21 Reports
Inspection Report — Jul 1, 2025
Complaint Investigation
Date: Jul 1, 2025
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On-site complaint investigation at a Nursing Care Institution conducted 1 July 2025.
Complaint Details
An offsite follow up survey was conducted on July 01, 2025. There were no deficiencies cited.
Findings
Two deficiencies were cited despite the initial comment stating no deficiencies were found.
Deficiencies (2)
R9-10-410 — No evidence text provided for the allegation of abuse.
R9-10-414 — No evidence text provided regarding the care plan ensuring the resident's highest practicable well-being.
Report Facts
Deficiencies cited: 2
Inspection Report — Apr 22, 2025
Complaint Investigation
Date: Apr 22, 2025
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On-site complaint investigation of multiple complaints including AZ00167573, AZ00167710, AZ00168392, AZ00171919, AZ00171921, AZ00173565, AZ00174902, AZ00177042, AZ00180019, AZ00182075, AZ00182565, and AZ00182628 at a Nursing Care Institution, conducted 22 April 2025.
Complaint Details
The Risk-Based complaint survey was conducted on April 22, 2025 for the investigation of intake numbers: AZ00167573 AZ00167710, AZ00168392, AZ00171919, AZ00171921, AZ00173565, AZ00174902, AZ00177042, AZ00180019, AZ00182075, AZ00182565, AZ00182628.
Findings
Two deficiencies were cited during this complaint investigation. No evidence text was provided for either deficiency.
Deficiencies (2)
R9-10-410 — No evidence text provided for the deficiency related to abuse prevention.
R9-10-414 — No evidence text provided for the deficiency related to ensuring nursing care assists the resident in maintaining their highest practicable well-being.
Report Facts
Deficiencies cited: 2
Inspection Report — Mar 17, 2025
Complaint Investigation
Date: Mar 17, 2025
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On-site complaint investigation of complaints 00122144, AZ00193109, AZ00190897, AZ00190951, AZ00189798 at a Nursing Care Institution, conducted 17 March 2025.
Complaint Details
The investigation of complaints 00122144, AZ00193109, AZ00190897, AZ00190951, AZ00189798 was conducted on March 17, 2025. Federal complaints AZ00190897, AZ00190950, AZ00193108, AZ00223771, and AZ00189798 were also investigated on the same date with no deficiencies cited.
Findings
No deficiencies were cited during this complaint investigation.
Report Facts
Complaints investigated: 5
Inspection Report — Feb 5, 2025
Complaint Investigation
Date: Feb 5, 2025
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On-site complaint investigation of intakes AZ00222568, AZ00222447, AZ00222567, and AZ00222446 at a Nursing Care Institution, conducted 5 February 2025.
Complaint Details
An onsite complaint survey was conducted on February 5, 2025 for the investigation of intake # AZ00222568, AZ00222447. Federal comments also note investigation of intake # AZ00222567, AZ00222446. There were no deficiencies cited.
Findings
This inspection resulted in no deficiencies cited or citations.
Inspection Report — Jan 27, 2025
Date: Jan 27, 2025
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On-site inspection for a bed increase at a Nursing Care Institution conducted 27 January 2025.
Findings
This inspection resulted in no deficiencies or citations.
Inspection Report — Nov 25, 2024
Date: Nov 25, 2024
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On-site other inspection of a Nursing Care Institution at TEMPE POST ACUTE conducted 25 November 2024.
Findings
The inspection found three deficiencies related to means of egress obstructions, improper sprinkler installation, and unsealed penetrations in smoke barriers. The facility provided plans of correction for all deficiencies.
Deficiencies (3)
Means of Egress - General — The facility failed to provide a clear and unimpeded means of egress in hallways with rooms 515-522 and 523-532 due to equipment and carts obstructing exit pathways.
NFPA 101 Life Safety Code, 2012, Chapter 19, Section 19.3.5.3 — The facility failed to ensure proper installation of the sprinkler system, with a ceiling-mounted sprinkler head in the Zone 1 Crash Cart room located too close to the wall.
NFPA 101 Life Safety Code, 2012, Chapter 19, Section 19.3.7.3 — The facility failed to seal multiple penetrations in smoke barriers in various rooms and walls, allowing potential smoke and heat transfer during a fire.
