Inspection Reports for
Springdale Village
7255 E Broadway Rd, Mesa, AZ 85208, United States, AZ, 85208
Back to Facility ProfileDeficiencies (last 5 years)
Deficiencies (over 5 years)
12.4 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
235% worse than Arizona average
Arizona average: 3.7 deficiencies/year
Deficiencies per year
28
21
14
7
0
Inspection Report
Complaint Investigation
Capacity: 82
Deficiencies: 1
Date: Oct 22, 2025
Visit Reason
One deficiency found related to environmental standards; floor repairs completed after inspection.
Complaint Details
Complaint 00146216
Findings
One deficiency found related to environmental standards; floor repairs completed after inspection.
Deficiencies (1)
R9-10-820.A.1.b. — Environmental Standards
Inspection Report
Complaint Investigation
Capacity: 82
Deficiencies: 2
Date: Aug 7, 2025
Visit Reason
Two deficiencies found related to medication storage and fire alarm system installation; temporary and permanent solutions implemented.
Complaint Details
Complaints 00134835 and 00138313
Findings
Two deficiencies found related to medication storage and fire alarm system installation; temporary and permanent solutions implemented.
Deficiencies (2)
R9-10-817.F.1. — Medication Services
R9-10-819.E.1.a-b. — Emergency and Safety Standards
Inspection Report
Complaint Investigation
Deficiencies: 6
Date: Apr 10, 2025
Visit Reason
The inspection was conducted to investigate complaints related to the facility's failure to ensure residents' rights to formulate advance directives, failure to notify family members after changes in residents' conditions, failure to develop complete care plans after falls, medication administration errors, inadequate supervision to prevent elopement, and incomplete medical records.
Complaint Details
The complaint investigation was substantiated with findings that the facility failed to ensure residents' rights to advance directives, failed to notify families after changes in condition, failed to properly plan care after falls, administered incorrect medication doses, failed to monitor elopement risk adequately, and failed to maintain complete medical records.
Findings
The facility was found deficient in multiple areas including failure to document and honor residents' advance directives, failure to notify family members after falls and changes in condition, failure to update care plans and conduct interdisciplinary reviews after falls, medication errors involving incorrect dosing of cyclobenzaprine, inadequate monitoring and notification related to resident elopement risk, and incomplete medical records due to lack of access to prior records from previous owners.
Deficiencies (6)
Failed to ensure two of three sampled residents reviewed had documented advance directives or evidence of discussion regarding code status.
Failed to notify family members of changes in condition for two residents after falls and elopement incidents.
Failed to develop complete care plans and conduct interdisciplinary reviews for falls for one resident.
Failed to administer medication according to physician orders resulting in overmedication of one resident.
Failed to properly monitor and document elopement risk and notifications for one resident at risk of elopement.
Failed to maintain complete and accessible medical records for one resident due to lack of access to prior records from previous owners.
Report Facts
Incorrect medication doses: 13
Care plan update timeframe: 7
BIMS score: 13
BIMS score: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse | Interviewed regarding advance directive paperwork process and fall assessments. | |
| Certified Nursing Assistant | Interviewed regarding locating code status paperwork in case of resident unresponsiveness. | |
| Licensed Practical Nurse | Interviewed regarding admission paperwork and documentation of advance directives and elopement risk. | |
| Director of Nursing | Interviewed regarding expectations for advance directive paperwork, fall notifications, and elopement protocols. | |
| Therapy Director | Interviewed regarding inability to access medical records prior to facility ownership change. | |
| Administrator | Interviewed regarding lack of access to electronic records from previous owners. |
Enforcement Action
Enforcement
Fines: 3
Total: $1,000.00
Date: Feb 10, 2025
Summary
The facility was found deficient in health and safety practices related to infection control, resident care planning, and cleanliness, resulting in civil fines totaling $1000.
Fines & Penalties (3)
| Amount | Reason | Status |
|---|---|---|
| $250.00 | Failure to ensure freedom from infectious tuberculosis posing potential illness risk to residents. | — |
| $500.00 | Failure to ensure resident service plan was reviewed and updated, posing risk if residents' current needs were not identified. | — |
| $250.00 | Failure to ensure premises were cleaned, posing a risk to health and safety of residents. | — |
Enforcement Action
Enforcement
Fines: 1
Total: $1,000.00
Date: Jan 14, 2025
Summary
The facility was fined $1,000.00 which has been paid in full as of the completed date.
