Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Tempe Post Acute during CMS and state inspections, most recent first.
A resident with multiple serious conditions, including COVID-19, sepsis, Klebsiella bacteremia, and DMII, reported that the room AC unit was dirty. Surveyors observed a visible layer of dust on top of the AC unit and heavy dust on both AC filters over multiple days, despite documentation that HVAC inspections were performed and a policy requiring routine equipment maintenance and logging. The maintenance manager stated AC units and filters were cleaned monthly and as needed, but later observation revealed one AC filter had a large hole that had not been replaced after cleaning, and the manager acknowledged that this damage would allow unfiltered air to circulate in the room and that the unit remained dirty.
A resident with multiple serious conditions, including COVID-19, sepsis, liver abscess, Klebsiella pneumonia, and DMII, reported that bedding and linens had not been changed since admission, and surveyors observed the same stained linens remaining on the bed over several days. The resident stated they received a shower on one date, but this was not documented; the shower record reflected only a single shower during the stay. CNAs, an RN, and the DON all described a practice of changing linens on shower days and providing showers twice weekly or as needed, but there was no bedding change log and the documentation did not support the reported frequency of showers. Facility policy required twice-weekly bathing, daily care, and appropriate documentation based on assessed needs.
A kitchen manager with a bandaged hand, showing a visible red spot, handled and served food without wearing gloves during a tray line and test tray temperature check. The staff member later explained the bandage covered a skin tear sustained earlier that day and acknowledged that facility practice required gloves when serving food with an open skin tear. Facility policies stated that staff with skin lesions were not permitted direct contact with residents or their food and that food service employees must follow sanitary and safe food-handling procedures.
The facility failed to follow physician orders for blood sugar monitoring and insulin administration for two residents with diabetes. One resident with severe cognitive impairment had multiple high blood sugar readings without rechecks or physician notification. Another resident with diabetic neuropathy also had a high reading without required follow-up. The facility's policy mandates accurate implementation of orders, which was not adhered to, compromising diabetes management.
The facility failed to maintain a clean and sanitary kitchen, leading to potential foodborne illness. Observations revealed incomplete cleaning logs, food debris, improperly stored trash, and live and dead roaches. Pest service logs and work orders showed inadequate pest control measures and no service requests for pest elimination or water leaks.
Failure to Maintain Clean and Intact AC Unit and Filters in Resident Room
Penalty
Summary
Surveyors identified a deficiency related to the facility’s failure to maintain a resident’s room air conditioning (AC) unit and filters in a clean and intact condition. The resident involved had been admitted with multiple serious diagnoses, including COVID-19, sepsis due to E. coli, liver abscess, Klebsiella pneumoniae, and Type II diabetes, and had a care plan for bacteremia due to Klebsiella with IV antibiotics and a goal to remain free from complications related to infection. During an interview in the resident’s room, the resident reported that the AC unit was working but dirty and stated it had been that way since admission. Observation at that time showed a visible layer of dust on the top surface of the AC unit and visible dust accumulation on two AC filters. Two subsequent observations on later dates showed that the top of the AC unit remained dirty and dusty and the filters remained full of dust. Review of the facility’s HVAC inspection log in the Direct Supply TELS preventive maintenance system showed the last HVAC inspection had been completed several months earlier. The Maintenance Manager stated that AC units and filters were cleaned monthly and as needed. However, during another observation of the same AC unit, one filter was found with an approximately 30-centimeter hole. The Maintenance Manager stated the filter had been cleaned the previous day but confirmed the damaged filter had not been replaced, acknowledged the top of the unit was dirty, and stated that the hole would prevent proper filtration and allow unfiltered air to circulate in the room, which could increase the risk of residents becoming ill. Facility policy required maintenance staff to maintain equipment per manufacturer instructions and document routine inspections and maintenance in the TELS system.
Failure to Provide Timely Linen Changes and Bathing for a Medically Complex Resident
Penalty
Summary
The deficiency involves the facility’s failure to maintain a clean and sanitary environment and to provide timely linen changes and bathing for a resident with multiple serious medical conditions. The resident was admitted with COVID-19, sepsis due to E. coli, a liver abscess, Klebsiella pneumonia, Diabetes Mellitus Type II, and other comorbidities, and had a care plan indicating bacteremia due to Klebsiella with IV antibiotics. The admission progress record documented that the resident was alert, oriented, and able to make needs known. On multiple observations from March 3 through March 6, the resident consistently reported that their bedding and linens had not been changed since admission. Surveyors observed stains, appearing to be food residue, in the area where the resident was seated on March 5, and on March 6 the same stained linens remained on the bed, confirming that the bedding had not been changed. The resident also reported having received a shower on March 4, but there was no documentation of this in the record. Review of the shower record showed only one documented shower since admission, on February 27. CNAs reported that usual practice was to change bed linens three times per week, particularly after showers or when linens were soiled, and that residents were expected to receive showers twice weekly. The RN and DON confirmed that bedding was to be changed on scheduled shower days or as needed, and that residents were scheduled for showers twice weekly or upon request. The DON stated the resident had three shower episodes since admission, but this was not supported by the shower record, which showed only one shower. The facility did not maintain a bedding change log. The facility’s Quality of Life policy stated that bathing would be offered twice weekly unless otherwise requested and that daily care, including personal hygiene, would be provided and documented according to assessed needs.
