Endeavor Hospice
A hospice in Mesa, Arizona 85206
4838 East Baseline Road Suite 102, Mesa, Arizona 85206. (480) 674-8228.
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The short answer
Record last released by CMS on Oct 23, 2026.
- 12 deficiencies cited in the last three years
- Not rated family caregiver rating
- 9of 10 CMS’s Hospice Care Index
Each figure’s source sits beside it, in its section below.
What these words mean2
- Inspection (survey)
- A visit by state inspectors, often unannounced, who check a place against the rules it must meet. For nursing homes and other places Medicare pays, CMS calls these visits surveys: a standard survey of a nursing home comes at least every 15 months, and a complaint survey whenever a complaint calls for one. Source: CMS; 42 CFR 488.308.
- Deficiency, citation, violation
- What inspectors write up when a place didn’t meet a rule: the rule, what they saw, and when. CMS calls it a deficiency; states may say citation or violation. It is the inspectors’ finding, not a court’s, and the place is usually asked for a plan to correct it. Source: CMS, statement of deficiencies (Form CMS-2567); each state’s licensing agency.
What did inspectors find?
12 deficiencies cited in the last three years
The middle of the 88 hospices serving ZIP code 85206 had 5.
The last inspection on record was on Sep 11, 2025: a reaccreditation inspection by The Joint Commission.
CMS, QCOR hospice inspection reports. Released Oct 23, 2026. Updated quarterly.
CMS, Hospice ZIP Data. Released Aug 26, 2026. Updated quarterly.
When those deficiencies happened
12 deficiencies in 1 month of the last 36. Last cited Sep 2025. Most serious: Standard-level. The last 3 years, to Oct 27, 2026.
| Jan | Feb | Mar | Apr | May | Jun | Jul | Aug | Sep | Oct | Nov | Dec | |
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 2023 | Nov | Dec | ||||||||||
| 2024 | Jan | Feb | Mar | Apr | May | Jun | Jul | Aug | Sep | Oct | Nov | Dec |
| 2025 | Jan | Feb | Mar | Apr | May | Jun | Jul | Aug | Sep | Oct | Nov | Dec |
| 2026 | Jan | Feb | Mar | Apr | May | Jun | Jul | Aug | Sep | Oct |
Hover or focus a month to read it.
Hearth Record drew this from the dates and levels in the source’s own records.
Each deficiency, as cited
Rule titles as CMS’s inspectors cite them, set in sentence case.
CMS, QCOR hospice inspection reports. Released Oct 23, 2026. Updated quarterly.
Sep 11, 2025: reaccreditation inspection by The Joint Commission12 deficiencies
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EP Training Program (42 CFR 418.113(d)(1)(i))
“Observed in HR File Review. In 4 of 10 HR records reviewed, the Operations Manager confirmed that staff and a volunteer had not received education on the emergency operations plan.”
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Content of plan of care (42 CFR 418.56(c))
The inspectors’ words, 178 words
“Observed in Record Review. On 4 of 14 active patient records reviewed, the hospice nurse surveyor noted that goals were not measurable and specific to the patient. On RRHV #1, it was noted that goals were not measurable and specific to the patient with example of ADLs met through anticipation. In addition, spiritual and MSW goals were not individualized to the patient. On RRHV #2, it was noted that the spiritual and MSW goals were generic goals that had not been individualized to the patient. In addition, goals were not measurable and specific to the patient such as ADLs met through anticipation and Bowel and bladder incontinence managed by caregivers. On RRHV #3, it was noted that the spiritual and MSW goals were generic goals that had not been individualized. In addition, a pain goal that was not measurable and specific to the patient’s need. On RRHV #4, it was noted that goals were not measurable and specific to the patient with example of dyspnea managed at acceptable level. This was reviewed and discussed with the hospice leadership.”
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Content of plan of care (42 CFR 418.56(c)(2))
“Observed in Record Review. In 1 of 2 discharged records reviewed, the organization did not get an physician order for discharge. On review of RRDC #2, it was noted that patient transferred to another hospice but no doctor’s order was obtained prior to transfer. This finding was reviewed and discussed with Hospice Leaders.”
