Lake Pleasant Post Acute Rehabilitation Center

Location & what’s nearby

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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

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.

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.

51.1% 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 112 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

Met the expected recovery: 71.0% 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 31 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 0.46 therapist hours per resident per day in 2026Q1 — more than 77% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 12% 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.

Staffing

How full it usually is: this home is certified for 128 beds and averages 101.5 residents a day — about 79% occupied, or roughly 26 beds typically open. It usually has some room. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.32 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.59 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 1.78 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 2.92 hrs/resident/day on weekends vs 3.49 on weekdays — 16% thinner on weekends. RN hours go from 0.65 to 0.46 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 50% is about the same as 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 unchanged from the previous inspection. 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.

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

• Potential for harm · E2026-02-26 · tag F0628 — pattern
  Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
  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 closed record review, staff interviews, review of facility process and policy the facility failed to ensure that all transfer/discharge notifications were made for one resident (#130). The sample size was four. The deficient practice could lead to notifications and pertinent information regarding the discharge/transfer not being provided.Findings include:Regarding Resident #130 -Resident #130 was admitted to the facility on [DATE] with diagnoses of orthopedic aftercare following surgical amputation, anemia, adjustment disorder, muscle weakness, and dysphagia. An admission Minimum Data Set assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating that the resident is cognitively intact. Additionally, the BIMS documented that the resident received physical therapy, occupational therapy, and speech therapy while at the facility. A physician order dated December 5, 2025 indicated that the resident would be discharged to a group home on December 9, 2025. A Discharge…

  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 · Ecited before2026-02-26 · tag F0812 — failed to store, cook, and serve food safely — pattern
  Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observations, staff interviews, review of facility documentation and policies and procedures, the facility failed to ensure that food was prepared, stored, distributed and served in accordance with professional standards for food service safety. The deficient practice could result in food- borne illness.Findings Include: Regarding Kitchen Cleanliness-An initial kitchen observation was conducted on February 23, 2026 at 8:12 A.M. in conjunction with kitchen staff #86. During the initial observation it was observed that floor had several areas of dark matter that appeared to have accumulation in the corners of the tile floor. It was observed that a square, depressed area under the dish sink had black matter that appeared wet within its perimeter. Various pieces of solid debris were located in this area. Visible debris was observed on the floor under food preparation counters. A gray, brown matter was observed covering the vent covers over the area where the food carts were stored in preparation for tray transportation to the units. An observation of the roll up door 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.

  Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2026-02-26 · tag F0641 — isolated
  Ensure each resident receives an accurate assessment.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interviews, facility policy and the Resident Assessment Instrument (RAI) manual , the facility failed to ensure MDS assessment for 2 of 3 sampled residents (#21 and #100) were accurate. The deficient practice could result in assessment inaccurately reflects the resident's status. Findings include:-Resident #100 was admitted on [DATE] with diagnoses of pathological fracture in neoplastic disease, benign neoplasm of left adrenal gland, cerebral palsy and muscle weakness. The face sheet of the clinical record revealed the preferred name of Resident #100. The clinical census sheet of the clinical record included the preferred name of Resident #100. The resident's insurance card on file revealed the resident's preferred name. The Resident #100's driver's license and Medicare card included that resident's legal name. The admission and 5-day MDS (Minimum Data Set) assessments dated October 8, 2025 revealed that the resident's legal name was entered in the A0500 -Legal name section…

  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 · D2026-02-26 · tag F0684 — failed to provide proper treatment and quality of care — isolated
  Provide 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, and policy review, the facility failed to ensure that one resident (#148) received care and treatment in accordance with professional standards of practice regarding intravenous antibiotic treatment. The sample size was 16. The deficient practice has the potential to cause the wound not to heal and increase the spread of infection.Findings include:-Resident #148 admitted to the facility on [DATE] with diagnoses of sepsis. A hospital Physician Progress Note dated February 16, 2026 documented that resident #148 will be discharged to a SNF (skilled nursing facility). Per the note, the resident had sepsis secondary to a right lower extremity diabetic wound infection with osteomyelitis. The resident al had MRSA (methicillin resistant staphylococcus aureus) and enterococcus bacteremia. The note indicated that resident is on broad spectrum intravenous antibiotics. The note indicated that the resident will need intravenous antibiotics at discharge. The note…

