Below average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Ahwatukee Post Acute during CMS and state inspections, most recent first.
The facility failed to send discharge notices to the Ombudsman for multiple residents who left the facility, including residents who left AMA and a resident on hospice whose POA requested discharge home. Records showed one resident with severe cognitive impairment, another who was cognitively intact but left without medication, and a third resident with multiple chronic conditions and hospice needs. Staff interviews confirmed that monthly discharge notices were not consistently sent and that the Ombudsman had not received most of the notices for the year.
Ordered medications were not available for three residents, including antidepressant and anxiety medications, and one resident also missed atorvastatin doses because the drugs were awaiting pharmacy delivery or otherwise pending. Records showed repeated missed administrations for residents with significant medical histories, and staff interviews confirmed that medication shortages, delayed reorders, and inconsistent follow-up were occurring.
A resident with dementia sustained serious fractures after being found on the floor beside her bed. The facility did not report the incident to the State Agency, as required by their policy. The DON concluded the resident fell out of bed based on her statement, and no further investigation was conducted.
A resident with dementia and other health issues was found on the floor with severe injuries, including a femur and hip fracture. Despite the severity, the facility did not report the incident to the State Agency. The DON concluded the resident fell out of bed based on her statement, and no thorough investigation was conducted, contrary to the facility's policy requiring immediate reporting of injuries of unknown source.
A resident with dementia and other medical conditions was found on the floor with severe injuries, but the facility failed to conduct a thorough investigation or report the incident to the state. The DON concluded the resident fell out of bed based on limited information, contrary to the facility's policy requiring comprehensive investigation of injuries of unknown origin.
The facility failed to protect residents from abuse by other residents, resulting in multiple incidents of physical and verbal altercations. A resident with impaired communication had their feeding tube pulled out by another resident with a history of aggression. In separate incidents, one resident was struck in the face by another, and another resident was kicked. These incidents highlight the facility's failure to manage residents with known aggressive behaviors.
The facility failed to thoroughly investigate allegations of abuse involving two residents and misappropriation of narcotics for three residents. Despite reports of verbal abuse and inappropriate behavior, no 5-day investigative reports were submitted to the State Agency. Additionally, missing narcotics prescribed to residents were not properly investigated, and necessary documentation was unavailable due to a change in facility ownership.
The facility failed to provide adequate ADL care for two residents, resulting in deficiencies in personal hygiene. One resident, with severe cognitive impairment, was not bathed or given oral care for several days, with no documentation of care refusal. Another resident, cognitively intact, had no records of bathing or showering for a week, despite the care plan's emphasis on personal hygiene. The DON confirmed the lack of documentation and adherence to facility policies.
A resident at high risk for skin breakdown developed wounds that were not properly treated due to incomplete transcription of physician orders into the treatment administration record. Despite having a care plan and physician orders for wound care, the facility failed to document and administer the necessary treatments, leading to a deficiency in care.
A resident with a C-diff infection was not placed on proper isolation precautions due to a lack of physician orders and implementation by the facility. Despite being on antibiotics, there was no evidence of isolation measures in the clinical record. Interviews with the DON indicated that the admissions nurse was responsible for obtaining necessary orders, but this was not done. The facility's infection control policy and guidelines for C-diff were not followed, leading to a deficiency in infection prevention and control practices.
A resident admitted for hospice respite care experienced a significant change in condition, including cardiac arrest, but the facility failed to notify the resident's medical power of attorney (MPOA). Despite staff acknowledging the responsibility to inform family and physicians, the facility's policy did not mandate notifying the resident's representative, leading to this deficiency.