Report Facts
Deficiencies cited: 3
Inspection Report — Nov 21, 2024
Complaint Investigation
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 — Nov 21, 2024
Annual Inspection
Date: Nov 21, 2024
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On-site complaint investigation and annual recertification survey conducted 18 through 21 November 2024 at a Nursing Care Institution, including investigation of complaints AZ00215229, AZ00188872, AZ00188217, AZ00188057, AZ00189089, AZ00188229, AZ00188488, AZ00188486, AZ00188113, and AZ00188171.
Complaint Details
The Recertification survey was conducted in conjunction with the investigation of Complaints #AZ00215229, AZ00188872, AZ00188217, AZ00188057, AZ00189089, AZ00188229, AZ00188488, AZ00188486, AZ00188113, and AZ00188171. Federal comments referenced similar complaint investigations with overlapping complaint numbers.
Findings
The inspection found one deficiency related to failure to follow physician orders for blood sugar monitoring and insulin administration for two residents. The facility did not recheck elevated blood sugars or notify the physician as ordered.
Deficiencies (1)
R9-10-414 — The facility failed to ensure physician orders were followed for blood sugar monitoring and insulin administration, including rechecking elevated blood sugars and notifying the physician for two residents. Staff interviews and clinical record reviews confirmed these omissions.
Report Facts
Deficiencies cited: 1
Complaints investigated: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff #17 | Certified Nursing Assistant | Interviewed regarding blood sugar checks and notification procedures. |
| Staff #82 | Licensed Practical Nurse | Interviewed regarding insulin administration and physician order compliance. |
| Staff #7 | Director of Nursing | Interviewed regarding nursing procedures and physician order compliance. |
Inspection Report — Jun 4, 2024
Complaint Investigation
Date: Jun 4, 2024
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On-site complaint investigation of intake numbers AZ00210800, AZ00195040, AZ00190318, AZ00210774, AZ00196266, and AZ00194979 at a Nursing Care Institution, conducted 4 June 2024.
Complaint Details
An onsite complaint survey was conducted on June 4, 2024 for the investigation of intake #s AZ00210800, AZ00195040, AZ00190318, AZ00210774, AZ00196266, and AZ00194979. There were no deficiencies cited.
Findings
This inspection resulted in no deficiencies cited.
Report Facts
Complaints investigated: 6
Inspection Report — May 2, 2024
Complaint Investigation
Date: May 2, 2024
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On-site complaint investigation of intake AZ00209835 at a Nursing Care Institution, conducted 2 May 2024.
Complaint Details
A complaint survey was conducted on May 2, 2024 for the investigation of intake #AZ00209835. Federal comments note a complaint survey for intake #AZ00209834. There were no deficiencies cited.
Findings
This inspection resulted in no deficiencies cited.
Inspection Report — Mar 21, 2024
Complaint Investigation
Date: Mar 21, 2024
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On-site complaint investigation of Intake #AZ00207833 and Intake #AZ00207832 at a Nursing Care Institution, conducted 21 March 2024.
Complaint Details
An onsite Complaint Survey was conducted on March 21, 2024 for the investigation of Intake #AZ00207833 and Intake #AZ00207832. There were no deficiencies cited.
Findings
No deficiencies were cited during this complaint investigation.
Inspection Report — Feb 26, 2024
Complaint Investigation
Date: Feb 26, 2024
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On-site complaint investigation of intakes AZ00206369, AZ00206346, AZ00193036, AZ00192873, and AZ00192878 at a Nursing Care Institution, conducted 26 February 2024.
Complaint Details
An onsite complaint survey was conducted on 2/26/2024 for the investigation of intake #s AZ00206369, AZ00206346, AZ00193036, AZ00192873, AZ00192878. Federal comments note investigation of intake #s AZ00206368, AZ00206346, AZ00193036, AZ00192873, AZ00192818. There were no deficiencies noted.
Findings
This inspection found no deficiencies.
Inspection Report — Dec 15, 2023
Routine
Date: Dec 15, 2023
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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, with observations including food debris, pest presence (live and dead roaches), improper food storage and thawing practices, standing water from leaks, and uncompleted cleaning logs. These deficiencies posed a potential risk for foodborne illness.
Deficiencies (6)
Failure to maintain a clean and sanitary kitchen including food debris under prep tables and near baseboards.
Presence of live and dead roaches in kitchen and dining areas.
