No sales calls · nothing personal collected unless you ask us to · no facility pays to be here
Text size
Contrast

Friendship Village Of Tempe

2525 East Southern Avenue, Tempe, AZ 85282 · Non profit - Other · 128 certified beds · (480) 831-3184 Medicare only — no Medicaid

Call the home — (480) 831-3184 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse/neglect citation on record (F0600) — cited Mar 2025
Insights

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

In its favor
  • a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
  • no federal fines or payment denials on record
  • 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 Mar 2025
  • 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 (21) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • its payroll-based staffing rating is low (1/5)

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 4 of 5
StaffingFrom payroll records (PBJ) 1 of 5
Quality measuresSelf-reported by the facility 4 of 5

Location & what’s nearby

Hospital
★★ 2/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
2242 W Southern Ave · (480) 756-6000 · Call to confirm hours
Pharmacy
1400 S Dobson Rd · (480) 412-4250 · Call to confirm hours
Grocery
1116 S Dobson Rd · (480) 833-3077 · Call to confirm hours
Park
4003 S Evergreen Rd · (480) 350-5200 · Typically dawn to dusk
Place of worship
3201 S Evergreen Rd · (480) 838-0207

Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.

Quality measures — how residents actually fare

Overall quality measures 4 of 5
Long-stay residentspeople who live here 3 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 held steady at 5 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 rating5★
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 increased14.0%10.7%15.4%typical
Long-stay residents who lose too much weight13.7%5.3%5.4%worse
Long-stay residents with a catheter left in their bladder3.5%0.8%0.9%worse
Long-stay residents with a urinary tract infection1.3%1.2%2.0%better
Long-stay residents with depressive symptoms1.3%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 injury11.5%2.1%3.3%worse
Long-stay residents whose ability to walk worsened10.1%12.8%16.1%better
Long-stay residents on antianxiety or hypnotic medication9.4%21.0%18.9%better
Long-stay residents given the seasonal flu vaccine76.0%94.6%95.3%worse
Long-stay residents with pressure ulcers7.6%4.4%4.7%worse
Long-stay residents with worsening bladder/bowel control30.3%20.6%21.2%worse
Long-stay residents who got an antipsychotic medication — see the note below the table24.4%10.6%17.1%worse
Short-stay residents who newly got an antipsychotic medication0.6%1.2%1.4%better
Short-stay residents given the seasonal flu vaccine92.7%87.3%79.4%better
Short-stay residents rehospitalized after admission26.2%23.7%22.6%worse
Short-stay residents with an outpatient ER visit11.5%10.4%12.0%typical
Long-stay hospitalizations per 1,000 resident days0.841.471.67better
Long-stay outpatient ER visits per 1,000 resident days1.601.421.80better

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.

64.4% 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 761 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

64.4%U.S. median 51.5%
Got home and stayed home
8.4%U.S. median 10.7%
Went back to hospital
85.9%U.S. median 56.6%
Met the expected recovery
0.98U.S. median 0.31
Therapy hours / resident / day
0.64hours / resident / day
Physical therapy
0.26hours / resident / day
Occupational therapy
0.08hours / resident / day
Speech therapy

Met the expected recovery: 85.9% 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 304 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 0.98 therapist hours per resident per day in 2026Q1 — more than 97% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 15% 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
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF64.4%CMS range 60.6–67.451.5%Oct 2022–Sep 2024better than U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF8.4%CMS range 6.8–10.110.7%Oct 2022–Sep 2024better than U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge85.9%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 discharge82.2%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 discharge75.3%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 identified99.0%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 setting98.5%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 discharge100.0%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay0.2%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 worsened2.1%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 hospitalization5.8%CMS range 4.1–8.27.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.941.02Oct 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

RN hours/ resident / day
LPN hours/ resident / day
Aide hours/ resident / day
Total nurse hours/ resident / day
RN hoursweekends
46.6%
Total nursing turnover
41.0%
RN turnover

How full it usually is: this home is certified for 128 beds and averages 57.1 residents a day — about 45% occupied, or roughly 71 beds typically open. It often has substantial empty capacity — worth asking why, since low census can reflect either a new or shrinking home or one families are avoiding. 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.

