Average — CMS composite of the measures below.
The next survey window likely opens around April 2027
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 Friendship Village Of Tempe during CMS and state inspections, most recent first.
A resident with severe cognitive impairment reported to her daughter that she was pulled out of bed and splashed with water by a staff member. The incident was communicated to facility staff and the social worker on the same day, but notifications to APS, police, and the state health department were not made until the following day, contrary to facility policy and federal requirements for immediate reporting of abuse allegations.
A resident with multiple medical conditions and intact cognition reported an incident of verbal abuse by a CNA, but the allegation was not documented in the clinical record despite an investigation being conducted. The DON stated that such incidents are not recorded in the clinical record to protect confidentiality, although facility policy requires documentation of all incidents, including alleged abuse.
A resident with intact cognition reported to an LPN that a CNA had held his hand too tightly and that a staff member threw a TV remote and used inappropriate language. The LPN, despite recent abuse training and facility policy requiring immediate reporting, failed to notify supervisors of the allegation, resulting in a significant delay before management became aware and began investigating. Multiple staff interviews confirmed the expectation for immediate reporting, but the policy was not followed in this instance.
A resident with multiple medical conditions reported to an LPN that a CNA had thrown a remote and held his hand too tightly, causing a scratch. The LPN did not immediately report the allegation to a supervisor, leaving her shift without doing so, despite recent abuse prevention training and facility policy requiring immediate reporting. The incident was not reported to management until several hours later, resulting in a delay in investigation and reporting.
A resident with dementia and moderate cognitive impairment was subjected to inappropriate physical and sexual contact by another resident with severe cognitive impairment. Multiple CNAs witnessed the incident, which included arm squeezing and breast grabbing, and staff had difficulty separating the residents despite attempts at intervention. The event was not fully documented in the clinical record, and staff expressed concerns about inadequate training and unclear guidance on managing behavioral issues.
Two residents with dementia were involved in an incident of inappropriate touching, which was witnessed and confirmed by staff. However, the event was not documented in the clinical records, and the required reports to the State Agency and APS were not made within the mandated two-hour timeframe. Staff interviews revealed inconsistent understanding of documentation and reporting requirements, and the facility's policy was not followed.
The facility did not report an alleged incident of abuse between two residents to the State Agency and APS within the required two-hour timeframe. Although staff witnessed and documented the inappropriate contact and notified the DON soon after the event, the official reports to authorities were delayed until the following day, contrary to regulatory requirements.
A resident with Alzheimer's disease and moderate cognitive impairment, identified as an elopement risk, was able to leave the facility unnoticed and was later found by security across the street. Despite interventions in the care plan, staff did not realize the resident was missing, did not initiate a search, and failed to document key details of the incident. Staff interviews revealed gaps in elopement training and awareness, and the facility did not review available camera footage to determine how the resident exited.
A resident with a UTI did not receive all prescribed doses of an antibiotic due to a delay in pharmacy delivery and lack of availability in the emergency kit. Staff did not document physician notification regarding the missed dose, contrary to facility policy and standard practice, resulting in incomplete antibiotic therapy.
Failure to Timely Report Suspected Staff-to-Resident Abuse
Penalty
Summary
The facility failed to ensure timely reporting of an alleged abuse incident involving a staff member and a resident with severe cognitive impairment. The resident, who had diagnoses including anxiety, depression, hypertension, head contusion, delirium, and epilepsy, was admitted with a BIMS score indicating severe cognitive impairment. On the morning of the incident, the resident reported to her daughter that she had been pulled out of bed and splashed with water by a staff member. The daughter attempted to notify the nursing supervisor immediately and also sent a text message to the facility's social worker later that afternoon. The social worker then approached the RN, who confirmed the resident had discussed the incident with her and an activity aide about 30 minutes prior. Facility records show that the incident occurred in the morning, but the official notifications to Adult Protective Services, the police, and the state health department were not made until the following day, with the earliest report to APS occurring nearly 24 hours after the event. Staff interviews confirmed that facility policy required immediate reporting of abuse allegations, with a maximum of 2 hours for incidents involving serious bodily injury and 24 hours for other abuse allegations. The DON and administrator both stated that the facility became aware of the allegation late in the afternoon, and notifications to authorities were made the next day, within 24 hours of the incident but not immediately as required by policy. Review of the facility's Abuse Prevention Program policy and federal regulations confirmed the requirement for immediate reporting of abuse allegations to the administrator and appropriate authorities. Despite these policies, the delay in reporting the incident was confirmed through interviews and documentation, indicating a failure to follow established procedures for timely reporting of suspected abuse.
