Inspection Reports for
Springdale Village
7255 E Broadway Rd, Mesa, AZ 85208, United States, AZ, 85208
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
7.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
97% worse than Arizona average
Arizona average: 3.7 deficiencies/year
Deficiencies per year
12
9
6
3
0
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. |
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
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. |
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. |
Report
April 10, 2025
Report
January 2, 2025
Report
October 3, 2024
Report
April 4, 2024
Report
December 15, 2022
Report
September 30, 2021
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