Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
Wellsprings of Gilbert
GILBERT, AZ · 32 certified beds · Last Life Safety survey October 2, 2024
CMS Certification Number 035285 · first certified March 2012
Ownership
Operated by THE ENSIGN GROUP · For profit - Corporation
- Ownership changed June 1, 2024 (change of ownership)from WELLSPRINGS CARE AND REHAB
Position within AZ
7 citations — more than 46% of the 140 certified nursing homes in AZ. Compared within AZ rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated
The latest survey found 2 citations; the earlier surveys on file averaged 2.5. With 3 surveys on file this is a direction of travel, not a conclusion.
When is the next survey likely?
Well past the typical window (December 2025 to August 2026), and past the point by which nine in ten AZ facilities have been surveyed. This facility’s last Life Safety survey was October 2024. Facilities in AZ are typically surveyed 14–23 months after the last one (median 18), measured over 157 consecutive surveys in the last two years of CMS records.
A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to about three years in Virginia. How the window is measured
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Emergency preparedness
1 of the 7 citations on file is Emergency Preparedness E-tags. E-tags are cited under 42 CFR §483.73 and concern the emergency plan, training, drills, communications and supplies. Nationally about half of certified facilities have at least one. The Emergency Preparedness Index
How that compares
Compared with the median facility in AZ, and nationally. Surveyors differ markedly between states, so the AZ figure is the meaningful one.
| Measure | Citations |
|---|---|
| This facility | 7 |
| Median facility in AZ | 7 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| June 22, 2022 | 3 |
| August 11, 2023 | 2 |
| October 2, 2024 | 2 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| K-0923 | Have proper medical gas storage and administration areas. | 1 | 2022-06-22 |
| K-0521 | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | 1 | 2022-06-22 |
| K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | 1 | 2024-10-02 |
| K-0223 | Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | 1 | 2022-06-22 |
| K-0324 | Provide properly protected cooking facilities. | 1 | 2023-08-11 |
| K-0351 | Install an approved automatic sprinkler system. | 1 | 2024-10-02 |
| E-0039 | Conduct testing and exercise requirements. | 1 | 2023-08-11 |
What the citations cover
- Smoke Deficiencies 3
- Egress Deficiencies 1
- Gas, Vacuum, and Electrical Systems Deficiencies 1
- Services Deficiencies 1
- Other 1
| Category | Citations |
|---|---|
| Smoke Deficiencies | 3 |
| Egress Deficiencies | 1 |
| Gas, Vacuum, and Electrical Systems Deficiencies | 1 |
| Services Deficiencies | 1 |
| Emergency Preparedness Deficiencies | 1 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
October 2, 2024 — 2 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0351 | Install an approved automatic sprinkler system. | Deficient, Provider has date of correction (November 14, 2024) |
| K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Deficient, Provider has date of correction (October 14, 2024) |
August 11, 2023 — 2 citations
June 22, 2022 — 3 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0223 | Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Deficient, Provider has date of correction (July 8, 2022) |
| K-0521 | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Deficient, Provider has date of correction (July 8, 2022) |
| K-0923 | Have proper medical gas storage and administration areas. | Deficient, Provider has date of correction (July 8, 2022) |
Reflects the CMS posting of October 1, 2026. Surveys conducted in the last few months may not appear yet.