Deficiencies (last 4 years)
Deficiencies (over 4 years)
5.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
57% worse than Arizona average
Arizona average: 3.7 deficiencies/yearDeficiencies per year
12
9
6
3
0
Inspection Report
Complaint Investigation
Capacity: 74
Deficiencies: 0
Date: Mar 17, 2025
Visit Reason
Investigation of multiple complaints with no deficiencies cited.
Findings
Investigation of multiple complaints with no deficiencies cited.
Inspection Report
Complaint Investigation
Capacity: 74
Deficiencies: 0
Date: Feb 5, 2025
Visit Reason
Onsite complaint survey conducted with no deficiencies cited.
Findings
Onsite complaint survey conducted with no deficiencies cited.
Inspection Report
Capacity: 74
Deficiencies: 0
Date: Jan 27, 2025
Visit Reason
Onsite survey for bed increase with no deficiencies cited.
Findings
Onsite survey for bed increase with no deficiencies cited.
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Nov 21, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to ensure physician orders were followed for blood sugar monitoring and insulin administration for two residents with diabetes.
Complaint Details
The complaint investigation found that physician orders for blood sugar monitoring and insulin administration were not followed for two residents, resulting in elevated blood sugar levels without appropriate rechecks or physician notification.
Findings
The facility failed to follow physician orders for blood sugar rechecks and notification of the physician when blood sugar levels were elevated for residents #215 and #46. This failure could result in residents having uncontrolled high blood sugar and potential harm.
Deficiencies (2)
Failure to recheck blood sugar and notify physician for resident #215 despite blood sugar levels above 401 as per physician's sliding scale order.
Failure to recheck blood sugar and notify physician for resident #46 after elevated blood sugar readings as per physician's sliding scale order.
Report Facts
Blood sugar readings: 447
Blood sugar readings: 463
Blood sugar readings: 430
Blood sugar readings: 491
Blood sugar readings: 449
Blood sugar readings: 415
Blood sugar readings: 402
Blood sugar readings: 401
Blood sugar readings: 407
Insulin units administered: 18
Insulin units administered: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Reviewed clinical records and stated that blood sugars should have been rechecked and physician notified; stated failure to follow physician orders did not meet facility expectations. |
| Licensed Practical Nurse | Licensed Practical Nurse | Interviewed regarding insulin administration process and confirmed failure to recheck blood sugars and notify physician as per orders. |
| Certified Nursing Assistant | Certified Nursing Assistant | Interviewed about blood sugar checks and reporting procedures. |
Inspection Report
Complaint Investigation
Capacity: 74
Deficiencies: 1
Date: Nov 18, 2024
Visit Reason
Recertification survey combined with complaint investigations; one deficiency cited related to care plan compliance.
Findings
Recertification survey combined with complaint investigations; one deficiency cited related to care plan compliance.
Deficiencies (1)
R9-10-414.B — Care plan compliance
Inspection Report
Capacity: 74
Deficiencies: 3
Date: Nov 18, 2024
Visit Reason
Recertification survey for Medicare Life Safety Code compliance; three deficiencies cited related to means of egress, sprinkler system installation, and smoke barrier construction.
Findings
Recertification survey for Medicare Life Safety Code compliance; three deficiencies cited related to means of egress, sprinkler system installation, and smoke barrier construction.
Deficiencies (3)
Means of Egress - General — Life safety code violation
Spinkler System - Installation — Life safety code violation
Subdivision of Building Spaces - Smoke Barrier Construction — Life safety code violation
Inspection Report
Complaint Investigation
Capacity: 74
Deficiencies: 0
Date: Jun 4, 2024
Visit Reason
Onsite complaint survey with no deficiencies cited.
Findings
Onsite complaint survey with no deficiencies cited.
Inspection Report
Complaint Investigation
Capacity: 74
Deficiencies: 0
Date: May 2, 2024
Visit Reason
Complaint survey with no deficiencies cited.
Findings
Complaint survey with no deficiencies cited.
