Maryland Gardens Post Acute
31 West Maryland Avenue, Phoenix, AZ 85013 · For profit - Limited Liability company · 58 certified beds · (602) 265-7484 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- no federal fines or payment denials on record
- CMS has flagged it for abuse
- it has an abuse, neglect, or exploitation citation (F0600), cited Jul 2026
- it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0607, F0609, F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- a high number of inspection citations overall (28) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- its facility-reported quality-measure score sits well above its independent inspection score
- its independent health-inspection rating is low (2/5)
- nursing-staff turnover (70%) runs well above the national median (45%)
- its last standard health inspection was over 2 years ago — the star rating may not reflect current conditions
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 2 of 5 |
| StaffingFrom payroll records (PBJ) | 3 of 5 |
| Quality measuresSelf-reported by the facility | 5 of 5 |
Worth a closer look. This home's quality-measure rating runs 3 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself — so a gap this large is worth reading the inspection record for.
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 | 5 of 5 |
| Long-stay residentspeople who live here | 5 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 3 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 | 1.1% | 10.7% | 15.4% | better |
| Long-stay residents who lose too much weight | 1.1% | 5.3% | 5.4% | better |
| 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 | 0.0% | 3.9% | 6.5% | check this* — see note marked star below the table |
| 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 | 1.4% | 2.1% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 0.0% | 12.8% | 16.1% | check this* — see note marked star below the table |
| Long-stay residents on antianxiety or hypnotic medication | 28.1% | 21.0% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 94.6% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 4.9% | 4.4% | 4.7% | typical |
| Long-stay residents with worsening bladder/bowel control | 11.3% | 20.6% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 36.7% | 10.6% | 17.1% | worse |
| Short-stay residents given the seasonal flu vaccine | 92.5% | 87.3% | 79.4% | better |
* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. Weigh it against the inspection record above.
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
Met the expected recovery: 55.0% 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 20 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 0.23 therapist hours per resident per day in 2026Q1 — more than 29% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 21% 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 | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 55.0% | 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 | 60.0% | 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 | 50.0% | 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 | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 3.3% | 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 | 6.7% | 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 | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality 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 58 beds and averages 56.6 residents a day — about 98% occupied, or roughly 1 bed typically open. It runs essentially full — expect a waiting list. 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 3.58 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.33 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.07 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 3.26 hrs/resident/day on weekends vs 3.70 on weekdays — 12% thinner on weekends. RN hours go from 0.39 to 0.18 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 70% is well above 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 more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
This trend is not current. The most recent of these two inspections was over 2 years ago; the arrow describes what inspectors found then, not what the home is like now.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
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.
28 citations, most serious first. The 10 most serious are shown; the remaining 18 are one tap away and print in full.
- Potential for harm · Ecited before2026-07-02 · tag F0600 — failed to protect residents from abuse and neglect — patternProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interviews, review of clinical record and policy review, the facility failed to protect the rights of 7 of 15 residents sampled (#6, #19, #22, #65, #66, #76, and #77) to be free from physical and verbal abuse between residents. The deficient practice could result in resident injury, psychological, or behavioral harm as well as continued resident to resident abuse.Findings include:Regarding Resident #66 and Resident #65:-Resident #66, the alleged victim, was re-admitted [DATE] with diagnoses that included major depressive disorder, mood disorder, cerebral infarction, aphasia, vascular dementia with behavioral disturbances, Schizoaffective disorder depressive type, and bipolar II disorder. The care plan revised on February 12, 2019 revealed that Resident #66 had a communication problem related to expressive aphasia secondary to cerebral vascular accident (CVA). The care plan also revealed that Resident #66 was able to make his needs known through few words and gestures and had a communication book…
