Fountain Hills Post Acute
16300 East Keith McMahan Drive, Fountain Hills, AZ 85268 · For profit - Limited Liability company · 64 certified beds · (480) 836-4800 Medicare only — no Medicaid
This home has serious findings on its record. Read them closely before you consider it.
- a middle-of-the-pack inspection score (3/5)
- lower-than-typical staff turnover (35% vs 45% nationally) — better care continuity
- it has an abuse, neglect, or exploitation citation (F0600), cited Mar 2024
- it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0608, F0609, F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- it has 1 actual-harm citation
- a high number of inspection citations overall (17) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $13,065 in federal fines (most recent 2026-04-22)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 3 of 5 |
| StaffingFrom payroll records (PBJ) | 3 of 5 |
| Quality measuresSelf-reported by the facility | 4 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 4 of 5 |
| Long-stay residentspeople who live here | 4 of 5 |
| Short-stay residentsrehab / post-hospital | 4 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 4 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 9.2% | 10.7% | 15.4% | better |
| Long-stay residents who lose too much weight | 6.0% | 5.3% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 0.0% | 0.8% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 0.0% | 1.2% | 2.0% | better |
| Long-stay residents with depressive symptoms | 10.8% | 3.9% | 6.5% | worse |
| Long-stay residents who were physically restrained | 0.0% | 0.3% | 0.1% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with falls causing major injury | 12.9% | 2.1% | 3.3% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 14.0% | 21.0% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 95.0% | 94.6% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 5.0% | 4.4% | 4.7% | typical |
| Long-stay residents with worsening bladder/bowel control | 30.1% | 20.6% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 13.8% | 10.6% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 0.8% | 1.2% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 87.7% | 87.3% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 33.0% | 23.7% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 12.6% | 10.4% | 12.0% | typical |
‡ 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.
63.9% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that better than the national rate. This is CMS’s risk-adjusted rate over 359 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 79.0% 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 114 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 0.63 therapist hours per resident per day in 2026Q1 — more than 89% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 5% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 63.9%CMS range 59.5–68.6 | 51.5% | Oct 2022–Sep 2024 | better than U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 10.5%CMS range 8.2–13.3 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 79.0% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 71.0% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 56.1% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | 96.0% | 100.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | 80.0% | 98.7% | Oct 2024–Sep 2025 | CMS 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 stay | 0.0% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 1.8% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 5.4%CMS range 3.5–8.4 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.86 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 64 beds and averages 58.3 residents a day — about 91% occupied, or roughly 6 beds typically open. It runs fairly full. 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 3.16 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.88 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 1.52 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 2.81 hrs/resident/day on weekends vs 3.30 on weekdays — 15% thinner on weekends. RN hours go from 1.13 to 0.28 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 35% 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
Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
17 citations, most serious first. The 11 most serious are shown; the remaining 6 are one tap away and print in full.
- Actual harm · G2026-04-22 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, resident and staff interviews, hospital records, facility documentation, policies and procedures, the facility failed to ensure physician-ordered diets were followed and implemented for 2 of 10 sampled residents (#9 and #12). This deficient practice resulted in resident #9 choking and requiring hospitalization.Findings include:Regarding Resident #9-Resident #9 was admitted on [DATE], with a diagnosis of heart failure, chronic atrial fibrillation, hypertensive heart and chronic kidney disease, with heart failure and chronic kidney disease, and moderate vascular dementia with anxiety. The Order Summary Report revealed an active physician order dated December 23, 2024, which prescribed a regular diet, regular texture, thin liquids consistency, cut into bite-sized pieces/large protein portions. No food allergies/no isolation. Further review of the Order Summary Report revealed no active order for speech therapy evaluation or treatment. A nutrition care plan, which was initiated on…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-05-29 · tag F0755 — failed to provide safe pharmacy services — isolatedProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
What the surveyor found here — an excerpt from the official record, may be distressing
