Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
CITADEL POST ACUTE
MESA, AZ · 128 certified beds · Last Life Safety survey February 21, 2025
CMS Certification Number 035103 · first certified March 1985
Ownership
Operated by THE ENSIGN GROUP · For profit - Corporation
No change of ownership on CMS record since January 1, 2016, when the records begin.
Position within AZ
7 citations — more than 48% 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 0 citations; the earlier surveys in the window averaged 3.5. 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: April 2026 to December 2026. This facility’s last Life Safety survey was February 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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2 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
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
Physical environment (health survey)
1 physical-environment citation 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 7 Life Safety citations above. The Physical Environment Index
- F-0880 Provide and implement an infection prevention and control program.
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 | 8 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| February 17, 2022 | 4 |
| April 14, 2023 | 3 |
| February 21, 2025 | 0 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| K-0363 | Install corridor and hallway doors that block smoke. | 2 | 2023-04-14 |
| K-0511 | Have properly installed electrical wiring and gas equipment. | 2 | 2023-04-14 |
| K-0355 | Properly select, install, inspect, or maintain portable fire extinguishes. | 1 | 2022-02-17 |
| K-0521 | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | 1 | 2022-02-17 |
| E-0004 | Develop and maintain an Emergency Preparedness Program (EP). | 1 | 2023-04-14 |
What the citations cover
- Smoke Deficiencies 3
- Services Deficiencies 3
- Emergency Preparedness Deficiencies 1
| Category | Citations |
|---|---|
| Smoke Deficiencies | 3 |
| Services Deficiencies | 3 |
| Emergency Preparedness Deficiencies | 1 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
April 14, 2023 — 3 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0004 | Develop and maintain an Emergency Preparedness Program (EP). | Deficient, Provider has date of correction (May 19, 2023) |
| K-0363 | Install corridor and hallway doors that block smoke. | Deficient, Provider has date of correction (May 19, 2023) |
| K-0511 | Have properly installed electrical wiring and gas equipment. | Deficient, Provider has date of correction (May 19, 2023) |
February 17, 2022 — 4 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0355 | Properly select, install, inspect, or maintain portable fire extinguishes. | Deficient, Provider has date of correction (March 9, 2022) |
| K-0363 | Install corridor and hallway doors that block smoke. | Deficient, Provider has date of correction (March 9, 2022) |
| K-0511 | Have properly installed electrical wiring and gas equipment. | Deficient, Provider has date of correction (March 9, 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 (March 9, 2022) |
Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.