Fines & Penalties (1)
| Amount | Reason | Status |
|---|---|---|
| $1,000.00 | Enforcement action fine | Paid |
Inspection Report
Routine
Deficiencies: 1
Date: Jan 2, 2025
Visit Reason
The inspection was conducted to assess the facility's compliance with infection prevention and control guidelines, specifically related to a resident experiencing diarrhea and potential clostridium difficile infection.
Findings
The facility failed to ensure appropriate infection control guidelines were implemented and followed for one resident with diarrhea symptoms. Contact precautions were not in place despite the resident being tested for C-diff, contrary to facility policy and staff statements.
Deficiencies (1)
Failure to provide and implement an infection prevention and control program for a resident with diarrhea and suspected clostridium difficile infection.
Report Facts
Episodes of diarrhea: 3
BIMS score: 15
Inspection Report
Annual Inspection
Capacity: 82
Deficiencies: 19
Date: Nov 19, 2024
Visit Reason
Nineteen deficiencies found involving compliance with multiple health and safety regulations including documentation, service plans, medical records, food safety, drills, and premises safety.
Complaint Details
Complaints AZ00203831, AZ00204156, AZ00204374, AZ00211815, AZ00216558, AZ00218846
Findings
Nineteen deficiencies found involving compliance with multiple health and safety regulations including documentation, service plans, medical records, food safety, drills, and premises safety.
Deficiencies (19)
A. A governing authority shall: 9. Ensure compliance with A.R.S. § 36-411.
C. A manager shall ensure that policies and procedures are established, documented, and implemented to protect health and safety.
C. A manager shall ensure policies and procedures are reviewed at least once every three years and updated as needed.
A manager shall ensure documented reports are submitted to governing authority including identification of concerns.
A. A manager shall ensure caregivers provide evidence of freedom from infectious tuberculosis (TB).
A. Except as provided in R9-10-808(B)(2), a manager shall ensure residents provide evidence of freedom from infectious tuberculosis before or within seven days.
B. A manager shall ensure acceptance documentation is dated within 90 calendar days before acceptance.
D. A manager shall ensure documented residency agreements are in place before or at acceptance.
A. A manager shall ensure residents have written service plans reviewed and updated based on condition changes.
A. A manager shall ensure residents' written service plans are signed by resident, manager, and nurse reviewer.
C. A manager shall ensure residents' medical records contain medication orders from medical practitioners.
C. A manager shall ensure residents' medical records contain documentation of orientation to exits.
B. A manager shall ensure medication administration policies and procedures are reviewed and approved by medical practitioners.
C. A manager shall ensure food is protected from potential contamination.
C. A manager shall ensure facility equipment and food contact surfaces are clean.
A. A manager shall ensure disaster drills for employees are conducted on each shift at least quarterly and documented.
A. A manager shall ensure evacuation drills for employees and residents are conducted at least semiannually.
A. A manager shall ensure premises and equipment are cleaned and disinfected as applicable.
F. A manager shall ensure swimming pool gates are locked when not in use.
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Oct 3, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding alleged abuse of a resident by a certified nursing assistant (CNA) at the facility.
Complaint Details
The complaint investigation was substantiated. The allegation involved a CNA (staff #141) who was found to have been more aggressive than necessary, causing bruising and skin tears to resident #1. The facility notified police, ombudsman, medical director, resident's family, and the CNA's staffing agency. Multiple staff interviews and evidence supported the findings.
Findings
The facility failed to protect the rights of one resident to be free from abuse by staff, as evidenced by bruising and skin tears consistent with being squeezed and scratched by a hand. The allegation was substantiated by interviews, documentation, and evidence collected during the investigation.
Deficiencies (1)
Failure to protect resident #1 from abuse by staff, resulting in bruising and skin tears on the resident's right forearm.
Report Facts
Braden Scale score: 12
BIMS Evaluation score: 99
BIMS Evaluation score: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant (CNA) | Alleged abuser (staff #141) involved in abuse incident with resident #1 | |
| Administrator | Interviewed regarding abuse incident and investigation | |
| Certified Nursing Assistant (CNA) | Staff #78 who reported bruising and relayed information about the incident | |
| Registered Nurse (RN) | Staff #61 who interviewed resident and reported incident to administrator | |
| Hospice Nurse | Staff #142 who visited resident and confirmed no bruises on admission |
Inspection Report
Annual Inspection
Deficiencies: 6
Date: Apr 4, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements including timely completion of Minimum Data Set (MDS) assessments, care plan development, discharge communication, activities program qualifications, staff CPR certification, and vaccination policies.
Findings
The facility was found deficient in completing timely MDS assessments for multiple residents, developing complete care plans with measurable interventions, ensuring discharge summaries were provided, directing the activities program by a qualified professional, maintaining current CPR certifications for staff, and administering pneumococcal vaccines as required.
