Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
Agave Grove Post Acute
GLENDALE, AZ · 225 certified beds · Last Life Safety survey May 9, 2025
CMS Certification Number 035154 · first certified April 1988
Ownership
Independently operated (no chain recorded by CMS) · Non profit - Corporation
No change of ownership on CMS record since January 1, 2016, when the records begin.
Position within AZ
23 citations — more than 93% 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 11 citations; the earlier surveys in the window averaged 6. With 3 surveys on file this is a direction of travel, not a conclusion.
When is the next survey likely?
The window is open now: July 2026 to March 2027. This facility’s last Life Safety survey was May 2025. Facilities in AZ are typically surveyed 14–22 months after the last one (median 18), measured over 143 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 three years in Maryland. How the window is measured
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3 inspection-and-testing tags have been cited here at more than one survey. Nationally, that pattern is common: about three quarters of cited facilities have at least one repeated tag, and half of the facilities ever cited for sprinkler inspection and testing are cited for it again. A repeat is usually a recordkeeping gap rather than a new hazard.
Emergency preparedness
6 of the 23 citations on file are 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
Physical environment (health survey)
3 physical-environment citations on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 23 Life Safety citations above. The Physical Environment 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 | 23 |
| Median facility in AZ | 8 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| April 8, 2022 | 9 |
| May 12, 2023 | 3 |
| May 9, 2025 | 11 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| K-0363 | Install corridor and hallway doors that block smoke. | 3 | 2025-05-09 |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | 2 | 2025-05-09 |
| K-0351 | Install an approved automatic sprinkler system. | 2 | 2025-05-09 |
| K-0222 | Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | 2 | 2023-05-12 |
| K-0511 | Have properly installed electrical wiring and gas equipment. | 2 | 2023-05-12 |
| E-0031 | Provide emergency officials' contact information. | 1 | 2025-05-09 |
| E-0024 | Establish policies and procedures for volunteers. | 1 | 2025-05-09 |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | 1 | 2025-05-09 |
What the citations cover
- Emergency Preparedness Deficiencies 6
- Smoke Deficiencies 6
- Gas, Vacuum, and Electrical Systems Deficiencies 5
- Egress Deficiencies 3
- Other 3
| Category | Citations |
|---|---|
| Emergency Preparedness Deficiencies | 6 |
| Smoke Deficiencies | 6 |
| Gas, Vacuum, and Electrical Systems Deficiencies | 5 |
| Egress Deficiencies | 3 |
| Services Deficiencies | 2 |
| Miscellaneous Deficiencies | 1 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
May 9, 2025 — 11 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0006 | Conduct risk assessment and an All-Hazards approach. | Deficient, Provider has date of correction (June 23, 2025) |
| E-0024 | Establish policies and procedures for volunteers. | Deficient, Provider has date of correction (June 23, 2025) |
| E-0025 | Create arrangements with other facilities to receive patients. | Deficient, Provider has date of correction (June 23, 2025) |
| E-0030 | List the names and contact information of those in the facility. | Deficient, Provider has date of correction (June 23, 2025) |
| E-0031 | Provide emergency officials' contact information. | Deficient, Provider has date of correction (June 23, 2025) |
| K-0291 | Install emergency lighting that can last at least 1 1/2 hours. | Deficient, Provider has date of correction (June 23, 2025) |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | Deficient, Provider has date of correction (June 23, 2025) |
| K-0351 | Install an approved automatic sprinkler system. | Deficient, Provider has date of correction (June 23, 2025) |
| K-0363 | Install corridor and hallway doors that block smoke. | Deficient, Provider has date of correction (June 23, 2025) |
| K-0761 | To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Deficient, Provider has date of correction (June 23, 2025) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (June 23, 2025) |
May 12, 2023 — 3 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0222 | Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Deficient, Provider has date of correction (July 28, 2023) |
| K-0363 | Install corridor and hallway doors that block smoke. | Deficient, Provider has date of correction (July 28, 2023) |
| K-0511 | Have properly installed electrical wiring and gas equipment. | Deficient, Provider has date of correction (July 28, 2023) |
April 8, 2022 — 9 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0020 | Establish policies and procedures including evacuation. | Deficient, Provider has date of correction (May 5, 2022) |
| K-0222 | Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Deficient, Provider has date of correction (May 5, 2022) |
| K-0351 | Install an approved automatic sprinkler system. | Deficient, Provider has date of correction (May 5, 2022) |
| K-0363 | Install corridor and hallway doors that block smoke. | Deficient, Provider has date of correction (May 5, 2022) |
| K-0511 | Have properly installed electrical wiring and gas equipment. | Deficient, Provider has date of correction (May 5, 2022) |
| K-0914 | Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Deficient, Provider has date of correction (May 5, 2022) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (May 5, 2022) |
| K-0921 | Ensure that testing and maintenance of electrical equipment is performed. | Deficient, Provider has date of correction (May 5, 2022) |
| K-0923 | Have proper medical gas storage and administration areas. | Deficient, Provider has date of correction (May 5, 2022) |
Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.