Average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Springdale Village Post Acute during CMS and state inspections, most recent first.
Two residents identified as being at risk for malnutrition had physician orders and care plan interventions for weekly weights over a four-week period, but staff did not consistently obtain or document these weights as required. For one cognitively intact resident with multiple comorbidities, only two weights were recorded during the ordered period, with no documentation of a weight or refusal on one of the scheduled weeks, despite staff acknowledging poor intake and the existence of weekly weight orders. For another resident with severe cognitive impairment and multiple diagnoses, only two weights were documented, with additional dates showing no recorded weight values and only references to nursing notes, and missing entries on other ordered dates. Staff interviews and facility policies confirmed that newly admitted and nutritionally at-risk residents were to receive weekly weights, that weights and refusals were to be documented in the EHR, and that these physician orders were not accurately implemented or recorded.
Two residents with complex medical conditions did not have signed advance directives or documentation of discussions regarding their code status in their clinical records, despite facility policy and staff expectations requiring this information to be completed and maintained in both physical and electronic formats. Staff interviews confirmed the deficiency and the lack of required documentation.
The facility did not ensure that representatives for two residents were notified after significant changes in condition, including a fall and two incidents of elopement. Although staff and policy indicated that family notification was required, there was no documentation in the clinical records that families were informed following these events.
A resident with severe cognitive impairment and a history of falls experienced two documented falls. Although assessments and notifications were completed after each incident, the care plan was not updated and no interdisciplinary team review was documented, contrary to facility policy requiring care plan revisions and team review after such events.
A resident with multiple chronic conditions was overmedicated with cyclobenzaprine due to a transcription error when hospital discharge orders were entered into the facility's records. The error resulted in the resident receiving a higher dose than prescribed on several occasions until the order was corrected, despite review processes by pharmacy and nursing staff.
A resident with a history of wandering and multiple medical conditions was not properly monitored for elopement risk, as required by facility policy. Despite being identified as at risk, the resident's care plan did not address elopement, and after being found outside the building on two occasions, there was no documentation of timely notifications to the provider or family. Staff interviews confirmed that required assessments and care plan updates were not completed.
A resident admitted with multiple chronic conditions did not have complete medical records available due to the facility's inability to obtain documentation from previous owners after a change in ownership. Staff confirmed that records prior to the transition were inaccessible, resulting in missing clinical information required by state law.
A resident with intact cognition experienced multiple episodes of diarrhea, but the facility failed to implement contact precautions as required by their policy. Despite the resident having a pending C-diff culture, only enhanced barrier precautions were in place. Interviews with staff confirmed that contact precautions should have been used, and the resident's room was not included in infection control monitoring.
A resident with severe cognitive impairment and a history of cerebrovascular disease was found with bruising on the right forearm, consistent with being squeezed by a hand. The incident occurred during a night shift when a CNA allegedly grabbed the resident's arm and threatened to hit back. The facility's investigation verified the abuse, despite having a policy to protect residents from such incidents.
The facility failed to complete MDS assessments for three residents within required timeframes. An LPN and the DON acknowledged a backlog due to a vacant MDS coordinator position. Efforts to catch up included completing extra assessments weekly, with progress monitored in weekly meetings.
A resident with multiple diagnoses, including depression and anxiety, did not have a comprehensive care plan in place. The care plan lacked specific interventions and did not specify medications, despite the resident receiving antipsychotic and antidepressant medications. Interviews with staff revealed that care plans should be updated regularly and be patient-specific, but this was not the case for this resident. The facility's policy requires detailed care plans, but this standard was not met.
The facility failed to ensure that an LPN and two CNAs maintained current CPR certifications, as required by policy. Despite the HR Director's responsibility to update files and notify when certifications expired, these staff members worked significant hours with expired certifications. Interviews revealed a lack of clarity and enforcement regarding certification maintenance, potentially compromising resident safety.
A resident with dementia, kidney disease, and type 2 diabetes was discharged without a complete discharge summary, as required by the facility's policy. Interviews with the Director of Social Services and the DON revealed a lack of clarity regarding the discharge process and responsibilities. The facility's policy mandates a discharge summary, but it was not provided in this case.
The facility failed to ensure the activities program was directed by a qualified professional. The Activity Director, with ten years in the role, did not meet state licensing requirements despite having relevant experience. The HR Director was unaware of the specific policy on licenses and certifications, contributing to the deficiency.