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 medication was acquired, received, and administered according to physician orders for one of three sampled residents (#2). The deficient practice could result in a resident not receiving medication as ordered by the physician.-Findings include:Resident #2 was admitted to the facility on [DATE], with diagnoses of secondary malignant neoplasm of the brain, malignant melanoma of skin, cognitive, social, or emotional deficit following nontraumatic intracerebral hemorrhage, visual disturbance, headache, chronic obstructive pulmonary disease, and a personal history of other venous thrombosis and embolism.A discharging hospital progress note dated March 27, 2026, for Resident #2 revealed that the assessment and plan for his brain metastasis included the resident being started on dexamethasone (corticosteroid medication).A physician's order dated March 28, 2026, included for dexamethasone tablet 2…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-02-18 · tag F0609 — failed to report abuse allegations — isolatedTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, and review of facility policy, the facility failed to ensure that an allegation of sexual abuse made by one (Resident #3) of three sampled residents was immediately reported to the administrator and to the appropriate state agency within the required timeframes (within 2 hours for allegations involving abuse or serious bodily injury), as required. This deficient practice had the potential to place residents at risk for ongoing abuse and delayed protective interventions.Findings Include:Resident #3 was admitted [DATE], with diagnoses including metabolic encephalopathy, traumatic brain injury history, depression, anxiety disorder, and muscle weakness.A review of Resident #3's most recent Medicare 5-day, Minimum Data Set (MDS) assessment dated [DATE], revealed that the Brief Interview for Mental Status (BIMS) score of 15, indicating that resident #3 was cognitively intact.Review of the clinical record for Resident #3 revealed a nursing progress note dated November 9, 2025, stating…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-11-19 · tag F0761 — failed to label and store drugs safely — isolatedEnsure 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, interview, review of clinical record, and review of facility policy and procedure, the facility failed to ensure medication was administered and stored according to policy for two of four sampled residents (#4 and #2). The deficient practice resulted in residents accidentally ingesting medication.Findings Include:-Regarding Resident #4:Resident #4 was admitted to the facility on [DATE], with diagnoses that included hyperlipidemia, anemia, type 2 diabetes mellitus, chronic pain syndrome, pressure ulcer of right buttock, and pressure ulcer of right ankle.An admission minimum data set (MDS) assessment dated [DATE], revealed Resident #14 had a brief interview for mental status (BIMS) score of 14, indicating intact cognition.A physician order dated September 30, 2025, for arformoterol tartrate inhalation nebulization solution 15 mcg/2ml indicated for 2 ml, to inhale every 12 hours as needed for chronic obstructive pulmonary disease (COPD).The clinical record revealed no evidence of a physician…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-05-30 · tag F0761 — failed to label and store drugs safely — isolatedEnsure 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 observations, staff interviews and policy review, the facility failed to ensure that medications were not left at the bedside for one resident (#9). The deficient practice could result in harm to the residents, and/or visitors who have access to medications. Findings include: During an initial observation of Resident #9's room on May 27, 2025 at 09:38 a.m., a tube of voltaren arthritis pain relieving cream was observed on the resident's bed side table. Resident #9 was admitted to the facility on [DATE] with diagnoses that included type 2 diabetes mellitus, paroxysmal atrial fibrillation, and muscle weakness. A physician order dated April 10, 2025 was written: voltaren external gel 1 % (diclofenac sodium (topical) apply 2 grams(gm) twice daily to back topically for back pain. Administered by clinician only. A care plan, initiated on April 10, 2025 revealed that the Resident #9 had an acute/chronic pain related to spinal stenosis and pressure ulcers to buttocks/coccyx region. Further, review of care plan…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-03-06 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, facility documentation, staff and resident interviews, and facility policy and procedures, the facility failed to protect the right of one resident(#10) to be free from abuse by staff. The deficient practice could result in residents being abused. Findings include: Resident #10 was admitted to the facility on [DATE] with diagnoses that included post traumatic stress disorder, generalized muscle weakness, and bipolar disorder. Review of the care plan for activities of daily living (ADLs) dated November 26, 2023 revealed that the resident had a performance deficit related to weakness. The resident required extensive assistance with bed mobility and was totally dependent with transfers, toileting, and dressing. The bowel and bladder incontinence care plan dated December 3, 2023 included the interventions to use disposable briefs and change as needed; check as required for incontinence; wash, rinse and dry perineum; and, change clothing as needed after incontinence episodes. The Minimum Data…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-01-25 · tag F0658 — failed to meet professional standards of care — isolatedEnsure 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 review of clinical records and policy, observations, and staff interviews the facility failed to ensure a complete anti-seizure medication regimen was administered to Resident # 295 within accepted