical record review, and review of policy and procedure, the facility failed to provide one sampled resident (#335) the necessary services to maintain good grooming and personal hygiene. The deficient practice could result in the resident's hygiene needs not being met. Findings include: Resident #335 was admitted to the facility on [DATE] with diagnoses that included pneumonitis due to inhalation of food and vomit, chronic obstructive pulmonary disease, unspecified, and pain, unspecified. The 5-day admission Minimum Data Set assessment dated [DATE] included that the resident scored 15 on the Brief Interview for Mental Status, indicating intact cognition. The resident displayed no behaviors including rejection of care, and required extensive to total 1-2 person physical assistance for most activities of daily living (ADL). An ADL Functional/Rehabilitation Potential care plan dated 04/20/22 related to debility post infection and hospitalization had a goal for ADL needs 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2019-12-12 · tag F0600 — failed to protect residents from abuse and neglect — isolated
    Protect 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 clinical record reviews, facility documentation, staff interviews, and policy review, the facility failed to ensure that one resident (#172) was free from abuse by another resident (#427). The deficient practice could result in the potential for further resident to resident abuse. Findings include: -Resident #172 was admitted to the facility on [DATE] with diagnoses that included dementia with behaviors, schizophrenia and anxiety disorder. Review of the care plan with a start date of 1/08/2019 revealed the resident had socially inappropriate and disruptive behaviors related to schizophrenia and dementia which included wandering into peers' rooms and physical aggression. Interventions included assessing whether the resident's behaviors endangered himself or others and intervening as needed, every 15 minute checks when indicated, maintaining a calm environment and approaching to de-escalate or prevent a situation. A quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident's cognitive…

    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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2019-12-12 · tag F0623 — isolated
    Provide 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 clinical record reviews, resident and staff interviews, and policy review, the facility failed to ensure the Office of the State Long-Term Ombudsman was sent a copy of the hospital transfer notice for two of four sampled residents (#185 and #229). The deficient practice could result in the ombudsman not being notified of transfers/discharges. Findings include: -Resident #185 was admitted to the facility on [DATE], with diagnoses that included chronic kidney disease and depression. Review of a nursing note dated November 9, 2019 at 12:14 a.m., revealed the resident was transferred to the hospital due to a change in condition. However, review of the clinical record revealed no evidence the Long-Term Care Ombudsman was sent a copy of the transfer/discharge notice. -Resident #229 was admitted to the facility on [DATE] with diagnoses that included cerebrovascular disease, diabetes, hypertension, and acute kidney failure. Review of the nursing discharge summary progress note dated October 2, 2019 revealed 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2019-12-12 · tag F0625 — isolated
    Notify 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 clinical record review, and resident and staff interviews, the facility failed to ensure one resident (#185) discharged to the hospital was informed in writing of the facility's bed hold policy. The deficient practice could result in residents that are transferred or discharged not being informed of the bed hold policy in writing. Findings include: Resident #185 was admitted to the facility on [DATE], with diagnoses that included chronic kidney disease and depression. A quarterly Minimum Data Set assessment dated [DATE] revealed a Brief Interview for Mental Status score of 12 which indicated the resident had moderate cognitive impairment. Review of a nursing note dated November 9, 2019 at 12:14 a.m., revealed the resident was transferred to the hospital due to a change in condition. A nursing progress note dated November 10, 2019 at 2:25 p.m. revealed the resident returned to the facility via stretcher. However, review of the clinical record revealed no evidence the resident was informed in writing 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2019-12-12 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure 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 clinical record review, facility documentation, and staff interviews, the facility failed to ensure two residents (#225 and #477) were provided adequate supervision to prevent accidents. The deficient practice could result in residents being at risk for accidents and injury. Findings include: -Resident #225 was admitted to the facility on [DATE], with diagnoses that included dementia with behavioral disturbance, Alzheimer's disease, and insomnia. The admission Minimum Data Set assessment dated [DATE] revealed the resident's cognitive skills for daily decision making was severely impaired. The assessment included the resident exhibited verbal and physical behavior symptoms directed toward others 1 to 3 days during the look-back period that put others at significant risk for physical injury. The assessment also included wandering behavior was not exhibited during the look-back period. Review of the care plan with a start date of October 4, 2019 revealed the resident had socially inappropriate and/or…

    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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2019-12-12 · tag F0757 — failed to avoid unnecessary drugs — isolated
    Ensure 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interviews and policy review, the facility failed to ensure one resident's (#377) medication regimen was free from unnecessary medication, by administering insulin outside of the physician ordered parameters. The deficient practice could result in poor blood glucose control and residents receiving medications unnecessarily. Findings include: Resident #377 was admitted on [DATE] for a one week respite stay, with a diagnosis of type 1 diabetes mellitus. A physician history and physical dated October 9, 2019 included to monitor finger stick blood sugars and provide sliding scale insulin. Review of the diabetes baseline care plan dated October 9, 2019 revealed a goal that the resident's blood sugars would remain within the acceptable range. Interventions were to monitor blood sugars before meals and at bedtime. Review of the October 2019 physician orders revealed orders for sliding scale insulin and orders for Lantus Insulin solution 100 unit/milliliter, give 16 units…