A resident with multiple health conditions, who was cognitively intact, consented to receive the pneumococcal vaccine upon admission. However, the facility failed to administer the vaccine, as confirmed by the DON during an interview. The consent was uploaded into the system, but no evidence of vaccination was found in the resident's records.
Failure to Follow Physician Orders for Weekly Weights for Residents at Nutritional Risk
Penalty
Summary
The deficiency involves the facility’s failure to follow physician orders for weekly weights and to document refusals or reasons weights were not obtained for two residents who were identified as being at risk for malnutrition. Facility policies required accurate implementation of physician orders and documentation of weights as ordered, including reasons when residents could not be weighed. The policy on vital signs specified that if a resident was unable to be weighed, the reason should be recorded and other provisions taken to monitor the resident’s size. Interviews with staff confirmed that newly admitted residents and those at nutritional risk were to receive weekly weights for four weeks, and that refusals or missed weights were expected to be documented in the electronic health record. For one resident with multiple diagnoses including a displaced trimalleolar fracture, type 2 diabetes, schizophrenia, chronic kidney disease, and a history of transient ischemic attack and cerebral infarction, a physician ordered weekly weights for four weeks starting in early February. An admission nutrition evaluation and progress note documented that this resident was at risk for malnutrition with a Mini Nutritional Assessment (MNA) score of 8.0. The care plan included an intervention to complete weekly weights for four weeks and then monthly if stable. Weight records showed a weight on February 6 and another on February 22, both 219.6 lbs on a mechanical lift scale, and the eMAR/eTAR showed weights on February 6 and 13, with a documented refusal on February 27. There was no evidence in the eMAR/eTAR that a weight was taken or refused on February 20, leaving a gap in the ordered weekly weights. Staff interviews revealed that the CNA recalled weighing this resident only once and noted poor oral intake, and the LPN and DON both acknowledged that the weekly weight order for four weeks was not followed, with only two weights documented during the resident’s stay and a “hole” in the eMAR documentation. For another resident with diagnoses including metabolic encephalopathy, muscle weakness, cognitive communication deficit, asthma, and hypothyroidism, a physician ordered weekly weights for four weeks beginning in early March. The care plan identified a nutritional problem or potential problem and noted that the resident was at risk on the MNA, with interventions to monitor and report signs of decreased appetite or unexpected weight loss. A progress note documented an MNA score of 9.0, indicating risk for malnutrition. Weight records showed a weight on March 5 of 156.6 lbs on a wheelchair scale and a weight on March 20 of 156 lbs on a standing scale. Progress notes on March 10 and March 17 indicated that staff were unable to obtain a weight and that the RNA was scheduled to obtain the weight the next day. However, the eMAR/eTAR contained no evidence that weights were taken on March 3 or March 24, and on March 10 and 17, no weight values were entered, only directions to see nursing notes. Staff interviews confirmed that weekly weights were expected for residents with such orders and that weights and refusals were to be documented in the EHR. The surveyors found that for both residents, physician orders for weekly weights were not consistently implemented or documented in accordance with facility policy and professional standards.
Failure to Document and Acknowledge Advance Directives for Residents
Penalty
Summary
The facility failed to ensure that two of three sampled residents had proper documentation and acknowledgement of their advance directives. For both residents, although physician orders and care plans indicated a full code status, there was no electronic or physical evidence in their clinical records of a signed advance directive or documentation of a discussion with the residents or their representatives regarding their code status. One resident had a BIMS score indicating no cognitive impairment, yet there was still no record of an advance directive discussion or signed document. Interviews with facility staff, including an RN, CNA, LPN, and the DON, confirmed that the facility's process required completion and storage of advance directive paperwork both physically and in the EMR. Staff acknowledged that the absence of this documentation could result in residents' wishes not being honored. The DON was unable to locate advance directive documentation for the two residents in question, and policy review confirmed that the facility was required to provide written information and maintain a copy of the advance directive in the medical record.
