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.
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
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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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
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 | 6 |
| Median facility in AZ | 8 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| December 8, 2021 | 2 |
| January 26, 2023 | 3 |
| May 10, 2024 | 1 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| K-0920 | Ensure proper usage of power strips and extension cords. | 2 | 2023-01-26 |
| K-0511 | Have properly installed electrical wiring and gas equipment. | 1 | 2023-01-26 |
| K-0363 | Install corridor and hallway doors that block smoke. | 1 | 2023-01-26 |
| E-0039 | Conduct testing and exercise requirements. | 1 | 2024-05-10 |
| K-0325 | Have properly installed hallway dispensers for alcohol-based hand rub. | 1 | 2021-12-08 |
What the citations cover
- Smoke Deficiencies 2
- Gas, Vacuum, and Electrical Systems Deficiencies 2
- Emergency Preparedness Deficiencies 1
- Services Deficiencies 1
| Category | Citations |
|---|---|
| Smoke Deficiencies | 2 |
| Gas, Vacuum, and Electrical Systems Deficiencies | 2 |
| Emergency Preparedness Deficiencies | 1 |
| Services Deficiencies | 1 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
May 10, 2024 — 1 citation
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0039 | Conduct testing and exercise requirements. | Deficient, Provider has date of correction (June 24, 2024) |
January 26, 2023 — 3 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0363 | Install corridor and hallway doors that block smoke. | Deficient, Provider has date of correction (March 5, 2023) |
| K-0511 | Have properly installed electrical wiring and gas equipment. | Deficient, Provider has date of correction (March 5, 2023) |
| K-0920 | Ensure proper usage of power strips and extension cords. | Deficient, Provider has date of correction (March 5, 2023) |
December 8, 2021 — 2 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0325 | Have properly installed hallway dispensers for alcohol-based hand rub. | Deficient, Provider has date of correction (January 10, 2022) |
| K-0920 | Ensure 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.