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Content of plan of care (42 CFR 418.56(c)(3))
The inspectors’ words, 267 words
“Observed in Record Review. In 7 of 14 active patient records reviewed, the hospice nurse surveyor noted that goals were not updated to reflect the current needs of the patient. On RRHV #3, it was noted that goals had not been updated to reflect current needs such as teaching for oxygen safety on the POC 2 months after admission. On RRNHV #1, it was noted that the patient has been on service for 4 months goals have not been updated to reflect current POC with example of teaching goals of skin integrity and pain management education since admit. On RRNHV #2, it was noted that patient has had teaching goals for the past year with the example of teaching skin integrity. On RRNHV #5 it was noted that patient still had admission goals related to verbalizing when to call hospice and for having DME supplies 2 months after admission. On RRNHV #6, it was noted on assessment that patient reported she didn’t know how to do her PRN medications and if the pill box wasn’t filled then she wouldn’t know how to take those either but there is nothing regarding medication management on the POC. On RRNHV #7 it was noted that patient had changes to anxiety medications, but the POC was not updated with goals to reflect the changes to care. On RRNHV #10 it was noted that patient had new medication of calmoseptine ointment for redness of skin but this is not updated on the POC with goals and interventions for teaching of the new medication. The was reviewed and discussed with the hospice leadership.”
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Content of plan of care (42 CFR 418.56(c)(4))
The inspectors’ words, 207 words
“Observed in Record Review. In 8 of 14 active patient records reviewed, the hospice nurse surveyor noted medication orders were not clear and accurate. On RRHV #1, the physician orders had duplicate anxiety medications of (Lorazapam oral and liquid) with no indication on how to handle the duplicate therapy. On RRHV #2, the physician orders had duplicate constipation medications (Senna, Biscodyl and Milk of Magnesia) with no indication how to handle the duplicate therapy. On RRHV #3, the physician orders had duplicate constipation medications (MiraLAX and Milk of Magnesia) with no indication how to handle the duplicate therapy. On RRNHV #1 the physician orders in the plan of care had duplicate PRN therapies for Pain (Acetaminophen, Voltaren and Morphine Sulfate) and constipation (MiraLAX and Milk of Magnesia) with no indication on how to handle the duplicate therapies. On RRNHV # 2 the physician’s orders in the plan of care had both duplicate PRN therapy for constipation (Milk of Magnesia and Magnesium Citrate) and chronic pain (Acetaminophen and oxycodone) with no indication how to handle the duplicate therapies. In addition, RRNHV #3, RRNHV #7, and RRNHV #8 had duplicate therapy for pain and/or constipation that the duplicate therapy was not addressed. This was discussed with the hospice leadership.”
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Quality assessment & performance improvement (42 CFR 418.58)
“Observed in Data Session. Upon review of QAPI, the Operations Manager confirmed that the Hospice QAPI program did not involve all their services, specifically they were missing the volunteer program.”
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Control (42 CFR 418.60(b))
“Observed in Infection Control System Tracer. During document review, the Operations Manager confirmed that the organization had not been following their policy titled Influenza Vaccination Program by collecting flu vaccination data from employees with a goal of 90% compliance.”
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Level of activity (42 CFR 418.78(e))
“Observed in Document Review. During a review of the volunteer program, the Operations Manager confirmed that volunteers had not provided at least 5% of the total patient care hours of all paid hospice employees and contract staff. They stood at 0.9% for 2025.”
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Training (42 CFR 418.100(g)(3))
“Observed in HR File Review. In 1 of 10 HR records reviewed, the Operations Manager that initial competence assessment had not been completed for the Associate Medical Director.”
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Content (42 CFR 418.104(a)(7))
“Observed in Record Review. In 1 out of 4 home visits conducted, the organization failed to ensure the medical record contained information to accurately reflect the patient’s care, treatment, and services. During the home observation for RRHV #4, the registered nurse noted that they were giving tramadol nightly for pain but the orders was for PRN use. In addition, the Levocetirizine had been stopped several weeks ago but the change had not been reflected on the medication list. This was reviewed and discussed with the Hospice leadership team.”
