Not rated by CMS — ratings are suppressed for new or low-volume facilities.
A standard survey is most likely before around October 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Caring House during CMS and state inspections, most recent first.
A resident with multiple chronic pain conditions did not receive timely or effective pain management, as staff failed to follow facility policy and professional standards for pain assessment, documentation, and provider notification. Pain reassessments after PRN opioid administration were frequently delayed or incomplete, and the resident experienced prolonged severe pain, including an episode of crying and distress lasting over two hours before hospital transfer. Staff interviews confirmed inconsistent and sometimes inaccurate pain documentation, contributing to inadequate pain control.
A resident with a documented DNR order and preference for Comfort Care Only was provided CPR after being found unresponsive, due to staff miscommunication about code status. CPR was performed for two minutes before the error was recognized and resuscitation efforts were stopped, contrary to the resident's advance directive.
A resident with significant cognitive impairment and a history of behavioral disturbances entered another resident's room and scratched her face, resulting in physical injury. Both residents were dependent on staff for care, and the aggressor had a known pattern of entering others' rooms and displaying physical behaviors toward others. Despite interventions such as staff awareness and redirection, the incident was not prevented.
A resident with multiple chronic conditions, including dementia, experienced a significant decline in ADL function and required increased assistance from staff after a COVID-19 infection. Despite clear documentation of these changes and staff observations of increased care needs, an SCSA was not completed, and the MDS RN was unaware of the resident's status change due to communication gaps.
Two residents were not adequately supervised, resulting in one resident falling in the shower after being left alone by a CNA, and another resident becoming agitated and striking a peer during a community outing. In both cases, staff did not follow individualized care plans or provide the required level of supervision, leading to preventable incidents.
A resident with multiple chronic pain conditions did not receive a timely or accurate pain reassessment after being given PRN oxycodone, as required by physician orders. The RN failed to document the effectiveness of the pain medication within the expected timeframe and later entered an inaccurate pain score in the EMR, which was not consistent with the resident's report. The DON confirmed that this documentation did not meet professional standards.
An LPN failed to perform hand hygiene after removing contaminated gloves and before donning new gloves while administering IV medication to a resident with a PICC line. This action was observed during medication administration, and both the LPN and the facility's Infection Preventionist confirmed that hand hygiene should have occurred between glove changes, as required by facility policy.
A resident with diabetes was incorrectly coded as having received insulin on the MDS assessment after staff misidentified Ozempic, a non-insulin diabetes medication, as insulin. Both the MDS nurse and DON initially classified Ozempic as insulin before later confirming it was not, leading to an inaccurate assessment.
Failure to Provide Timely and Effective Pain Management
Penalty
Summary
Facility staff failed to provide safe and appropriate pain management for a resident with multiple chronic pain conditions, including thoracic spine pain, systemic lupus erythematosus, Sjogren syndrome, ankylosing spondylitis, chronic pain syndrome, osteoporosis, and a history of spinal fusion and fractures. Despite physician orders and a care plan requiring regular pain assessments and timely reassessment after administration of as-needed (PRN) opioid pain medication, staff did not consistently assess or document the location, intensity, frequency, pattern, and severity of the resident's pain for each occurrence. Pain reassessments were frequently delayed, often occurring several hours after medication administration instead of within the required one-hour timeframe, and were sometimes documented as "unknown" or inaccurately recorded. There was also no evidence that staff notified the provider when pain medication was ineffective or that additional interventions were offered when the resident continued to experience high pain levels. The resident experienced prolonged and severe pain episodes, including an incident where she was observed crying and tearful for over two hours before being transferred to the hospital for severe back pain. Documentation showed repeated instances where the resident reported pain levels of 8/10 or 9/10, with PRN opioid medication administered but with little to no relief, and no timely follow-up or escalation of care. Staff interviews revealed a lack of adherence to facility policy and professional standards regarding pain assessment and documentation, with some staff admitting to making assumptions about pain location and intensity, and others acknowledging that pain assessments were not completed as required. Inaccurate documentation of pain levels was also noted, with one nurse admitting to recording a pain level of zero when the resident was still experiencing significant pain. The facility's own policies required comprehensive pain assessments and timely reassessment after PRN pain medication, as well as provider notification when pain management was ineffective. However, these procedures were not followed, resulting in inadequate pain management for the resident. The failure to properly assess, document, and respond to the resident's pain led to prolonged suffering and ultimately necessitated hospital transfer for pain control.
