Cycle 1
Health 2024-10-31 · Fire 2024-10-31
10 health deficiencies
Top issue: Resident Rights (3 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Glendale, AZ
Bella Vita Health And Rehabilitation Center
3-star overall rating with 2-star inspections with abuse icon flag with $12,735 in total fines with 10 recent health deficiencies
5125 North 58th Avenue, Glendale, AZ
(623) 931-5800
Overall
3 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
176
Certified beds
Average residents
152
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
The Ensign Group
Operator or chain grouping
Approved since
1984-03-27
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
0.25
Registered nurse staffing · state 0.72 · national 0.68
LPN hours / resident day
1.45
Licensed practical nurse staffing · state 1.04 · national 0.87
Aide hours / resident day
2.16
Nurse aide staffing · state 2.36 · national 2.35
Total nurse hours
3.85
All reported nurse hours · state 4.12 · national 3.89
Licensed hours
1.69
RN + LPN hours · state 1.76 · national 1.54
Weekend hours
3.40
Weekend nurse staffing · state 3.62 · national 3.43
Weekend RN hours
0.24
Weekend registered nurse coverage · state 0.51 · national 0.47
Physical therapist
0.08
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.27
CMS adjusted RN staffing hours
Adjusted total hours
4.13
CMS adjusted total nurse staffing hours
Case-mix index
1.28
Higher values indicate more complex resident acuity
RN turnover
46%
Annual RN turnover · state 45% · national 45%
Total nurse turnover
51%
Annual nurse turnover · state 48% · national 46%
SNF VBP
Value-based purchasing
Program rank
778
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
63.90
Composite VBP score used to determine payment impact.
Payment multiplier
1.0185
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
9.01
Baseline 26.69% · Performance 17.26% · Measure score 9.01 · Achievement 9.01 · Improvement 9
Healthcare-associated infections
8.87
Baseline 8.78% · Performance 5.23% · Measure score 8.87 · Achievement 8.70 · Improvement 8.87
Total nurse turnover
4.13
Baseline 52.35% · Performance 46.78% · Measure score 4.13 · Achievement 4.13 · Improvement 1.52
Adjusted total nurse staffing
3.54
Baseline 3.62 hours · Performance 4.09 hours · Measure score 3.54 · Achievement 3.54 · Improvement 1.67
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.48% |
10.72%
0.8 pts worse
|
No Different than the National Rate · Eligible stays 157 · Observed rate 12.74% · Lower 95% interval 8.66% |
| Discharge to community | 52.33% |
50.57%
1.8 pts better
|
No Different than the National Rate · Eligible stays 126 · Observed rate 46.03% · Lower 95% interval 45.27% |
| Medicare spending per beneficiary | 0.87 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 125 · Denominator 125 |
| Falls with major injury | 0.8% |
0.77%
About the same
|
Numerator 1 · Denominator 125 |
| Discharge self-care score | 72.41% |
53.69%
18.7 pts better
|
Numerator 63 · Denominator 87 |
| Discharge mobility score | 60.92% |
50.94%
10 pts better
|
Numerator 53 · Denominator 87 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 125 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 5.23% |
7.12%
1.9 pts better
|
No Different than the National Rate · Eligible stays 78 · Observed rate 1.28% · Lower 95% interval 2.79% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 239 |
| Staff flu vaccination coverage | 12.54% |
42%
29.5 pts worse
|
Numerator 41 · Denominator 327 |
| Discharge function score | 71.26% |
56.45%
14.8 pts better
|
Numerator 62 · Denominator 87 |
| Transfer of health information to provider | 98.51% |
95.95%
2.6 pts better
|
Numerator 66 · Denominator 67 |
| Transfer of health information to patient | 76.47% |
96.28%
19.8 pts worse
|
Numerator 26 · Denominator 34 |
| Resident COVID-19 vaccinations up to date | 6.9% |
25.2%
18.3 pts worse
|
Numerator 4 · Denominator 58 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 79.8% |
97.1%
17.3 pts worse
|
93.4%
13.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 83.3% · Q2 76.0% · Q3 75.6% · Q4 84.0% · 4Q avg 79.8% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 75.0% |
94.6%
19.6 pts worse
|
95.5%
20.5 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 75.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.0% |
2.1%
1.1 pts better
|
3.3%
2.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.0% · Q2 1.0% · Q3 1.2% · Q4 1.0% · 4Q avg 1.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.9% |