Inspection Report
Complaint Investigation
Capacity: 74
Deficiencies: 0
Date: Mar 21, 2024
Visit Reason
Complaint survey with no deficiencies cited.
Findings
Complaint survey with no deficiencies cited.
Inspection Report
Complaint Investigation
Capacity: 74
Deficiencies: 0
Date: Feb 26, 2024
Visit Reason
Complaint survey with no deficiencies cited.
Findings
Complaint survey with no deficiencies cited.
Inspection Report
Routine
Census: 51
Deficiencies: 6
Date: Dec 15, 2023
Visit Reason
The inspection was conducted to assess the facility's compliance with food safety and sanitation standards in the kitchen area.
Findings
The facility failed to maintain a clean and sanitary kitchen environment, with observations including food debris, pest presence, improper food storage, and water leaks, posing a potential risk for foodborne illness.
Deficiencies (6)
Failure to maintain a clean and sanitary kitchen, including uncompleted cleaning logs, food debris under prep tables, and crushed boxes near food prep areas.
Presence of live and dead roaches in the kitchen and dining areas.
Improper thawing of processed ham under running water near uncovered dessert trays.
Use of a white bath towel under a mobile refrigerator, which could harbor bacteria.
Standing water under dry food storage shelf with vinyl baseboard damage and crusted lifted floor tile from a water leak.
Baseboards behind ice machine with dead roaches and debris buildup near a floor drain with broken tiles and exposed sub-floor.
Report Facts
Resident census: 51
Date survey completed: Dec 15, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kitchen Manager | Staff #46 involved in observations and interviews related to kitchen deficiencies |
Inspection Report
Complaint Investigation
Capacity: 74
Deficiencies: 2
Date: Dec 11, 2023
Visit Reason
Recertification survey combined with complaint investigations; two deficiencies cited related to food safety and premises cleanliness.
Findings
Recertification survey combined with complaint investigations; two deficiencies cited related to food safety and premises cleanliness.
Deficiencies (2)
§483.60(i) — Food safety requirements
R9-10-425.A — Premises and equipment cleanliness
Inspection Report
Capacity: 74
Deficiencies: 0
Date: Dec 11, 2023
Visit Reason
Recertification survey for Life Safety Code compliance with no deficiencies cited.
Findings
Recertification survey for Life Safety Code compliance with no deficiencies cited.
Inspection Report
Complaint Investigation
Capacity: 74
Deficiencies: 0
Date: Sep 27, 2023
Visit Reason
Complaint investigation with no deficiencies cited.
Findings
Complaint investigation with no deficiencies cited.
Inspection Report
Complaint Investigation
Capacity: 74
Deficiencies: 0
Date: Jun 7, 2023
Visit Reason
Complaint survey with no deficiencies cited.
Findings
Complaint survey with no deficiencies cited.
Inspection Report
Complaint Investigation
Capacity: 74
Deficiencies: 0
Date: Jun 7, 2023
Visit Reason
Complaint survey with no deficiencies cited.
Findings
Complaint survey with no deficiencies cited.
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: May 2, 2023
Visit Reason
The inspection was conducted due to concerns regarding the facility's failure to ensure a resident (#10) received dialysis services as per physician's orders, including missed dialysis appointments and conflicting dialysis scheduling information.
Complaint Details
The investigation was complaint-related, focusing on missed dialysis treatments and conflicting dialysis scheduling information for resident #10. The complaint was substantiated by findings of missed dialysis appointments, conflicting orders, and adverse resident outcomes.
Findings
The facility failed to ensure resident #10 received dialysis according to physician orders, with conflicting dialysis schedules between physician orders and the facility's dashboard. The resident missed dialysis appointments on April 6 and April 15, 2023, with no documented reasons, and experienced adverse health effects including hospitalization due to missed dialysis. Transportation issues and dialysis center refusals contributed to missed treatments. Documentation and communication deficiencies were also noted.
Deficiencies (1)
Failure to ensure resident received dialysis services as per physician's orders, including missed treatments and conflicting scheduling information.
