Phoenix, AZ

Maryland Gardens Post Acute

2-star overall rating with 2-star inspections with abuse icon flag with 7 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle

31 West Maryland Avenue, Phoenix, AZ

(602) 265-7484

Compare this facility

Overall

2 / 5

CMS overall stars

Health inspections

2 / 5

Survey and complaint cycles

Staffing

1 / 5

RN + nurse staffing

Quality measures

5 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

Certified beds

Average residents

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

Pacs Group

Operator or chain grouping

Approved since

1998-07-20

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Chain footprint

264 facilities

Chain averages 3 overall / 3 health / 2 staffing / 4 quality stars

Changed ownership

Within the last 12 months

Family council

Yes

Resident and family council reported

Sprinklers

Yes

Automatic sprinklers in all required areas

Staffing

Hours and turnover

RN hours / resident day

0.00

Registered nurse staffing

LPN hours / resident day

0.00

Licensed practical nurse staffing

Aide hours / resident day

0.00

Nurse aide staffing

Total nurse hours

0.00

All reported nurse hours

Licensed hours

0.00

RN + LPN hours

Weekend hours

0.00

Weekend nurse staffing

Weekend RN hours

0.00

Weekend registered nurse coverage

Physical therapist

0.00

Reported PT staffing

Adjusted RN hours

0.00

CMS adjusted RN staffing hours

Adjusted total hours

0.00

CMS adjusted total nurse staffing hours

Case-mix index

0.00

Higher values indicate more complex resident acuity

RN turnover

43%

Annual RN turnover · state 45% · national 45%

Total nurse turnover

53%

Annual nurse turnover · state 48% · national 46%

SNF VBP

Value-based purchasing

Program rank

7,843

Lower is better among SNFs in the FY 2026 VBP program.

Performance score

28.63

Composite VBP score used to determine payment impact.

Payment multiplier

0.9851

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

Not reported

This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.

Healthcare-associated infections

Not reported

This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.

Total nurse turnover

1.24

Baseline 56.82% · Performance 58.62% · Measure score 1.24 · Achievement 1.24 · Improvement 0

Adjusted total nurse staffing

4.49

Baseline 3.97 hours · Performance 4.36 hours · Measure score 4.49 · Achievement 4.49 · Improvement 1.63

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	Not Available	10.72%	Not Available · Eligible stays 11 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly.
Discharge to community	Not Available	50.57%	Not Available · Eligible stays 12 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly.
Medicare spending per beneficiary	Not Available	1.02	Too few residents or stays to report publicly.
Drug regimen review with follow-up	100%	95.27% 4.7 pts better	Numerator 24 · Denominator 24
Falls with major injury	4.17%	0.77% 3.4 pts worse	Numerator 1 · Denominator 24
Discharge self-care score	Not Available	53.69%	Numerator Not Available · Denominator 12 · Too few residents or stays to report publicly.
Discharge mobility score	Not Available	50.94%	Numerator Not Available · Denominator 12 · Too few residents or stays to report publicly.
Pressure ulcers or injuries, new or worsened	0%	2.29% 2.3 pts better	Numerator 0 · Denominator 24 · Adjusted rate 0%
Healthcare-associated infections requiring hospitalization	Not Available	7.12%	Not Available · Eligible stays 5 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly.
Staff COVID-19 vaccination coverage	0.83%	8.2% 7.4 pts worse	Numerator 1 · Denominator 121
Staff flu vaccination coverage	3.17%	42% 38.8 pts worse	Numerator 4 · Denominator 126
Discharge function score	Not Available	56.45%	Numerator Not Available · Denominator 12 · Too few residents or stays to report publicly.
Transfer of health information to provider	Not Available	95.95%	Numerator Not Available · Denominator 9 · Too few residents or stays to report publicly.
Transfer of health information to patient	Not Available	96.28%	Numerator Not Available · Denominator 5 · Too few residents or stays to report publicly.
Resident COVID-19 vaccinations up to date	5%	25.2% 20.2 pts worse	Numerator 1 · Denominator 20

