Above average — CMS composite of the measures below.
The next survey window likely opens around December 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 Northpark Health And Rehabilitation Of Cascadia during CMS and state inspections, most recent first.
A resident with dementia and severe cognitive impairment was care planned for elopement risk and wandering with multiple interventions, yet the MDS documented no wandering behavior and the wandering/elopement risk evaluation was inconsistently documented, with an entry struck out and the assessment not signed and locked until after the resident was later found outside the facility at night and sent to the hospital. Staff interviews showed differing views of the resident’s wandering risk, with an LPN reporting the resident was anxious and wanted to go home but not considered at risk, and a CNA reporting no observed wandering, while the DON confirmed that the original elopement evaluation entry was incorrect and that the assessment was actually completed after the incident, resulting in a medical record that did not accurately reflect the resident’s status and care as required by facility policy.
A resident with hypertension, chronic kidney disease, diabetes, atrial fibrillation on anticoagulant therapy, and diuretic therapy was given multiple oral medications that were not ordered, including aspirin, carvedilol, lisinopril, and nifedipine, instead of the prescribed furosemide, spironolactone, calcitriol, and guaifenesin. An LPN entered the wrong room, used the wrong MAR, did not verify the resident’s identity, and administered the other resident’s medications. After the error, the resident’s BP readings dropped to hypotensive levels over several hours, and the resident reported that the nurse had not asked her name and that the incorrect medications took days to clear from her system. Documentation and staff interviews confirmed that these medications were not ordered for the resident and that facility policy required verification of the right resident and right medication before administration.
Surveyors found that medications were stored past their expiration dates in two medication storage rooms, including Geri-Dryl (diphenhydramine) and melatonin. The ACNO confirmed the medications were expired and stated that staff who stock the rooms are expected to check for expiration dates. The CNO reported that both central supply and nursing leadership are responsible for inventorying storage rooms, ensuring medications are checked for expiration before leaving storage, and removing expired medications. Facility policy requires nursing leadership to inspect medication storage areas for expired drugs and to promptly remove and dispose of them according to policy and DEA guidelines.
A resident with severe cognitive impairment and multiple medical conditions was not accompanied to an orthopedic appointment, where the provider instructed the facility's driver to take the resident to the ER for a potential intracranial bleed. This instruction was not followed or communicated to the necessary parties. The resident later fell at the facility, resulting in a hematoma, and was eventually sent to the hospital where multiple fractures and a subdural hematoma were diagnosed. The facility's internal investigation revealed communication failures and a lack of adherence to physician orders.
The facility failed to provide prescribed low air loss mattresses for two residents, despite physician orders and care plans indicating their necessity for preventing pressure ulcers. Staff inaccurately documented that the mattresses were in place and functional, leading to a significant deficiency in care.
The facility failed to ensure that physician orders for low air loss mattresses were correctly transcribed and implemented for two residents. Despite documentation indicating compliance, observations and staff interviews revealed that the residents were using regular mattresses instead, contrary to the physician's orders.
The facility failed to ensure their Infection Preventionist (IP) had completed the required specialized training in Infection Prevention and Control before assuming the role. The IP, an LPN, had not completed the CMS and CDC developed training course until several months after starting the role. Additionally, there was no documentation of a dedicated person with specialized training performing the IP duties in the interim period.
A resident with a MRSA abscess infection of the spine did not receive the prescribed Teflaro medication during their stay. Instead, the resident was given Vancomycin, which was not an option for treatment. Staff interviews and record reviews revealed procedural gaps and lack of proper notification to the provider and pharmacy.
A resident with multiple diagnoses, including a MRSA abscess infection, did not receive prescribed doses of Teflaro due to a failure in the facility's process for handling IV antibiotics. Staff interviews revealed that IV antibiotics are not automatically linked to the facility's PCC system and require manual approval, which was not done in this case.
A resident with multiple serious diagnoses did not receive a prescribed intravenous antibiotic during their stay. Staff failed to notify the physician or pharmacy about the unavailability of the medication, contrary to facility policy.