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 before2026-07-02 · tag F0607 — failed to have anti-abuse policies — isolatedDevelop and implement policies and procedures to prevent abuse, neglect, and theft.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, facility documentation, staff interviews, and policy review, the facility failed to implement their abuse policy involving an allegation of abuse with 3 of 15 residents (#6, #22, and #80). The deficient practice could result in the appropriate State Agencies not being notified and allegations of abuse not being thoroughly investigated. -Regarding Resident #80 Resident #80 was admitted on [DATE] with diagnoses that included unspecified mood disorder, suicidal ideations, anxiety disorder, and depression. A Nurses Note dated May 15, 2026 7:08 a.m. revealed that the writer was alerted by Resident #80 that she had been in a physical altercation with a Certified Nursing Assistant (CNA #12). The nurses note goes on to reveal that prior to this incident Resident #80 was resistant to having CNAs helping her with a shower. The note documents that Resident #80 came out yelling stating she was in a fight with the CNA. The note also documented that there were some visible scratches to her…
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 before2026-07-02 · 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 clinical record review, staff interviews, facility documentation, and policy review, the facility to ensure that an allegation of abuse for 3 out of 15 residents (#6, #22, and #80) was reported to all applicable state agencies within the required timeframe. The deficient practice could result in a delay in the proper investigation of abuse allegations. Findings include:Regarding Resident #80:Resident #80 was admitted on [DATE] with diagnoses that included unspecified mood disorder, suicidal ideations, anxiety disorder, and depression. A Nurses Note dated May 15, 2026 7:08 a.m. revealed that the writer was alerted by Resident #80 that she had been in a physical altercation with a Certified Nursing Assistant (CNA #12). The nurses note goes on to reveal that prior to this incident Resident #80 was resistant to having CNAs helping her with a shower. The note documents that Resident #80 came out yelling stating she was in a fight with the CNA. The note also documented that there were some visible scratches…
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 before2025-01-23 · 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 clinical record reviews, facility documentation, resident and staff interviews, and policy review, the facility failed to ensure that one resident (#1) was free from abuse. The deficient practice could result in further incidents of resident to resident abuse. Findings include: -Regarding resident #1: Resident was admitted to the facility on [DATE] with diagnosis that included intracerebral hemorrhage, unspecified, flaccid hemiplegia affecting left dominant side, major depressive disorder, single episode, unspecified, anxiety disorder, unspecified, unspecified mood [affective] disorder. A review of the quarterly MDS (minimum data set) dated December 23, 2024 revealed a BIMS (brief interview of mental status) score of 14, indicating resident's cognition is intact. Further review of the MDS revealed no indicators for mood or behaviors. A review of the resident's care plan, initiated on December 23, 2024 revealed a focus for impaired cognitive function/impaired thought processes related to impaired…
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 · D2025-01-23 · 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 observation, staff interviews, clinical record review and facility documentation and policy review, the facility failed to ensure accurate documentation for one resident's injuries (#1 ). This deficient practice could result in residents not receiving the necessary treatment to address their medical issues/problems. Findings include: -Regarding resident #1: Resident was admitted to the facility on [DATE] with diagnosis that included intracerebral hemorrhage, unspecified, flaccid hemiplegia affecting left dominant side, major depressive disorder, single episode, unspecified, anxiety disorder, unspecified, unspecified mood [affective] disorder. A review of the quarterly MDS (minimum data set) dated December 23, 2024 revealed a BIMS (brief interview of mental status) score of 14, indicating resident's cognition is intact. Further review of the MDS revealed no indicators for mood or behaviors. A review of the resident's care plan, initiated on December 23, 2024 revealed a focus for impaired cognitive…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-01-08 · 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 clinical record review, interviews, observations, facility documentation, and policies, the facility failed to ensure that a resident was not abused by another resident for 2 of 3 sampled residents (#1 and #3). The deficient practice could result in continued psychosocial and/or physical harm to resident. Findings Include: -Regarding Resident #1: Resident #1 was admitted to the facility on [DATE], with diagnoses that included hemiplegia and hemiparesis affecting the right side, aphasia, major depressive disorder, cerebral infarction, and chronic kidney disease. A care plan dated February 12, 2024, revealed that the resident has a communication problem due to expressive aphasia with an intervention in place that Resident #1 is able to communicate by answering yes/no questions, hand gestures, and utilizing a communication book. Additionally, an intervention was to validate Resident #1's message by repeating aloud. An additional care plan revised April 04, 2024, revealed that Resident #1 has a behavioral…
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 before2025-01-08 · tag F0607 — failed to have anti-abuse policies — isolatedDevelop and implement policies and procedures to prevent abuse, neglect, and theft.