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	100.0%	97.1% 2.9 pts better	93.4% 6.6 pts better	Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0%
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine	100.0%	94.6% 5.4 pts better	95.5% 4.5 pts better	Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0%
Percentage of long-stay residents experiencing one or more falls with major injury	2.0%	2.1% 0.1 pts better	3.3% 1.3 pts better	Long Stay · 2024Q4-2025Q3 · Q1 2.0% · Q2 2.0% · Q3 2.0% · Q4 1.9% · 4Q avg 2.0% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms	1.0%	4.2% 3.2 pts better	11.4% 10.4 pts better	Long Stay · 2024Q4-2025Q3 · Q1 4.3% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 1.0%
Percentage of long-stay residents who lose too much weight	0.6%	5.3% 4.7 pts better	5.4% 4.8 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 2.2% · 4Q avg 0.6%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	28.7%	20.5% 8.2 pts worse	19.6% 9.1 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 26.2% · Q2 30.2% · Q3 27.3% · Q4 31.1% · 4Q avg 28.7%
Percentage of long-stay residents who received an antipsychotic medication	43.2%	11.8% 31.4 pts worse	16.7% 26.5 pts worse	Long Stay · 2024Q4-2025Q3 · 4Q avg 43.2% · Used in QM five-star
Percentage of long-stay residents who were physically restrained	0.0%	0.3% 0.3 pts better	0.1% 0.1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0%
Percentage of long-stay residents whose ability to walk independently worsened	1.8%	14.5% 12.7 pts better	16.3% 14.5 pts better	Long Stay · 2024Q4-2025Q3 · Q1 6.4% · 4Q avg 1.8% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	3.5%	10.8% 7.3 pts better	14.9% 11.4 pts better	Long Stay · 2024Q4-2025Q3 · Q1 2.4% · Q2 7.0% · Q3 4.5% · Q4 0.0% · 4Q avg 3.5% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder	0.0%	0.9% 0.9 pts better	1.0% 1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star
Percentage of long-stay residents with a urinary tract infection	0.0%	1.2% 1.2 pts better	1.7% 1.7 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	10.9%	20.5% 9.6 pts better	19.8% 8.9 pts better	Long Stay · 2024Q4-2025Q3 · Q1 24.1% · Q2 11.3% · Q3 3.7% · Q4 5.2% · 4Q avg 10.9%
Percentage of long-stay residents with pressure ulcers	6.1%	4.8% 1.3 pts worse	5.1% 1 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 6.3% · Q2 10.4% · Q3 6.3% · Q4 1.8% · 4Q avg 6.1% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	100.0%	91.1% 8.9 pts better	81.7% 18.3 pts better	Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0%
Percentage of short-stay residents who newly received an antipsychotic medication	6.9%	1.1% 5.8 pts worse	1.6% 5.3 pts worse	Short Stay · 2024Q4-2025Q3 · 4Q avg 6.9% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	92.5%	87.3% 5.2 pts better	79.7% 12.8 pts better	Short Stay · 2024Q3-2025Q2 · 4Q avg 92.5%

Survey summary

Recent inspection cycles

Cycle 1 Health 2024-07-12 · Fire 2024-07-12

7 health deficiencies

Top issue: Freedom from Abuse and Neglect and Exploitation (3 deficiencies)

3 fire-safety deficiencies

Top issue: Smoke (3 deficiencies)

Cycle 2 Health 2023-03-10 · Fire 2023-03-10

14 health deficiencies

Top issue: Freedom from Abuse and Neglect and Exploitation (6 deficiencies)

2 fire-safety deficiencies

Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)

Cycle 3 Health 2022-02-25 · Fire 2022-02-25

4 health deficiencies

Top issue: Resident Assessment and Care Planning (2 deficiencies)

6 fire-safety deficiencies

Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)

Fire safety

Fire-safety citations

D · Potential for more than minimal harm 2024-07-12

K321 · Smoke Deficiencies

Fire Safety

Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

Corrected 2024-08-30

D · Potential for more than minimal harm 2024-07-12

K355 · Smoke Deficiencies

Fire Safety

Properly select, install, inspect, or maintain portable fire extinguishes.

Corrected 2024-08-30

D · Potential for more than minimal harm 2024-07-12

K363 · Smoke Deficiencies

Fire Safety

Install corridor and hallway doors that block smoke.

Corrected 2024-08-30

D · Potential for more than minimal harm 2023-03-10

K363 · Smoke Deficiencies

Fire Safety

Install corridor and hallway doors that block smoke.

Corrected 2023-05-10

D · Potential for more than minimal harm 2023-03-10

K920 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure proper usage of power strips and extension cords.

Corrected 2023-05-10

E · Potential for more than minimal harm 2022-02-25

K511 · Services Deficiencies

Fire Safety

Have properly installed electrical wiring and gas equipment.

