Cycle 1
Health 2024-11-20 · Fire 2024-11-20
2 health deficiencies
Top issue: Nursing and Physician Services (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Mesa, AZ
Alta Mesa Health And Rehabilitation
5-star overall rating with 4-star inspections with 2 recent health deficiencies
5848 East University Drive, Mesa, AZ
(480) 981-0098
Overall
5 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
70
Certified beds
Average residents
62
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
The Ensign Group
Operator or chain grouping
Approved since
1988-08-02
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
329 facilities
Chain averages 3 overall / 3 health / 3 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
Hours and turnover
RN hours / resident day
0.69
Registered nurse staffing · state 0.72 · national 0.68
LPN hours / resident day
1.05
Licensed practical nurse staffing · state 1.04 · national 0.87
Aide hours / resident day
2.45
Nurse aide staffing · state 2.36 · national 2.35
Total nurse hours
4.18
All reported nurse hours · state 4.12 · national 3.89
Licensed hours
1.74
RN + LPN hours · state 1.76 · national 1.54
Weekend hours
3.58
Weekend nurse staffing · state 3.62 · national 3.43
Weekend RN hours
0.40
Weekend registered nurse coverage · state 0.51 · national 0.47
Physical therapist
0.16
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.65
CMS adjusted RN staffing hours
Adjusted total hours
3.98
CMS adjusted total nurse staffing hours
Case-mix index
1.44
Higher values indicate more complex resident acuity
RN turnover
43%
Annual RN turnover · state 45% · national 45%
Total nurse turnover
44%
Annual nurse turnover · state 48% · national 46%
SNF VBP
Value-based purchasing
Program rank
2,785
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
47.75
Composite VBP score used to determine payment impact.
Payment multiplier
1.0014
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
8.42
Baseline 16.44% · Performance 17.53% · Measure score 8.42 · Achievement 8.42 · Improvement 0
Healthcare-associated infections
7.16
Baseline 5.94% · Performance 5.70% · Measure score 7.16 · Achievement 7.16 · Improvement 2.12
Total nurse turnover
2.42
Baseline 67.74% · Performance 55.22% · Measure score 2.42 · Achievement 2.07 · Improvement 2.42
Adjusted total nurse staffing
1.10
Baseline 3.54 hours · Performance 3.39 hours · Measure score 1.10 · Achievement 1.10 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.31% |
10.72%
0.6 pts worse
|
No Different than the National Rate · Eligible stays 189 · Observed rate 11.64% · Lower 95% interval 8.25% |
| Discharge to community | 65.04% |
50.57%
14.5 pts better
|
Better than the National Rate · Eligible stays 172 · Observed rate 63.37% · Lower 95% interval 56.13% |
| Medicare spending per beneficiary | 0.77 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 150 · Denominator 150 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 150 |
| Discharge self-care score | 67.59% |
53.69%
13.9 pts better
|
Numerator 73 · Denominator 108 |
| Discharge mobility score | 53.7% |
50.94%
2.8 pts better
|
Numerator 58 · Denominator 108 |
| Pressure ulcers or injuries, new or worsened | 0.67% |
2.29%
1.6 pts better
|
Numerator 1 · Denominator 150 · Adjusted rate 0.52% |
| Healthcare-associated infections requiring hospitalization | 5.7% |
7.12%
1.4 pts better
|
No Different than the National Rate · Eligible stays 107 · Observed rate 3.74% · Lower 95% interval 3.63% |
| Staff COVID-19 vaccination coverage | 2.54% |
8.2%
5.7 pts worse
|
Numerator 3 · Denominator 118 |
| Staff flu vaccination coverage | 54.79% |
42%
12.8 pts better
|
Numerator 80 · Denominator 146 |
| Discharge function score | 66.67% |
56.45%
10.2 pts better
|
Numerator 72 · Denominator 108 |
| Transfer of health information to provider | 99.13% |
95.95%
3.2 pts better
|
Numerator 114 · Denominator 115 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 19 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 21.92% |
25.2%
3.3 pts worse
|
Numerator 16 · Denominator 73 |
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 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 4.2% |
2.1%
2.1 pts worse
|
3.3%
0.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 4.2% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 3.0% |
4.2%
1.2 pts better
|
11.4%
8.4 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 3.0% |
| Percentage of long-stay residents who lose too much weight | 3.3% |
5.3%
2 pts better
|
5.4%
2.1 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 3.3% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 21.0% |