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, interviews, observations, facility documentation, and policies, the facility failed to implement written policies and procedures that prohibit and prevent abuse for 2 of 3 sampled residents (#1 and #3). The deficient practice could lead to a failure of the facility to fully investigate and report allegations of abuse within required timeframes, and could lead to harm to a resident. Findings Include: -Regarding Resident #1: Resident #1 was admitted to the facility on [DATE], with diagnoses that included hemiplegia and hemiparesis affecting the right side, aphasia, major depressive disorder, cerebral infarction, and chronic kidney disease. A physician order dated January 4, 2025, revealed a change in condition for: redness/ mild edema to left eye orbital, and that the provider was notified. A review of the resident's clinical record revealed no evidence of any progress notes on January 4, 2025, that described an incident involving Resident #1. There was 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 before2025-01-08 · 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 clinical record review, interviews, observations, facility documentation, and policies, the facility failed to ensure that an allegation of abuse was reported to mandatory reporting agencies within the required timeframe for 2 of 3 sampled residents (#1 and #3). The deficient practice could result in abuse allegation not being reported. Findings Include: -Regarding Resident #1: Resident #1 was admitted to the facility on [DATE], with diagnoses that included hemiplegia and hemiparesis affecting the right side, aphasia, major depressive disorder, cerebral infarction, and chronic kidney disease. A review of the quarterly Minimum Data Set (MDS), dated [DATE], revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 10, indicating moderate cognitive impairment. A facility Reportable Incident Self-Report submitted to the state health department on January 4, 2025 at 10:06 AM, revealed that at approximately 9:00 a.m., on January 04, 2025, a nurse (Staff #14) notified the Administrator…
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 before2025-01-08 · 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, interviews, observations, facility documentation, and policies, the facility failed to ensure that residents were protected from further abuse during an ongoing investigation of an allegation of abuse for 2 of 3 sampled residents (#1 and #3). The deficient practice could result in continued psychosocial and/or physical harm to a resident. Findings Include: -Regarding Resident #1: Resident #1 was admitted to the facility on [DATE], with diagnoses that included hemiplegia and hemiparesis affecting the right side, aphasia, major depressive disorder, cerebral infarction, and chronic kidney disease. A review of the resident's clinical record revealed no evidence of any progress notes on January 4, 2025, that described an incident involving Resident #1. There was no evidence of a physician order for one to one staff monitoring for Resident #1. A facility Reportable Incident Self-Report submitted to the state health department on January 4, 2025 at 10:06 AM, revealed that 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 · E2024-12-04 · tag F0558 — failed to accommodate residents' needs and preferences — patternReasonably accommodate the needs and preferences of each 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 observations, clinical record reviews, interviews and policy review, the facility failed to ensure an accessible bathroom was readily available for resident use for two residents (#34 and #46); and, failed to ensure that the bathroom of two residents (#23 and #28) were not used by other residents. The deficient practice could result in residents not receiving necessary assistance to help maintain their independence. The Census was 55. Findings include: -Resident #34 was admitted on [DATE] with diagnoses of hypertension, cerebrovascular accident, depression and bipolar disorder. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview Mental Status (BIMS) score of 9, which indicated the resident had moderate cognitive impairment. The MDS revealed that the resident may need extra help with specific activities, had experienced social isolation on rare occasions and was receiving an antidepressant. -Resident #46 was admitted on [DATE] with diagnoses of major depressive…
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 18 citations
- Potential for harm · E2024-12-04 · tag F0584 — failed to keep a safe, clean, comfortable home — patternHonor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, clinical record reviews, interviews and policy review, the facility failed to ensure a safe, comfortable and homelike environment was provided to two residents (#34 and #46). The deficient practice could result in residents' preferences were not honored and residents being prevented from having individualized area. The census was 55. Findings include: -Resident #34 was admitted on [DATE] with diagnoses of hypertension, cerebrovascular accident, depression and bipolar disorder. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview Mental Status (BIMS) score of 9, which indicated the resident had moderate cognitive impairment. The MDS revealed that the resident may need extra help with specific activities, had experienced social isolation on rare occasions and was receiving an antidepressant. A psychiatric note dated November 26, 2024 included the resident was alert and oriented x 4. -Resident #46 was admitted on [DATE] with diagnoses of major depressive…