Weekend coverage: total nurse staffing is 5.27 hrs/resident/day on weekends vs 5.88 on weekdays — 10% thinner on weekends. RN hours go from 1.96 to 1.64 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 47% is about the same as the national median of 45%.

Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.

Inspection trend

0
deficiencies at the latest standard inspection (2026-05-01)
10
at the previous standard inspection (2025-01-17)

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.

21 citations, most serious first. The 10 most serious are shown; the remaining 11 are one tap away and print in full.

  • Potential for harm · Dcited before2025-04-01 · tag F0609 — failed to report abuse allegations — isolated
    Timely 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, resident and staff interviews, and policy review, the facility failed to ensure that an incident involving abuse between a staff member and one resident (#30) was reported in a timely manner. The deficient practice could result in continued staff to resident abuse. Findings include: Resident #30 was admitted to the facility on [DATE] with diagnoses that included anxiety, depression, hypertension, head contusion, delirium, and epilepsy. A 5-Day Medicare Minimum Data Set (MDS) assessment initiated on February 18, 2025, revealed a Brief Interview for Mental Status (BIMS) score of 03, which indicated severe cognitive impairment. A progress note dated March 6, 2025 at 8:38 a.m. revealed that Resident #30 spoke to her daughter who reported to the Registered Nurse (RN/Staff#4) that the resident was pulled out of bed and splashed with water by a staff member in the morning. Review of the facility investigation report for staff-to-resident abuse dated March 6, 2025 revealed that 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-04-01 · 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 clinical record review, staff interviews, observations, and facility documentation, staff interviews and policy review, the facility failed to ensure professional standards of quality were met regarding accurate documentation for one of three sampled residents (#24). The deficient practice could result in residents' clinical record not being accurate and complete. Findings include : Resident #24 was admitted to the facility on [DATE] with diagnoses that included atrial fibrillation, hypertension, pacemaker, and anemia. A quarterly Minimum Data Sheet (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 15 which indicated intact cognition. The clinical record dated February 14, 2025 through February 16, 2025, revealed no evidence of the resident ' s allegation of abuse that occurred on February 14, 2025, despite the facility investigation regarding abuse on February 14, 2025. A facility allegation record, dated February 14, 2025 revealed that Resident #24 reported to…

    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 before2025-03-20 · tag F0607 — failed to have anti-abuse policies — isolated
    Develop 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, resident and staff interviews, and policy review, the facility failed to ensure that the abuse policy was followed regarding an incident of abuse between a staff member and one resident (#63). The deficient practice could result in continued staff to resident abuse. Findings include: Resident #63 was admitted to the facility on [DATE] with diagnoses that included sepsis, anemia, long term use of anticoagulants, depression, insomnia, and type 2 diabetes. A progress note dated March 7, 2025 at 1:29 p.m. revealed that Resident #63 reported to overnight staff that another staff member threw a TV remote at him, and that the staff member cussed him out and raised her voice when she came into the room. A Minimum Data Set (MDS) assessment initiated on March 9, 2025 revealed that Resident #63 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. Review of the facility investigation dated March 7, 2025 at 1:55 p.m. revealed that the incident occurred…