Deficiencies (6)
Failure to complete comprehensive Minimum Data Set (MDS) assessments within regulatory time frames for residents #8, #10, and #12.
Failure to develop and implement a complete care plan with specific interventions for resident #4.
Failure to ensure a discharge summary was completed and provided for resident #14 at discharge.
Activities program not directed by a qualified professional; staff #21 did not meet all regulatory qualifications.
Three staff members (#35, #15, #17) had expired CPR certifications but continued to work.
Failure to administer pneumococcal vaccine to resident #4 despite signed consent.
Report Facts
Hours worked with expired CPR certification: 860
Hours worked with expired CPR certification: 175
Hours worked with expired CPR certification: 140
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff #38 | MDS Coordinator / Licensed Practical Nurse | Named in relation to backlog and efforts to catch up on MDS assessments. |
| Staff #33 | Director of Nursing | Acknowledged issues with MDS assessments, care plans, discharge summaries, and vaccination policies. |
| Staff #6 | Facility Administrator | Acknowledged issues with MDS assessments and monitoring progress. |
| Staff #21 | Activity Director | Named in relation to activities program direction deficiency. |
| Staff #52 | Human Resources Director and Business Office Director | Provided information on employee file reviews and licensing/certification policies. |
| Staff #72 | Director of Social Services | Interviewed regarding discharge summary process and responsibilities. |
| Staff #53 | Infection Preventionist | Interviewed regarding vaccination policies and resident #4's vaccine status. |
| Staff #50 | Licensed Practical Nurse | Interviewed regarding care plan process. |
| Staff #51 | Licensed Practical Nurse | Interviewed regarding care plan process and updates. |
Enforcement Action
Enforcement
Fines: 1
Total: $250.00
Date: Mar 8, 2024
Summary
The facility was fined $250.00 which has been paid in full as of the report date.
Fines & Penalties (1)
| Amount | Reason | Status |
|---|---|---|
| $250.00 | Fine associated with enforcement action #00111604 | Paid |
Enforcement Action
Enforcement
Fines: 1
Total: $1,750.00
Date: Oct 20, 2023
Summary
The enforcement resulted in an agreement to pay civil fines totaling $1750 for repeat deficiencies and hazards identified during inspections and complaint investigations.
Fines & Penalties (1)
| Amount | Reason | Status |
|---|---|---|
| $1,750.00 | Civil fines for five repeat deficiencies and hazards including fingerprint clearance, service plan errors, medical determinations, and facility hazards. | — |
Enforcement Action
Enforcement
Fines: 1
Total: $1,750.00
Date: Oct 10, 2023
Summary
The facility was fined $1,750.00 which has been paid in full as of 11/29/2023.
Fines & Penalties (1)
| Amount | Reason | Status |
|---|---|---|
| $1,750.00 | Fine associated with enforcement action #00112415 | Paid |
Inspection Report
Annual Inspection
Capacity: 82
Deficiencies: 9
Date: Sep 19, 2023
Visit Reason
Nine deficiencies found including failures in fall prevention training, fingerprint clearance compliance, tuberculosis documentation, resident service plans, medical record notifications, and premises safety.
Findings
Nine deficiencies found including failures in fall prevention training, fingerprint clearance compliance, tuberculosis documentation, resident service plans, medical record notifications, and premises safety.
Deficiencies (9)
36-420.01. — Health care institutions; fall prevention and fall recovery; training programs
A. A governing authority shall: 9. Ensure compliance with A.R.S. § 36-411.
A. A manager shall ensure that: 8. Medical documentation of freedom from infectious tuberculosis (TB).
A. A resident must have a written service plan including level of service expected.
A. A resident's written service plan must be reviewed and updated based on condition changes.
A. A resident's written service plan must be signed by resident, manager, and nurse reviewer.
C. A resident's medical record must contain documentation of vaccination availability notification.
B. A manager must ensure residents confined to bed or chair have PCP or other documentation.
A. A manager shall ensure premises are free from conditions causing physical injury.
Inspection Report
Complaint Investigation
Capacity: 82
Deficiencies: 2
Date: Jul 20, 2023
Visit Reason
Two deficiencies found related to alert systems for resident needs and premises safety.
Complaint Details
Complaints AZ00190428 and AZ00198165
Findings
Two deficiencies found related to alert systems for resident needs and premises safety.
Deficiencies (2)
E. A manager shall ensure bell, intercom, or mechanical alert means are available and accessible.
A. A manager shall ensure premises are free from conditions causing physical injury.
Inspection Report
Routine
Deficiencies: 11
Date: Dec 15, 2022
Visit Reason
The inspection was a routine survey to assess compliance with regulatory requirements related to resident care, medication administration, infection control, staffing, and other facility operations.