  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 · D2026-02-26 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
  Provide safe and appropriate respiratory care for a resident when needed.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observations, clinical record review, staff interviews and facility policy review, the facility failed to ensure there was a physician order for oxygen use for one sampled resident (#12). This deficient practice could result in the resident receiving unnecessary oxygen or not receiving the correct oxygen flow rate needed. Findings include:Resident #12 was readmitted at the facility on February 17, 2026 with diagnoses of polyosteoarthritis, chronic pain syndrome and schizoaffective disorder bipolar type. The initial admission record included the resident was alert and oriented x4 and had oxygen at 2 LPM (liters per minute) via NC (nasal cannula). The nursing note dated February 17, 2026 revealed the resident had O2 (oxygen) saturation of 86% on RA (room air); and that, O2 saturation of the resident improved to 94% after resident was placed on 2 liters of oxygen. The documentation also included that the resident was instructed to keep the oxygen on at this time. The initial care plan dated February 17, 2026 included focus areas such as cognition, skin, ADLs (activities 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.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2024-05-10 · tag F0550 — failed to protect resident dignity and rights — pattern
  Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observations, resident and staff interviews, the facility failed to provide a dignified dining experience to Resident #62, Resident #149, Resident #47 and Resident #42. The facility census was 99. Findings include: Observation was conducted on May 6, 2024 at 8:20 AM of resident dining during breakfast. Observation revealed residents eating breakfast out of Styrofoam containers with plastic cutlery. Multiple residents reported that food has been served that way for a long time and often was cold by the time they received it. Resident #42 stated in an interview on 5/6/24 at 10:18AM that the food was always cold and came in clamshell containers with plastic silverware. During an interview with Resident #149 conducted on 5/6/24 at 10:33AM, he stated that the food was served in a clam shell container and came cold. In an interview with the ombudsman on 05/07/24 at 12:26 PM, the ombudsman reported that residents have been eating out of Styrofoam for about a year now. She reported that she had discussed with the administrator and the administrator stated that the facility was…

  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 · Ecited before2024-05-10 · tag F0812 — failed to store, cook, and serve food safely — pattern
  Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, staff interviews, and policy review, the facility failed to ensure food was stored in accordance with professional standards for food service safety. The deficient practice could contribute to the spread of foodborne illness. Findings include: Upon initial tour of the kitchenon 5/6/24 at 8:20 AM, it was observed that some of the items, such as dry pasta, stored in original bag that had been tied on itself had no additional labeling or dating. Observation in the refrigerator and freezer revealed lack of labeling and dating of items. Most items were observed stored in cardboard boxes. There were no dates or labels on multiple boxes in the refrigerator and no dates on most boxes in the freezer. Observation was made of sealed bags of shredded lettuce stored in the refrigerator without label or date. Further observation in the refrigerator revealed prepared food items in unlabeled metal tins. Surveyor noted prepared meatballs stored in a metal tin with plastic wrap on top without label or date. A brown gravy in a metal tin was also observed uncovered and unlabeled.…

  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.

  Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2024-05-10 · 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, and policy review, the facility failed to provide evidence that monthly billing statements were issued to one resident (#62). The deficient practice could result in residents not being informed of the monthly payment deducted from their personal accounts. Findings include: Resident #62 was admitted on [DATE] with diagnoses that included cellulitis of buttock, chronic obstructive pulmonary disease, and type 2 diabetes mellitus. Review of the admission Record face sheet revealed the resident was their own financial responsible party. Review of the MDS revealed a Brief Interview for Mental Status (BIMS) was conducted revealing a BIMS score of 15 which suggests that cognition is intact. An interview was conducted with resident #62 on May 9, 2024 08:37 a.m. Resident #62 stated she is concerned with the amount of money left in her account after her payment to the facility. She stated she does not feel that the financial part has been thoroughly explained to her as why…

  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 · D2024-05-10 · tag F0696 — isolated
  Provide appropriate care/assistance for a resident with a prosthesis.
  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 and policy and procedures, the facility failed to ensure that care and assistance were provided to one resident (#1) with a prosthesis that did not fit properly. The deficient practice could result in a decline in mobility and level of functioning, requiring more assistance and being more dependent. Findings include: Resident #1 was admitted on [DATE], with diagnoses that included fracture of nasal bones, subsequent encounter for fracture with routine healing, type 2 diabetes mellitus with foot ulcer, unspecified open wound, right foot, subsequent encounter, peripheral vascular disease, unspecified, other abnormalities of gait and mobility, acquired absence of left leg below knee, A Medicare 5-day MDS(Minimum Data Set) assessment dated [DATE] revealed the resident scored 13 on the Brief Interview for Mental Status (BIMS), indicating cognition was intact. The MDS assessment revealed no impairment with upper extremity, lower extremity impairment 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.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2024-05-10 · tag F0880 — failed to prevent and control infections — isolated
  Provide and implement an infection prevention and control program.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on personnel record reviews, staff interviews and policies and procedures, the facility failed to ensure that one of 10 sampled employees (#80) had current evidence of freedom from infectious Tuberculosis (TB). The deficient practice could result in the potential of residents and employees being exposed to TB. Findings include: A review of personnel records conducted on May 9, 2024 at 10:57 a.m. with Human Resources Manager (Staff # 43) and HR Clinical Resource (Staff # 157) revealed the following: A review of the personnel record for a Activities Director (ACT/staff #80) revealed a hire date of September 30, 2015. The record further revealed no prior documentation of a negative TB skin, nor was there current documentation that staff #80 was free of TB. Staff #157 stated she would download the document, print and provide a copy. HR Clinical Resource (Staff #157) provided a copy of a completed TB Skin Test Consent Form. Review of the form revealed date given as 5/15/24 at 0700 and date read as 5/17/24 at 0800. An interview was conducted on May 9, 2024 at 03:27 PM with staff…

  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.

  Infection Control 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.

Fines & penalties

No federal fines in the current CMS record.

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 →

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

CMS files one row per role, so the 14 rows in the source record cover these 10 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.

2 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 $1.8M 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

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