Failure to Document Allegation of Verbal Abuse in Clinical Record
Penalty
Summary
Staff failed to ensure that professional standards for accurate documentation were met for one resident. The clinical record for a resident admitted with atrial fibrillation, hypertension, a pacemaker, and anemia did not contain any documentation of an allegation of verbal abuse that occurred over a three-day period, despite the facility conducting an investigation into the incident. The resident, who was cognitively intact according to a recent BIMS assessment, reported to a registered nurse that a CNA was rude, loud, and made an inappropriate comment during personal care. The facility's Director of Nursing stated that allegations of abuse are not recorded in the clinical record to protect resident confidentiality, as all staff have access to these records. Instead, such incidents are investigated separately. However, a review of the facility's Abuse Prevention Program policy indicated that all incidents, including allegations or suspicions of abuse, should be documented. A registered nurse also confirmed the importance of documenting such allegations in the clinical record for resident safety and care.
Failure to Follow Abuse Reporting Policy After Resident Allegation
Penalty
Summary
The facility failed to follow its abuse prevention policy in response to an allegation of staff-to-resident abuse. A resident with intact cognition reported to overnight staff that a staff member threw a TV remote at him, used inappropriate language, and raised her voice. The resident also reported to an LPN during early morning medication administration that a CNA had held his hand too tightly during care. The LPN did not report the allegation to a supervisor as required by policy, stating she was too busy, despite having received recent abuse training. The facility's policy required immediate reporting of any abuse allegations to management, with physical abuse with injury to be reported within two hours of suspicion. Interviews with multiple staff members, including CNAs, an RN, the administrator, and the DON, confirmed that the expectation was for immediate reporting of abuse allegations. However, the LPN failed to report the incident until much later, resulting in a delay in the facility's investigation and response. The DON confirmed that the facility did not become aware of the allegation until several hours after it was reported to the LPN, and the investigation and reporting process did not begin until the following day. This delay in reporting and investigation was contrary to the facility's abuse prevention policy.
Failure to Timely Report Alleged Abuse Incident
Penalty
Summary
The facility failed to ensure timely reporting of an alleged abuse incident involving a resident and a staff member. The resident, who had diagnoses including sepsis, anemia, depression, and diabetes, reported to an overnight LPN that a CNA had thrown a TV remote at him and held his hand too tightly during care, resulting in a scratch. The LPN did not immediately report the allegation to a supervisor, citing being too busy and unable to find her supervisor during shift change. The LPN left her shift without reporting the incident, despite having received recent abuse prevention training and acknowledging the requirement to report such allegations immediately. The incident was not reported to facility management until approximately seven hours later, when the resident informed an admissions assistant. Interviews with staff, including the LPN, other CNAs, the RN, the administrator, and the DON, confirmed that facility policy required immediate reporting of abuse allegations to management, with physical abuse with injury to be reported within two hours. The DON stated that the delay in reporting was not in line with expectations and that all staff had recently completed abuse policy training. The facility's investigation and policy review corroborated that the LPN's failure to report the allegation promptly constituted a breach of protocol, resulting in a delay in initiating the investigation and reporting process.
Failure to Protect Resident from Physical and Sexual Abuse by Another Resident
Penalty
Summary
The facility failed to protect a resident with moderate cognitive impairment and dementia from physical and sexual abuse by another resident with severe cognitive impairment. On the night in question, the resident was observed by multiple Certified Nursing Assistants (CNAs) to be inappropriately touched by another resident, including having her arms squeezed and her breasts grabbed, despite her verbal objections and staff attempts at redirection. The incident occurred while both residents were near an elevator, with the female resident in a wheelchair and the male resident standing behind her. The male resident continued the inappropriate behavior even after being told to stop by the female resident and staff, and only ceased after intervention by his spouse and staff. Staff interviews confirmed that the inappropriate touching was considered potential abuse, and that the staff present attempted to intervene but found it difficult to separate the residents. One CNA expressed frustration with the lack of adequate training on managing residents with behavioral issues and conflicting instructions from supervisors regarding intervention. The Director of Nursing (DON) acknowledged that inappropriate touching would be considered abuse and that such incidents should be reported immediately. However, the DON also stated that documentation in the clinical record would only be expected if injury occurred, and that most documentation for investigations would be in the form of paper statements. A review of facility policy indicated that all incidents of alleged or suspected abuse should be documented and reported promptly to facility management and the State Department of Health. Despite this, the clinical record for the resident did not reflect the abuse incident, and the rationale for room changes and transfers was not clearly documented. The facility's camera footage was inconclusive due to an obstructed view, but did show staff present and the male resident touching the female resident's arms and head. The facility failed to ensure a safe environment free from abuse, as required by policy and regulation.