    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 · Dcited before2025-03-20 · tag F0609 — failed to report abuse allegations — isolated
    Timely 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, resident and staff interviews, and policy review, the facility failed to ensure that an incident involving abuse between a staff member and one resident (#63) was reported in a timely manner. The deficient practice could result in continued staff to resident abuse. Findings include: Resident #63 was admitted to the facility on [DATE] with diagnoses that included sepsis, anemia, long term use of anticoagulants, depression, insomnia, and type 2 diabetes. A progress note dated March 7, 2025 at 1:29 p.m. revealed that Resident #63 reported to overnight staff (Licensed Practical Nurse/LPN) (Staff #117) that another staff member (Certified Nursing Assistant/CNA) (Staff#150) threw a TV remote at him. A 5-Day Medicare Minimum Data Set (MDS) assessment initiated on March 9, 2025, revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. Review of the facility investigation dated March 7, 2025 at 1:55 p.m. revealed that the incident occurred on…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-03-06 · 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 observation, clinical record review, facility documentation, and staff interviews, the facility failed to ensure that one resident (#39) was not physically or sexually abused by another resident (#55). Findings include: Resident #39 was admitted to the facility on [DATE] with diagnoses that included cellulitis of the left upper limb, dementia without behavioral disturbance, and generalized muscle weakness. Review of the Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 11, indicating moderate cognitive impairment. Review of the resident's care plan revealed a focus, initiated on February 16, 2025, that indicated that the resident had memory deficits related to her diagnosis of dementia. Review of Resident #39's progress notes revealed no evidence that any potential abuse situations had occurred on the night of March 2, 2025. There was evidence that a skin assessment was completed, noting bruising on multiple parts of the resident's body, which 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-03-06 · tag F0607 — failed to have anti-abuse policies — isolated
    Develop 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, staff interviews, facility documentation and policy review, the facility failed to develop and implement policies and procedures for documenting and reporting alleged violations involving abuse, in accordance with federal and state laws and regulations. The deficient practice resulted in an alleged violation concerning abuse not being documented in the residents' (#39 and #55) clinical records, and the allegation not being reported within the mandatory two-hour timeframe to Adult Protective Services (APS) and the State Agency. This deficient practice could result in further allegations not being documented or reported in a timely manner, which could impact residents' quality of life and care. Findings include: Resident #39 was admitted to the facility on [DATE] with diagnoses that included cellulitis of the left upper limb, dementia without behavioral disturbance, and generalized muscle weakness. Review of Resident #39's progress notes revealed no evidence that any potential…

    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 · Dcited before2025-03-06 · tag F0609 — failed to report abuse allegations — isolated
    Timely 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

    Based on clinical record reviews, facility documentation, and staff interviews, the facility failed to ensure that an alleged violation involving abuse (involving Resident #39 and Resident #55) was reported to the State Agency and Adult Protective Services (APS) within the required timeframe of two hours. Findings include: Review of the facility's reportable event record/report revealed that on March 2, 2025, a female resident (#39) had asked a male resident (#55) to push her wheelchair into the elevator to go to the second floor. When staff attempted to intervene, Resident #39 became very upset, and Resident #55 attempted to console her. In the process, Resident #55 touched Resident #39's arms, head, and sides of her breasts. The dates and times listed in the reportable event record were inconsistent, with one section listing the time of this event as March 2, 2025 at 1:30PM. Another section listed the event as occurring on March 2, 2025 at 08:30PM. Another section listed that it occurred on 3/3/3035 with no specified time. Review of the complete investigation revealed that 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-03-06 · 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, clinical record review, facility documentation, and staff interviews, the facility failed to ensure that adequate supervision was provided to one resident (#14) to prevent elopement from the facility. The deficient practice resulted in one resident leaving the building without notice, and could result in other residents going missing and/or getting injured. Findings include: Resident #14 was admitted to the facility on [DATE] with diagnoses that included Alzheimer's disease, unspecified hearing loss, and influenza. Review of the admission / Medicare 5-day Minimum Data Set (MDS), dated [DATE], revealed that the resident had a Brief Interview for Mental Status (BIMS) score of 9, indicating moderate cognitive impairment. Review of the elopement evaluation completed on February 11, 2025 revealed that the resident scored a 6, indicating the resident was at risk for elopement. Review of the resident's careplan revealed a focus, initiated on February 11, 2025, that indicated that 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-01-17 · tag F0677 — failed to help fully-dependent residents with daily care — pattern
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    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 and facility documentation and policy review, the facility failed to ensure that Activity of Daily Living (ADL) care was provided for 1 resident (#2). This deficiency could result in psychosocial harm, and skin breakdown. Findings include: Resident #2 was admitted on [DATE] with diagnoses of fracture of the sacrum and other disorders of bone density and structure. A care plan dated June 13, 2024 included that resident had a current functional performance of extensive assistance with one-person assist with most activities of daily living (ADLs) such as personal hygiene and transfers. The care plan also included that the resident's vision and hearing were impaired. Interventions included announce self when entering room, explain procedures and anticipate and meet needs promptly. The care plan on daily preferences with revision date of June 16, 2024 included that it was important to the resident to choose between a tub bath, shower, bed bad, or sponge bath. A quarterly…

