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Phoenix Mountain Post Acute

13232 North Tatum Blvd, Phoenix, AZ 85032 · For profit - Corporation · 130 certified beds · (602) 996-5200 Medicare & Medicaid certified

Call the home — (602) 996-5200 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse/neglect citation on record (F0600) — cited Jun 20241 actual-harm citation$8,018 in federal fines
Insights

This home has serious findings on its record. Read them closely before you consider it.

In its favor
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • it has an abuse, neglect, or exploitation citation (F0600), cited Jun 2024
  • it has 1 actual-harm citation
  • a high number of inspection citations overall (27) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $8,018 in federal fines (most recent 2024-06-11)
  • its facility-reported quality-measure score sits well above its independent inspection score
  • its independent health-inspection rating is low (2/5)
  • its payroll-based staffing rating is low (2/5)
  • nursing-staff turnover (68%) runs well above the national median (45%)

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.

3/5
CMS overall
3 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 2 of 5
StaffingFrom payroll records (PBJ) 2 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

Hospital
★★★ 3/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
4760 E Thunderbird Rd · (602) 229-2070 · Call to confirm hours
Grocery
12500 N Tatum Blvd · (602) 569-7600 · Call to confirm hours
Park
13230 N 44th St · (602) 262-6696 · Typically dawn to dusk
Place of worship
4712 E Thunderbird Rd · (602) 788-1620

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
Short-stay residentsrehab / post-hospital 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 improved from 1 to 2 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.

Overall rating2★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased14.5%10.7%15.4%typical
Long-stay residents who lose too much weight4.3%5.3%5.4%better
Long-stay residents with a catheter left in their bladder0.8%0.8%0.9%better
Long-stay residents with a urinary tract infection1.1%1.2%2.0%better
Long-stay residents with depressive symptoms1.9%3.9%6.5%better
Long-stay residents who were physically restrained0.0%0.3%0.1%better than state — see note marked double-dagger below the table
Long-stay residents with falls causing major injury2.1%2.1%3.3%better
Long-stay residents whose ability to walk worsened15.9%12.8%16.1%typical
Long-stay residents on antianxiety or hypnotic medication22.9%21.0%18.9%worse
Long-stay residents given the seasonal flu vaccine89.5%94.6%95.3%typical
Long-stay residents with pressure ulcers1.7%4.4%4.7%better
Long-stay residents with worsening bladder/bowel control27.6%20.6%21.2%worse
Long-stay residents who got an antipsychotic medication — see the note below the table4.7%10.6%17.1%better
Short-stay residents who newly got an antipsychotic medication1.9%1.2%1.4%worse
Short-stay residents given the seasonal flu vaccine78.5%87.3%79.4%typical

On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.

§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.

CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.

Short-stay rehab — if you are coming here from a hospital

Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.

66.9% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that better than the national rate. This is CMS’s risk-adjusted rate over 134 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

66.9%U.S. median 51.5%
Got home and stayed home
10.8%U.S. median 10.7%
Went back to hospital
83.3%U.S. median 56.6%
Met the expected recovery
0.36U.S. median 0.31
Therapy hours / resident / day
0.18hours / resident / day
Physical therapy
0.15hours / resident / day
Occupational therapy
0.03hours / resident / day
Speech therapy

Met the expected recovery: 83.3% 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 36 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 0.36 therapist hours per resident per day in 2026Q1 — more than 61% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 4% of this home’s weekday level — it runs therapy on weekdays, with essentially none at the weekend. 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
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF66.9%CMS range 59.3–73.551.5%Oct 2022–Sep 2024better than U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF10.8%CMS range 7.9–13.710.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge83.3%56.6%Oct 2024–Sep 2025CMS 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 discharge86.1%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge50.0%50.0%Oct 2024–Sep 2025CMS 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 identified100.0%98.7%Oct 2024–Sep 2025CMS 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 setting100.0%100.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final dischargenot 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 stay2.0%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened0.0%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization7.9%CMS range 4.6–12.97.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.831.02Oct 2022–Sep 2024CMS makes no comparison for this measure

From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.

Staffing

0.55
RN hours/ resident / day
0.72
LPN hours/ resident / day
1.98
Aide hours/ resident / day
3.26
Total nurse hours/ resident / day
0.47
RN hoursweekends
68.4%
Total nursing turnover
61.9%
RN turnover

How full it usually is: this home is certified for 130 beds and averages 118.9 residents a day — about 91% occupied, or roughly 11 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.26 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.551 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 1.98 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 3.00 hrs/resident/day on weekends vs 3.37 on weekdays — 11% thinner on weekends. RN hours go from 0.59 to 0.47 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 68% is well above the national median of 45%. 1 administrator has left in the past year.