professional standards of practice. The deficient practice of incomplete medication administration does not align with accepted professional standards of practice and may result in undesirable quality of care. Findings Include: Resident # 295 was admitted on [DATE] with diagnoses of burn of unspecified degree of buttock, essential hypertension, and unspecified convulsions. The most recent admission Minimum Data Set (MDS) assessment revealed a Brief Interview for Mental Status (BIMS) score of 13 which indicated the resident was cognitively intact. On admission, Resident # 295 had the following anti-seizure medication regimen: Vimpat (Lacosamide) oral tablet 200 milligrams, give 1 table by mouth two times a day for seizures, dated January 22, 2024 and Lamotrigine oral tablet 25 milligrams, give 2 tablets by…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-01-25 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of clinical records and policy, observations, and staff interviews the facility failed to ensure cautionary slippery-floor safety signs were present near a hazardous area for Resident #295. The deficient practice of reduced safety measures may result in a higher likelihood of accidental falls. Findings Include: Resident #295 was admitted on [DATE] with diagnoses of burn of unspecified degree of buttock, muscle weakness, abnormalities of gait and mobility, and unspecified convulsions. The most recent admission Minimum Data Set (MDS) assessment revealed a Brief Interview for Mental Status (BIMS) score of 13 which indicated the resident was cognitively intact. Care plan initiated on January 19, 2024, revealed a goal for Resident #295 was not to sustain serious injury due to risk for falls related to impaired mobility. On January 22, 2024 at 9:34 AM, Resident #295 was observed walking in front of room [ROOM NUMBER] with Physical Therapist (PT/Staff #81). On January 22, 2024 at 9:34 AM, an observation…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2022-10-20 · tag F0725 — failed to have enough nursing staff — patternProvide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
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 reviews, resident and staff interviews, facility document, and facility assessment, the facility failed to ensure that there was sufficient nursing staff to meet the needs of multiple residents (#s 11, 19, 27, 85, 129, and 180). The census was 27. The deficient practice could result in residents' care needs not being met. Findings include: -Resident #11 was admitted on [DATE] with diagnoses that included fractures and other multiple trauma, aphasia, and Parkinson's disease. Review of the admission MDS (Minimum Data Set) assessment dated [DATE] revealed the BIMS (Brief Interview for Mental Status) was not completed. The MDS stated the resident was totally dependent on two staff with toilet use, and extensive assistance with personal hygiene, and eating. During an interview conducted with the resident on October 18, 2022 at 11:25 a.m., the resident stated that he put on his call light during the night and waited 12 hours for a staff member to come in to change his wet brief. -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.
- Potential for harm · D2022-10-20 · tag F0552 — isolatedEnsure that residents are fully informed and understand their health status, care and treatments.
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 (#21) was informed in advance of the risks and benefits of psychoactive medications. The sample size was 2. The deficient practice could result in residents and/or their representatives not being made aware of the risks and benefits of psychoactive medications. Findings include: Resident #21 was admitted to the facility on [DATE] with diagnoses that included major depressive disorder, anxiety disorder, and unspecified mood (affective) disorder. Review of physician orders revealed an order dated September 22, 2022 for Bupropion (antidepressant), and an order dated September 28, 2022 for Citalopram for depression. A care plan initiated on September 26, 2022 stated the resident was on antidepressant medication use related to depression as evidenced by sad affect, sleeplessness and social isolation. The interventions stated to educate the resident, family/caregivers about risks, benefits and the side…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-10-20 · tag F0580 — failed to tell family and doctor about changes — isolatedImmediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interviews, and review of policy and procedures, the facility failed to ensure the provider received notification of an unwitnessed fall regarding one resident (#84). The sample size was 12. The deficient practice could result in delayed care. Findings include: Resident #84 was admitted to the facility on [DATE] with diagnoses that included encephalopathy, unspecified dementia, anxiety, and bipolar disorder. A risk for falls care plan was initiated on 10/14/22 related to dementia, psychoactive drug use, and weakness. The goal was for the resident not to sustain serious injury. Interventions included encouraging the resident to participate in activities that promote exercise and physical activity for strengthening and improved mobility. The Fall Risk Evaluation dated 10/14/22 revealed the resident was assessed to be at high risk for falls. The nursing progress note dated 10/17/22 at 7:24 a.m. revealed the resident was found on the floor by the bedside during the midnight…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 6 citations
- Potential for harm · D2022-10-20 · tag F0608 — failed to report suspected crimes — isolatedDevelop and implement policies and procedures to ensure (1) employees report any suspicion of a crime against any resident, according to timelines; (2) post the notice of employee rights; and (3) prohibit and prevent retaliation for reporting.