    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 · Ecited before2025-01-17 · tag F0757 — failed to avoid unnecessary drugs — pattern
    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 that one resident (#154) was free from unnecessary medications by failing to ensure pain medications were administered as ordered by the physician and following the ordered parameters. The deficient practice could result in the resident receiving unnecessary medication and being overmedicated. Findings include: Resident #154 was admitted on [DATE], with diagnoses of lymphedema, pain, osteonecrosis due to drugs, pelvis and muscle weakness. The clinical admission note dated January 2, 2025 revealed that the resident was alert and oriented x 3, had vocal complaints of generalized chronic pain; and that, the resident reported that her pain was always above a 10. A pain care plan dated January 2, 2025, revealed a goal that the resident will receive relief from discomfort within 20-45 minutes after interventions. The interventions included to medicate per physician's order, evaluate for pain using pain scale of 1-10,…

    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
Show the remaining 11 citations
  • Potential for harm · E2025-01-17 · tag F0812 — failed to store, cook, and serve food safely — pattern
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, staff interviews, and facility policy review, the facility failed to ensure that food was stored under sanitary conditions. The deficient practice could result in foodborne illnesses. Findings include: On January 14, 2025 at 8:22 a.m., an initial tour of kitchen was conducted with kitchen manager (staff #80). There was a ladder/speed rack that had 4 uncovered trays of uncooked breaded cod fish with opened date of January 13, 2025 in the walk-in refrigerator. There was a label/sticker for a discard date of January 15, 2025 placed on the side of the ladder/speed rack. There was also one tray of uncovered cooked beef pot pie on flat metal trays on the rack above the rack where that uncooked breaded cod fish was. The individual food items (fish and beef pot pie) on the rack were not covered; and, was the entire ladder/speed rack containing these trays were also not covered. An interview was conducted on January 14, 2025 at 8:22 a.m. with kitchen manager (staff #80) who stated that the uncooked breaded cod fish on the trays were not covered; and that, the cooked…

    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 · E2025-01-17 · 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, clinical record review, resident and staff interviews, and review of facility policy, the facility failed to ensure proper infection control were followed and maintained regarding placement of the catheter bag for one resident (#12) and, oxygen tubing for one resident (#155). The deficient practice could result in development and transmission of infections. Findings include: Resident #12 was re-admitted to the facility on [DATE] with diagnoses that included urinary tract infection, hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease and urinary incontinence. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 14, indicating the resident had an intact cognition. The assessment also included that the resident had an indwelling catheter and urinary incontinence. The Foley catheter care plan initiated on January 9, 2025 included interventions to maintain closed drainage system…

    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 · D2025-01-17 · 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 and facility policy, the facility failed to ensure that staff respect and value the resident's private space by knocking and requesting permission before entering the room for one resident (#17). This deficient practice could result in resident rights not respected and honored. Findings include: Resident #17 was admitted on [DATE] with diagnoses of encephalopathy, acute respiratory failure with hypoxia, and type 2 diabetes mellitus. A care plan dated December 16, 2024 included daily preferences with interventions that it was important to the resident to be able to use the phone in private. An observation was conducted on January 14, 2024 at 10:32 a.m. The resident's call light was not turned on. While conducting an interview with resident #17, a Certified Nursing Assistant (CNA/staff #145) entered the resident's room and stated that the call light was on. The CNA did not knock or announce her presence prior to entering the resident's room. The CNA then spoke to…

    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 · Dcited before2025-01-17 · tag F0609 — failed to report abuse allegations — isolated
    Timely 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, resident and staff interviews review of facility documentation and policy, the facility failed to ensure an alleged violation for one resident (#31) was reported to the State Agency (SA), Adult Protective Services (APS) and law enforcement. The deficient practice could result in compromised protection of the residents and appropriate action not taken. Findings include: Resident #31 was admitted on [DATE] with a diagnoses of multiple fractures of the pelvis without disruption of pelvic ring, age related osteoporosis with current pathological fracture, anxiety disorder and cognitive communication disorder. Review of the Minimum Data Set (MDS) assessment revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15/15 indicating the resident had intact cognition. The care plan on functional abilities dated December 12, 2024 revealed the resident required maximum assistance of 2 for transfers to and from bed, toilet, chair with assistive device of walker &…