Findings
The facility was found deficient in multiple areas including failure to maintain a clean environment, incomplete care plan updates after falls, medication administration errors, inadequate shower and hygiene care, incomplete wound and pressure ulcer care, improper catheter care and urinary output monitoring, inaccurate nurse staffing postings, unsecured expired medications and supplies, and improper disposal of biohazardous materials.
Deficiencies (11)
Failed to ensure housekeeping services necessary to maintain a safe and clean environment were provided for one resident (#58).
Failed to ensure the comprehensive care plan was updated to reflect the changing needs of one resident (#3) after falls.
Failed to ensure medications were administered as ordered by the physician for one resident (#123).
Failed to ensure one resident (#8) was provided showers as ordered and documented.
Failed to ensure one resident (#223) received treatment and care in accordance with professional standards of practice.
Failed to ensure necessary care and services related to pressure ulcer was provided for one resident (#3).
Failed to provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections for residents (#222, #274, #42).
Failed to ensure the Daily Staff Postings for nursing staff was accurate for actual hours worked by licensed and unlicensed direct care nursing staff.
Failed to ensure the medication error rate was less than 5% by failing to ensure two out of three residents reviewed (#20 and #62) received medications according to the physician orders.
Failed to ensure that expired supplies and medication with missing and/or damaged labels were not available for resident use; and failed to ensure that a resident's home medications were not left unsecured on a counter in the medication room.
Failed to ensure that biohazardous material/sharps were disposed of properly.
Report Facts
Sample size: 18
Medication error rate: 6.67
Staffing hours discrepancy: 7
Staffing hours discrepancy: 13.25
Staffing hours discrepancy: 6
Staffing hours discrepancy: 6.95
Staffing hours discrepancy: 6.25
Staffing hours discrepancy: 12.25
Staffing hours discrepancy: 3.25
Staffing hours discrepancy: 31.75
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff #72 | Director of Nursing | Interviewed regarding housekeeping, medication errors, catheter care, staffing postings, and infection control deficiencies |
| Staff #76 | Licensed Practical Nurse | Observed medication pass and medication room; interviewed about medication errors and expired supplies |
| Staff #99 | Registered Nurse | Observed medication pass and interviewed about medication administration |
| Staff #54 | Certified Nursing Assistant | Interviewed about catheter care documentation |
| Staff #45 | Staffing Coordinator | Interviewed about accuracy of staff postings |
| Staff #111 | Administrator | Interviewed about staff postings accuracy |
Inspection Report
Routine
Deficiencies: 4
Date: Sep 30, 2021
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to PASARR screening, respiratory care, food storage, and meal service practices at Springdale Village Post Acute.
Findings
The facility failed to complete required PASARR screenings for residents staying longer than 30 days, failed to have a physician order for oxygen use for one resident, and did not maintain nourishment refrigerators at appropriate temperatures. Additionally, the facility failed to dispose of bread by best buy dates and allowed uncovered beverages to be delivered to residents.
Deficiencies (4)
Failure to ensure PASARR screening was completed for residents staying longer than 30 days.
Failure to ensure one resident had a physician order for oxygen use.
Failure to maintain nourishment refrigerators at appropriate temperatures and failure to dispose of bread by best buy date.
Failure to ensure beverages were covered when delivered to residents.
Report Facts
Refrigerator temperature readings above 41 degrees F: 12
Number of residents affected by PASARR deficiency: 2
Sample size for oxygen order review: 3
Number of loaves of bread past best buy date: 8
Distance uncovered beverages carried: 35
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff #21 | Social Worker / Social Services Director | Interviewed regarding PASARR screening requirements and facility practices. |
| Staff #1 | Director of Nursing (DON) | Interviewed regarding PASARR screening expectations, oxygen order entry, and food service policies. |
| Staff #103 | Clinical Vice President (VP) / Corporate Resource | Interviewed regarding PASARR form instructions and facility policy adherence. |
| Staff #75 | Dietary Manager | Interviewed regarding nourishment refrigerator temperatures, food storage policies, and beverage service practices. |
| Staff #105 | Licensed Practical Nurse (LPN) | Interviewed regarding oxygen order requirements and resident #34's oxygen administration. |
| Staff #58 | Director of Admission | Interviewed regarding PASARR screening process and hospital responsibilities. |
| Staff #18 | Certified Nursing Assistant (CNA) | Interviewed regarding beverage service practices. |
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