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 · E2024-12-04 · tag F0919 — failed to provide a working call system — patternMake 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, clinical record reviews, interviews and policy review, the facility failed to ensure an accessible, working call light was available for use for two residents (#34 and #46). The deficient practice could result in residents not having the means to communicate with staff. The census was 55. Findings include: -Resident #34 was admitted on [DATE] with diagnoses of hypertension, cerebrovascular accident, depression and bipolar disorder. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview Mental Status (BIMS) score of 9, which indicated the resident had moderate cognitive impairment. The MDS revealed that the resident may need extra help with specific activities, had experienced social isolation on rare occasions and was receiving an antidepressant. A psychiatric note dated November 26, 2024 included the resident was alert and oriented x 4. -Resident #46 was admitted on [DATE] with diagnoses of major depressive disorder, unspecified hearing loss, and personal…
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 · E2024-12-04 · tag F0920 — patternProvide at least one room set aside to use as a resident dining room and for activities, that is a good size, with good lighting, air flow and furniture.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, clinical record reviews, interviews and policy review, the facility failed to provide a designated room to accomodate resident dining while undergoing renovations. The deficient practice could result in residents individual needs and preferences not accommodated. The census was 55. Findings include: An observation on December 4, 2024 at 11:21 a.m. the facility had one dining room for the 55 residents that were residing in the skilled and long term care units. The tables and chairs were not placed in the main dining room area for the residents to eat at; and, the tables were in front of the kitchen food serving area, with the dining room chairs stacked up together. There were two hospital-type beds in the dining room and there were black screens approximately 2 feet on the left and right sides of the bed and approximately a foot from the end of the bed. An uncovered white clothing racks were placed around the dining room walls. The dining room was used as a bedroom by two residents An interview was conducted on December 4, 2024 at 11:32 a.m. with one of 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.
- Potential for harm · Dcited before2024-08-27 · 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 clinical record review, staff interviews, facility documentation and policies and procedures, the facility failed to ensure one resident (#4) was not abused by another resident (#5). The deficient practice could result in residents being abused. Findings include: -Regarding Resident #4: Resident #4 admitted to the facility on [DATE] with diagnosis that included Post Traumatic Stress Disorder, alcohol abuse, depression and pain. The Minimum Data Set (MDS) assessment from May 30, 2024 revealed that the resident's Brief Interview for Mental Status (BIMS) score was 09 which indicated moderate cognitive impairment. The assessment also revealed that the resident had verbal behaviors directed towards others 1 to 3 days during 7 day look back period Care plan initiated on June 15, 2024, Resident #4 was care planned for legal blindness and extreme hard of hearing. A progress note from July 16, 2024 documented a change in condition due to Resident #4 and Resident #5 becoming verbally aggressive with each other.…
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 · D2024-07-12 · 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, policy review, and facility document review, the facility failed to ensure one resident (#46) had the right to refuse use of psychotropic medication was honored. The deficient practice could result in the resident not able to make decisions regarding their choice of treatment. Findings include: Resident #46 was admitted to the facility on [DATE] with diagnoses that included schizophrenia, bipolar disorder, and peripheral vascular disease. The admission Minimum Data Set (MDS) assessments dated February 7, 2024 revealed a Brief Interview for Mental Status (BIMS) score was 12 indicating the resident had moderate cognitive impairment. The MDS assessment also revealed the resident had hallucination and no delusions, physical behavioral symptoms not exhibited, and verbal behavioral symptoms occurred. Review of care plan initiated in January 31, 2024 revealed the resident had a behavior problem related to diagnoses of schizophrenia, bipolar disorder, anxiety disorder,…
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 before2024-07-12 · 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 Regarding resident #18 and resident #205 -Resident #205 was admitted at the facility on April 15, 2022 with diagnoses of bipolar disorder, major depressive disorder, and unspecified dementia. The MDS admission assessment dated [DATE] revealed resident had a BIMS score of 8 indicating the resident had moderate cognitive impairment. The assessment also included that the resident was receiving antipsychotic and antidepressant medication. The care plan initiated dated April 20, 2022 revealed the resident was dependent on staff for activities, cognitive stimulation, social interaction related to immobility. Interventions included for alll staff to converse with resident while providing care. assist with arranging community activities. arrange transportation and assure that the activities were compatible with physical and mental capabilities, known interests and preferences and needs and abilities. The care plan dated April 23, 2022 included that the resident had impaired cognitive function/dementia or impaired…
