17 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Phoenix, AZ
2-star overall rating with 1-star inspections with 17 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
15810 South 42nd Street, Phoenix, AZ
(480) 759-0358
Overall
2 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Beds
192
Certified beds
Average residents
120
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Pacs Group
Operator or chain grouping
Approved since
2008-05-29
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
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
RN hours / resident day
0.21
Registered nurse staffing · state 0.72 · national 0.68
LPN hours / resident day
1.14
Licensed practical nurse staffing · state 1.04 · national 0.87
Aide hours / resident day
1.82
Nurse aide staffing · state 2.36 · national 2.35
Total nurse hours
3.17
All reported nurse hours · state 4.12 · national 3.89
Licensed hours
1.35
RN + LPN hours · state 1.76 · national 1.54
Weekend hours
3.15
Weekend nurse staffing · state 3.62 · national 3.43
Weekend RN hours
0.27
Weekend registered nurse coverage · state 0.51 · national 0.47
Physical therapist
0.09
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.23
CMS adjusted RN staffing hours
Adjusted total hours
3.52
CMS adjusted total nurse staffing hours
Case-mix index
1.23
Higher values indicate more complex resident acuity
RN turnover
67%
Annual RN turnover · state 45% · national 45%
Total nurse turnover
56%
Annual nurse turnover · state 48% · national 46%
SNF VBP
Program rank
8,842
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
25.50
Composite VBP score used to determine payment impact.
Payment multiplier
0.9838
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
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
3.81
Baseline 65.91% · Performance 48.19% · Measure score 3.81 · Achievement 3.79 · Improvement 3.81
Adjusted total nurse staffing
1.28
Baseline 3.20 hours · Performance 3.44 hours · Measure score 1.28 · Achievement 1.28 · Improvement 0.44
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.65% |
10.72%
0.1 pts better
|
No Different than the National Rate · Eligible stays 49 · Observed rate 12.24% · Lower 95% interval 6.54% |
| Discharge to community | 50.67% |
50.57%
0.1 pts better
|
No Different than the National Rate · Eligible stays 52 · Observed rate 34.62% · Lower 95% interval 36.28% |
| Medicare spending per beneficiary | 1.01 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 64 · Denominator 64 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 64 |
| Discharge self-care score | 71.79% |
53.69%
18.1 pts better
|
Numerator 28 · Denominator 39 |
| Discharge mobility score | 56.41% |
50.94%
5.5 pts better
|
Numerator 22 · Denominator 39 |
| Pressure ulcers or injuries, new or worsened | 4.69% |
2.29%
2.4 pts worse
|
Numerator 3 · Denominator 64 · Adjusted rate 5.04% |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 23 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 107 |
| Staff flu vaccination coverage | 5.73% |
42%
36.3 pts worse
|
Numerator 11 · Denominator 192 |
| Discharge function score | 74.36% |
56.45%
17.9 pts better
|
Numerator 29 · Denominator 39 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 36 · Denominator 36 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 13 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 22.22% |
25.2%
3 pts worse
|
Numerator 12 · Denominator 54 |
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.4% |
97.1%
2.3 pts better
|
93.4%
6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 98.6% · Q3 98.7% · Q4 100.0% · 4Q avg 99.4% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 98.9% |
94.6%
4.3 pts better
|
95.5%
3.4 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 98.9% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.6% |
2.1%
0.5 pts better
|
3.3%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.5% · Q2 1.4% · Q3 1.3% · Q4 2.2% · 4Q avg 1.6% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 10.1% |
4.2%
5.9 pts worse
|
11.4%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.5% · Q2 13.4% · Q3 17.1% · Q4 2.4% · 4Q avg 10.1% |
| Percentage of long-stay residents who lose too much weight | 1.9% |
5.3%
3.4 pts better
|
5.4%
3.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.3% · Q2 4.4% · Q3 0.0% · Q4 0.0% · 4Q avg 1.9% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 18.2% |
20.5%
2.3 pts better
|
19.6%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 16.1% · Q2 23.5% · Q3 19.7% · Q4 14.1% · 4Q avg 18.2% |
| Percentage of long-stay residents who received an antipsychotic medication | 6.1% |
11.8%
5.7 pts better
|
16.7%
10.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.3% · Q2 8.3% · Q3 4.3% · Q4 3.6% · 4Q avg 6.1% · 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 | 14.1% |
14.5%
0.4 pts better
|
16.3%
2.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q2 15.4% · Q3 27.7% · Q4 8.8% · 4Q avg 14.1% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 7.5% |
10.8%
3.3 pts better
|
14.9%
7.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.8% · Q2 1.6% · Q3 16.1% · Q4 9.6% · 4Q avg 7.5% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.4% |
0.9%
0.5 pts better
|
1.0%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.7% · Q3 0.0% · Q4 0.0% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.7% |
1.2%
0.5 pts better
|
1.7%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.5% · Q2 0.0% · Q3 0.0% · Q4 1.2% · 4Q avg 0.7% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 19.4% |
20.5%
1.1 pts better
|
19.8%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 32.9% · Q2 25.0% · Q3 8.8% · Q4 12.7% · 4Q avg 19.4% |
| Percentage of long-stay residents with pressure ulcers | 9.7% |
4.8%
4.9 pts worse
|
5.1%
4.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.3% · Q2 5.2% · Q3 16.9% · Q4 9.1% · 4Q avg 9.7% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 98.0% |