Report Facts
Missed dialysis appointments: 2
Dialysis treatments received: 5
Physician order date: Apr 5, 2023
Survey completion date: May 2, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dialysis Center Administrator | Interviewed regarding resident's dialysis schedule and missed appointments. | |
| Licensed Practical Nurse (LPN) | Interviewed about dialysis orders and transport issues. | |
| Medical Records Supervisor/Transportation | Interviewed about dialysis scheduling and transportation issues. | |
| Director of Nursing (DON) | Interviewed about expectations for dialysis scheduling and documentation. |
Inspection Report
Complaint Investigation
Capacity: 74
Deficiencies: 2
Date: May 1, 2023
Visit Reason
Complaint survey with two deficiencies cited related to dialysis services.
Findings
Complaint survey with two deficiencies cited related to dialysis services.
Deficiencies (2)
§483.25(l) — Dialysis services
R9-10-417 — Dialysis services administration
Inspection Report
Deficiencies: 6
Date: Nov 10, 2022
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, medication administration, housekeeping, nutrition, activities of daily living, and psychotropic medication monitoring at Tempe Post Acute nursing facility.
Findings
The facility was found deficient in multiple areas including failure to maintain a clean and homelike environment upon admission, inaccurate Minimum Data Set (MDS) assessments, medication administration outside physician orders without notification, inadequate provision of showers to residents, inconsistent documentation and provision of meals, and failure to monitor behaviors and side effects for residents on psychotropic medications. These deficiencies posed risks of harm such as unsafe environment, inaccurate care planning, inadequate treatment, poor hygiene, nutritional deficits, and unmonitored medication effects.
Deficiencies (6)
Failure to provide housekeeping services necessary to maintain a clean and homelike environment for one resident (#200), including admission to a room not cleaned prior to occupancy.
Failure to ensure the MDS assessment was accurate for one resident (#103), specifically not coding a documented fall.
Failure to ensure medications were administered as ordered by the physician for two residents (#101 and #199), including administration of Carvedilol outside ordered parameters without physician notification and missed antibiotic doses without documented reasons.
Failure to ensure one resident (#104) was provided with showers as scheduled, resulting in only two showers in approximately 29 days despite a twice weekly schedule.
Failure to ensure one resident (#249) was consistently provided meals and that food intake was properly documented, with multiple instances of missing documentation and possible missed meals.
Failure to ensure one resident (#156) was free from unnecessary drugs by not monitoring behaviors and side effects related to psychotropic medications as required by facility policy.
Report Facts
Sample size: 13
Sample size: 13
Sample size: 5
Sample size: 3
Sample size: 5
Sample size: 5
Medication administration outside parameters: 4
Missed antibiotic doses: 8
Showers provided: 2
BIMS score: 15
Fall risk score: 7
MNA score: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff #33 | Housekeeper | Interviewed about deep cleaning procedures and admission room cleaning |
| Staff #84 | Housekeeping Supervisor | Interviewed about deep cleaning process and admission room cleaning |
| Staff #300 | Director of Nursing (DON) | Interviewed about grievances, medication administration, shower provision, and psychotropic medication monitoring |
| Staff #42 | MDS Coordinator | Interviewed about MDS coding for falls |
| Staff #30 | Licensed Practical Nurse (LPN) | Interviewed about medication administration outside parameters |
| Staff #99 | Assistant Director of Nursing (ADON) | Interviewed about medication administration and shower provision |
| Staff #26 | Restorative Nurse Assistant (RNA) | Interviewed about shower schedules and documentation |
| Staff #102 | Dietary Supervisor | Interviewed about food intake documentation and meal provision |
| Staff #22 | Certified Nursing Assistant (CNA) | Interviewed about food intake monitoring and documentation |
| Staff #27 | Case Manager Director/Social Services | Interviewed about food-related grievances |
| Staff #71 | Licensed Practical Nurse (LPN) | Interviewed about psychotropic medication monitoring |
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