Corrected 2022-03-28

D · Potential for more than minimal harm 2022-02-25

E20 · Emergency Preparedness Deficiencies

Fire Safety

Establish policies and procedures including evacuation.

Corrected 2022-03-28

D · Potential for more than minimal harm 2022-02-25

K345 · Smoke Deficiencies

Fire Safety

Have approved installation, maintenance and testing program for fire alarm systems.

Corrected 2022-03-28

D · Potential for more than minimal harm 2022-02-25

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2022-03-28

D · Potential for more than minimal harm 2022-02-25

K920 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure proper usage of power strips and extension cords.

Corrected 2022-03-28

D · Potential for more than minimal harm 2022-02-25

K926 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk.

Corrected 2022-03-28

Inspection history

Recent health citations

D · Potential for more than minimal harm 2025-01-23

F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Corrected 2025-03-24

D · Potential for more than minimal harm 2025-01-23

F684 · Quality of Life and Care Deficiencies

Health

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected 2025-03-24

D · Potential for more than minimal harm 2025-01-08

F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Corrected 2025-02-28

D · Potential for more than minimal harm 2025-01-08

F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Develop and implement policies and procedures to prevent abuse, neglect, and theft.

Corrected 2025-02-28

D · Potential for more than minimal harm 2025-01-08

F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Corrected 2025-02-28

D · Potential for more than minimal harm 2025-01-08

F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Respond appropriately to all alleged violations.

Corrected 2025-02-28

E · Potential for more than minimal harm 2024-12-04

F558 · Resident Rights Deficiencies

Health

Reasonably accommodate the needs and preferences of each resident.

Corrected 2025-01-31

E · Potential for more than minimal harm 2024-12-04

F584 · Resident Rights Deficiencies

Health

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

Corrected 2025-01-31

E · Potential for more than minimal harm 2024-12-04

F919 · Environmental Deficiencies

Health

Make sure that a working call system is available in each resident's bathroom and bathing area.

Corrected 2025-01-31

E · Potential for more than minimal harm 2024-12-04

F920 · Environmental Deficiencies

Health

Provide at least one room set aside to use as a resident dining room and for activities, that is a good size, with good lighting, air flow and furniture.

Corrected 2025-01-31

D · Potential for more than minimal harm 2024-08-27

F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Corrected 2024-10-04

D · Potential for more than minimal harm 2024-07-12

F552 · Resident Rights Deficiencies

Health

Ensure that residents are fully informed and understand their health status, care and treatments.

Corrected 2024-08-30

D · Potential for more than minimal harm 2024-07-12

F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Corrected 2024-08-30

D · Potential for more than minimal harm 2024-07-12

F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Corrected 2024-08-30

D · Potential for more than minimal harm 2024-07-12

F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Respond appropriately to all alleged violations.

Corrected 2024-08-30

D · Potential for more than minimal harm 2024-07-12

F658 · Resident Assessment and Care Planning Deficiencies

Health

Ensure services provided by the nursing facility meet professional standards of quality.

Corrected 2024-08-30

D · Potential for more than minimal harm 2024-07-12

F689 · Quality of Life and Care Deficiencies

Health

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Corrected 2024-08-30

D · Potential for more than minimal harm 2024-07-12

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2024-08-30

E · Potential for more than minimal harm 2023-03-10

F812 · Nutrition and Dietary Deficiencies

Health

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Corrected 2023-05-10

D · Potential for more than minimal harm 2023-03-10

F658 · Resident Assessment and Care Planning Deficiencies

Health

Ensure services provided by the nursing facility meet professional standards of quality.

Corrected 2023-05-10

D · Potential for more than minimal harm 2023-03-10

F727 · Nursing and Physician Services Deficiencies

Health

Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.

Corrected 2023-05-10

E · Potential for more than minimal harm 2022-02-25

F658 · Resident Assessment and Care Planning Deficiencies

Health

Ensure services provided by the nursing facility meet professional standards of quality.

Corrected 2022-03-31

D · Potential for more than minimal harm 2022-02-25

F645 · Resident Assessment and Care Planning Deficiencies

Health

PASARR screening for Mental disorders or Intellectual Disabilities

Corrected 2022-03-31

D · Potential for more than minimal harm 2022-02-25

F755 · Pharmacy Service Deficiencies

Health

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Corrected 2022-03-31

D · Potential for more than minimal harm 2022-02-25

F812 · Nutrition and Dietary Deficiencies

Health

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Corrected 2022-03-31

Penalties and ownership