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

5
deficiencies at the latest standard inspection (2025-11-19)
14
at the previous standard inspection (2023-07-06)

Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.

Inspection deficiencies

State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.

ABCDEFGHIJKL

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.

27 citations, most serious first. The 11 most serious are shown; the remaining 16 are one tap away and print in full.

  • Actual harm · G2024-06-11 · tag F0600 — failed to protect residents from abuse and neglect — isolated
    Protect 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 resident, resident representative, and staff interviews and facility documentation, the facility failed to protect the resident's (#11) right to be free from sexual abuse by a staff. The deficient practice could result in residents' increase risk of further harm and abuse. Findings include: Resident #11 admitted to the facility on [DATE] and discharged on 02/22/2024 with diagnoses that included Wernicke's encephalopathy, anxiety, post-traumatic stress disorder, migraines, major depressive disorder, and suicidal behavior. The care plan initiated on 09/25/2023 indicated she preferred a female caregiver relation to her risk of re-traumatization related to a history of intimate partner violence. On 02/01/2024, a goal was initiated for potential for a psychosocial well-being problem related to an inappropriate relationship with a non-caregiving associate as evidenced by Anxiety, depression, and suicidal ideation. Interventions included consultations with pastoral care, social services, and psychiatric…

    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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-11-19 · tag F0803 — failed to meet residents' dietary needs — pattern
    Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, record review, and interviews, the facility failed to ensure that menus provided alternate meal options for residents who refused the food offered. The census was 110, and the sample size was 22. The deficient practice had the potential to affect all residents in the facility by limiting resident choice and failing to meet individual nutritional preferences and needs. Findings include:An initial screening interview was conducted with Resident #106 on September 16, 2025 at 8:55 AM who stated that the facility had not provided other meal options for breakfast, lunch, and dinner. Resident #106 showed this surveyor their breakfast meal tray, which was still present on the resident's bedside table during the interview and appeared untouched. Resident #106 also stated that the facility menu had not always been limited. Resident #106 stated that about 6 months ago, the menus had changed and that they no longer included alternate options. Resident #106 stated that she had been able to request food items such as quesadillas and beef burgers if they did not prefer 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 · Ecited before2025-11-19 · tag F0880 — failed to prevent and control infections — pattern
    Provide and implement an infection prevention and control program.
    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, record review, interviews, and policy review, the facility failed to ensure that proper infection control practices were implemented according to professional standards for five residents (#6,11, 25, 67 and 99). This deficient practice could lead to the spread of infection.Based on observation, clinical record review, interviews and a review of policies and procedures, the facility failed to ensure Enhanced Barrier Precautions (EBP) were in place for four residents (#99, #6, #25, and #11). This deficient practice could result in an increased risk of pathogen transmission. Findings include: Based on the resident matrix and a review of resident records, Residents #25, #6, #99, and #11 were receiving catheter care. However, EBP signage was not present outside these residents' rooms on two consecutive days—September 16 and 17, 2025. In an interview with Infection Preventionist Staff #91 regarding this issue, Staff #91 stated that sometimes the signs fall off or are removed by residents.…

    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
  • Potential for harm · D2025-11-19 · tag F0679 — failed to provide activities — isolated
    Provide activities to meet all resident's needs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Number of residents sampled: 110Number of residents cited: 1Based on observations, clinical record review, staff interviews, and policy review, the facility failed to ensure that individualized activities were consistently offered to one resident (#9). The facility census consisted of 110 residents, and the target sample size was 22. The deficient practice could result in residents not consistently being provided with activities that meet their interests and support their physical, mental, and psychosocial well-being.Findings include:Resident #9 was admitted to the facility on [DATE], with diagnoses including: vascular dementia, unspecified severity, with other behavioral disturbance.During the initial pool conducted on September 16, 2025, at 11:12 a.m., resident #9 stated that she finds the activities juvenile and childlike and has no interest in them. Resident #9 stated she wished they would offer her more adult-like activities that she could participate in. A review of a Care Plan, initiated on February 20,…