Failure to Timely Document and Report Alleged Abuse
Penalty
Summary
The facility failed to develop and implement adequate policies and procedures for documenting and reporting alleged violations involving abuse, as required by federal and state regulations. On the night in question, two residents with dementia and other medical conditions were involved in an incident where one resident was observed touching another inappropriately while attempting to exit the unit. Although staff witnessed the event and confirmed the allegations through statements, there was no documentation of the alleged abuse in either resident's clinical records. Additionally, the rationale for a room change for one of the residents was not documented in the clinical record. The facility's investigative report confirmed the incident and the staff's observations, but the reporting of the alleged abuse to the State Agency and Adult Protective Services occurred more than 18 hours after the event, exceeding the mandatory two-hour reporting timeframe. Interviews with staff and the DON revealed inconsistent understanding and application of reporting and documentation requirements, with some staff expecting documentation in the clinical record and others relying on paper statements. The facility's own policy required all incidents to be documented and serious allegations to be reported within two hours, but this was not followed in practice.
Failure to Timely Report Alleged Abuse to Authorities
Penalty
Summary
The facility failed to report an alleged incident of abuse involving two residents to the State Agency and Adult Protective Services (APS) within the required timeframe. On March 2, 2025, a female resident requested assistance from a male resident to push her wheelchair, during which the male resident inappropriately touched her arms, head, and sides of her breasts. Multiple Certified Nursing Assistants (CNAs) witnessed the incident and provided written statements on the same day, confirming the inappropriate contact and the female resident's request for the behavior to stop. The nurse manager on duty also witnessed the event and notified the Director of Nursing (DON) by phone shortly after the incident occurred. Despite immediate internal awareness and documentation of the event, the facility did not report the alleged abuse to the Arizona Department of Health Services and APS until the following day, exceeding the two-hour reporting requirement for abuse allegations. The DON stated that she believed only allegations involving injury required reporting within two hours, while other allegations could be reported within 24 hours. Facility policy and federal regulations require that all allegations of abuse be reported immediately, but not later than two hours if the event involves abuse or results in serious bodily injury. The investigation revealed inconsistencies in the documentation of the event's date and time, but staff statements supported that the incident occurred on the evening of March 2, 2025.
Resident Elopement Due to Inadequate Supervision and Monitoring
Penalty
Summary
A deficiency occurred when a resident with Alzheimer's disease and moderate cognitive impairment, who had been assessed as an elopement risk, was able to leave the facility without staff knowledge. The resident's care plan identified her as an elopement risk and included interventions such as keeping an identification bracelet on at all times, using distractions to prevent wandering, and requiring staff or family to accompany her outside the neighborhood. Despite these interventions, the resident was found by security across the street from the facility, appearing unaware of her surroundings, and was returned unharmed. Facility documentation and staff interviews revealed that no staff had noticed the resident was missing prior to her being found by security. There was no evidence that staff had initiated a search or taken action to locate the resident before being notified by security. The investigative report lacked statements from all staff present on the day of the incident, and there was no documentation that camera footage was reviewed to determine how the resident exited the building. Additionally, the facility's policy required detailed documentation of such incidents, but the clinical notes did not include information such as when the resident was last seen or the condition of the resident and her clothing upon return. Interviews with staff indicated gaps in training and awareness regarding elopement prevention and response. A CNA reported not recalling any specific training on elopement, and the DON confirmed that statements from key staff were not obtained during the investigation. The front desk staff, who were provided with photos of elopement risk residents, did not notice the resident leaving, and the camera system did not retain footage from the date of the incident. The facility's failure to provide adequate supervision and monitoring allowed the resident to leave the premises unnoticed.
Failure to Administer Antibiotic as Ordered and Notify Physician of Missed Dose
Penalty
Summary
A deficiency occurred when a resident with diagnoses including encephalopathy, pneumonia, and a urinary tract infection (UTI) did not receive antibiotic therapy as ordered. The resident was prescribed Fosfomycin Tromethamine to be administered orally every two days for three doses, starting on May 16, 2024. Documentation revealed that the first dose was not administered on the scheduled start date because the medication was not yet delivered from the pharmacy, and the facility did not have the medication available in the emergency kit. The resident ultimately received only two of the three prescribed doses, with no evidence that the third dose was given. Additionally, there was no documentation that the physician was notified about the missed dose of antibiotic, as required by facility practice and as confirmed by staff interviews. The facility's policy mandates timely administration of medications and physician notification when a dose is missed, but the clinical record lacked evidence of such notification or documentation of attempts to obtain the medication. Interviews with nursing staff and the DON confirmed that the expected protocol was not followed in this instance.
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 270 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 Tempe
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Tempe Post Acute | 3.4 mi | ★★★★★ | 6 | 0 |
| River Park Post Acute | 3.4 mi | ★★★★★ | 0 | 0 |
| Sandridge Post Acute | 3.7 mi | ★★★★★ | 6 | 0 |
| Mirabella At Asu | 4 mi | ★★★★★ | 1 | 0 |
| Plaza Healthcare | 5.1 mi | ★★★★★ | 4 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Friendship Village Of Tempe.
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.