Failure to Notify Ombudsman of Resident Discharges
Penalty
Summary
The facility failed to send a copy of the notice of transfer or discharge to the representative of the Office of the State Long-Term Care Ombudsman for 3 of 3 sampled residents. The deficiency was identified through closed record review, staff interviews, review of facility documentation and policy, and the State Agency complaint tracking system. The report states that the omission affected residents who were discharged from the facility and that the notices were not sent to the Ombudsman as required. Resident #150 was admitted with diagnoses including hypertension and status post recovery from incarcerated/strangulated inguinal hernia repair. Admission documentation indicated the resident could communicate needs and wants effectively, although the 5-day MDS showed a BIMS score of 3.0, indicating severe impairment. Progress notes documented that the resident became unhappy with the food, requested discharge back home, and later left against medical advice with the resident's representative/family wanting the resident to return home. The resident was discharged on March 7, 2025. Resident #142 was readmitted with diagnoses including anxiety, depression, and chronic back pain. The BIMS assessment showed a score of 15.0, indicating cognitive intactness. IDT notes described the resident as bedbound, needing minimum assistance for transfers and contact guard assistance for ADLs, and progress notes showed orders for Gabapentin, methocarbamol, and Morphine Sulfate for pain management. The resident left the facility against medical advice without medication and was picked up by a family member on March 18, 2025. Resident #147 had diagnoses including CAD, heart failure, hypertension, DM, malnutrition, and anxiety disorder, was under hospice care, and had a BIMS score of 7.0. Records showed the resident remained on hospice with ongoing monitoring and care planning, but the resident's POA later requested discharge home, signed the AMA form, and removed the resident from the facility on June 26, 2025. Staff interviews showed inconsistent understanding and performance of the discharge-notification process. The case manager stated that discharge notices should be sent monthly to the Ombudsman, but also stated that notices had not been sent for several months and that she had recently sent June and July discharge notifications. The Ombudsman stated she had received only the November and December 2024 notices and had not received the other notices for the year except the one recently sent. The social service director stated that discharge notices are part of the discharge process and should be sent monthly, while another staff member covering case management stated she did not send the notices for April through June and acknowledged that the facility had not sent notices from January through May 2025. The DON stated that the Ombudsman is notified at the end of the month, but also stated that the case manager was not sending the notices.
Medications Not Available as Ordered
Penalty
Summary
The facility failed to ensure that ordered medications were available for use for three residents. The deficiency involved resident #5, resident #43, and resident #7, and the report states that the failure could result in residents not receiving physician-ordered medications that were necessary. Review of clinical records, progress notes, and facility policies showed that medications were not administered because they were pending from the pharmacy, awaiting delivery, or otherwise not available when due. Resident #5 had diagnoses including cerebral infarction, hemiplegia, aphasia, anemia, bipolar disorder, schizophrenia, and epilepsy, and the care plan identified antidepressant use related to poor appetite. The physician ordered mirtazapine 7.5 mg, 2 tablets daily for depression as evidenced by poor appetite. Progress notes showed the medication was not given on multiple occasions, including entries stating it was not administered because it was pending from the pharmacy and pending delivery from the pharmacy. Resident #43 had diagnoses including hemiplegia, aphasia, diabetes mellitus type 2, anemia, anxiety, hyperlipidemia, depression, and hypertension, and the care plan identified antidepressant use related to decreased appetite. The physician ordered mirtazapine 15 mg daily for depression as evidenced by decreased appetite, and progress notes showed mirtazapine and atorvastatin 80 mg were not administered because they were awaiting from the pharmacy or awaiting delivery. Resident #7 had diagnoses including osteomyelitis, muscle wasting, depression, diabetes mellitus type 2, hypertension, chronic kidney disease, anemia, and anxiety, and the physician ordered buspirone 7.5 mg, 2 tablets every 12 hours for anxiety as evidenced by restlessness. An LPN stated that residents running out of medications happens often, that missing medications are sometimes due to pharmacy issues or cost control, that documentation and follow-up depend on who is working, and that missing medications may be borrowed from other residents rather than refilled correctly. The DON stated that medications should be activated in the system and delivered within a couple of hours, and that missing medications and failure to reorder appropriately did not meet her standards. Facility policy stated that medications must be administered in accordance with prescriber orders and refilled medications must be reordered from the issuing pharmacy to ensure availability.
Failure to Report Major Injury
Penalty
Summary
The facility failed to implement its abuse policy regarding a major injury sustained by a resident. The resident, who had a history of dementia, major depressive disorder, hyperlipidemia, and gout, was found on the floor beside her bed, complaining of pain in her right upper leg. She was transferred to the emergency room, where it was discovered that she had sustained a left periprosthetic femur fracture and a right hip fracture. Despite the severity of the injuries, the facility did not report the incident to the State Agency as required by their policy. Interviews with the Director of Nursing (DON) and Assistant Director of Nursing (ADON) revealed that the incident was not witnessed, and the DON concluded that the resident fell out of bed based on the resident's statement expressing a desire to leave. The only investigation conducted was a conversation with the nurse who found the resident. The DON did not believe the incident warranted reporting to the state, although she acknowledged understanding the perspective of an outside observer. The facility's policy requires immediate reporting of any injury of unknown source, but this was not adhered to in this case.