Failure to Notify Resident Representatives After Change in Condition
Penalty
Summary
The facility failed to notify resident representatives after significant changes in condition for two residents. One resident, with a history of metabolic encephalopathy, Parkinson's disease, and cerebral infarction, experienced a fall. Although the provider was notified, there was no documentation or evidence that the family was informed of the incident. Staff interviews confirmed that family notification was expected but not completed, and a review of the clinical record found no record of family contact. Another resident, admitted with dysphagia, hemiplegia, hemiparesis, cognitive communication deficit, and depression, was found outside the facility on two occasions. While staff redirected the resident and notified a corporate nurse, and later arranged for hospital transport, there was no documentation that the family was notified of either incident. Staff interviews and policy reviews confirmed that family notification was required but not documented in the clinical record for these events.
Failure to Update Care Plan and Conduct Interdisciplinary Review After Resident Falls
Penalty
Summary
The facility failed to ensure that professional standards were followed regarding care planning and interdisciplinary review after falls involving a resident with severe cognitive impairment, encephalopathy, aphasia, and depression. The resident required partial to moderate assistance for transfers and was identified as being at risk for falls due to a history of falls and cognitive impairment. Despite documented falls on two separate occasions, there was no evidence in the clinical record that the care plan was updated or that an interdisciplinary team meeting was conducted to review the incidents, as required by facility policy. Nursing notes indicated that after each fall, assessments were performed, vital signs were checked, and the resident's family and providers were notified. However, interviews with staff and review of the clinical record confirmed that the care plan was not revised to address the falls, and there was no documentation of an interdisciplinary review. The facility's Fall Management System policy requires that the care plan be updated to address factors contributing to falls, but this was not done for the resident in question.
Incorrect Transcription of Medication Order Led to Overmedication
Penalty
Summary
A resident with diagnoses including anemia in chronic kidney disease, chronic obstructive pulmonary disease, and type 2 diabetes was admitted to the facility. Upon admission, the resident's hospital discharge instructions specified cyclobenzaprine 10 mg, to be taken orally as one tablet three times a day as needed for spasms. However, the medication order transcribed into the facility's records incorrectly stated to administer three tablets by mouth every eight hours as needed. This transcription error resulted in the resident receiving an incorrect, higher dose of cyclobenzaprine on multiple occasions, as documented in the Medication Administration Record (MAR) and Treatment Administration Record (TAR) for both February and March. The error persisted until the medication order was corrected in March, after which the resident received the medication as prescribed. The Director of Nursing confirmed that the order was transcribed from the hospital discharge instructions and reviewed by both pharmacy and nursing staff, but acknowledged the error and stated the resident was overmedicated. Facility policy required that admission orders be reviewed with the physician and transcribed based on discharge instructions, but this process failed to prevent the medication error in this instance.
Failure to Monitor and Care Plan for Resident at Elopement Risk
Penalty
Summary
The facility failed to properly monitor a resident at risk for elopement, resulting in multiple incidents where the resident was found outside the building. The resident, admitted with dysphagia, hemiplegia, hemiparesis, cognitive communication deficit, and depression, was identified as having a history of wandering and exit-seeking behavior. Despite an elopement risk assessment indicating the need for elopement risk protocol, there was no evidence that this risk was incorporated into the resident's comprehensive care plan. Additionally, there was no documentation of a completed admission Minimum Data Set (MDS) assessment or a wander risk assessment following the elopement incidents. Clinical records showed that after the resident was found outside the facility on two separate occasions, appropriate notifications to the provider and family were not documented. Staff interviews confirmed that the expected protocol for elopement risk, including care plan updates and timely notifications, was not followed. The facility's own policy required individualized care plans and timely assessments for residents at risk of elopement, but these measures were not implemented for this resident.
Incomplete and Inaccessible Medical Records Following Ownership Change
Penalty
Summary
The facility failed to ensure that complete and readily accessible medical records were maintained for a resident who was admitted with diagnoses including anemia in chronic kidney disease, chronic obstructive pulmonary disease, and type 2 diabetes. Upon review, it was found that the clinical record contained no documentation of any entries prior to a change in facility ownership. The facility's Administrator confirmed that they were unable to obtain certain parts of the electronic records from the previous owners, as access was denied despite attempts to retrieve the information. The Therapy Director also reported being unable to access records prior to a specific date. This deficiency was identified during a review of clinical records, interviews with facility staff, and examination of facility documentation. The lack of accessible records was further highlighted by a complaint filed with the State Agency, which indicated that the resident did not receive the insurance-authorized time for therapy during her admission. Arizona state law requires health care providers to retain medical records for at least six years, but the facility was unable to produce records for the period before the change in ownership.