Inaccurate and Incomplete Elopement Risk Documentation for Cognitively Impaired Resident
Penalty
Summary
The deficiency involves the facility’s failure to maintain an accurate and complete medical record for a resident assessed and care planned for elopement risk and wandering. The resident was admitted with dementia, encephalopathy, hypertension, and osteoarthritis, and had a BIMS score of 03, indicating severe cognitive impairment. The admission MDS assessment documented that the resident had not exhibited wandering behavior, even though a care plan dated the following day identified a focused care area for elopement risk/wandering related to decreased cognition and decreased safety awareness, with multiple interventions such as redirection, diversional activities, structured activities, toileting, walking, and reorientation strategies. An evaluation summary entry dated the same day initially indicated that a wandering/elopement risk evaluation had been completed, but this note was later struck out. A wandering/elopement risk evaluation dated that same day was not signed and locked until several weeks later, after an incident in which the resident was found outside the facility at night by another resident’s family member, lying on her stomach and complaining of back pain, unable to move or roll over, and subsequently sent to the hospital. The evaluation summary and recommendations section included instructions to keep the door closed on the resident’s unit and to have the receptionist close the front doors when off duty so only staff could unlock them. Staff interviews revealed inconsistent understanding of the resident’s wandering risk: an LPN stated the resident was not considered at risk for wandering before the incident, though the resident had been anxious and expressed a desire to go home, and a CNA reported not observing wandering behavior. The DON confirmed that the struck-out wandering/elopement risk evaluation was incorrect because the resident was not considered an elopement risk at that time and that the elopement assessment was actually completed after the incident, contrary to the documentation. This conflicted with facility policy requiring the medical record to accurately represent the resident’s experiences and condition, including changes, plan of care goals, and interventions.
Wrong-Resident Medication Administration Leading to Hypotension
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident received only medications ordered by the provider, resulting in administration of multiple medications that were not prescribed. The resident had diagnoses including hypertension, chronic kidney disease, type 2 diabetes, atrial fibrillation with anticoagulant therapy, and diuretic therapy for fluid overload. The care plan included avoiding aspirin due to anticoagulant therapy and administering diuretics as ordered. Provider orders and the MAR for the relevant period showed active orders for furosemide, spironolactone, calcitriol, and guaifenesin, and no active orders for aspirin 325 mg, carvedilol 6.25 mg, lisinopril 40 mg, or nifedipine ER 90 mg. On the date of the incident, an LPN entered the resident’s room with medications that were intended for another resident. The LPN later stated that she had used the wrong MAR and entered the wrong room, and that she realized the error only after the resident questioned an enoxaparin injection following administration of the oral medications. The incident note documented that the LPN administered aspirin 325 mg, carvedilol 6.25 mg, lisinopril 40 mg, and nifedipine ER 90 mg instead of the resident’s ordered furosemide 80 mg, spironolactone 25 mg, calcitriol 0.25 mcg, and guaifenesin 600 mg. Interviews with nursing staff confirmed that these medications were not ordered for the resident and that the resident did have orders for the diuretic and other listed medications that were not given at that time. Following the administration of the wrong medications, the resident experienced low blood pressure readings documented in the blood pressure summary, with systolic readings dropping below 100 mmHg and diastolic readings in the 30s and 40s over the subsequent hours. Staff interviews described that the resident’s blood pressure dropped significantly after the error, that the resident was monitored for hypotension, and that the provider was notified. The resident reported that the nurse did not ask for her name, told her the medications were for high blood pressure, and that she knew something was wrong when the nurse attempted to give an enoxaparin injection, which she did not receive as part of her usual regimen. The resident stated that the wrong medications took about two to three days to clear from her system and that staff had difficulty keeping her blood pressure in a normal range during that time. Additional documentation from a clinical consultant pharmacist outlined potential adverse reactions associated with carvedilol, lisinopril, nifedipine, and aspirin, including hypotension and bleeding, and indicated that the hypotensive medications would be eliminated from the resident’s system in two to three days. An internal investigation report recorded that the resident had a history of acute chronic diastolic heart failure, hypertension, and high risk for hypotension, and that on the date of the incident the LPN administered medications intended for another resident. The investigation noted that the resident’s creatinine rose to 2.9 with an eGFR of 15. Facility policy on medication administration required staff to follow the rights of medication administration, including right medication and right resident, but interviews and the resident’s account showed that the nurse did not verify the resident’s identity according to policy before administering the medications.
Expired Medications Found in Medication Storage Rooms
Penalty
Summary
Surveyors identified a failure to ensure medications were not stored past their expiration dates, as required by facility policy and professional standards. During an observation of a medication storage room conducted with the Assistant Chief Nursing Officer (ACNO), one bottle of Geri-Dryl (Diphenhydramine Hydrochloride) with an expiration date of 07/2025 was found stored beyond its expiration. In a second medication storage room observed shortly afterward, two bottles of Melatonin 3 milligrams with an expiration date of 11/2025 were also found stored past expiration. In an interview, the ACNO confirmed that the identified medications were expired and stated that the expectation was that staff responsible for stocking the medication rooms also check medications to ensure they are not expired. The ACNO stated that the risk associated with storing expired medications is that the medications are less effective. In a separate interview, the Chief Nursing Officer (CNO) stated that both central supply and nursing leadership are responsible for inventorying the medication storage rooms and disposing of expired medications, and that medications are expected to be checked for expiration before leaving the storage room. The CNO stated that the risk associated with storing expired medications is that there could be adverse reactions. Review of the facility’s “Medication Storage and Labeling” policy showed that nursing leadership is responsible for inspecting medication carts and storage rooms for expired medications and that expired medications must be promptly removed and disposed of per facility policy and DEA guidelines.