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 before2024-07-12 · 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 resident and staff interviews, clinical record review, and facility policy, the facility failed to ensure an allegation of abuse for one resident (#41) was reported to the State Agency (SA) within the required timeframe. The deficient practice could result in residents not protected from further abuse. Findings include: Resident # 41 was admitted to the facility on [DATE] with diagnoses of hemiplegia and hemiparesis following cerebral infarction, type II diabetes, depression and psychotic disorder with delusions due to known physiological condition. The admission Minimum Data Set (MDS) assessment dated on June 17, 2024 a Brief Interview for Mental Status (BIMS) revealed a score of 14 which indicated the resident was cognitively intact. The care plan dated June 26, 2024 revealed the resident had a behavior problem related to psych diagnoses, was monitored for restlessness, verbalizing anxiety , false accusations, was resistive to cares,refusal of cares, verbally aggressive, had exhibited being impatient,…
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 before2024-07-12 · 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 resident and staff interviews, clinical record review, and facility policy, the facility failed to ensure an allegation of abuse for one resident (#41) was thoroughly investigated. The deficient practice could result in appropriate corrective action not taken to prevent further abuse. Findings include: Resident # 41 was admitted to the facility on [DATE] with diagnoses of hemiplegia and hemiparesis following cerebral infarction, type II diabetes, depression and psychotic disorder with delusions due to known physiological condition. The admission Minimum Data Set (MDS) assessment dated on June 17, 2024 a Brief Interview for Mental Status (BIMS) revealed a score of 14 which indicated the resident was cognitively intact. Review of the clinical record revealed no documentation that the any other incident from July 4 through 9, 2024. The undated written statement signed by resident #41 revealed that the resident needed to go to the bathroom but the leg rest was in the way; and that, the alleged CNA (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.
- Potential for harm · Dcited before2024-07-12 · 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 resident and staff interviews, clinical record review, and facility policy, the facility failed to ensure medication was administered as ordered by the physician for one resident (#13). The deficient practice could result in resident not receiving the necessary treatment for their condition. Findings include: -Resident #13 was admitted on [DATE] with diagnoses of schizoaffective disorder, schizophrenia, generalized anxiety disorder, and depression. The hospital record of the resident's medication list dated 05/23/2024 revealed Abilify (antipsychotic) 400 mg (milligram) was administered on 05/18/2024. A physician order dated 05/30/2024 included for Aripiprazole (generic name for Abilify) intramuscular prefilled syringe 400 mg injection every 28 days to treat her schizophrenia as evidenced by paranoia. This order was transcribed onto the MAR (medication administration record) for May 2024. Despite documentation that the last Aripiprazole injection that the resident received was on 05/18/2024, 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.
- Potential for harm · D2024-07-12 · 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 clinical record review, staff interviews and facility policy review, the facility failed to ensure staff implemented fall interventions for one resident (#29). The deficient practice could resulted in resident having a fall incident. Findings include: Resident #29 admitted to the facility on [DATE] with diagnoses that included dementia, neuralgia and neuritis, schizophrenia, and anxiety. The fall care plan dated 11/09/2020 revealed that the resident was at risk for falls related to gait/balance problems, incontinence and psychoactive drug use. It also included that the resident will sit herself on the floor and place herself on the floor from her bed and wheelchair. Interventions included call light within reach, ER (emergency room) evaluation and treatment, anticipate and meet resident's needs and bed bolster mattress to help define parameters in bed. The ADL (activities of daily living) care plan dated 11/09/2020 included that the resident had ADL self-care deficit related to dementia and impaired…
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 · D2024-07-12 · 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 observation and staff interviews, the facility failed to ensure staff performed hand hygiene during medication pass. The deficient practice could result in residents developing complications and illnesses. Findings include: A medication pass observation with a registry nurse (staff #300) was conducted on July 10, 2024 from 7:59 a.m. through 8:42 a.m. In multiple occasions during this observation, the registry nurse touched the medication cart with bare hands and prepare the medications without performing hand hygiene. The registry nurse then proceeded to administer the prepared medications to the residents without performing hand hygiene after each resident. In an interview conducted with the registry nurse (staff #300) conducted on July 10, 2024 at 8:42 a.m., the registry nurse stated that she did not sanitize her hands after giving medication to each resident out in the patio. She then pointed and indicated that the hand sanitizer was on top of her medication cart. An interview with the director of nursing (DON/staff #81) was conducted at 4:03 p.m. on July 11, 2024. 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.