    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 · D2025-01-17 · tag F0610 — failed to investigate and act on abuse reports — isolated
    Respond 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, resident and staff interviews review of facility documentation and policy, the facility failed to ensure an alleged violation for one resident (#31) was thoroughly investigated. The deficient practice could result in compromised protection of the residents and appropriate action not taken. Findings include: Resident #31 was admitted on [DATE] with diagnoses of multiple fractures of the pelvis without disruption of pelvic ring, age related osteoporosis with current pathological fracture, anxiety disorder and cognitive communication disorder. Review of the Minimum Data Set (MDS) assessment revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15/15 indicating the resident had intact cognition. The care plan on functional abilities dated December 12, 2024 revealed the resident required maximum assistance of 2 for transfers to and from bed, toilet, chair with assistive device of walker & wheelchair. Review of a progress note dated January 1, 2025 included that…

    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 · D2025-01-17 · tag F0623 — isolated
    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 interview, record review, and facility policy review, the facility failed to ensure that a written notification of transfer and the reason/s of the transfer was provided to the resident representative for one resident (#33); and failed to ensure a copy of that notice of transfer for one resident (#33) was sent to the long term care Ombudsman. The deficient practice could result in residents not having the added protection from being inappropriately transferred or discharged . Findings include: Resident #33 was admitted on [DATE] with diagnoses that included type 2 diabetes, epilepsy, dysphagia, and dementia. The discharge care plan dated December 17, 2024 revealed the resident expressed a wish to be discharged to home. Interventions included to determine discharge date , location, and needs with the health care team and physician. A Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had severely impaired daily decision making skills. A nursing progress note dated January 13, 2025…

    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 · D2025-01-17 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interviews and facility policy, the facility failed to ensure that a medication was provided as ordered; and, failed to ensure that the physician was notified for a missed dose of antibiotic therapy for one resident (#104). The deficient practice could result in resident not receiving the treatment needed to meet his needs. Findings include: Resident #104 was admitted on [DATE] with diagnoses of encephalopathy, pneumonia, and urinary tract infection. An admission Minimum Data Set (MDS) assessment dated [DATE] revealed a brief interview for mental status (BIMS) score of 13 indicating the resident had intact cognition. It also included that active diagnosis of urinary tract infection (UTI) in the last 30 days. The care area assessment (CAA) worksheet signed and dated May 12, 2024 included that the resident had a diagnosis of dementia and had difficulty with making her needs known. Medications included gentamycin (antibiotic) and tobramycin (antibiotic). A care plan dated May…

    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 · D2025-01-17 · tag F0755 — failed to provide safe pharmacy services — isolated
    Provide 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 observation, clinical record review, staff interviews, and facility policy review, the facility failed to ensure scheduled medications were obtained and administered accurately for one resident (#24) of four sampled residents. The deficient practice could result in medications not being available for residents and medications not administered according to physician's orders. Findings include: Resident #24 was admitted on [DATE] with diagnoses of hypertension, encounter for surgical after care following surgery on the digestive system, and vitamin deficiency. Review of nursing progress note dated December 30, 2024 revealed right lower abdomen with glue open to air, and left lower abdomen stitches with wound dressing in place. The care plan dated December 30, 2024 revealed the resident had a hypertension problem, had skin integrity potential/skin breakdown related to recent surgery and had pain and potential alterations in level of comfort recent surgery and sciatica problem. The goal is resident will be…