20.5%
0.5 pts worse
|
19.6%
1.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 21.0% |
| Percentage of long-stay residents who received an antipsychotic medication | 0.0% |
11.8%
11.8 pts better
|
16.7%
16.7 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% · 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 · 4Q avg 0.0% |
| Percentage of long-stay residents whose need for help with daily activities has increased | 1.9% |
10.8%
8.9 pts better
|
14.9%
13 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 1.9% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.3% |
0.9%
0.4 pts worse
|
1.0%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 1.3% · 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 · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 38.3% |
20.5%
17.8 pts worse
|
19.8%
18.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 38.3% |
| Percentage of long-stay residents with pressure ulcers | 3.1% |
4.8%
1.7 pts better
|
5.1%
2 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 3.1% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.0% |
91.1%
7.9 pts better
|
81.7%
17.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 98.8% · Q3 98.1% · Q4 99.1% · 4Q avg 99.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 5.9% |
10.7%
4.8 pts better
|
12.0%
6.1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 5.9% · Observed 6.1% · Expected 11.5% · 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 | 93.6% |
87.3%
6.3 pts better
|
79.7%
13.9 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 93.6% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 25.3% |
24.6%
0.7 pts worse
|
23.9%
1.4 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 25.3% · Observed 25.3% · Expected 23.8% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-09-15 · Fire 2023-09-15
4 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2022-08-04 · Fire 2022-08-04
5 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (2 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2022-08-04
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2022-09-12
Inspection history
Recent health citations
E · Potential for more than minimal harm
2024-11-20
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2025-01-03
D · Potential for more than minimal harm
2024-11-20
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-01-03
E · Potential for more than minimal harm
2023-09-15
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 2023-10-23
D · Potential for more than minimal harm
2023-09-15
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2023-10-23
D · Potential for more than minimal harm
2023-09-15
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-10-23
D · Potential for more than minimal harm
2023-09-15
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 2023-10-23
E · Potential for more than minimal harm
2022-08-04
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2022-09-16
D · Potential for more than minimal harm
2022-08-04
F606 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Not hire anyone with a finding of abuse, neglect, exploitation, or theft.
Corrected 2022-09-16
D · Potential for more than minimal harm
2022-08-04
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2022-09-16
D · Potential for more than minimal harm
2022-08-04
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2022-09-16
D · Potential for more than minimal harm
2022-08-04
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2022-09-16
Penalties and ownership
What sits behind the stars
Ownership
Bandera Healthcare LLC
5% Or Greater Direct Ownership Interest · Organization
The Ensign Group Inc
5% Or Greater Indirect Ownership Interest · Organization
Burnam, Soon
Corporate Officer · Individual
King, Bret
Operational/Managerial Control · Individual
Monks, Chandler
Corporate Officer · Individual
Nandipati, Harish
Operational/Managerial Control · Individual
Peterson, Forrest
Corporate Officer · Individual
Sato, Ami
Corporate Officer · Individual
Nearby options
Other facilities in reach
#1
Advanced Healthcare Of Mesa
Mesa, AZ
5-star overall rating with 5-star inspections with 1 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#2
Desert Blossom Health & Rehab Center
Mesa, AZ
4-star overall rating with 3-star inspections with $8,278 in total fines with 9 recent health deficiencies
#3
Mi Casa Nursing Center
Mesa, AZ
3-star overall rating with 2-star inspections with abuse icon flag with $6,510 in total fines with 8 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
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