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Lake Pleasant Post Acute Rehabilitation Center Inspection Report, Violations & Safety Grade (PEORIA, Arizona)

20625 NORTH LAKE PLEASANT ROAD, PEORIA, Arizona 85382

Phone: 6235660642

CMS Overall:4/5

Overview & Bed Count

Certified Beds
128
Avg Residents/Day
102.9
Ownership
For profit - Limited Liability company
Provider Type
Medicare and Medicaid
County
Maricopa
Sprinkler Systems
Yes
Special Focus
None
Abuse Icon
No

CMS Star Ratings

Overall4/5
Health3/5
Staffing2/5
Quality5/5

Nurse Staffing Check

MetricThis FacilityArizona AvgDifference
RN Hours per Resident per Day0.520.74-0.21
Total Nurse Hours per Resident per Day3.334.08-0.75
CMS Staffing Rating2/53/5-
Nursing Staff Turnover49.5%44.8%-

Health Citation History

20 health citations on record

DateCategoryDescriptionSeverity
2026-02-26Resident Rights DeficienciesProvide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.E – Moderate Harm Potential
2026-02-26Nutrition and Dietary DeficienciesProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.E – Moderate Harm Potential
2026-02-26Resident Assessment and Care Planning DeficienciesEnsure each resident receives an accurate assessment.D – Moderate Harm Potential
2026-02-26Quality of Life and Care DeficienciesProvide appropriate treatment and care according to orders, resident’s preferences and goals.D – Moderate Harm Potential
2026-02-26Quality of Life and Care DeficienciesProvide safe and appropriate respiratory care for a resident when needed.D – Moderate Harm Potential
2024-05-10Resident Rights DeficienciesHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.E – Moderate Harm Potential
2024-05-10Nutrition and Dietary DeficienciesProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.E – Moderate Harm Potential
2024-05-10Resident Rights DeficienciesGive residents notice of Medicaid/Medicare coverage and potential liability for services not covered.D – Moderate Harm Potential
2024-05-10Quality of Life and Care DeficienciesProvide appropriate care/assistance for a resident with a prosthesis.D – Moderate Harm Potential
2024-05-10Infection Control DeficienciesProvide and implement an infection prevention and control program.D – Moderate Harm Potential
2024-01-17Quality of Life and Care DeficienciesProvide enough food/fluids to maintain a resident's health.E – Moderate Harm Potential
2023-12-13Freedom from Abuse, Neglect, and Exploitation DeficienciesTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.D – Moderate Harm Potential
2023-12-13Freedom from Abuse, Neglect, and Exploitation DeficienciesRespond appropriately to all alleged violations.D – Moderate Harm Potential
2023-01-26Resident Assessment and Care Planning DeficienciesEnsure services provided by the nursing facility meet professional standards of quality.E – Moderate Harm Potential
2023-01-26Nursing and Physician Services DeficienciesProvide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.E – Moderate Harm Potential
2023-01-26Pharmacy Service DeficienciesImplement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.E – Moderate Harm Potential
2023-01-26Resident Rights DeficienciesImmediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.D – Moderate Harm Potential
2023-01-26Quality of Life and Care DeficienciesProvide care and assistance to perform activities of daily living for any resident who is unable.D – Moderate Harm Potential
2023-01-26Quality of Life and Care DeficienciesAssist a resident in gaining access to vision and hearing services.D – Moderate Harm Potential
2023-01-26Pharmacy Service DeficienciesEnsure each resident’s drug regimen must be free from unnecessary drugs.D – Moderate Harm Potential

Fire Safety Citation History

6 fire safety citations on record

DateCategoryDescriptionSeverity
2024-05-10Emergency Preparedness DeficienciesConduct testing and exercise requirements.D – Moderate Harm Potential
2023-01-26Smoke DeficienciesInstall corridor and hallway doors that block smoke.D – Moderate Harm Potential
2023-01-26Services DeficienciesHave properly installed electrical wiring and gas equipment.D – Moderate Harm Potential
2023-01-26Gas, Vacuum, and Electrical Systems DeficienciesEnsure proper usage of power strips and extension cords.D – Moderate Harm Potential
2021-12-08Smoke DeficienciesHave properly installed hallway dispensers for alcohol-based hand rub.D – Moderate Harm Potential
2021-12-08Gas, Vacuum, and Electrical Systems DeficienciesEnsure proper usage of power strips and extension cords.D – Moderate Harm Potential

Total Penalties & Fines

$0
Total Fine Amount (CMS)
0
Number of Fines
0
Total Penalties

No penalty records found.

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