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Discharge or transfer of care (42 CFR 418.104(e)(1)(i))
“Observed in Record Review. In 1 of 2 discharge records reviewed, the organization failed to provide a written discharge summary to the receiving hospice. During record review for RRDC #2, the Hospice Nurse Surveyor observed that no discharge summary was sent to the receiving hospice. This was discussed and reviewed with the Hospice Leadership Team.”
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Label dispose storage drugs (42 CFR 418.106(e)(2)(i)(A))
The inspectors’ words, 95 words
“Observed in Patient Home. In 2 of 4 Home Visits conducted, the surveyor noted that there was no documentation provided to the patient regarding their policy on controlled substance disposal. On review the admission packet, it was noted the organization did not provide a copy of its written policies and procedures on the management and disposal of controlled medications in the packet. On RRHV #3 and RRHV #4, it was noted that the patient was not given a copy of the agency’s policy on controlled substance disposal. This was discussed and reviewed with agency leadership.”
The one inspection in the last three years
| Date | Visit | What the record says |
|---|---|---|
| Sep 11, 2025 | Reaccreditation inspection by The Joint Commission | 12 deficiencies cited |
Is it certified?
- Medicare-certified hospice since Nov 17, 2022.
- CMS doesn’t list its type of ownership.
- No For hospices, home health agencies, hospitals and dialysis facilities, CMS writes deficiencies at two levels. Standard is the usual one; condition-level is the more serious, when a problem is serious enough that the provider doesn’t meet a whole condition of taking part in Medicare. Source: CMS, State Operations Manual. deficiency or CMS’s most serious finding: the place’s failure to meet a rule caused, or was likely to cause, serious injury, harm, impairment or death to someone in its care. Source: CMS; 42 CFR 489.3. on record in the last three years.
CMS, Hospice General Information. Released Aug 26, 2026. Updated quarterly.
CMS, QCOR hospice inspection reports. Released Oct 23, 2026. Updated quarterly.
Has anything been proven against it?
- CMS doesn’t publish fines or other penalties for hospices, so none are shown.
- 0 deficiencies cited in the last three years came from inspections that included a complaint investigation.
CMS, QCOR hospice inspection reports. Released Oct 23, 2026. Updated quarterly.
Who does the caring?
- From Medicare claims (Jan 1, 2023 to Dec 31, 2024): 20.9 nurse care minutes per routine home care day, 7.8% of skilled nursing minutes at weekends and a visit near death for 100% of patients who died.
- Where its patients were cared for (Jan 1, 2024 to Dec 31, 2024): 55% at home, 42% in assisted living, 1% in a nursing facility, 1% in a skilled nursing facility, 1% in a hospital.
CMS, Hospice Provider Data. Released Aug 26, 2026. Updated quarterly.
| Measure | This provider |
|---|---|
| Nurse care minutes per routine home care day | 20.9 min |
| Skilled nursing minutes at weekends | 7.8% |
| Visits near death | 100.0% of patients who died |
Who owns it?
- Endeavor Hospice Group, LLC owns 100% directly since Jan 10, 2023.
- 9 owners or officers are people: David M Rodgers (owns 5% or more through other companies, 100%); David M Rodgers (corporate director, 100%); Katherine M Gerdes (managing employee (on the payroll)); David M Rodgers (corporate officer); David M Rodgers (managing employee (on the payroll)); Joseph H Hunt (corporate officer, 0%); Charlene A Tidd (managing employee (on the payroll), 0%); Gerard Brophy Chamberlin (managing employee (under contract), 0%); Armen Derian (managing employee (under contract), 0%).
- No private-equity firm among the owners CMS lists.
- No real-estate investment trust among the owners CMS lists.
CMS, Hospice All Owners and Hospice Enrollments. Released Sep 29, 2026. Updated quarterly.
| Organisation | Role | Share | Since |
|---|---|---|---|
| Mission Lakes, LLC | Owns 5% or more through other companies | 100% | Jan 24, 2023 |
| Endeavor Hospice Group, LLC | Owns 5% or more directly | 100% | Jan 10, 2023 |
What do families say?