Failure to Report Major Injury of Resident
Penalty
Summary
The facility failed to report a major injury sustained by a resident, which could result in other injuries of unknown origin to residents. The resident, who had a history of dementia, major depressive disorder, hyperlipidemia, and gout, was found on the floor beside her bed, complaining of pain in her right upper leg. She was transferred to the emergency room, where it was discovered that she had sustained a left periprosthetic femur fracture and a right hip fracture. Despite the severity of the injuries, the facility did not report the incident to the State Agency as required. Interviews with the Director of Nursing (DON) and Assistant Director of Nursing (ADON) revealed that the incident was not witnessed, and the DON concluded that the resident fell out of bed based on the resident's statement. The only investigation conducted was speaking with the nurse who found the resident. The DON did not believe the incident warranted reporting to the state, although she acknowledged understanding the perspective of an outside observer. The facility's policy requires immediate reporting of any injury of unknown source, but this protocol was not followed in this case.
Failure to Investigate Resident Injury
Penalty
Summary
The facility failed to investigate a major injury sustained by a resident, which could lead to other injuries of unknown origin not being thoroughly investigated. The resident, who had a history of dementia, major depressive disorder, hyperlipidemia, and gout, was found on the floor beside her bed, expressing a desire to leave the facility. Despite the resident's statement and the severity of her injuries, which included a left periprosthetic femur fracture and a right hip fracture, the Director of Nursing (DON) concluded that the resident fell out of bed and did not report the incident to the state. The facility's policy requires thorough investigation of any allegations of abuse, neglect, or injury of unknown source, including reviewing documentation, interviewing witnesses, and assessing the resident's condition. However, the only investigation conducted was a conversation with the nurse who found the resident. The DON did not feel the incident warranted state reporting, despite acknowledging the potential for different interpretations of the situation. This lack of a comprehensive investigation and failure to report the incident constitutes a deficiency in the facility's handling of the situation.
Failure to Protect Residents from Abuse by Other Residents
Penalty
Summary
The facility failed to protect residents from abuse by other residents, resulting in multiple incidents of physical and verbal altercations. Resident #128, who had impaired communication and was non-ambulatory, was involved in an incident with Resident #15, who had a history of physical aggression. During a verbal altercation, Resident #15 allegedly pulled out Resident #128's feeding tube, which was later found next to Resident #128. Staff intervened, but Resident #15 continued to exhibit aggressive behavior, including shoving a CNA. In another incident, Resident #15 was involved in a physical altercation with Resident #11 in the dining room. Resident #11, who had a history of verbal outbursts and psychiatric disorders, struck Resident #15 in the face, resulting in a laceration to Resident #15's lip. The altercation was broken up by staff, and both residents were separated and escorted to their rooms. Additional incidents involved Resident #17 kicking Resident #161 in the smoking area and Resident #3 punching Resident #14 in the face. These incidents highlight the facility's failure to adequately monitor and manage residents with known aggressive behaviors, leading to multiple instances of resident-to-resident abuse.
Failure to Investigate Abuse and Narcotic Misappropriation
Penalty
Summary
The facility failed to provide evidence of thorough investigations into allegations of abuse and misappropriation of narcotics involving several residents. For two residents, there were allegations of abuse that were not properly investigated. One resident, who was cognitively intact, reported verbal abuse from another resident, but there was no evidence of a 5-day investigative report being submitted to the State Agency (SA) or that the incident was thoroughly investigated. Another resident, with moderate cognitive impairment, reported inappropriate behavior from a staff member, but again, there was no evidence of a thorough investigation or a 5-day report submitted to the SA. Additionally, the facility did not thoroughly investigate the misappropriation of narcotics involving three residents. These residents were prescribed narcotics such as oxycodone and Percocet, and a self-report indicated that narcotics were missing. Despite the suspension of a staff member pending investigation, there was no evidence of a 5-day investigative report submitted to the SA, nor were there narcotic count sheets or documentation of the investigation available. Interviews with the facility's administrator and Director of Nursing revealed that they were unable to locate the necessary documents due to a change in facility ownership. The facility's policies required thorough investigations and submission of reports within 5 business days, but these procedures were not followed, leading to the deficiencies noted in the report.
