Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record

Lake Pleasant Post Acute Rehabilitation Center

PEORIA, AZ · 128 certified beds · Last Life Safety survey May 10, 2024

CMS Certification Number 035111 · first certified July 1985

Ownership

Operated by THE ENSIGN GROUP · For profit - Limited Liability company

No change of ownership on CMS record since January 1, 2016, when the records begin.

6
Citations on file
Rolling three-year window
3
Life Safety surveys
In the same window
1
Tags cited more than once
Across separate surveys
2
Inspection & testing records
Of the citations on file

Position within AZ

6 citations — more than 41% 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

Improvingfewer citations at the latest survey than at its earlier surveys in the window.

The latest survey found 1 citation; the earlier surveys in the window 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 (July 2025 to March 2026), and past the point by which nine in ten AZ facilities have been surveyed. This facility’s last Life Safety survey was May 2024. 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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Which alerts

Emergency preparedness

1 of the 6 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 6 Life Safety citations above. The Physical Environment Index

  • F-0880 Provide and implement an infection prevention and control program.

How that compares

Citations on file over three years

Compared with the median facility in AZ, and nationally. Surveyors differ markedly between states, so the AZ figure is the meaningful one.

This facility6AZ median8National median11
Citations on file over three years, compared
MeasureCitations
This facility6
Median facility in AZ8
Median facility nationally11

Survey history

Citations at each Life Safety survey
22021-1232023-0112024-05
Citations at each Life Safety survey
Survey dateCitations
December 8, 20212
January 26, 20233
May 10, 20241

Most-cited tags

Most-cited tags at this facility
K-09202K-05111K-03631E-00391K-03251
Most-cited tags at this facility
TagWhat the surveyor checksTimes citedLast cited
K-0920Ensure proper usage of power strips and extension cords.22023-01-26
K-0511Have properly installed electrical wiring and gas equipment.12023-01-26
K-0363Install corridor and hallway doors that block smoke.12023-01-26
E-0039Conduct testing and exercise requirements.12024-05-10
K-0325Have properly installed hallway dispensers for alcohol-based hand rub.12021-12-08

What the citations cover

Citations by CMS category
  • Smoke Deficiencies 2
  • Gas, Vacuum, and Electrical Systems Deficiencies 2
  • Emergency Preparedness Deficiencies 1
  • Services Deficiencies 1
Citations by CMS category
CategoryCitations
Smoke Deficiencies2
Gas, Vacuum, and Electrical Systems Deficiencies2
Emergency Preparedness Deficiencies1
Services Deficiencies1

Every citation on file

As published by CMS, newest survey first. Descriptions are CMS’s own wording.

May 10, 2024 — 1 citation

Citations issued on May 10, 2024
TagWhat the surveyor checksStatus
E-0039Conduct testing and exercise requirements.Deficient, Provider has date of correction (June 24, 2024)

January 26, 2023 — 3 citations

Citations issued on January 26, 2023
TagWhat the surveyor checksStatus
K-0363Install corridor and hallway doors that block smoke.Deficient, Provider has date of correction (March 5, 2023)
K-0511Have properly installed electrical wiring and gas equipment.Deficient, Provider has date of correction (March 5, 2023)
K-0920Ensure proper usage of power strips and extension cords.Deficient, Provider has date of correction (March 5, 2023)

December 8, 2021 — 2 citations

Citations issued on December 8, 2021
TagWhat the surveyor checksStatus
K-0325Have properly installed hallway dispensers for alcohol-based hand rub.Deficient, Provider has date of correction (January 10, 2022)
K-0920Ensure proper usage of power strips and extension cords.Deficient, Provider has date of correction (January 10, 2022)

Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.