    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 · Dcited before2025-11-19 · tag F0757 — failed to avoid unnecessary drugs — isolated
    Ensure each resident’s drug regimen must be free from unnecessary drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interviews, and facility policy, the facility failed to ensure medications were administered within ordered parameters and according to accepted standards of practice for 1 of 5 residents reviewed for unnecessary medications (Resident #6). The census was 110, and the sample size was 22. The deficient practice had the potential to cause adverse drug effects and place residents at risk for harm from unnecessary medications that were not clinically indicated at the time of administration.Findings include:Resident #6 was admitted on [DATE], with the diagnosis of hypotension and unspecified dementia, unspecified severity, with anxiety.A physician's order dated July 1, 2024, revealed an order for Midodrine HCl Tablet 2.5 MG, one tablet three times a day for hypotension. The order also revealed that the medication is to be held if the systolic blood pressure (SBP) is greater than 120.A quarterly MDS (Minimum Data Set) assessment dated [DATE], revealed a Brief Interview for Mental…

    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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-11-19 · tag F0770 — failed to provide lab services — isolated
    Provide timely, quality laboratory services/tests to meet the needs of residents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on clinical record review, facility documentation, staff interview, and policy review, the facility failed to ensure the Narcotic Log/count Q shift Monitoring sheet was accurately completed. The deficient practice could result in narcotics not being accounted for. During an observation conducted on September 17, 2025, at 9:58 AM of the medication cart 200 even numbered room, with License Practical Nurse (LPN/Staff #39) stated that the Narcotic Log/Count Q shift Monitoring was incomplete for the following days in September 2025: 10, 11, 13, 14, 15. She further stated that there was no day shift nurse signature for September 10th and 11th of 2025. She also stated that there was no night shift nurse signature for September 13th, 14th, and 15th of 2025An interview was conducted on September 17, 2025, at 10:16 AM with the Unit Manager (LPN/Staff # 117), who stated that the medication cart 200 Odd number room Narcotic Log, Count Q Shift Monitoring was incomplete for nursing signatures for the following dates in September 2025: 3, 7, 14, 15, and 16. He further stated that the 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.

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-07-11 · tag F0908 — failed to keep essential equipment working — pattern
    Keep all essential equipment working safely.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interviews, facility documentation and policy, the facility failed to ensure patient care equipment was maintained according to manufactures recommendations and kept in safe operating condition. The deficient practice could result in a resident not receiving basic life support with an Automated External Defibrillator (AED). Findings Include: An observation was conducted with the Executive Director (Staff # 07) on May 28, 2025 at 12:00 p.m. of the facility's Core Crash Cart. The defibrillator is stored in the bottom drawer of the Core Crash Cart with a blinking green light. The crash cart daily checkoff list is located on top of the cart. According to an invoice dated December 20, 2021, the facility acquired the AED machine. According to the user manual, version DAC-A580-EN-DL, the Operator's Checklist should be used as a basis for routine maintenance. The manual includes specific maintenance tasks that are recommended to be performed on a regular basis to ensure machine readiness. The 2024 Facility Assessment revealed ways of ensuring an adequate supply of equipment…

    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.

    Environmental Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-07-11 · tag F0557 — isolated
    Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
    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, observations, interviews, facility documentation and policy, the facility failed to ensure that one resident (#435) with an intellectual disability was properly groomed, and provided proper hygiene. The sample size was three residents. The deficient practice could result in the resident being ostracized and ridiculed at the facility, adversely impacting self esteem. Findings include:Resident # 435 was admitted to the facility on [DATE], with diagnoses that included unspecified intellectual disabilities, adjustment disorder with mixed anxiety and depressed mood, pyoderma gangrenosum (a rare, inflammatory skin disease where painful pustules or nodules become ulcers), and psoriasis vulgaris (a chronic inflammatory skin condition characterized by red raised patches, covered with silvery white scales).The Activities of Daily Living (ADL) care plan dated October 1, 2021, revealed that the resident required assistance with self-care and mobility. The care plan goal included the resident…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-06-17 · tag F0726 — failed to have competent, trained nursing staff — isolated
    Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the facility assessment, facility documentation, staff interviews, personnel files, and facility policy, the facility failed to ensure that one staff member (#65) had the competencies and skill sets necessary to provide nursing and related services to safely meet one resident's (#166) transfer needs. The deficient practice regarding resident transfer equipment could increase the risk for accident-related injuries. Findings include: Resident #166 was admitted to the facility on [DATE] with the diagnosis type 2 diabetes and muscle weakness. A care plan focus of self-care performance deficit with the initiation dated of August 29, 2019 revealed that Resident #166 requires a Hoyer lift for transfers. A quarterly MDS (Minimum Data Set) assessment dated [DATE] revealed that Resident #166 had been dependent on helper assistance for chair to bed transfers, toilet transfers, and shower/tub transfers. Indicating that the resident relied on staff assistance to transfer in and out of their bed, and, into…