Failure to Implement Contact Precautions for Resident with Diarrhea
Penalty
Summary
The facility failed to implement appropriate infection control guidelines for a resident who was experiencing diarrhea, potentially leading to the spread of infectious disease. The resident, who had intact cognition and was previously mostly continent, experienced multiple episodes of diarrhea, which were documented in the CNA task log. Despite these symptoms, there was no evidence that contact precautions were ordered or implemented for the resident, as only enhanced barrier precautions were in place. The facility's policy indicated that residents with suspected Clostridium difficile infection (CDI) should be placed on contact precautions, but this was not done for the resident in question. Interviews with staff, including a CNA, an LPN, and the Infection Preventionist, revealed that contact precautions should have been used for residents with diarrhea, and that the resident had a pending C-diff culture. The infection control mapping did not include the resident's room for monitoring, despite the symptoms. The Administrator confirmed that contact precautions should have been in place for residents with recent diarrhea and those being tested for C-diff. The facility's policy on Clostridium difficile also supported the use of contact precautions for residents with acute, unexplained diarrhea while awaiting laboratory results.
Failure to Protect Resident from Abuse by Staff
Penalty
Summary
The facility failed to protect a resident from abuse by a staff member, which was identified through clinical record review, resident and staff interviews, and policy review. The resident, who had a history of cerebrovascular disease, dementia, and major depressive disorder, was at risk for skin breakdown and required assistance with activities of daily living. On a particular night shift, a certified nurse assistant (CNA) was on duty, and the following day, a skin tear and bruising were observed on the resident's right forearm. The bruising was consistent with being squeezed by a hand, and the facility's investigation verified the allegation of abuse. The resident's cognitive impairment was severe, as indicated by a Brief Interview for Mental Status (BIMS) score, making it difficult for the resident to communicate effectively. The resident's roommate reported that the CNA had grabbed the resident's arm and threatened to hit back if the resident attempted to hit the CNA. This account was corroborated by another CNA who observed the markings on the resident's arm and reported the incident to a registered nurse. The facility's administrator was informed, and the police, ombudsman, and medical director were notified. The facility's policy on abuse and neglect, revised in October 2022, emphasizes the residents' right to be free from abuse and neglect. Despite this policy, the incident occurred, highlighting a failure in protecting the resident from physical abuse. The facility conducted an in-service training on abuse following the incident, but the report does not detail any corrective actions taken to address the deficiency at the time of the incident.
Failure to Complete MDS Assessments Timely
Penalty
Summary
The facility failed to complete comprehensive Minimum Data Set (MDS) assessments for three residents within the required regulatory time frames. Resident #8 had both an annual and a quarterly assessment marked as 'In Progress' beyond the required timeframe. Resident #10's quarterly assessment was also 'In Progress' and not completed on time. Similarly, Resident #12's discharge assessment was not completed within the required timeframe. These deficiencies were identified through clinical record reviews and staff interviews. Interviews with the MDS coordinator and other staff revealed that the facility had a backlog of MDS assessments due to the MDS coordinator position being vacant for a period. The current MDS coordinator, who started in mid-January, acknowledged the backlog and mentioned efforts to catch up by completing additional assessments weekly. The Director of Nursing and the facility Administrator confirmed the issue, noting that the previous person responsible for MDS assessments had left, and there was a lack of qualified personnel to handle the task. They also mentioned that the facility was monitoring the progress of MDS completion during weekly meetings.
Failure to Develop Comprehensive Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for a resident who was admitted with multiple diagnoses, including type 2 diabetes mellitus, atrial fibrillation, depression, anxiety disorder, and seizures. The resident was cognitively intact, as indicated by a BIMS score of 15, and was receiving antipsychotic and antidepressant medications. Despite these complexities, the care plan lacked specific interventions and did not specify the medications being administered. Interviews with staff, including LPNs and the Director of Nursing, revealed that the care plan process was initiated during admission and was supposed to be updated as the resident's needs changed. However, the care plan for the resident in question did not include necessary details such as specific interventions related to the resident's depression and medication use. The staff acknowledged that the care plan should be patient-specific and updated regularly, but this was not reflected in the resident's care plan. The facility's policy on care plans, revised in March 2022, requires that baseline care plans include instructions for effective, person-centered care, including initial goals, physician orders, and other necessary information. However, the care plan for the resident did not meet these standards, as it lacked specific interventions and details necessary to address the resident's needs effectively. This deficiency could result in the resident's care needs not being met.