Failure to Use Gloves While Handling Food With a Bandaged Hand
Penalty
Summary
The deficiency involves failure to follow food safety and infection control practices when a kitchen manager with a hand wound handled food without gloves. On March 4, 2026, during a test tray food temperature check in the conference room, surveyors observed Staff #65, the kitchen manager, with a bandage on her right hand that had a visible red spot on the outer part of the bandage. Despite this, Staff #65 did not wear gloves while performing the food temperature procedure and was involved in serving trays, including the test tray. In an immediate interview, Staff #65 reported that the injury was a skin tear sustained earlier that morning when she struck her right hand on a shelf in the soiled utility room. She stated that a nurse had cleaned the wound and applied the bandage. Staff #65 acknowledged that she was not supposed to serve food with a bandage and bare hands and that the kitchen’s normal practice required wearing gloves when serving food if there was an open skin tear covered with a bandage. She confirmed that serving food with an open wound covered by a bandage without gloves could encourage cross-contamination and potentially spread infection. Facility policies on Infection Prevention and Control and Employee Sanitary Practices stated that staff with skin lesions were not permitted to have direct contact with residents or their food and that nutrition and food service employees were required to practice good personal hygiene and safe food-handling procedures.
Failure to Follow Physician Orders for Blood Sugar Monitoring
Penalty
Summary
The facility failed to adhere to physician orders for blood sugar monitoring and insulin administration for two residents, leading to a deficiency in professional standards of care. Resident #215, who has severe cognitive impairment and Type II Diabetes Mellitus, had multiple instances where blood sugar levels exceeded 401, yet there was no evidence of rechecking the blood sugar or notifying the physician as required by the physician's orders. The Licensed Practical Nurse (LPN) and Director of Nursing (DON) confirmed that the blood sugars should have been rechecked and the physician notified, but this was not documented in the clinical records. Similarly, Resident #46, who has Type 2 Diabetes Mellitus with Diabetic Neuropathy and no cognitive impairment, had a blood sugar reading of 407. The physician's order required a recheck and physician notification if the blood sugar remained elevated, but there was no evidence of these actions being taken. The DON reviewed the records and confirmed that the blood sugar should have been rechecked according to the physician's order. The facility's policy on physician orders, revised in September 2024, mandates accurate implementation of orders, including medication orders, in accordance with the resident's plan of care. The failure to follow these orders for both residents indicates a lapse in adhering to professional standards, potentially compromising the residents' diabetes management.
Failure to Maintain a Clean and Sanitary Kitchen
Penalty
Summary
The facility failed to maintain a clean and sanitary kitchen, which could result in a potential for foodborne illness. During an initial walk-through of the kitchen, it was observed that logs for freezer, fridge, dishwasher, cleaning bucket, food temperatures, cleaning schedule, and sanitizing concentration were not completed for the Monday AM shift prior to morning food service. Additionally, there were five empty crushed boxes stored near the food prep area, food debris under an enclosed refrigerator shelf, and a black sticky substance on the floor. Over the next few days, further observations revealed several empty crushed boxes, food debris under food prep tables, and a live roach in the Kitchen Manager's office. The Kitchen Manager acknowledged these issues and attempted to address them on the spot, but the problems persisted throughout the kitchen, including food debris, improperly stored trash, and thawing processed ham under running water near uncovered dessert cakes, which posed a risk of cross-contamination. Other issues included a crusted dry towel under a mobile refrigerator, dead and live roaches, standing water under a dry food storage shelf, and broken tiles with exposed sub-floor near a floor drain sink with black debris particles build-up in the resident dining room. The facility's pest service logs and work orders were reviewed, revealing inadequate pest control measures and no service requests for pest elimination or water leaks in the kitchen. The Maricopa County Food Inspection Report from October 2, 2023, also noted excess soil residue and old food debris under the hand wash sink in the cook line area, which the Person in Charge (PIC) had stated would be cleaned. Despite these findings, the facility had not taken sufficient action to address the cleanliness and sanitation issues in the kitchen, leading to the potential for foodborne illness among residents.
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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 Tempe
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| River Park Post Acute | 2.8 mi | — | 0 | 0 |
| Friendship Village Of Tempe | 3.4 mi | — | 0 | 0 |
| Mirabella At Asu | 3.8 mi | — | 1 | 0 |
| Ahwatukee Post Acute | 5.6 mi | — | 0 | 0 |
| Chandler Post Acute And Rehabilitation | 5.6 mi | — | 9 | 0 |
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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.