    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.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-06-17 · tag F0842 — failed to keep accurate, complete medical records — isolated
    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, staff interviews, and review of policies and procedures, the facility failed to ensure clinical record documentation was accurately documented for one resident (#111) regarding medication administration. The deficient practice has the potential for clinical records to inaccurately and incompletely reflect the administration of medications to all residents. Findings include: Resident #111 was admitted to the facility on [DATE] with the diagnosis of Schizophrenia. An order dated November 28, 2023 revealed that a complete blood count with differential is to be completed every Monday for Clozapine monitoring, and, to fax the results to the pharmacy for review. An order dated December 6, 2023 an order of Clozapine 25 MG oral tablet one time a day for Schizophrenia. This ordered had been discontinued on February 20, 2024. A Minimum Data Set (MDS) assessment dated [DATE], revealed the resident had a Brief Interview for Mental Status score of 14, which indicated the resident 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 Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-07-06 · tag F0584 — failed to keep a safe, clean, comfortable home — pattern
    Honor 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, resident and staff interviews, and facility policy and procedures, the facility failed to ensure that walls were painted in 4 (#64, #154, #40, and #63) residents' rooms and blinds were not broken in two residents' (#64 and #154) rooms. The census was 104. The deficient practice may result in the facility not maintaining a safe/clean, comfortable and homelike environment. Findings include: -Resident #64 was admitted to the facility on [DATE] with diagnoses that included anxiety, morbid obesity, and diabetes. The census record revealed that the resident was transferred to room [ROOM NUMBER] on December 21, 2022. The Minimum Data Set (MDS) dated [DATE] included a brief interview for mental status score of 15 indicating the resident was cognitively intact. Review of the work orders revealed that the wall behind the bed had torn areas and that the work was completed on May 22, 2023. During an interview conducted on June 28, 2023 at 11:33 a.m. with resident #64, there were 9 places on the wall…

    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
Show the remaining 16 citations
  • Potential for harm · E2023-07-06 · tag F0623 — pattern
    Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
    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 documentation, staff interviews, and facility policy and procedures, the facility failed to notify two residents in writing (#10 and #24) of the reason for transfers. The sample size was 27. The deficient practice may result in residents and/or their representatives not being notified of the rationale for resident transfers. Findings include: -Resident #10 was admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease, acute gastric ulcer with perforation, unspecified asthma. The minimum data set (MDS) dated [DATE] included a brief interview for mental status (BIMS) score of 15 indicating the resident was cognitively intact. Review of the progress notes dated May 31, 2023 at 7:20 a.m. included that a DuoNeb treatment was administered, and was ineffective. According to the note, the resident's oxygen saturation decreased to 71% after nebulizer treatment and [the resident] continued to present with respiratory distress. Findings were reported to the 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-07-06 · tag F0625 — pattern
    Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
    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 documentation, staff interviews, and facility policy and procedures, the facility failed to provide two residents (#10 and #2) with the bed-hold policy prior to being transferred to the hospital. The sample size was 27. The deficient practice may result in residents and/or their representatives not being informed of the bed-hold policy. Findings include: -Resident #10 was admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease, acute gastric ulcer with perforation, unspecified asthma. The minimum data set (MDS) dated [DATE] included a brief interview for mental status (BIMS) score of 15, indicating the resident was cognitively intact. Review of the progress notes dated May 31, 2023 at 7:20 a.m. included that a DuoNeb treatment was administered, and was ineffective. According to the note, the resident's oxygen saturation decreased to 71% after nebulizer treatment and [the resident] continued to present with respiratory distress. Findings were reported to 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-07-06 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — pattern
    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff interviews, clinical record review and policy, the facility failed to ensure two residents (#23, #79) received catheter care and services in accordance with professional standards of practice. The sample size was 2. The deficient practice may increase the risk for urinary tract infections (UTI). Findings include: -Resident #23 was admitted on [DATE] with diagnoses that included Escherichia coli, hydronephrosis and neuromuscular dysfunction of bladder. Review of Nurse Practitioner (NP) and Internal Medicine (IM) Progress notes January 2023 through June 2023 revealed that a Foley catheter was placed by urology and would remain in place to promote perineal wound healing. A quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. The assessment also included the presence of an indwelling catheter. An indwelling catheter care plan initiated on January 16, 2023 related to neurogenic bladder…