Failure to Honor Resident's DNR Order Resulting in Unwanted CPR
Penalty
Summary
A resident with chronic kidney disease, atrial fibrillation, and hypertension was admitted to the facility and had a signed Living Will Instruction Form indicating a preference for Comfort Care Only and a Do Not Resuscitate (DNR) order. The resident's advance directive clearly stated that in the event of a terminal condition, cardiopulmonary resuscitation (CPR) should not be performed. Despite these documented wishes, when the resident was found unresponsive, facility staff initiated CPR after someone incorrectly called out that the resident was a Full Code. Two minutes of CPR were performed before it was clarified that the resident was DNR, at which point resuscitation efforts ceased and the resident was pronounced dead. The facility's policy on advance directives, which aligns with Arizona state law, requires that residents' wishes regarding treatment and resuscitation be honored. In this case, the resident's documented refusal of CPR was not followed, resulting in the administration of unwanted life-saving measures. The Assistant Administrator acknowledged upon review that the resident was indeed DNR and that providing CPR was a mistake.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect a resident's right to be free from physical abuse when one resident entered another's room and scratched her face. Both residents involved were significantly cognitively impaired, with documented histories of dementia and dependence on staff for all care. The resident who committed the abuse had a known pattern of entering other residents' rooms, taking their belongings, and displaying physical behavioral symptoms toward others, including a prior attempt to strike another resident. Despite these known behaviors, the interventions in place at the time included staff awareness, redirection, and maintaining a calm environment, but did not prevent the incident from occurring. On the evening of the incident, staff had just assisted the victim to bed and left the room when, within two minutes, a scream was heard. The aggressor was observed leaving the victim's room, and the victim was found with a one-inch scratch on her face. The aggressor had no recall of the event. The care plan for the aggressor had previously identified the risk for conflict with other residents, but the measures in place were insufficient to prevent the physical abuse that occurred.
Failure to Complete Significant Change Assessment for Resident with Declining ADL Function
Penalty
Summary
A significant change in status assessment (SCSA) was not completed for a resident who experienced a notable decline in her ability to perform activities of daily living (ADLs). The resident, admitted with diagnoses including hypertension, diabetes mellitus, and dementia, was observed to have increased care needs following a COVID-19 infection. Staff interviews revealed that the resident, who previously required only supervision or limited assistance, became dependent on two staff members for bed mobility, transfers, toileting, and bathing. She also became more confused, spent more time in bed, became incontinent, and was no longer able to express her needs as before. Review of the resident's electronic medical records showed a documented increase in the level of assistance required, as reflected in monthly summaries. However, the MDS Registered Nurse confirmed that an SCSA was not completed and was unaware of the resident's increased care needs until after the fact. The facility's policy requires that significant changes in a resident's status be consistently reflected in assessments, progress notes, and care plans, but this was not done in this case due to a communication gap among staff.
Failure to Provide Adequate Supervision and Accident Prevention
Penalty
Summary
Staff failed to provide adequate supervision to two residents, resulting in separate incidents that compromised resident safety. In the first incident, a resident with a history of dementia, behavioral disturbances, and physical impairments participated in a community outing to a ball game. During the process of seating residents in a small, crowded suite, the resident became agitated and struck another resident on the leg while attempting to transfer. Staff present at the outing were not fully familiar with the resident's care plan, which included multiple interventions for managing agitation and aggression, and did not have the necessary transfer equipment (slide board) available. The environment was noisy and overstimulating, which contributed to the resident's agitation and subsequent physical outburst. In the second incident, a resident with a history of cerebral infarction, memory deficit, neuromuscular dysfunction of the bladder, and dementia was left unsupervised in the shower by a CNA. The resident, who required substantial to maximum assistance for bathing, attempted to reach for a washcloth and fell from the shower chair, which also tipped over. The resident was found on the floor by another CNA after the call light was activated. The care plan for this resident specifically required that at least one staff member remain with the resident during showering, but this intervention was not followed, resulting in the fall. Both incidents involved lapses in staff adherence to individualized care plans and supervision requirements. In the first case, staff did not anticipate or adequately manage the resident's behavioral triggers in a group setting, and in the second, a staff member left a dependent resident unattended in a high-risk situation. These failures led to preventable accidents and minor injuries, as documented in the facility's investigations and resident interviews.