- Potential for harm · Ecited before2023-03-10 · tag F0812 — failed to store, cook, and serve food safely — patternProcure 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, and policy, the facility failed to ensure multiple food items were stored in accordance with professional standards. The deficient practice could result in placing residents at risk for foodborne illnesses's. Findings include: During a walk through in the kitchen conducted on March 6, 2023 at 8:34 a.m. with the Dietary Director (staff #32), the following items were observed in the large refrigerator, freezer, and dry storage: -Sandwich dated 2/27/23 -Mushrooms in box with no open or use by dates -No open or use by date for grape jelly in one-gallon clear container -No open or use by date box of tomato's -Food boxes on the floor of the freezer -Hamburger buns no dates or use by -Oatmeal snack cakes with no open or use date -Bowls with cereal with no open or use by dates. -No open or use by dates on one-gallon containers of ranch dressing or Italian dressing. During a walk through in the kitchen conducted on March 6, 2023 at 8:24 a.m. with the Dietary Director (staff #32), he stated that there should be an open date and use by date when any…
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 before2023-03-10 · 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 clinical record review, staff interview, and policy review, the facility failed to ensure medication was administered as ordered for resident #31. The sample size was 5. The deficient practice can lead to medications not given as ordered. The findings include: Resident #31 was admitted to the facility on [DATE] with diagnoses that included chronic systolic (congestive) heart failure, type 2 diabetes mellitus with diabetic neuropathy and depression. The quarterly MDS [minimum data set] dated December 13, 2022 revealed the resident scored 15 on the Brief Interview for Mental Status, indicating intact cognition. In addition, the resident reported having frequent pain with an intensity numerical rating of 7 out of 10 on a pain scale. Review of physician orders dated October 18, 2022 included oxycodone-acetaminophen (opioid and non-opioid analgesic) 5-325 milligrams (mg); give 1 tablet by mouth every 12 hours as needed for pain 6-10. A care plan dated on October 18, 2022 revealed a black box warning for 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.
- Potential for harm · D2023-03-10 · tag F0727 — failed to provide required RN coverage — isolatedHave a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on staff interviews and review of the facility documentation and policy, the facility failed to use the services of a Registered Nurse (RN) for at least eight consecutive hours a day, seven days a week. The deficient practice could result in not enough staff to meet the resident's needs. The findings include: A review of the Daily Staffing sheets for December 2022 revealed no evidence of Registered Nurse coverage for these days: -December 3. 2022 -December 4, 2022 -December 10, 2022 -December 11, 2022 -December 17. 2022 -December 18 2022 -December 24, 2022 -December 25, 2022 -December 31, 2022 A review of the Daily Staffing sheets for January 2023 revealed no evidence of Registered Nurse coverage for these days: -January 1 2023 -January 7, 2023 -January 8, 2023 -January 14, 2023 -January 15 2023 -January 21,2023 -January 25, 2023 -January 28, 2023 -January 29, 2023, A review of the Daily Staffing sheets for February 2023 revealed no evidence of Registered Nurse coverage for these days: -February 4, 2023 -February 5, 2023 -February 11, 202, -February 12, 2023 -February 18, 2023…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2022-02-25 · tag F0658 — failed to meet professional standards of care — patternEnsure 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 the clinical record review, staff interviews, and policy reviews, the facility failed to ensure a medication was administered as ordered for one of five sampled residents (#21) and that a physical therapy evaluation was conducted as ordered for one of three sampled residents (#21). The deficient practice could result in residents not receiving medications as ordered by the physician and could result in residents not receiving therapy. Findings include: Resident #21 was admitted to the facility on [DATE] with diagnoses that included major depressive disorder, mood (affective) disorder, hypertension, rheumatoid arthritis, anxiety disorder, abnormalities of gait and mobility, muscle weakness, anemia, and insomnia. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 11 which indicated the resident had moderate impaired cognition. Regarding Methotrexate: Review of the care plan initiated on June 25, 2021 revealed the resident has chronic…
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 · D2022-02-25 · tag F0645 — isolatedPASARR screening for Mental disorders or Intellectual Disabilities