    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 · E2023-07-06 · tag F0725 — failed to have enough nursing staff — pattern
    Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, resident and staff interviews, facility records, and the facility assessment, the facility failed to ensure that there was sufficient nursing staff to meet the needs of residents 6 residents (#8, #72, #49, #52, #94, and #64). The census was 104. The deficient practice could result in resident's care needs not being met. Findings include: During the initial phase of the survey 6 out of 27 residents identified concerns of not having enough staff. The resident interviews were as follows: -Resident #8 was admitted on [DATE] with diagnoses that included type 2 diabetes mellitus with diabetic neuropathy, major depressive disorder, and need for assistance with personal care. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. The MDS revealed that the resident was extensive assist with bed mobility, dressing, toilet use and personal hygiene. During an interview…

    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.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2023-07-06 · tag F0770 — failed to provide lab services — pattern
    Provide timely, quality laboratory services/tests to meet the needs of residents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, facility documentation, staff interviews, policy review, and the glucose control solution instructions, the facility failed to ensure that 2 bottles of glucometer control solutions were dated when opened on 2 out of 3 medication carts observed. The sample size was 27. The deficient practice could result in inaccurate blood glucose test results. Findings include: An observation was conducted on June 28, 2023 at 11:00 a.m. of 1 of three medication carts near the central nurse's station with a Licensed Practical Nurse (LPN/staff #182). An opened glucose control testing solution was identified as not have an opened date on it. An observation was conducted on June 28, 2023 at 12:15 p.m. of 2 of 3 medication carts near the central nurse's station with Registered Nurse (RN/staff #151). One opened glucose control testing solution was noted without an opened date on it. An interview was conducted on June 28, 2023 at 12:15 p.m. with the RN (staff #151). The nurse examined the bottle of glucose control testing solution and stated that the bottle of did not have an opened…

    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.

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-07-06 · 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, interviews, and record review, the facility failed to ensure that dishes and utensils were cleaned under sanitary conditions and that spoiled and/or unpalatable refrigerated and frozen foods were available to be served to residents. The census was 104. The deficient practice could result in residents becoming ill. Findings include: -Regarding dish/utensil sanitation: On June 28, 2023 at 8:29 a.m., a brief kitchen inspection was conducted with the Dietary Supervisor (staff #126). The dishwasher was observed to be running and staff #126 stated that it was a low-pressure dishwasher which runs at 120 degrees Fahrenheit. During this time, she conducted a litmus test to determine the sanitation level and stated that the test had to achieve 50 parts per million (pmm). She utilized a litmus strip and the test result was 10 pmm, which she stated was low. She stated there was a risk of residents becoming ill if the dishes and utensils were not sanitized properly. She stated that her dishwashers were responsible for testing the sanitation level on a daily basis, but did…

    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 · D2023-07-06 · tag F0550 — failed to protect resident dignity and rights — isolated
    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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, clinical record review, interviews and policy review, the facility failed to ensure an alternate food choice during meals was provided to one out of two residents reviewed (#12). The deficient practice could result in not honoring the choices that are significant to the resident. Findings include: Resident #12 was admitted on [DATE], with diagnoses of dementia with other behavioral disturbance, generalized muscle weakness and need for assistance with personal care. The nutritional problem/increased nutrition needs care plan initiated on March 30, 2023 related to underweight status and history of poor meal intakes had a goal to maintain adequate nutritional status as evidenced by maintaining weight, with no signs or symptoms of malnutrition. Interventions included to honor the resident's right to make personal dietary choices. The admission Minimum Data Set (MDS) assessment April 6, 2023 included a Brief Interview for Mental Status score of 3 which indicated resident had severely 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-07-06 · tag F0658 — failed to meet professional standards of care — isolated
    Ensure 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 review, staff interviews, and facility policy and procedures, the facility failed to monitor and administer one resident's (#97) medications as prescribed in accordance with professional standards of practice. The sample size was 5. The deficient practice could result in residents' medical conditions not being effectively managed. Findings include: Resident #97 was admitted on [DATE] with diagnoses the included anemia, chronic systolic heart failure, and acute kidney failure. The minimum data set (MDS) dated [DATE] included a brief interview for mental status score of 15, indicating the resident was cognitively intact. Review of the physician's order summary included: -June 3, 2023: trazodone HCl (antidepressant) 50 milligrams (mg). Give 50 mg by mouth at bedtime for depression as evidenced by (AEB) sleeplessness. -June 3, 2023: heparin sodium solution, (anticoagulant) 5000 units/milliliter (ml). Inject 5000 units intramuscularly every 8 hours for deep vein thrombosis prophylaxis for 30 days.…