Uncompleted cleaning logs for freezer, fridge, dishwasher, and cleaning schedules prior to morning food service.
Improper thawing of processed ham under running water near uncovered dessert trays.
Standing water under dry food storage shelf and water leak causing crusted lifted floor tile.
Baseboards behind ice machine with dead roaches and debris buildup near floor drain with broken tiles and exposed sub-floor.
Report Facts
Date of survey completion: Dec 15, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kitchen Manager | Staff #46 interviewed and involved in observations of kitchen conditions | |
| Food Service Director | Staff #46 identified as Food Service Director involved in kitchen tour and interviews |
Inspection Report — Dec 15, 2023
Annual Inspection
Date: Dec 15, 2023
Visit Reason
Recertification survey conducted December 12 through December 15, 2023, in conjunction with the investigation of complaints AZ00197129, AZ00197170, AZ00197489, AZ00197562, AZ00198063, AZ00199743, AZ0019810, AZ00199871, AZ00199941, AZ00200031, AZ00200039, AZ00200264, AZ00200458, AZ00200489, AZ00200864, AZ00201045, AZ00201443, AZ00202518, AZ00203349, and AZ00203852 at a Nursing Care Institution.
Complaint Details
The recertification survey was conducted December 12 through December 15, 2023, in conjunction with the investigation of complaints AZ00197129, AZ00197170, AZ00197489, AZ00197562, AZ00198063, AZ00199743, AZ0019810, AZ00199871, AZ00199941, AZ00200031, AZ00200039, AZ00200264, AZ00200458, AZ00200489, AZ00200864, AZ00201045, AZ00201443, AZ00202518, AZ00203349, AZ00203852.
Findings
The inspection found two deficiencies related to failure to maintain a clean and sanitary kitchen, including pest presence, unclean surfaces, and incomplete cleaning logs. These conditions could result in potential food borne illness.
Deficiencies (2)
§483.60(i) — The facility failed to maintain a clean and sanitary kitchen, with observations including incomplete cleaning logs, food debris, pest presence, and water leaks that could lead to food borne illness.
R9-10-425 — The facility failed to ensure the nursing care institution's premises and equipment were cleaned and disinfected according to policies, evidenced by pest infestations, unclean food prep areas, and incomplete cleaning documentation.
Report Facts
Deficiencies cited: 2
Complaints investigated: 20
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff #46 | Kitchen Manager | Conducted kitchen tours and provided statements regarding pest sightings and cleaning practices. |
Inspection Report — Dec 15, 2023
Date: Dec 15, 2023
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On-site inspection of a Nursing Care Institution at Tempe Post Acute conducted 15 December 2023. The inspection type was Other and the worksheet type was Nursing Care Institution.
Findings
No deficiencies were found during this inspection. The facility met all applicable federal, state, and local standards.
Inspection Report — Sep 27, 2023
Complaint Investigation
Date: Sep 27, 2023
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On-site complaint investigation of complaints AZ00200595 and AZ00200594 at a Nursing Care Institution, conducted 27 September 2023.
Complaint Details
The investigation of complaint AZ00200595 was conducted on 09/27/2023. The investigation of complaint AZ00200594 was conducted on 09/27/2023. No deficiencies were cited.
Findings
No deficiencies were found during this complaint investigation.
Inspection Report — Jun 9, 2023
Complaint Investigation
Date: Jun 9, 2023
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On-site complaint investigation of intakes AZ00196275, AZ00196334, AZ00196273, and AZ00196333 at a Nursing Care Institution, conducted 7 through 9 June 2023.
Complaint Details
An onsite survey was conducted on June 7 through June 9, 2023 for the investigation of intake #s: AZ00196275 and AZ00196334. A complaint survey was conducted on June 7 through June 9, 2023 for the investigation of intake #s: AZ00196273 and AZ00196333. There were no deficiencies cited.
Findings
No deficiencies were cited during this complaint investigation.
Inspection Report — Jun 7, 2023
Complaint Investigation
Date: Jun 7, 2023
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On-site complaint investigation of intakes AZ00175865 and AZ00195308 at a Nursing Care Institution, conducted 7 June 2023.
Complaint Details
An onsite survey was conducted on June 7, 2023 for the investigation of intake #s AZ00175865 and AZ00195308. No deficiencies were cited. A complaint survey was conducted on June 7, 2023 for the investigation of intake #s AZ00175865 and AZ00195307. No deficiencies were cited.