Expired CPR Certifications Among Staff
Penalty
Summary
The facility failed to ensure that three staff members, including an LPN and two CNAs, maintained current CPR certification, which is a mandatory requirement for all clinical positions according to the facility's policy. During a review of employee files, it was discovered that these staff members had expired CPR certifications. The HR Director, responsible for updating employee files and verifying certifications, was unaware of the policy regarding licenses and certifications. Despite the policy stating that staff with expired certifications should be removed from the schedule, these staff members continued to work significant hours with expired certifications. Interviews with the HR Director, DON, and Administrator revealed a lack of clarity and enforcement regarding the maintenance of CPR certifications. The HR Director stated that he would notify relevant parties when a certification expired, but the DON indicated that it was the staff's responsibility to keep their certifications current. Despite this, the LPN and CNAs worked numerous hours with expired certifications, potentially compromising resident safety in the event of a medical emergency.
Failure to Provide Discharge Summary for Resident
Penalty
Summary
The facility failed to ensure a discharge summary was completed for a resident at the time of their planned discharge. The resident, who had been admitted with diagnoses of dementia, kidney disease, and type 2 diabetes, was transferred to a sister facility without a full discharge summary being provided to them or their representative. The discharge Minimum Data Set (MDS) assessment indicated the resident had moderate cognitive impairment. Despite receiving a notice of discharge, the progress notes did not reflect that a comprehensive discharge summary was prepared or communicated. Interviews with facility staff revealed a lack of clarity and understanding regarding the discharge process and responsibilities. The Director of Social Services was unsure of the facility's policy on required discharge paperwork and who was responsible for completing the discharge summary. Similarly, the Director of Nursing, who was new to the role, was not familiar with the current discharge process but expressed a desire for a more structured approach. The facility's policy, implemented in November 2017, required a discharge summary to be part of the discharge plan, but this was not adhered to in this instance.
Unqualified Activity Director
Penalty
Summary
The facility failed to ensure that the activities program was directed by a qualified professional, as required by regulation. The deficiency was identified through interviews, facility documents, and employee record reviews. Staff #21, who was promoted to the Director of Activity position in 2013, did not meet the necessary qualifications. Although staff #21 had two years of experience in a social or recreational program within the last five years, she did not meet the requirement of being licensed or registered by the State in which she was practicing. The Human Resources Director and Business Office Director, staff #52, was responsible for verifying licenses and certifications but was unaware of the specific policy on licenses and certifications. Staff #21 had been in the Activity Director role for ten years and had a total of thirteen years with the company. Her responsibilities included organizing monthly activity calendars and staff schedules, ensuring activities were available seven days a week, including holidays and evenings. Despite her experience and involvement in activity professional group meetings, she had not taken any courses or training approved by the State. This lack of state-approved training contributed to her not meeting the qualifications required for her role as the Director of Activity, leading to the identified deficiency.
Failure to Administer Pneumococcal Vaccine
Penalty
Summary
The facility failed to ensure that a resident was administered the pneumococcal vaccine, which constitutes a deficiency. The resident, who was admitted with multiple diagnoses including type 2 diabetes mellitus, atrial fibrillation, asthma, chronic obstructive pulmonary disease, and seizures, was cognitively intact as indicated by a BIMS score of 15. Upon admission, the resident had signed a consent form to receive the pneumonia vaccine. However, a review of the resident's records revealed no evidence that the vaccine was administered, despite the consent being uploaded into the system. During an interview, the Director of Nursing confirmed that the resident had consented to the vaccination but did not receive it.
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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 Mesa
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Mission Palms Post Acute | 1.2 mi | ★★★★★ | 7 | 0 |
| Mi Casa Nursing Center | 1.7 mi | ★★★★★ | 4 | 0 |
| Desert Blossom Health & Rehab Center | 2.3 mi | ★★★★★ | 1 | 0 |
| Advanced Healthcare Of Mesa | 2.4 mi | ★★★★★ | 3 | 0 |
| Alta Mesa Health And Rehabilitation | 2.5 mi | ★★★★★ | 0 | 0 |
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