- CMS gives no family caregiver survey rating: “The number of cases is too small to report Star Ratings.”
- CMS’s Hospice Care Index: 9 of 10 (Jan 1, 2023 to Dec 31, 2024).
- 95.52% of patients were assessed on all seven of CMS’s measures at the start of care (Oct 1, 2024 to Sep 30, 2025); 85.9% had visits from a nurse or social worker on at least 2 of their last 3 days (Jan 1, 2023 to Dec 31, 2024).
CMS, CAHPS Hospice Survey and Hospice Provider Data. Released Aug 26, 2026. Updated quarterly.
| Measure | Rating |
|---|---|
| Family caregiver survey ratingCMS star rating from its survey of patients’ family caregivers, 1 to 5 | Not rated |
| Hospice Care IndexCMS’s Hospice Care Index, 0 to 10 (higher is better): a point for each of ten measures from Medicare claims on which the hospice meets CMS’s threshold | 9 of 10 |
How does it compare nearby?
- Of the 88 hospices CMS’s data show serving patients in ZIP code 85206, where this hospice’s office is, the middle number of deficiencies cited in the last three years was 5; this one had 12.
CMS, Hospice ZIP Data. Released Aug 26, 2026. Updated quarterly.
CMS, QCOR hospice inspection reports. Released Oct 23, 2026. Updated quarterly.
| Place | Deficiencies, 3 years |
|---|---|
| Vital Hc, Inc. | 10 |
| Endeavor Hospice This hospice | 12 |
| Arizona Life Hospice | 0 |
| Americare Hospice and Palliative Care | Not given |
| Casa De La Luz East Valley | Not given |
| Aegis Hospice, Inc. | Not given |
| Hospice at Home of Arizona, LLC | Not given |
| Enhabit Hospice | Not given |
| Holy Cross Hospice | Not given |
| Hospice of America, LLC | Not given |
| Anthem Hospice Care | 3 |
| Ahc Home Health of Arizona, LLC | 4 |
What the record doesn’t say
- CMS doesn’t publish fines or other penalties for hospices, so none are shown.
- Only complaints that led to a citation appear; complaints that didn’t aren’t published.
- CMS ended its Special Focus Program for hospices with serious problems on Feb 14, 2025, so no hospice is marked as one.
- Hospice quality measures have a gap from October 2025: CMS replaced its patient assessment then, and public results from the new one (HOPE) are expected around November 2027.
Sources
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Centers for Medicare & Medicaid Services, Hospice General Information (yc9t-dgbk).
Released Aug 26, 2026 and checked Oct 27, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Hospice Provider Data (252m-zfp9).
Released Aug 26, 2026 and checked Oct 27, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, CAHPS Hospice Survey (gxki-hrr8).
Released Aug 26, 2026 and checked Oct 27, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, QCOR hospice inspection reports (Hospice Survey Reports - Oct 2021 through Sep 2026.xlsx).
Released Oct 23, 2026 and checked Oct 27, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Hospice All Owners (e983965e-1603-4cb8-82b5-c40090e380d1).
Released Sep 29, 2026 and checked Oct 27, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Hospice Enrollments (25704213-e833-4b8b-9dbc-58dd17149209).
Released Sep 29, 2026 and checked Oct 27, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Hospice ZIP Data (95rg-2usp).
Released Aug 26, 2026 and checked Oct 27, 2026. Updated quarterly. Public domain (U.S. Government work).
If you believe something here is wrong, a correction starts with the agency whose record this copies: CMS. CMS’s own record is on Care Compare. If Hearth Record copied something wrongly, it will fix it and log the correction publicly, with its date: how corrections work.
This copy of the record was made on Oct 27, 2026.
From the hospice
The public record above comes first. Anything the hospice adds will appear here, below it, and say who wrote it.
Replies
None. Replies aren’t open yet. When they open, the hospice will be able to answer any finding for free, and the reply will show beside that finding, unedited and dated.
Paid listing
None. Paid listings aren’t open yet. When they open, anything paid for will say “Paid by the hospice”, and paying will never change a finding, a rating or the order of results.