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interviews, and policy and procedure, the facility failed to ensure a Level II PASRR (Preadmission Screening and Resident Review) evaluation and determination was completed for one resident (#18). The sample size was 2. The deficient practice could result in specialized services not being provided and needs not being met for residents with mental disorders. Findings include: Resident #18 was admitted on [DATE] with diagnoses of bipolar disorder and schizoaffective disorder. The PASRR Level I Screening Tool dated December 2, 2021 revealed the section on exemption, the 30-day convalescent care or respite admission for up to 30 days was not marked; and that, the resident did not have a primary diagnosis of dementia. Per the documentation, the resident had SMI (serious mental illness), schizoaffective disorder, hallucinations or delusions and psychosis. Continued review of the tool revealed that section D - Referral Determination for Level II was not marked as completed. The NP…
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 · D2022-02-25 · 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 clinical record review, facility documentation, interviews, and policy reviews, the facility failed to ensure a scheduled medication was obtained and available for one of five sampled residents (#21). The deficient practice could result in medications not being available for residents. Findings include: Resident #21 was admitted to the facility on [DATE] with diagnoses that included major depressive disorder, mood (affective) disorder, hypertension, rheumatoid arthritis, anxiety disorder, abnormalities of gait and mobility, muscle weakness, anemia, insomnia. A Physician order dated September 7, 2021 included for Methotrexate Sodium (antimetabolites)15 milligrams (mg) tablet by mouth one time a day every Saturday related to rheumatoid arthritis. Review of the Medication Administration Record (MAR) for January 2022 revealed Methotrexate Sodium tablet was not administered on January 8, 2022 and January 22, 2022. The MAR was marked as '9', a code that meant Other/See Nurse Notes. The corresponding nurse…
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 before2022-02-25 · tag F0812 — failed to store, cook, and serve food safely — isolatedProcure 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 and procedures, the facility failed to ensure food items in the kitchen refrigerator were sealed and/or dated. The deficient practice could result in a potential for food borne illness. Findings include: An initial observation of the kitchen refrigerator was conducted with the Dietary Manager (staff #52) on 02/22/22 at 10:26 AM. Several apple pies were observed uncovered and undated on a tray. One of the pies was missing a piece. An interview was conducted with staff #52 on 02/24/22 at 11:17 AM. Staff #52 stated that some of the pies were eaten on 02/21/22 and it appeared the evening and weekend staff did not cover or date the pies. He added that he did not notice it during the morning inspection. He stated that it is his expectation that all foods be labeled and stored properly. Staff #52 stated this was a mistake and the pies were disposed of, and that they had become susceptible to contamination. He stated that he will have an in-service on food storage. An interview was conducted with the kitchen supervisor (Contractor #1)…
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
No federal fines in the current CMS record.
Part of a chain
This home belongs to PACS GROUP — 274 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 | 2.9 | +0.1 vs chain |
| Health inspection | 2 of 5 | 2.5 | -0.5 vs chain |
| Staffing | 3 of 5 | 2.5 | +0.5 vs chain |
| Quality measures | 5 of 5 | 4.4 | +0.6 vs chain |
The other 273 homes this chain runs (chain average 2.9★, per CMS)
Showing 40 of 273; 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 |
|---|---|---|---|---|
| PROVIDENCE GROUP INC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | since 03/01/2023 |
| CARROLL, KEITH | Individual | W-2 MANAGING EMPLOYEE | — | since 03/01/2023 |
| APT, FREDERICK | Individual | CORPORATE OFFICER | — | since 03/01/2023 |
| MITCHELL, JOHN | Individual | CORPORATE OFFICER | — | since 03/01/2023 |
1 organizational owner 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 $409K paid to related parties (affiliated landlords or management companies) in its most recent cost report.
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
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Arizona Medicaid page.
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 035247. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2024-07-12, 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 →
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