Failure to Follow Physician Orders and Ensure Timely Medical Care
Penalty
Summary
The facility failed to ensure that a resident received services according to professional standards, specifically regarding the notification to a provider, required communication, and clarifying and following a physician's order. The resident, who had severe cognitive impairment and multiple medical conditions including a chronic right humeral fracture, was not accompanied by a caregiver to an orthopedic appointment. During the appointment, the orthopedic provider instructed the facility's driver to take the resident to the emergency room for evaluation of a potential intracranial bleed, but this instruction was not followed or communicated to the necessary parties. Upon returning to the facility, the resident was not assessed for the condition that prompted the emergency room recommendation. The Charge Nurse and other staff members failed to notify the resident's physician or family about the orthopedic provider's instructions. The resident later experienced a fall at the facility, resulting in a hematoma, and was eventually sent to the hospital where multiple fractures and a subdural hematoma were diagnosed. The facility's internal investigation revealed communication failures and a lack of adherence to physician orders, leading to the termination of several staff members. The report highlights the breakdown in communication and failure to follow physician orders, which resulted in the resident not receiving timely medical evaluation and treatment. The facility's policies on physician orders and change of condition were not adhered to, contributing to the resident's subsequent injuries and delayed medical care. Interviews with staff and the resident's family further underscored the lack of communication and appropriate action following the orthopedic appointment.
Failure to Provide Prescribed Pressure Ulcer Prevention Measures
Penalty
Summary
The facility failed to ensure that care and services were provided to prevent the development of pressure ulcers for two residents. Resident #26, who had multiple diagnoses including diabetes mellitus with foot ulcer and peripheral vascular disease, was admitted with an order for a low air loss mattress to prevent pressure ulcers. However, it was observed that the resident did not have the prescribed mattress, and staff confirmed that the mattress had not been provided despite the physician's order. The resident's care plan included various skin care interventions, but the lack of the low air loss mattress was a significant oversight in their care plan execution. Similarly, Resident #39, who was admitted with diagnoses including peripheral vascular disease and acute osteomyelitis, was also supposed to have a low air loss mattress as per the physician's order. Despite documentation indicating that the mattress was being checked for functionality every shift, it was observed that the resident had a regular mattress instead. Interviews with staff confirmed that the resident did not have the prescribed low air loss mattress, which was crucial for preventing pressure ulcers given the resident's condition. Both residents had care plans and physician orders that included the use of low air loss mattresses to prevent pressure ulcers. However, the facility failed to provide these mattresses, and staff inaccurately documented that the mattresses were in place and functional. This discrepancy between the documented care and the actual care provided represents a significant deficiency in the facility's ability to prevent and manage pressure ulcers in these residents.
Failure to Implement Physician Orders for Low Air Loss Mattresses
Penalty
Summary
The facility failed to ensure that physician orders for low air loss mattresses were correctly transcribed and implemented for two residents. Resident #26, who was admitted with multiple diagnoses including type 2 diabetes mellitus with foot ulcer and heart failure, had a physician's order for a low air loss mattress to be checked for functionality every shift. Despite documentation in the Treatment Administration Record (TAR) indicating compliance, an observation revealed that the resident did not have the prescribed mattress. Interviews with staff confirmed the discrepancy and highlighted the potential risk of worsening the resident's wound due to the incorrect mattress type. Similarly, Resident #39, admitted with diagnoses including Peripheral Vascular Disease and Acute Osteomyelitis of the Left Ankle and Foot, also had a physician's order for a low air loss mattress. The TAR indicated that the mattress was being checked every shift, but an observation and staff interviews revealed that the resident was using a regular mattress instead. The Chief Nursing Officer and other staff confirmed the inconsistency between the physician's order and the actual mattress provided, which could impact the resident's risk for pressure ulcers. The facility's policy on the prevention and treatment of pressure ulcers was not adhered to in these cases.