Deficiencies in ADL Care for Residents
Penalty
Summary
The facility failed to provide adequate activities of daily living (ADL) care for two residents, leading to deficiencies in personal hygiene maintenance. Resident #127, admitted for a hospice respite stay with severe cognitive impairment, required assistance with toileting and personal hygiene. Despite the care plan indicating the need for oral care and hygiene assistance, documentation revealed that the resident was not bathed or dressed for four days and did not receive oral care for three days. There was no record of the resident refusing care, and the Director of Nursing (DON) confirmed the lack of documentation for the provided care. Resident #137, with diagnoses including cerebral palsy and immunodeficiency, had a care plan emphasizing the importance of choosing between a shower and a bed bath. Despite being cognitively intact, as indicated by a BIMS score of 15, there was no documentation of bathing or showering from October 27 through November 3, 2021, nor any record of the resident refusing care. The DON acknowledged the absence of shower sheets for the specified period. The facility's policies outlined responsibilities for personal care and coordination with hospice, but these were not adhered to, resulting in the noted deficiencies.
Failure to Administer Ordered Wound Care Treatments
Penalty
Summary
The facility failed to provide appropriate care and services related to pressure ulcers for a resident, leading to a deficiency. The resident was admitted with multiple diagnoses, including encephalopathy and traumatic hemorrhages, and was identified as being at high risk for skin breakdown. The care plan included interventions such as preventive skin care, application of barrier cream, and weekly wound assessments. Despite these measures, the resident developed an abrasion on the left buttock, and later, blisters and non-blanchable redness on the lower extremities. Physician orders were given for specific wound care treatments, but these were not fully transcribed into the treatment administration record (TAR), resulting in a lack of documented treatment for certain wounds. The deficiency was further highlighted by the absence of evidence showing that the prescribed treatments for the resident's wounds were administered. The clinical record did not indicate why the treatments were not provided, nor was there documentation of physician notification regarding the missed treatments. Interviews with the Director of Nursing and the wound care nurse confirmed that the orders should have been entered into the TAR or MAR, but were not, leading to incomplete wound care. The resident was eventually discharged to the hospital, but the failure to administer the ordered treatments remained unaddressed in the facility's records.
Failure to Implement C-diff Precautions
Penalty
Summary
The facility failed to implement proper infection prevention and control practices for a resident diagnosed with Clostridium difficile (C-diff) infection. The resident was admitted with diagnoses of sepsis due to Serratia and enterocolitis due to C-diff. Despite being on antibiotics for the C-diff infection, there was no evidence in the clinical record of any physician order for isolation or contact precautions. The progress notes indicated that the resident was on contact isolation, but this was not supported by any documented orders or evidence of isolation precautions being implemented. Interviews with the Director of Nursing (DON) revealed that there was no physician order to place the resident on isolation precautions for the C-diff infection. The DON stated that the admissions nurse was responsible for setting up the room, placing signs, and obtaining orders from the doctor. The facility's infection control policy aimed to prevent, detect, investigate, and control infections, but it was not followed in this case. The Clinical Practice Guidelines for C-diff infection require healthcare workers and visitors to use gloves and gowns when entering the room of a patient with a C-diff infection, which was not adhered to in this instance.
Failure to Notify Resident's Representative of Change in Condition
Penalty
Summary
The facility failed to notify the resident's representative of a significant change in condition for a resident admitted for a hospice respite stay. The resident, who had diagnoses of heart failure and atherosclerosis of coronary artery bypass graft, experienced a decline in condition and was not responsive during a shift. Despite hospice being notified and the resident being sent to the hospital after CPR was initiated, there was no documentation indicating that the resident's medical power of attorney (MPOA) was informed of these changes. Interviews with staff, including an LPN and the Director of Nursing (DON), revealed that it was the responsibility of the nursing staff to notify the family, physician, and hospice of any change in a resident's condition. However, the facility's policy on acute condition changes did not include a requirement to notify the resident's representative. This oversight in policy and practice led to the deficiency, as the resident's MPOA was not informed of the resident's cardiac arrest and subsequent hospitalization.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 280 citations issued within 25 miles in the last 12 months — including the 1 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Phoenix
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Tempe Post Acute | 5.6 mi | ★★★★★ | 6 | 0 |
| Desert Peak Care Center | 6.3 mi | ★★★★★ | 9 | 0 |
| Chandler Post Acute And Rehabilitation | 6.4 mi | ★★★★★ | 9 | 0 |
| Sante Of Chandler | 6.4 mi | ★★★★★ | 3 | 0 |
| Archstone Care Center | 6.4 mi | ★★★★★ | 4 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Ahwatukee Post Acute.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.