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, State Agency (SA) database, review of facility records, and review of policies and procedures, the facility failed to report an allegation of abuse regarding one sampled resident (#130), to the law enforcement agency within the required time frame. The deficient practice could result in more reasonable suspicions of crime not being reported. Findings include: Resident #130 was admitted to the facility on [DATE] with diagnoses that included wedge compression fracture of unspecified lumbar vertebra, contusion of left forearm, and generalized muscle weakness. An admission Minimum Data Set (MDS) assessment dated [DATE] included a BIMS (Brief Interview of Mental Status) score of 15 indicating resident #130 had intact cognition. The assessment stated the resident required extensive assistance with bed mobility, transfer, toilet use and personal hygiene with one-person physical assistance. Review of the State Agency (SA) Complaint/Incident Investigation Report, dated…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-10-20 · tag F0610 — failed to investigate and act on abuse reports — isolatedRespond appropriately to all alleged violations.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interviews, facility documentation, the State Agency (SA) database, and policy review, the facility failed to ensure that an allegation of abuse was investigated regarding one sampled resident (#130). The deficient practice could result in further allegations of abuse not being investigated. Findings include: Resident #130 was admitted to the facility on [DATE] with diagnoses that included wedge compression fracture of unspecified lumbar vertebra, contusion of the left forearm, and generalized muscle weakness. The resident was discharged [DATE]. An admission Minimum Data Set (MDS) assessment dated [DATE] included a BIMS (Brief Interview of Mental Status) score of 15 indicating resident #130 had intact cognition. The assessment stated the resident required extensive assistance with bed mobility, transfer, toilet use and personal hygiene with one-person physical assistance. Review of the State Agency (SA) Complaint/Incident Investigation Report, dated February 10, 2022 at…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-10-20 · tag F0692 — failed to prevent malnutrition and dehydration — isolatedProvide enough food/fluids to maintain a resident's health.
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, resident and staff interviews, and review of policies, the facility failed to ensure two sample residents (#3 & #14) were consistently provided care and services to maintain acceptable parameters of nutritional status. The deficient practice could result in residents with unplanned weight loss and dehydration. Findings include: -Resident #3 admitted to the facility on [DATE] with diagnoses that included Parkinson's disease, Alzheimer's disease, and aphasia. A nutritional problem/potential nutritional problem care plan dated 05/03/21 related to abnormal labs, impaired cognition, and leaving 25% or more at meals, had a goal for the resident to maintain adequate nutritional status as evidenced by no significant weight changes. Interventions stated for the registered dietician to evaluate and make diet change recommendations. A physician order dated 09/02/21 included weekly weights, every day shift, every Tuesday per protocol. The annual Minimum Data Set assessment dated [DATE]…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-10-20 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interviews, and policy reviews, the facility failed to ensure respiratory care was provided consistent with professional standards of practice for one resident (#19) by failing to ensure there was a physician order and ongoing care and monitoring for the use of a CPAP (continuous positive airway pressure) machine and not providing oxygen as ordered. The sample size was 2. The deficient practice could result in residents not having an order for the use of a CPAP machine and not receiving oxygen as ordered. Findings include: Resident #19 was admitted on [DATE] with diagnoses that included heart failure, other asthma, obstructive sleep apnea, and pleural effusion. An admission MDS (minimum data set) assessment dated [DATE] revealed resident #19 BIMS (brief interview of mental status) score was 11 which indicated moderate cognitive impairment. A physician order dated September 21, 2022 stated oxygen at 2 liters per minute via nasal cannula every shift for monitoring. Review of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-10-20 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, staff interviews, the CDC (Centers for Disease Control and prevention) and policy review, the facility failed to ensure visual alerts were posted to ensure everyone was aware of the recommended infection control practices in the facility. The deficient practice could result in the spread of infection. Findings include: Upon entrance into the facility on October 19, 2022 at approximately 7:24 AM, it was observed that there was no signage posted on the door regarding infection prevention and control (IPC) practices in the facility. Review of the facility's resident matrix revealed residents in the facility had COVID. Observations conducted throughout the survey revealed no signage to inform visitors of appropriate IPC actions to take while in the facility. An interview was conducted on 10/20/22 at 9:09 AM with the Infection Control Prevention Specialist (staff #44) who stated there used to be signage that instructed what personal protective equipment (PPE) to wear while in the facility. An interview was conducted with the Director of Nursing (DON/staff #11) on…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-10-20 · tag F0919 — failed to provide a working call system — isolatedMake sure that a working call system is available in each resident's bathroom and bathing area.
