Citadel Post Acute
Mesa, Arizona · CCN 035103
20 surveys since 2011, 2 of them producing a finding at harm level or worse.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
- Citations on record
- 83
- Surveys
- 20
- Harm or worse
- 2
- Immediate jeopardy
- 0
Findings where a surveyor recorded actual harm to a resident.
Older surveys no longer in CMS’s monthly file or on Care Compare. They are shown here.
The facility
- Certified beds
- 128
- Ownership
- For profit - Corporation
- Chain
- THE ENSIGN GROUP
- County
- Maricopa
- Medicare-certified since
- 1985
CMS ratings
- Overall
- 5
- Health inspection
- 5
- Staffing
- 3
- Quality measures
- 5
CMS’s own Five-Star ratings.
Compared with similar facilities
Not shown for this facility: too few citations in window (n=11, floor 20).
Last survey on record
Jul 18, 2025
479 days ago.
Counts surveys with at least one finding. A clean survey leaves no record here, so the real gap may be shorter.
Staffing
| Measure | This facility | Peer median |
|---|---|---|
| Nurse hours per resident day | 3.55 | 3.68 |
| Registered-nurse hours per resident day | 0.44 | — |
| Annual nurse turnover | 43.8% | 44.1% |
As reported by the facility to CMS, beside the peer-group median.
Enforcement
No fines, payment denials or special-focus designation on the current CMS record.
Severity of recent findings
| Severity | Isolated | Pattern | Widespread |
|---|---|---|---|
| Immediate jeopardy | J— | K— | L— |
| Actual harm | G— | H— | I— |
| No harm, potential for more than minimal | D5100.0% | E— | F— |
| No harm, potential for minimal | A— | B— | C— |
In the surveyor’s words
From the most serious findings on record at Citadel Post Acute, in the surveyor’s own words.
- No harm, potential for more than minimal, patternF658Dec 22, 2021
Based on clinical record reviews, an observation, staff interviews, and review of facility policies, the facility failed to ensure that a blood pressure medication was administered as ordered for one resident (#6) and failed to ensure that physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The deficient practice could result in residents not receiving medications as ordered by the physician and could result in increased risk of side effects. Findings include: Regarding the blood pressure medication -Resident #6 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . […]
- No harm, potential for more than minimal, patternF880Nov 10, 2021
Based on facility documentation, interviews, facility policy, and Centers for Disease Control (CDC) guidance, the facility failed to ensure that multiple staff members were screened for signs and symptoms of COVID-19 upon entry to the building. The deficient practice could increase the risk for transmission of COVID-19. Findings include: Review of the facility's employee COVID-19 screening logs for October 2021 revealed the following: -A Certified Nursing Assistant (CNA/staff #149) did not complete COVID-19 screening questions or provide a temperature for approximately 10 days. The punch detail for the CNA indicated the staff member worked those 10 days. -A Registered Nurse (RN/staff #47) did not complete COVID-19 screening questions or provide a temperature for more than 5 days. […]
- No harm, potential for more than minimal, patternF886Nov 10, 2021
Based on facility documentation, staff interviews, facility policy, and Centers for Disease Control (CDC) guidance, the facility failed to ensure that multiple staff were tested for COVID-19 at the required frequency. The deficient practice could result in increased risk of COVID-19 transmission. Findings include: During the entrance conference conducted on 11/9/2021 at 9:30 a.m. with the administrator (staff #97) and the Assistant Director of Nursing (ADON/staff #39), they stated that there were currently 10 COVID-19 positive residents in the facility and two staff members who had tested positive for COVID-19. They stated that all of the cases were facility acquired. […]
- No harm, potential for more than minimal, patternF880Feb 10, 2021
Based on observations, staff interviews, facility posting, policy review, and the Center for Prevention and Disease Prevention (CDC) guidance, the facility failed to ensure infection control standards were maintained regarding personal protective equipment (PPE) and hand hygiene. The deficient practice could result in the spread of infections, including COVID-19 to residents and staff. Findings include: During an interview conducted with the Director of Nursing (DON/staff #49) on February 9, 2021 at 9:15 a.m., the DON stated that all residents in the facility were on contact/droplet isolation precautions related to the facility outbreak status. She stated that staff were to be wearing a mask and eye protection at all times. […]
- No harm, potential for more than minimal, isolatedF600Jul 18, 2025
Based on clinical record review, staff interviews, facility documentation, policy review, and the State's Agency (SA) complaint tracking system, the facility failed to protect two residents (#3 and #9) right to be free from sexual abuse by other residents (#4 and #10). The deficient practice could result in residents being at risk for further abuse.Based on clinical record review, staff interviews, facility documentation, policy review, and the State's Agency (SA) complaint tracking system, the facility failed to protect two residents (#3 and #9) right to be free from sexual abuse by other residents (#4 and #10). […]
Read 22 findings in full →The most serious and the most recent: 22 of 83 on record.
Every survey on record
FindingsAt actual harm or above
- Jul 18, 2025Complaint1 finding
- Feb 21, 2025Standard3 findings
- Apr 14, 2023Standard1 finding
- Dec 22, 2021Complaint2 findings
- Nov 10, 2021Infection control2 findings
- Feb 10, 2021Infection control2 findings
- Nov 30, 2020Infection control1 finding
- Nov 10, 2020Infection control2 findings
Show the 12 earlier surveys
- Oct 3, 2019Standard6 findings
- Aug 10, 2018Standard2 findings
- Apr 27, 2016Standard and complaint10 findings
- Oct 15, 2015Complaint5 findings
- Feb 5, 2015Standard and complaint1 finding
- Sep 25, 2014Complaint3 findings
- Apr 1, 2014Complaint3 findings
- Oct 30, 2013—12 findings · 1 harm
- May 22, 2013—1 finding
- Sep 27, 2012—12 findings
- Mar 14, 2012—3 findings
- Aug 2, 2011—11 findings · 1 harm
Surveys that found no deficiencies are not in CMS’s files and do not appear here.
Comparable facilities
The nearest facilities to this one in the same peer group, by weighted findings.
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