    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 · Dcited before2023-07-06 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure 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 observation, staff and resident interviews, and the facility policy and procedures, the facility failed to ensure hazardous chemicals were stored safely for one resident (#64). The census was 104. The deficient practice could result in residents being harmed by unsecured chemicals. Findings include: Resident #64 was admitted to the facility on [DATE] with diagnoses that included anxiety, morbid obesity, and diabetes. The census records revealed that the resident was transferred to room [ROOM NUMBER] on December 21, 2022. The Minimum Data Set (MDS) dated [DATE] included a brief interview for mental status score of 15, indicating the resident was cognitively intact. During an interview conducted on June 28, 2023 at 11:33 a.m. with resident #64, she stated that large cockroaches were coming up from the drain in the bathroom and that she had seen them a couple of days ago. A bottle of Clorox with bleach was observed sitting on the toilet tank in the bathroom and she stated that staff leave it there to spray…

    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 · D2023-07-06 · tag F0732 — isolated
    Post nurse staffing information every day.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on facility documentation, staff interviews and policy review, the facility failed to ensure that current nurse staffing information was accurate for actual hours worked and actual staffing totals worked by licensed and unlicensed direct care nursing staff for 6 out of 7 days reviewed. The census was 104. The deficient practice could result in residents and visitors not being informed of accurate and current staffing information. Findings include: A review of 7 randomly chosen days of staff postings compared with the actual hours worked by staff on those days and actual total number of staff on those days revealed that six of the staff postings matched the actual number of staff, and the actual number of hours worked. -June 5, 2023 - Staff posting indicated 3 Certified Nursing Assistants (CNAs) worked on the night shift (10:30 PM to 6:30 AM) for a total of 21.53 hours. However, review of the punch detail reviewed that a total of 5 nurses worked for a total of 31.03 hours. -June 6, 2023 - staff posting indicated 4 CNAs worked on the night shift for a total of 27.09 hours.…

    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.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-07-06 · tag F0757 — failed to avoid unnecessary drugs — isolated
    Ensure each resident’s drug regimen must be free from unnecessary drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interviews, and facility policy and procedures, the facility failed to ensure one (#97) resident did not receive pain medication outside of the physician's ordered parameters. The sample size was 5. The deficient practice could result in residents receiving unnecessary medications. Findings include: Resident #97 was admitted on [DATE] with diagnoses that included anemia, chronic systolic heart failure and acute kidney failure. Review of a physician's order dated June 3, 2023, included hydromorphone HCl (opioid analgesic) 2 milligrams (mg). Give 2 mg by mouth every 4 hours as needed for pain 4-10/10. Review of the pain management care plan initiated June 5, 2023 related to opioids and potential for adverse outcomes from opioid use had a goal to be free from adverse reactions. Interventions included to administer opioid as prescribed. The minimum data set (MDS) assessment dated [DATE] included a brief interview for mental status score of 15, indicating the resident 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-07-06 · tag F0814 — failed to dispose of garbage properly — isolated
    Dispose of garbage and refuse properly.
    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 that refuse was disposed of appropriately. The deficient practice could result in an unsanitary condition and the harborage of pests and insects. Findings include: During a brief kitchen inspection conducted on June 28, 2023 at 8:29 a.m. with Dietary Supervisor (staff #126), 4 surgical gloves that were inside out, 2 fruit cups, 1 medication cup, 1 hairnet, 1 M&M bag, 1 straw, 2 cigarette butts, and other papers were observed on the ground around the large garbage compactor. Staff #126 stated that maintenance is supposed to clean the area around the large garbage compactor daily and there is a risk of possible contamination if the surgical gloves were used. During an interview conducted on July 3, 2023 at 11:35 a.m. with the Administrator (staff #180), he stated that it is difficult to keep the area clean around the large garbage compactor because the facility shares the compactor with the company next door. He also acknowledged that it was the responsibility of maintenance to keep 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 · Dcited before2023-07-06 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interviews, facility documentation and policy and procedures, the facility failed to maintain infection prevention and control during catheter care for one resident (#23). The sample size was 2. The deficient practice could result in transmission of infection, or exposing the resident to other organisms. Findings include: Resident #23 was admitted on [DATE] with diagnoses that included Fournier gangrene, Escherichia coli and neuromuscular dysfunction of bladder. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. The MDS confirmed the presence of an indwelling catheter. Review of an indwelling catheter care plan initiated on January 16, 2023 related to neurogenic bladder had interventions that include to provide catheter care every shift and as needed, and to monitor/record/report to medical doctor for signs or symptoms of UTI. Review of physician orders included:…

