01 / INSPECTION LEDGER
Survey cycles in this release
| Cycle | Health date | Health deficiencies | Fire date | Fire deficiencies |
|---|---|---|---|---|
| Cycle 1 | 2026-02-26 | 5 | 2024-05-10 | 1 |
| Cycle 2 | 2024-05-10 | 5 | 2023-01-26 | 3 |
| Cycle 3 | 2023-01-26 | 10 | 2021-12-08 | 2 |
CMS CCN 0351112026-08-01 PROCESSING DATE
NURSING HOME PUBLIC RECORD
Lake Pleasant Post Acute Rehabilitation Center
20625 North Lake Pleasant Road · Peoria, AZ 85382 · Maricopa County
Certified beds128CMS provider file
Recent citation rows26current CMS citation release
Penalty rows0current CMS penalties file
Read this record carefully.
The citation files cover the three most recent standard inspections plus qualifying complaint and infection-control inspections in the prior three years. A correction date is a CMS field; this site does not independently verify conditions. Absence from a file is not proof that no issue exists.
02 / CITATION DETAIL
26 rows in the current release
0 rows carry G–L scope/severity codes; 0 carry J–L. 2 tag codes appear on more than one survey date. These counts describe citation rows, not residents or incidents.
2026-02-26 · HEALTHF0628Severity E · pattern; potential for more than minimal harm
Resident Rights Deficiencies
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Correction field: Deficient, Provider has date of correction · 2026-04-15 · complaint2026-02-26 · HEALTHF0641Severity D · isolated; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Ensure each resident receives an accurate assessment.
Correction field: Deficient, Provider has date of correction · 2026-04-152026-02-26 · HEALTHF0684Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Correction field: Deficient, Provider has date of correction · 2026-04-152026-02-26 · HEALTHF0695Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide safe and appropriate respiratory care for a resident when needed.
Correction field: Deficient, Provider has date of correction · 2026-04-152026-02-26 · HEALTHF0812Severity E · pattern; potential for more than minimal harm
Nutrition and Dietary Deficiencies
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Correction field: Deficient, Provider has date of correction · 2026-04-152024-05-10 · FIREE0039Severity D · isolated; potential for more than minimal harm
Emergency Preparedness Deficiencies
Conduct testing and exercise requirements.
Correction field: Deficient, Provider has date of correction · 2024-06-242024-05-10 · HEALTHF0550Severity E · pattern; potential for more than minimal harm
Resident Rights Deficiencies
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Correction field: Deficient, Provider has date of correction · 2024-06-242024-05-10 · HEALTHF0582Severity D · isolated; potential for more than minimal harm
Resident Rights Deficiencies
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Correction field: Deficient, Provider has date of correction · 2024-06-242024-05-10 · HEALTHF0696Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide appropriate care/assistance for a resident with a prosthesis.
Correction field: Deficient, Provider has date of correction · 2024-06-242024-05-10 · HEALTHF0812Severity E · pattern; potential for more than minimal harm
Nutrition and Dietary Deficiencies
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Correction field: Deficient, Provider has date of correction · 2024-06-242024-05-10 · HEALTHF0880Severity D · isolated; potential for more than minimal harm
Infection Control Deficiencies
Provide and implement an infection prevention and control program.
Correction field: Deficient, Provider has date of correction · 2024-06-242024-01-17 · HEALTHF0692Severity E · pattern; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide enough food/fluids to maintain a resident's health.
Correction field: Deficient, Provider has date of correction · 2024-03-01 · complaint2023-12-13 · HEALTHF0609Severity D · isolated; potential for more than minimal harm
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Correction field: Deficient, Provider has date of correction · 2024-01-19 · complaint2023-12-13 · HEALTHF0610Severity D · isolated; potential for more than minimal harm
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Respond appropriately to all alleged violations.
Correction field: Deficient, Provider has date of correction · 2024-01-19 · complaint2023-01-26 · HEALTHF0580Severity D · isolated; potential for more than minimal harm
Resident Rights Deficiencies
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Correction field: Deficient, Provider has date of correction · 2023-03-052023-01-26 · HEALTHF0658Severity E · pattern; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Ensure services provided by the nursing facility meet professional standards of quality.