Inaccurate Pain Assessment and Documentation in Resident Medical Record
Penalty
Summary
The facility failed to ensure the accuracy of medical records for a resident with multiple chronic pain-related diagnoses, including thoracic spine pain, systemic lupus erythematosus, Sjogren syndrome, ankylosing spondylitis, chronic pain syndrome, and osteoporosis. Physician orders required pain assessments every shift using a 0-10 scale, with documentation of pain location, non-medication interventions, and the effectiveness of PRN pain medication. On the day in question, a registered nurse administered PRN oxycodone for severe pain but did not perform a timely or complete reassessment of the resident's pain as required. During medication administration, the nurse asked the resident about their pain level, which remained at 9/10 after receiving oxycodone earlier that morning. The nurse did not inquire further about the pain's location, intensity, or duration, nor did she document a reassessment within the expected 30-60 minute window. The Medication Administration Record (MAR) initially lacked documentation of the pain medication's effectiveness, and a later entry indicated the medication was effective, but this was not supported by the resident's report or timely assessment. A progress note created by the nurse later that day inaccurately documented the resident's pain level as 0/10, which the nurse later admitted was incorrect and attributed to rushing and attempting to match expected documentation times. The Director of Nursing confirmed that pain reassessments should be documented in real time and within one hour of administration, and that inaccurate or delayed documentation does not meet professional standards. Facility policy supports the use of electronic medical records but requires accurate and timely documentation.
Failure to Perform Hand Hygiene Between Glove Changes During IV Medication Administration
Penalty
Summary
During a medication administration observation, a licensed nurse prepared and administered an intravenous (IV) antibiotic to a resident with a peripherally inserted central catheter (PICC) line. The nurse followed aseptic technique while flushing the PICC line prior to medication administration. However, after moving the IV pump and reconnecting a dislodged electrical cord, the nurse removed her gloves and immediately donned a new pair without performing hand hygiene in between glove changes. The nurse acknowledged during the observation that she had skipped the required hand hygiene step after removing contaminated gloves. The facility's Infection Preventionist confirmed that the expectation is for staff to perform hand hygiene between glove changes. Review of the facility's infection prevention and control policy also indicated that hand hygiene must be performed after removing gloves, even if gloves are used during resident care.
Inaccurate MDS Assessment Due to Misclassification of Diabetes Medication
Penalty
Summary
The facility failed to accurately assess a resident for the Minimum Data Set (MDS) assessment by incorrectly coding the administration of insulin. The resident was admitted with diagnoses including type 2 diabetes mellitus with hyperglycemia and was prescribed Ozempic, a medication for diabetes, but not an insulin. During the quarterly MDS assessment, the nurse responsible for completing the assessment coded that the resident had received insulin during the lookback period, based on the administration of Ozempic. Interviews with the MDS nurse and the Director of Nursing revealed a lack of understanding regarding the classification of Ozempic, with both initially identifying it as insulin. Upon further review using a drug guide, it was clarified that Ozempic is not insulin. The facility's policy requires comprehensive and accurate assessments to inform person-centered care plans, but this process was not followed, resulting in an inaccurate MDS assessment for the resident.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Sacaton
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Oasis Pavilion Nursing & Rehabilitation Center | 12.5 mi | — | 3 | 0 |
| The Center At Val Vista, Llc | 14.3 mi | — | 0 | 0 |
| Wellsprings Of Gilbert | 15 mi | — | 0 | 0 |
| Archstone Care Center | 16.8 mi | — | 4 | 0 |
| Sante Of Chandler | 16.8 mi | — | 2 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.