Findings
No deficiencies were cited during this complaint investigation.
Inspection Report — May 2, 2023
Complaint Investigation
Date: May 2, 2023
Visit Reason
The inspection was conducted due to concerns about 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 schedules for resident #10. The complaint was substantiated with findings of missed dialysis on April 6 and April 15, 2023, and transportation issues contributing to missed appointments.
Findings
The facility failed to ensure resident #10 received dialysis according to physician orders, with conflicting dialysis schedules between orders and the dashboard, missed dialysis appointments without documented reasons, and transportation issues contributing to missed treatments. The resident experienced adverse health effects including hospitalization due to missed dialysis.
Deficiencies (1)
Failure to provide dialysis services as per physician's orders for resident #10, including missed treatments and conflicting scheduling information.
Report Facts
Missed dialysis appointments: 2
Dialysis treatments received: 5
Physician order date: Apr 5, 2023
Order change date: Apr 22, 2023
Order hold date: Apr 25, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dialysis Center Administrator | Interviewed regarding resident #10's dialysis schedule and missed appointments. | |
| Licensed Practical Nurse (LPN) | Interviewed about dialysis order discrepancies and transport issues. | |
| Medical Records Supervisor/Transportation | Interviewed about dashboard instructions, transportation issues, and documentation. | |
| Director of Nursing (DON) | Interviewed regarding expectations for dialysis scheduling and documentation. |
Inspection Report — Nov 10, 2022
Complaint Investigation
Date: Nov 10, 2022
Visit Reason
The inspection was conducted due to complaints regarding housekeeping services, medication administration, resident assessments, personal hygiene, nutrition, and psychotropic medication monitoring at Tempe Post Acute nursing home.
Complaint Details
The complaint investigation was substantiated with findings including unclean resident rooms, inaccurate resident assessments, medication administration errors, failure to provide scheduled showers, inadequate nutrition documentation and provision, and lack of psychotropic medication monitoring.
Findings
The facility failed to maintain a clean and homelike environment for residents, ensure accurate Minimum Data Set assessments, administer medications as ordered, provide scheduled showers, maintain adequate nutrition for residents, and monitor behaviors and side effects for psychotropic medications. These deficiencies posed risks of harm including unsafe environment, inaccurate care planning, inadequate treatment, poor hygiene, nutritional deficits, and unmonitored medication effects.
Deficiencies (6)
Failed to provide housekeeping services necessary to maintain a clean and homelike environment for one resident (#200).
Failed to ensure the MDS assessment was accurate for one resident (#103), missing documentation of a fall.
Failed to ensure medications were administered as ordered by the physician for two residents (#101 and #199).
Failed to ensure one resident (#104) was provided with showers as scheduled, resulting in poor personal hygiene.
Failed to ensure one resident (#249) was consistently provided meals to maintain adequate nutrition.
Failed to ensure one resident (#156) was free from unnecessary psychotropic drugs by not monitoring behaviors and side effects.
Report Facts
Sample size: 13
Sample size: 5
Medication administration outside parameters: 4
Missed medication doses: 8
Resident showers provided: 2
Meal intake missing: 13
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 miscommunication regarding room cleaning |
| Staff #300 | Director of Nursing (DON) | Interviewed regarding grievances, medication administration, shower provision, and psychotropic monitoring |
| Staff #42 | MDS Coordinator | Interviewed about MDS coding and fall documentation |
| Staff #30 | Licensed Practical Nurse (LPN) | Interviewed about medication administration policy and Carvedilol administration |
| Staff #99 | Assistant Director of Nursing (ADON) | Interviewed about medication administration, shower schedules, and documentation |
| 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 #303 | Registered Dietitian (RD) | Interviewed about resident meal portions and nutrition |
| Staff #27 | Case Manager Director/Social Services | Interviewed about food-related grievances |
| Staff #71 | Licensed Practical Nurse (LPN) | Interviewed about psychotropic medication monitoring |
Inspection Report — Nov 10, 2022
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 |
4 CMS Surveys
CMS Survey — May 2, 2023
May 2, 2023
CMS Survey — Nov 10, 2022
Nov 10, 2022
CMS Survey — Dec 15, 2023
Dec 15, 2023
CMS Survey — Nov 21, 2024
Nov 21, 2024
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