    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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2019-12-12 · tag F0761 — failed to label and store drugs safely — isolated
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    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 policy and procedures, the facility failed to ensure that medications were secured for one (#62) out of 34 residents. Unsecured medications pose a risk, as medications/ointments could be applied or consumed by residents. Findings include: Resident #62 was admitted on [DATE] and readmitted on [DATE], with diagnoses that included dermatitis, rash and other unspecified skin eruption. A care plan dated July 22, 2019, revealed the resident had burns to her leg and foot, upon admission to the facility. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview Mental Status score of 15, indicating the resident was cognitively intact. A physician's order dated November 21, 2019 included for Silver Sulfadiazine cream 1% (topical antimicrobial drug) one application each dose topically for second degree burn of the left foot twice a day. This order was discontinued on November 22, 2019. Review of a physician's order dated November 21, 2019,…

    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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • No harm found · B2019-12-12 · tag F0732 — pattern
    Post nurse staffing information every day.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, staff interviews, and review of policies and procedures, the facilty failed to post the actual hours worked by licensed and unlicensed nursing staff on a daily basis. The deficient practice could result in residents and visitors not being aware of the nurse staffing data information. Findings include: A review of the facility's daily nurse staffing information for the previous three months revealed that the actual hours worked by licensed and unlicensed nursing staff were only posted on the following days: November 8, 9, 27, 28, 29 and 30, 2019 and December 4, 6 and 7, 2019. An interview was conducted with the staffing coordinator (staff #6) on December 11, 2019 at 1:00 p.m. Staff #6 stated that she was unaware that it was a requirement to post the actual hours worked on a daily basis. An interview was conducted with the Administrator (staff #85) on December 11, 2019 at 1:15 p.m. Staff #85 stated she noticed that the actual hours worked by licensed and unlicensed nursing staff was not posted. Staff #85 stated that the actual hours worked was posted on 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.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction

“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.

Worried about a resident here? There are three different people you can turn to, and they do different jobs:
  • 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.
Not sure where to start, or need other help? Dial 2-1-1 for local resources — and if a call is hard or impossible for you, many local 211s also take a text (send your ZIP code to 898-211) or a web chat at 211.org; both vary by area, and 211.org will show what yours offers. Deaf or hard of hearing: dial 711 for the telecommunications relay service, then any number above. In an emergency, call 911.
It is illegal for a facility to retaliate against a resident or family for reporting a concern: federal law gives a resident the right to voice grievances — to the home or to any outside agency — without discrimination or reprisal (42 CFR §483.10(j)(1)). You may report anonymously.

Fines & penalties

No federal fines in the current CMS record.

Part of a chain

This home belongs to ATIED ASSOCIATES — 12 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

RatingThis homeChain avg
Overall 2 of 51.8+0.2 vs chain
Health inspection 2 of 52.2-0.2 vs chain
Staffing 4 of 51.8+2.2 vs chain
Quality measures 3 of 53.2-0.2 vs chain
The other 11 homes this chain runs (chain average 1.8★, per CMS)

A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.

Who owns this facility

Owner / managerTypeRoleShareSince
ROTHNER, WILLIAMIndividual5% OR GREATER DIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL40%since 03/06/2012
ROTHNER, DANIELIndividual5% OR GREATER INDIRECT OWNERSHIP INTEREST7%since 03/06/2012
ROTHNER, MELISSAIndividual5% OR GREATER INDIRECT OWNERSHIP INTEREST7%since 03/06/2012
ROTHNER, RACHELIndividual5% OR GREATER INDIRECT OWNERSHIP INTEREST7%since 03/06/2012
FRIEBUS, HEATHERIndividualW-2 MANAGING EMPLOYEEsince 07/01/2012
ZIMMERMAN, JOEIndividualOPERATIONAL/MANAGERIAL CONTROLsince 07/01/2012

CMS files one row per role, so the 7 rows in the source record cover these 6 parties — each is shown once here with every role it holds. Nothing is omitted.

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.

$21.5M
Net patient revenuemost recent cost report
+0.1%
Operating marginrevenue minus expenses
$2.9M
Related-party expense13% of expenses
Who pays — share of resident-days
Medicaid 72%Medicare 2%Other / private 26%

About 72% 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. This home reported $2.9M paid to related parties — landlords or management companies under common ownership — equal to about 13% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals.

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

$306per resident / day
operating cost
$9,296per month
≈ monthly operating cost
$306per day
avg. revenue, all payers

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

Paying with Medicaid

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.

Typical monthly cost in Arizona
$8,365/mo
Nursing home (semi-private)
$11,437/mo
Nursing home (private)
$6,250/mo
Assisted living

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 035145. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2023-07-14, 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.

What to do next