    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
  • Potential for harm · E2022-05-12 · tag F0698 — failed to provide proper dialysis care — pattern
    Provide safe, appropriate dialysis care/services for a resident who requires such services.
    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 procedures, the facility failed to ensure dialysis services were consistent with professional standards of practice for one of one sampled residents (#44). The deficient practice could result in dialysis related complications not being readily identified and treated timely. Findings include: Resident #44 admitted to the facility on [DATE] with diagnoses that included end stage renal disease (ESRD), dependence on renal dialysis, chronic kidney disease, and acute kidney failure. Review of the physician's orders dated February 10, 2022 revealed: The resident had dialysis on Tuesday, Thursday, and Saturday at the dialysis center with pick up at 1:30 p.m.; May use weight obtained at dialysis center; Discontinue dialysis center post dialysis instructions-follow facility protocol; and Check vital signs (respirations, temperature, pulse, and blood pressure) pre and post dialysis on dialysis days, two times a day every Tuesday, Thursday, and Saturday.…

    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 · Dcited before2022-05-12 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility and clinical records, staff interviews, observation, and review of policy and procedure, the facility failed to provide a care planned and ordered assistive device to one resident (#53) related to a history of falls. The sample size was four residents. The deficient practice could result in increased resident injuries. Findings include: Resident #53 admitted to the facility on [DATE] with diagnoses that included Alzheimer's disease, muscle weakness, repeated falls, osteoporosis, and unsteadiness on feet. A care plan focus initiated April 18, 2019 noted the resident was at risk for falls with risk factors including decreased mobility, gait/balance problems, impaired cognition with poor safety awareness, psychotropic medications, history of falls, fall August 28, 2020, June 29, 2021, September 11, 2021, April 10 and 11, 2022, and April 30, 2022. The goal was the resident would not sustain major injury and the interventions included low bed with mats on both sides (added April 11, 2022).…

    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 · D2022-05-12 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, resident and staff interviews, facility documentation, and facility policy and procedure, the facility failed to ensure that the oxygen tubing was changed for one of one sampled residents (#37). The deficient practice could result in respiratory complications. Findings include: Resident #37 was admitted at the facility on March 3, 2022 with diagnosis that include, acute respiratory failure with hypoxia, obstructive sleep apnea (adult), heart failure, unspecified, muscle weakness (generalized). Findings include: A review of a care plan initiated March 7, 2022 included the following: The resident has Oxygen Therapy r/t (related to) Ineffective gas exchange. Goals of the care plan include the resident will have no signs/symptoms of poor oxygen absorption through the review date, give medications as ordered by physician, monitor/document side effects and effectiveness, monitor for signs and symptoms of respiratory distress and report symptoms to the doctor as needed, and that the resident's…

    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

“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.

Worried about a resident here? There are three different people you can turn to, and they do different jobs:
  • 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.
Not sure where to start, or need other help? Dial 2-1-1 for local resources — and if a call is hard or impossible for you, many local 211s also take a text (send your ZIP code to 898-211) or a web chat at 211.org; both vary by area, and 211.org will show what yours offers. Deaf or hard of hearing: dial 711 for the telecommunications relay service, then any number above. In an emergency, call 911.
It is illegal for a facility to retaliate against a resident or family for reporting a concern: federal law gives a resident the right to voice grievances — to the home or to any outside agency — without discrimination or reprisal (42 CFR §483.10(j)(1)). You may report anonymously.

Fines & penalties

$8,018 in federal fines across 1 penalty.

  • $8,018 — penalty dated 2024-06-11

Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.

Part of a chain

This home belongs to THE ENSIGN GROUP — 342 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