    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 before2025-01-17 · 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 observation, clinical record review, staff interviews, and facility policy review, the facility failed to ensure the clinical record was accurate for one resident (#24) The deficient practice could result in resident receiving inappropriate care and treatment. Findings include: Resident #24 was admitted on [DATE] with diagnoses of hypertension, encounter for surgical after care following surgery on the digestive system, and vitamin deficiency. Review of nursing progress note dated December 30, 2024 revealed right lower abdomen with glue open to air, and left lower abdomen stitches with wound dressing in place. The care plan dated December 30, 2024 revealed the resident had a hypertension problem, had skin integrity potential/skin breakdown related to recent surgery and had pain and potential alterations in level of comfort recent surgery and sciatica problem. The goal is resident will be free of complications related to hypertension, will maintain blood pressure and pulse within acceptable limits per…

    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 · E2023-10-06 · tag F0732 — pattern
    Post nurse staffing information every day.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on documentation, staff interviews, and facility procedures, the facility failed to ensure that the information posted on the daily staff posting was complete and correct. Findings include: Review of the daily staff posting dated July 4, 2023 did not reveal the number of registered nurses or licensed practical nurses scheduled to work on the day shift, 6:00 a.m. to 6:30 p.m., or the night shift, 6:00 p.m. to 6:30 a.m. Review of the daily staff posting dated August 6, 2023 did not reveal the number of registered nurses or licensed practical nurses scheduled to work on the day shift, 6:00 a.m. to 6:30 p.m., or the night shift, 6:00 p.m. to 6:30 a.m. The total number of hours worked for one certified nursing assistant (CNA) documented was 24 hours for the night shift, 6:00 p.m. to 6:30 a.m. Review of the daily staff posting dated September 16, 2023 did not reveal the number of registered nurses scheduled to work on the day shift, 6:00 a.m. to 6:30 p.m., or the night shift, 6:00 p.m. to 6:30 a.m. During an interview conducted on October 5, 2023 at 8:36 a.m. with Staff Development…

    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 before2023-10-06 · tag F0757 — failed to avoid unnecessary drugs — pattern
    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

    Based on review of clinical records and policy, and staff interviews the facility failed to ensure an order for pain medication was followed as prescribed for Resident #32 by failing to administer medication within the physician ordered parameters. The deficient practice of administering unnecessary medication may result in undesirable medication-induced harm. Resident #32 was admitted into the facility on August 8, 2023 with diagnoses that included fracture of upper end of left humerus, pain, Alzheimer's, dementia, anxiety, and constipation. Review of the physician orders revealed the following: Morphine Sulfate Oral Solution 20 milligram (mg) / 5 milliliters (ml) (Morphine Sulfate) to give 0.125 milliliters sublingually every 4 hours as needed for pain 4-10 with start date of August 21, 2023. Review of Medication Administration Records (MAR) revealed that this medication was administered outside of physician ordered parameters (pain 4-10) on: Thursday August 24, 2023 pain level of 3. Monday September 18, 2023 pain level of 2. Tuesday September 19, 2023 pain level of 3. Friday…

    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

“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

No federal fines in the current CMS record.