Correction field: Deficient, Provider has date of correction · 2023-03-052023-01-26 · HEALTHF0677Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide care and assistance to perform activities of daily living for any resident who is unable.
Correction field: Deficient, Provider has date of correction · 2023-03-052023-01-26 · HEALTHF0685Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Assist a resident in gaining access to vision and hearing services.
Correction field: Deficient, Provider has date of correction · 2023-03-052023-01-26 · HEALTHF0725Severity E · pattern; potential for more than minimal harm
Nursing and Physician Services Deficiencies
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Correction field: Deficient, Provider has date of correction · 2023-03-052023-01-26 · HEALTHF0757Severity D · isolated; potential for more than minimal harm
Pharmacy Service Deficiencies
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Correction field: Deficient, Provider has date of correction · 2023-03-052023-01-26 · HEALTHF0758Severity E · pattern; potential for more than minimal harm
Pharmacy Service Deficiencies
Implement 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.
Correction field: Deficient, Provider has date of correction · 2023-03-052023-01-26 · FIREK0363Severity D · isolated; potential for more than minimal harm
Smoke Deficiencies
Install corridor and hallway doors that block smoke.
Correction field: Deficient, Provider has date of correction · 2023-03-052023-01-26 · FIREK0511Severity D · isolated; potential for more than minimal harm
Services Deficiencies
Have properly installed electrical wiring and gas equipment.
Correction field: Deficient, Provider has date of correction · 2023-03-052023-01-26 · FIREK0920Severity D · isolated; potential for more than minimal harm
Gas, Vacuum, and Electrical Systems Deficiencies
Ensure proper usage of power strips and extension cords.
Correction field: Deficient, Provider has date of correction · 2023-03-0503 / ENFORCEMENT FILE
Penalties reported by CMS
Fine amounts and payment-denial days are shown exactly as aggregated from the current penalties file. They do not imply an unpaid balance.
| Date | Type | Fine amount | Payment-denial days |
|---|---|---|---|
| No penalty row appeared in the August 2026 penalties file. | |||
04 / OWNERSHIP DISCLOSURES
Who appears in the CMS file
- HILL, SEANIndividual · MANAGING CONTROL - GOVERNING BODYNOT APPLICABLE · since 07/01/2015
- NAGLE, CRAIGIndividual · MANAGING CONTROL - GOVERNING BODYNOT APPLICABLE · since 05/15/2025
- PETERSON, FORRESTIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 01/01/2019
- BURNAM, SOONIndividual · CORPORATE OFFICERNOT APPLICABLE · since 07/01/2015
- FISCHBECK, COURTNEYIndividual · CORPORATE OFFICERNOT APPLICABLE · since 01/01/2025
- KEETCH, CHADIndividual · CORPORATE OFFICERNOT APPLICABLE · since 03/01/2011
- SATO, AMIIndividual · CORPORATE OFFICERNOT APPLICABLE · since 09/09/2024
- HILL, SEANIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 07/01/2015
- NAGLE, CRAIGIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 05/15/2025
- PORT, BARRYIndividual · INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNFNOT APPLICABLE · since 08/06/2025
- ENSIGN SERVICES INCOrganization · ADP OF THE SNFNOT APPLICABLE · since 07/01/2015
- SUN GROVE VILLAGE CARE CENTER, LLCOrganization · ADP OF THE SNFNOT APPLICABLE · since 10/23/1995
- HILL, SEANIndividual · ADP OF THE SNFNOT APPLICABLE · since 07/01/2015
- NAGLE, CRAIGIndividual · ADP OF THE SNFNOT APPLICABLE · since 05/15/2025
Names and roles are self-reported CMS disclosure fields. Exact-name pages do not prove that similarly named people or organizations are the same entity.
05 / CMS STAFFING FIELDS
Reported hours and turnover
Staffing fields are provider-reported and case-mix context matters. CMS applies footnotes and exclusions not reproduced as a new score here.
Total nurse hours3.32per resident day
RN hours0.59per resident day
Weekend nurse hours2.92per resident day
Staff turnover50.0%CMS reported field
06 / LOCAL RECORDS
Open the Peoria ledger →