RatingThis homeChain avg
Overall 3 of 53.2-0.2 vs chain
Health inspection 2 of 52.8-0.8 vs chain
Staffing 2 of 52.7-0.7 vs chain
Quality measures 5 of 54.4+0.6 vs chain
The other 341 homes this chain runs (chain average 3.2★, per CMS)
1 of 5Aspen Health And WellnessOverland Park, KS 1 of 5Bennett Hills Rehabilitation and Care CenterGooding, ID 1 of 5Broadway By The SeaLong Beach, CA 1 of 5Chatsworth Park Health Care CenterChatsworth, CA 1 of 5Clarion Wellness and Rehabilitation CenterClarion, IA 1 of 5Colonial Manor of RandolphRandolph, NE 1 of 5Durango Health And RehabilitationDurango, CO 1 of 5Fort Dodge Health and RehabilitationFort Dodge, IA 1 of 5Greater Southside Health and RehabilitationDes Moines, IA 1 of 5Hearthstone Health And RehabilitationSparks, NV 1 of 5Heritage Gardens Rehabilitation and HealthcareCarrollton, TX 1 of 5Hillcrest Health Care CenterHawarden, IA 1 of 5Lake Village Nursing And Rehabilitation CenterLewisville, TX 1 of 5Lakeside Rehabilitation and Care CenterCoeur d'Alene, ID 1 of 5Legend Oaks Healthcare And Rehabilitation - NorthAustin, TX 1 of 5Legend Oaks Healthcare And Rehabilitation - WaxahaWaxahachie, TX 1 of 5Legend Oaks Healthcare and Rehabilitation - Fort WKeller, TX 1 of 5Madera Post Acute CenterEl Monte, CA 1 of 5Medallion Post Acute RehabilitationColorado Springs, CO 1 of 5Mesquite Post Acute CareLubbock, TX 1 of 5Millbrook Healthcare and Rehabilitation CenterLancaster, TX 1 of 5Misty Willow Healthcare and Rehabilitation CenterHouston, TX 1 of 5New Orange HillsOrange, CA 1 of 5Northeast Rehabilitation and Healthcare CenterSan Antonio, TX 1 of 5Northgate PlazaIrving, TX 1 of 5Oak View Health And RehabilitationConway, SC 1 of 5Oakwood Care And RehabilitationLakewood, CO 1 of 5Omaha Nursing and Rehabilitation CenterOmaha, NE 1 of 5Onion Creek Nursing and Rehabilitation CenterAustin, TX 1 of 5Park Manor Bee CaveBee Cave, TX 1 of 5Pelican Pointe Health And Rehabilitation CenterWindsor, CO 1 of 5Premier Care Center For Palm SpringsPalm Springs, CA 1 of 5Provo Rehabilitation and NursingProvo, UT 1 of 5Rock Canyon Respiratory And Rehabilitation CenterPueblo, CO 1 of 5Rosewood Rehabilitation CenterReno, NV 1 of 5San Marcos Rehabilitation and Healthcare CenterSan Marcos, TX 1 of 5Sonterra Health CenterSan Antonio, TX 1 of 5SouthlandNorwalk, CA 1 of 5Southland Rehabilitation And Healthcare CenterLufkin, TX 1 of 5Spencer Post Acute Rehabilitation CenterSpencer, IA

Showing 40 of 341; lowest-rated first.

A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.

Who owns this facility

Owner / managerTypeRoleSince
BURNAM, SOONIndividualMANAGING CONTROL - GOVERNING BODY; CORPORATE OFFICERsince 01/01/2022
HAERTER, CHARLTONIndividualMANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 05/01/2021
WAGNER, CLAYTONIndividualMANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 04/01/2019
KEETCH, CHADIndividualCORPORATE OFFICERsince 01/01/2014
PETERSON, FORRESTIndividualCORPORATE OFFICERsince 01/01/2022
PORT, BARRYIndividualINDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNFsince 08/20/2025
ENSIGN SERVICES INCOrganizationADP OF THE SNFsince 01/01/2022
STANDARD BEARER HEALTHCARE OP, LPOrganizationADP OF THE SNFsince 01/01/2022
SUMMIT TRAIL HEALTH HOLDINGS LLCOrganizationADP OF THE SNFsince 01/01/2022
THE ENSIGN GROUP INCOrganizationADP OF THE SNFsince 01/01/2022

CMS files one row per role, so the 15 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.

4 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.

Follow the money — this home’s finances

Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.

$16.7M
Net patient revenuemost recent cost report
+14.1%
Operating marginrevenue minus expenses
$1.7M
Related-party expense12% of expenses
Who pays — share of resident-days
Medicaid 76%Medicare 4%Other / private 19%

About 76% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $1.7M paid to related parties — landlords or management companies under common ownership — equal to about 12% 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

$339per resident / day
operating cost
$10,309per month
≈ monthly operating cost
$395per day
avg. revenue, all payers

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

Paying with Medicaid

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.

Typical monthly cost in Arizona
$8,365/mo
Nursing home (semi-private)
$11,437/mo
Nursing home (private)
$6,250/mo
Assisted living

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 035072. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-11-19, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →

Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.

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