Part of a chain

This home belongs to LIFE CARE SERVICES — 43 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 54.1-1.1 vs chain
Health inspection 4 of 53.7+0.3 vs chain
Staffing 1 of 54.4-3.4 vs chain
Quality measures 4 of 54.0≈ chain avg
The other 42 homes this chain runs (chain average 4.1★, per CMS)
1 of 5Burcham Hills Retirement CenterEast Lansing, MI 1 of 5Cottage Grove PlaceCedar Rapids, IA 2 of 5Casa De Las CampanasSan Diego, CA 2 of 5Linn Manor Care CenterMarion, IA 2 of 5Oakton Place Health And Rehabilitation At The ArliNaples, FL 2 of 5Pavilion At Brandon WildeEvans, GA 2 of 5Signature PointeDallas, TX 2 of 5The Stewart Health CenterCharlotte, NC 3 of 5Carillon INCLubbock, TX 3 of 5Westminster Village - West LafayetteWest Lafayette, IN 4 of 5Croasdaile VillageDurham, NC 4 of 5Dallas Retirement Village Health CenterDallas, OR 4 of 5Health Care Ctr At The Forum At Rancho San AntonioCupertino, CA 4 of 5Oaks Health Ctr At The Marshes Of Skidaway IslandSavannah, GA 4 of 5Parkwood VillageBedford, TX 4 of 5The Cedars of Chapel HillChapel Hill, NC 4 of 5Wesley Pines Retirement CommunityLumberton, NC 4 of 5Whitestone a Masonic and Eastern Star CommunityGreensboro, NC 5 of 5Acacia Health CenterPhoenix, AZ 5 of 5Avalon Health Care Center At StoneridgeMystic, CT 5 of 5Briarwood At Timber RidgeIssaquah, WA 5 of 5Chestnut Grn Hlth Ctr BlakehurTowson, MD 5 of 5Cypress Glen Retirement CommunityGreenville, NC 5 of 5Eastcastle Pl Bradford Ter Conv CtrMilwaukee, WI 5 of 5Essex Meadows Health CenterEssex, CT 5 of 5Friendship VillageKalamazoo, MI 5 of 5Green Hills Health Care CenterAmes, IA 5 of 5Greenwood Village SouthGreenwood, IN 5 of 5Hearthwood SNF Senior LivingBartlett, IL 5 of 5MarquetteIndianapolis, IN 5 of 5Premier Place At The GlenviewNaples, FL 5 of 5Radford GreenLincolnshire, IL 5 of 5Residences At Vantage PointColumbia, MD 5 of 5Rolling Green VillageGreenville, SC 5 of 5Somerfield At The HeritageBrentwood, TN 5 of 5Springs At Monarch Landing, TheNaperville, IL 5 of 5Terraces At The ClareChicago, IL 5 of 5The Arbour At Westminster ManorAustin, TX 5 of 5The Birches At Trillium WoodsPlymouth, MN 5 of 5The Preston Health CenterHilton Head Island, SC

Showing 40 of 42; 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 / managerTypeRoleShareSince
TEMPE LIFE CARE VILLAGE INCOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST100%since 09/04/2012
THE BANK OF NEW YORK MELLON TRUST COMPANYOrganization5% OR GREATER SECURITY INTERESTsince 10/04/2021
CAMBERG, KEVINIndividualCORPORATE DIRECTORsince 01/01/2024
CASSANO, DONALDIndividualCORPORATE DIRECTORsince 01/02/1983
CRAWFORD, CATHLENEIndividualCORPORATE DIRECTORsince 06/08/2021
FOSTER, SHELLEYIndividualCORPORATE DIRECTORsince 01/01/2022
JENSEN, DARRELLIndividualCORPORATE DIRECTOR; CORPORATE OFFICERsince 01/01/2025
PEARSON, TODDIndividualCORPORATE DIRECTOR; CORPORATE OFFICERsince 01/01/2020
PULSIFER, MARCIndividualCORPORATE DIRECTOR; CORPORATE OFFICERsince 01/01/2019
RECK, ROSSIndividualCORPORATE DIRECTOR; CORPORATE OFFICERsince 01/01/2019
WELLS, SHIRLEYIndividualCORPORATE DIRECTORsince 02/01/2017
WOODS, COREYIndividualCORPORATE DIRECTORsince 01/06/2015
LIFE CARE SERVICES LLCOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 03/01/1980
COMBS, SUZANNEIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 04/23/2025
GARBA, EMILYIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 05/01/2026
MARVIN, COLEIndividualOPERATIONAL/MANAGERIAL CONTROLsince 03/01/2007

CMS files one row per role, so the 23 rows in the source record cover these 16 parties — each is shown once here with every role it holds. Nothing is omitted.

3 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.

$66.1M
Net patient revenuemost recent cost report
+4.5%
Operating marginrevenue minus expenses
Who pays — share of resident-days
Medicaid 0%Medicare 30%Other / private 70%

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

$1,439per resident / day
operating cost
$43,753per month
≈ monthly operating cost
$1,507per 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

CMS lists this home as Medicare-certified only — it is not Medicaid-certified, so it generally cannot accept Medicaid as payment for a long-term stay. That makes it one of roughly 545 homes nationally where a Medicaid-funded placement is not an option. If you expect to rely on Medicaid, ask the home directly before you tour, and see the Arizona Medicaid page for homes that do.

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 035074. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-05-01, 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.

What to do next