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, family and staff interviews, clinical record review, and review of policy, the facility failed to ensure the call light for one resident (#84) was appropriately placed within the resident's reach. The sample size was 12. The deficient practice could result in residents not having the means to communicate with staff and not receiving care or services in a timely manner. Findings include: Resident #84 was admitted to the facility on [DATE] with diagnoses that included encephalopathy, unspecified dementia, severe, anxiety, and bipolar disorder. A risk for falls care plan initiated on 10/14/22 related to dementia, psychoactive drug use, and weakness, had a goal the resident would not sustain serious injury. Interventions included keeping needed items, such as water, etc., in reach. On 10/18/22 at 10:17 a.m., an interview was conducted with the resident's representative. She stated the resident had fallen out of bed in the morning of the previous day. The representative stated that she did not…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
$13,065 in federal fines across 1 penalty.
- $13,065 — penalty dated 2026-04-22
Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.
Part of a chain
This home belongs to THE ENSIGN GROUP — 342 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 →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 3 of 5 | 3.2 | -0.2 vs chain |
| Health inspection | 3 of 5 | 2.8 | +0.2 vs chain |
| Staffing | 3 of 5 | 2.7 | +0.3 vs chain |
| Quality measures | 4 of 5 | 4.4 | -0.4 vs chain |
The other 341 homes this chain runs (chain average 3.2★, per CMS)
Showing 40 of 341; lowest-rated first.
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 / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| DARK SKY HOLDINGS LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST; ADP OF THE SNF | 100% | since 10/01/2022 |
| BURNAM, SOON | Individual | MANAGING CONTROL - GOVERNING BODY; CORPORATE OFFICER | — | since 10/01/2022 |
| MONKS, CONNER | Individual | MANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 10/01/2022 |
| PRABHAKARAN, VINAY | Individual | MANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 10/01/2022 |
| KEETCH, CHAD | Individual | CORPORATE OFFICER | — | since 03/01/2011 |
| ENSIGN SERVICES INC | Organization | ADP OF THE SNF | — | since 10/01/2022 |
| STANDARD BEARER HEALTHCARE OP, LP | Organization | ADP OF THE SNF | — | since 10/01/2022 |
| THE ENSIGN GROUP INC | Organization | ADP OF THE SNF | — | since 10/01/2022 |
CMS files one row per role, so the 14 rows in the source record cover these 8 parties — each is shown once here with every role it holds. Nothing is omitted.
4 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
This home reported $705K paid to related parties — landlords or management companies under common ownership — equal to about 10% 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
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
CMS lists this home as Medicare-certified only — it is not Medicaid-certified, so it generally cannot accept Medicaid as payment for a long-term stay. That makes it one of roughly 545 homes nationally where a Medicaid-funded placement is not an option. If you expect to rely on Medicaid, ask the home directly before you tour, and see the Arizona Medicaid page for homes that do.
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 035260. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-05-30, 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.