91.1%
6.9 pts better
|
81.7%
16.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 97.4% · Q2 96.9% · Q3 98.6% · Q4 99.0% · 4Q avg 98.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 2.8% |
10.7%
7.9 pts better
|
12.0%
9.2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 2.8% · Observed 3.0% · Expected 12.1% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.1%
1.1 pts better
|
1.6%
1.6 pts better
|
Short 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 short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 95.4% |
87.3%
8.1 pts better
|
79.7%
15.7 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 95.4% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 20.3% |
24.6%
4.3 pts better
|
23.9%
3.6 pts better
|
Short Stay · 20240701-20250630 · Adjusted 20.3% · Observed 21.2% · Expected 24.9% · Used in QM five-star |
Survey summary
Top issue: Quality of Life and Care (4 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Top issue: Quality of Life and Care (5 deficiencies)
2 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Top issue: Quality of Life and Care (5 deficiencies)
9 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Fire safety
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 2023-10-27
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2023-10-27
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-10-27
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-10-27
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2022-07-21
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-07-21
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2020-04-15
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2020-04-15
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2020-04-15
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2020-04-15
Fire Safety
Provide properly protected cooking facilities.
Corrected 2020-04-15
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2020-04-15
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2020-04-15
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2020-04-15
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2020-04-15
Inspection history
Health
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Corrected 2025-09-11
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2025-04-04
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2025-04-04
Health
Respond appropriately to all alleged violations.
Corrected 2025-04-04
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2024-04-23
Health
Respond appropriately to all alleged violations.
Corrected 2024-05-10
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2024-05-10
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-04-29
Health
Provide and implement an infection prevention and control program.
Corrected 2024-04-26
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2024-05-14
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2023-11-30
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-11-30
Health
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.
Corrected 2023-11-30
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-11-30
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2023-11-30
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2023-11-30
Health
Provide activities to meet all resident's needs.
Corrected 2023-11-30
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2023-11-30
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2023-11-30
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2023-11-30
Health
Provide timely, quality laboratory services/tests to meet the needs of residents.
Corrected 2023-11-30
Health
Provide and implement an infection prevention and control program.
Corrected 2023-11-30
Health
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
Corrected 2023-11-30
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-08-17
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2023-07-18
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2023-05-05
Health
Ensure each resident receives an accurate assessment.
Corrected 2022-07-25
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2022-07-25
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2022-07-25
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2022-07-25
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2022-07-25
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 2022-07-25
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2022-07-25
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2022-07-25
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2022-07-25
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2022-07-25
Health
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected 2022-07-25
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2022-07-25
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2022-07-25
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2020-04-10
Health
Ensure each resident receives an accurate assessment.
Corrected 2020-04-10
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2020-04-10
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2020-04-10
Penalties and ownership
5% Or Greater Direct Ownership Interest · Organization
Corporate Officer · Individual
5% Or Greater Indirect Ownership Interest · Individual
Corporate Officer · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Corporate Officer · Individual
5% Or Greater Indirect Ownership Interest · Individual
5% Or Greater Indirect Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Organization
Operational/Managerial Control · Individual
5% Or Greater Security Interest · Organization
Nearby options
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Chandler, AZ
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