Victory Hospice LLC
Mesa, Arizona · CCN 031735
1533 N Alma School Rd Ste 14
24 federal deficiencies across 4 surveys, November 20, 2024 to September 8, 2025.
Excludes the inspector’s preamble, which is not a finding
Federal surveys with at least one deficiency
Findings against a Condition of Participation — a compliance grade, not a measure of harm
What level the findings sit at
- Condition-level14.2%
- The agency was out of compliance with a federal Condition of Participation — a requirement it must meet to take part in Medicare at all.
- Standard-level2395.8%
- A requirement within a Condition of Participation. The Condition itself was not cited.
These are compliance grades, not harm grades: how deep in the regulation a finding sits, not whether anyone was harmed.
Who conducted the surveys
ACHC, State Agency.
Federal surveys are carried out by the state agency or a CMS-approved accrediting organisation.
Most-cited requirements
- L0545Content of Plan of Care3
- L0587Core Services3
- L0522Initial Assessment2
- L0523Timeframe for Completion of Assessment2
- L0541Approach to Service Delivery2
Survey record
Condition-level
| Survey | Type | Deficiencies | Condition-level |
|---|---|---|---|
| Sep 8, 2025 | Initial with CCN | 3 | 1 |
| Jul 30, 2025 | Initial with CCN | 11 | — |
| Jan 6, 2025 | Recertification | 5 | — |
| Nov 20, 2024 | Recertification | 5 | — |
In the inspector’s words
The complete written findings for this hospice, in the inspector’s own words.
Read all 18 findings in full →
CMS publishes written findings for 18 of the 24 deficiencies on this hospice’s record.
Hospice findings published by CMS on QCOR, covering surveys from November 20, 2024 to September 8, 2025. The inspectors’ written findings come from a single CMS survey-report extract.
Federal survey findings only. State licensure findings for hospices are not shown.
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