Infection Preventionist Lacked Required Training
Penalty
Summary
The facility failed to ensure that their Infection Preventionist (IP) had completed the specialized training in Infection Prevention and Control prior to assuming the role. A review of the Licensed Practical Nurse/Infection Preventionist's (LPN, staff #300) personnel/training record revealed that staff #300 had not completed all the Center for Medicare and Medicaid (CMS) recommended specialized training topics. Specifically, he had not been awarded a certificate for the CMS and CDC developed training titled The Nursing Home Infection Preventionist Training Course. Staff #300 had been in the role since April 2023 but only completed the course in July 2023. Additionally, there was no documentation that a dedicated person with specialized training was performing the duties of the IP in the interim period, despite staff #300 being trained by the Regional Clinical (RC) staff. The facility's policy indicated that the IP should have clinical professional training and specialized training in infection prevention and control. The CMS QSO policy memo dated March 11, 2019, noted that effective November 28, 2019, the final requirement for infection control prevention and control training for nursing homes included specialized training for individuals responsible for the facility's Infection Prevention and Control Program. The memo further noted that CMS and CDC collaborated on the development of a free online training course in infection prevention and control for nursing home staff, which is approximately 19 hours and comprised of 23 modules. In order to receive the certificate of completion, learners must complete all modules and pass a post-course exam.
Failure to Administer Prescribed Medication
Penalty
Summary
The facility failed to ensure that a resident was free from neglect by not providing necessary provider-prescribed medications. Resident #152, who had multiple diagnoses including a MRSA abscess infection of the spine, was admitted with a physician's order for Teflaro 600mg to be administered intravenously twice daily. However, during the resident's stay from October 7, 2022, to October 10, 2022, the medication was not administered at all. Instead, the resident received Vancomycin, which was not an option for treatment as indicated by the consulting infectious disease doctor. This lapse in medication administration was confirmed through a review of the Medication Administration Record (MAR) and physician's notes, which highlighted the necessity of Teflaro for the resident's condition and the failure of Vancomycin as a treatment option. Interviews with facility staff, including an LPN and the Director of Nursing (DON), revealed procedural gaps that contributed to the deficiency. The LPN stated that new orders for IV antibiotics are called into the pharmacy by nursing, and in the event of a medication not being delivered, the provider and pharmacy should be notified. However, no such notification was documented. The DON confirmed that IV antibiotics and expensive medications require approval and that the resident did not receive any doses of Teflaro. The facility's policy on pharmacy services mandates accurate acquiring, receiving, dispensing, and administering of drugs to meet residents' needs, which was not adhered to in this case.
Failure to Administer Prescribed IV Antibiotics
Penalty
Summary
The facility failed to ensure that Resident #152 was treated according to professional standards. The resident, who was admitted with diagnoses including a MRSA abscess infection of the spine, Bacteremia, COPD, Diabetes type 2, Anxiety, and Hypertension, had a physician's order for Teflaro 600mg to be administered intravenously twice daily for a spinal abscess. However, a review of the Medication Administration Record (MAR) revealed that the resident did not receive any doses of Teflaro during their stay from October 7, 2022, to October 10, 2022. Interviews with staff indicated that the facility's process for handling IV antibiotics was flawed. The Licensed Practical Nurse (LPN) stated that IV antibiotics are not automatically linked to the facility's PCC system and require manual intervention. The Director of Nursing (DON) confirmed that IV antibiotics could be missed if not approved, especially if they are over $200. The DON also noted that the resident received doses of Vancomycin but not Teflaro. The facility policy requires staff to notify the attending physician when issues with medication administration arise, but this protocol was not followed in this case.
Failure to Administer Prescribed Medication
Penalty
Summary
The facility failed to ensure that medications were available as ordered for a resident with multiple serious diagnoses, including a MRSA abscess infection of the spine, Bacteremia, COPD, Diabetes type 2, Anxiety, and Hypertension. The resident was admitted with a physician's order for an intravenous antibiotic, which was not administered at any point during the resident's stay. The Medication Administration Record (MAR) confirmed that the resident did not receive any doses of the prescribed medication from admission to discharge. Interviews with staff revealed that the standard procedure for new IV antibiotic orders involves calling the pharmacy, and if a medication is not available, notifying the provider and pharmacy to obtain a stat order or adjust the medication. However, there was no evidence that the physician or pharmacy were notified about the unavailability of the medication. The Director of Nursing confirmed that the resident did not receive the medication and stated that staff should have notified her and the provider if the drug did not arrive on time. The facility's policy on Pharmacy Services mandates procedures to ensure the accurate acquiring, receiving, dispensing, and administering of drugs to meet the needs of each resident, which was not followed in this case.
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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.
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Nursing homes near Phoenix
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Diamondback Healthcare Center | 0.8 mi | ★★★★★ | 6 | 0 |
| Palm Valley Post Acute | 5.2 mi | ★★★★★ | 4 | 0 |
| Estrella Health And Rehabilitation Center | 5.4 mi | ★★★★★ | 8 | 0 |
| Bella Vita Health And Rehabilitation Center | 5.5 mi | ★★★★★ | 3 | 0 |
| Sun Health La Loma Care Center | 6.5 mi | ★★★★★ | 1 | 0 |
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