CMS · Arizona Department of Health Services publishes each citation’s tag, official description and scope/severity letter. The surveyor’s written findings are in the Statement of Deficiencies (CMS-2567) for each survey, linked above.
F550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.Scope/severity DStandard
Dignity & rights
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-02-16Record 035134-20231214-F550
F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Scope/severity DStandard
Abuse & neglect
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-02-16Record 035134-20231214-F600
F607Develop and implement policies and procedures to prevent abuse, neglect, and theft.Scope/severity EStandard
Abuse & neglect
Pattern; no actual harm, potential for more than minimal harm.Corrected 2024-02-16Record 035134-20231214-F607
F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Scope/severity DStandard
Abuse & neglect
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-02-16Record 035134-20231214-F609
F610Respond appropriately to all alleged violations.Scope/severity EStandard
Abuse & neglect
Pattern; no actual harm, potential for more than minimal harm.Corrected 2024-02-16Record 035134-20231214-F610
F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Scope/severity DStandard
Abuse & neglect
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-08-18Record 035134-20230609-F600
F607Develop and implement policies and procedures to prevent abuse, neglect, and theft.Scope/severity EStandard
Abuse & neglect
Pattern; no actual harm, potential for more than minimal harm.Corrected 2023-08-18Record 035134-20230609-F607
F610Respond appropriately to all alleged violations.Scope/severity EStandard
Abuse & neglect
Pattern; no actual harm, potential for more than minimal harm.Corrected 2023-08-18Record 035134-20230609-F610
F657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.Scope/severity EStandard
Care planningRecords
Pattern; no actual harm, potential for more than minimal harm.Corrected 2023-08-18Record 035134-20230609-F657
F658Ensure services provided by the nursing facility meet professional standards of quality.Scope/severity EStandard
Care planningRecords
Pattern; no actual harm, potential for more than minimal harm.Corrected 2023-08-18Record 035134-20230609-F658
F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-08-18Record 035134-20230609-F684
F727Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.Scope/severity EStandard
Staffing
Pattern; no actual harm, potential for more than minimal harm.Corrected 2023-08-18Record 035134-20230609-F727
F740Ensure each resident must receive and the facility must provide necessary behavioral health care and services.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-08-18Record 035134-20230609-F740
F759Ensure medication error rates are not 5 percent or greater.Scope/severity DStandard
Medication
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-08-18Record 035134-20230609-F759
F804Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.Scope/severity DStandard
Food & nutrition
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-08-18Record 035134-20230609-F804
F880Provide and implement an infection prevention and control program.Scope/severity EStandard
Infection control
Pattern; no actual harm, potential for more than minimal harm.Corrected 2023-08-18Record 035134-20230609-F880
F552Ensure that residents are fully informed and understand their health status, care and treatments.Scope/severity DStandard
Dignity & rights
Isolated; no actual harm, potential for more than minimal harm.Corrected 2022-06-15Record 035134-20220408-F552
F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Scope/severity DStandard
Abuse & neglect
Isolated; no actual harm, potential for more than minimal harm.Corrected 2022-06-15Record 035134-20220408-F600
F604Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.Scope/severity DStandard
Abuse & neglect
Isolated; no actual harm, potential for more than minimal harm.Corrected 2022-06-15Record 035134-20220408-F604
F607Develop and implement policies and procedures to prevent abuse, neglect, and theft.Scope/severity DStandard
Abuse & neglect
Isolated; no actual harm, potential for more than minimal harm.Corrected 2022-06-15Record 035134-20220408-F607
F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Scope/severity DStandard
Abuse & neglect
Isolated; no actual harm, potential for more than minimal harm.Corrected 2022-06-15Record 035134-20220408-F609
F610Respond appropriately to all alleged violations.Scope/severity DStandard
Abuse & neglect
Isolated; no actual harm, potential for more than minimal harm.Corrected 2022-06-15Record 035134-20220408-F610
F641Ensure each resident receives an accurate assessment.Scope/severity DStandard
Care planningRecords
Isolated; no actual harm, potential for more than minimal harm.Corrected 2022-06-15Record 035134-20220408-F641
F644Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.Scope/severity DStandard
Care planningRecords
Isolated; no actual harm, potential for more than minimal harm.Corrected 2022-06-15Record 035134-20220408-F644
F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Scope/severity DStandard
Care planningRecords
Isolated; no actual harm, potential for more than minimal harm.Corrected 2022-06-15Record 035134-20220408-F656
F657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.Scope/severity DStandard
Care planningRecords
Isolated; no actual harm, potential for more than minimal harm.Corrected 2022-06-15Record 035134-20220408-F657
F658Ensure services provided by the nursing facility meet professional standards of quality.Scope/severity DStandard
Care planningRecords
Isolated; no actual harm, potential for more than minimal harm.Corrected 2022-06-15Record 035134-20220408-F658
F677Provide care and assistance to perform activities of daily living for any resident who is unable.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2022-06-15Record 035134-20220408-F677
F679Provide activities to meet all resident's needs.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2022-06-15Record 035134-20220408-F679
F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2022-06-15Record 035134-20220408-F686
F692Provide enough food/fluids to maintain a resident's health.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2022-06-15Record 035134-20220408-F692
F697Provide safe, appropriate pain management for a resident who requires such services.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2022-06-15Record 035134-20220408-F697
F725Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.Scope/severity EStandard
Staffing
Pattern; no actual harm, potential for more than minimal harm.Corrected 2022-06-15Record 035134-20220408-F725
F757Ensure each resident’s drug regimen must be free from unnecessary drugs.Scope/severity DStandard
Medication
Isolated; no actual harm, potential for more than minimal harm.Corrected 2022-06-15Record 035134-20220408-F757
F758Implement 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.Scope/severity DStandard
Medication
Isolated; no actual harm, potential for more than minimal harm.Corrected 2022-06-15Record 035134-20220408-F758
F759Ensure medication error rates are not 5 percent or greater.Scope/severity DStandard
Medication
Isolated; no actual harm, potential for more than minimal harm.Corrected 2022-06-15Record 035134-20220408-F759
F770Provide timely, quality laboratory services/tests to meet the needs of residents.Scope/severity EStandard
Records
Pattern; no actual harm, potential for more than minimal harm.Corrected 2022-06-15Record 035134-20220408-F770
F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Scope/severity EStandard
Food & nutrition
Pattern; no actual harm, potential for more than minimal harm.Corrected 2022-06-15Record 035134-20220408-F812
F880Provide and implement an infection prevention and control program.Scope/severity EStandard
Infection control
Pattern; no actual harm, potential for more than minimal harm.Corrected 2022-06-15Record 035134-20220408-F880
F888Ensure staff are vaccinated for COVID-19Scope/severity EStandard
Infection control
Pattern; no actual harm, potential for more than minimal harm.Corrected 2022-06-15Record 035134-20220408-F888
F943Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.Scope/severity DStandard
Abuse & neglect
Isolated; no actual harm, potential for more than minimal harm.Corrected 2022-06-15Record 035134-20220408-F943