4.2%
3.3 pts better
|
11.4%
10.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.5% · Q2 1.1% · Q3 0.0% · Q4 0.0% · 4Q avg 0.9% |
| Percentage of long-stay residents who lose too much weight | 3.7% |
5.3%
1.6 pts better
|
5.4%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.2% · Q2 5.8% · Q3 4.1% · Q4 3.6% · 4Q avg 3.7% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 13.4% |
20.5%
7.1 pts better
|
19.6%
6.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.8% · Q2 16.1% · Q3 12.3% · Q4 13.1% · 4Q avg 13.4% |
| Percentage of long-stay residents who received an antipsychotic medication | 2.9% |
11.8%
8.9 pts better
|
16.7%
13.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.8% · Q2 5.7% · Q3 2.3% · Q4 1.9% · 4Q avg 2.9% · 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 | 13.9% |
14.5%
0.6 pts better
|
16.3%
2.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.6% · Q2 17.4% · Q3 14.7% · Q4 13.7% · 4Q avg 13.9% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 5.1% |
10.8%
5.7 pts better
|
14.9%
9.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.4% · Q2 4.8% · Q3 1.4% · Q4 5.1% · 4Q avg 5.1% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.0% |
0.9%
0.1 pts worse
|
1.0%
About the same
|
Long Stay · 2024Q4-2025Q3 · Q1 1.1% · Q2 0.0% · Q3 2.0% · Q4 0.9% · 4Q avg 1.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.3% |
1.2%
0.9 pts better
|
1.7%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 1.0% · 4Q avg 0.3% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 15.2% |
20.5%
5.3 pts better
|
19.8%
4.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 16.7% · Q2 20.7% · Q3 15.0% · Q4 8.2% · 4Q avg 15.2% |
| Percentage of long-stay residents with pressure ulcers | 1.2% |
4.8%
3.6 pts better
|
5.1%
3.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.1% · Q2 0.9% · Q3 0.9% · Q4 0.7% · 4Q avg 1.2% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 94.3% |
91.1%
3.2 pts better
|
81.7%
12.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 92.3% · Q2 92.7% · Q3 95.5% · Q4 96.8% · 4Q avg 94.3% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 11.7% |
10.7%
1 pts worse
|
12.0%
0.3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 11.7% · Observed 14.1% · Expected 13.4% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.2% |
1.1%
0.9 pts better
|
1.6%
1.4 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.4% · Q4 0.4% · 4Q avg 0.2% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 87.0% |
87.3%
0.3 pts worse
|
79.7%
7.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 87.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 15.3% |
24.6%
9.3 pts better
|
23.9%
8.6 pts better
|
Short Stay · 20240701-20250630 · Adjusted 15.3% · Observed 17.2% · Expected 26.8% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-03-10 · Fire 2023-03-10
2 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (2 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Cycle 3
Health 2022-02-10 · Fire 2022-02-10
9 health deficiencies
Top issue: Resident Rights (3 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2023-03-10
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-04-27
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-12-29
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 2026-02-12
D · Potential for more than minimal harm
2025-12-29
F628 · Resident Rights Deficiencies
Health
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Corrected 2026-02-12
G · Actual harm
2025-11-06
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-12-14
E · Potential for more than minimal harm
2025-03-19
F660 · Resident Assessment and Care Planning Deficiencies
Health
Plan the resident's discharge to meet the resident's goals and needs.
Corrected 2025-05-09
D · Potential for more than minimal harm
2025-03-19
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2025-05-09
D · Potential for more than minimal harm
2024-10-31
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 2024-12-16
D · Potential for more than minimal harm
2024-10-31
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2024-12-16
D · Potential for more than minimal harm
2024-10-31
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2024-12-16
D · Potential for more than minimal harm
2024-10-31
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2024-12-16
D · Potential for more than minimal harm
2024-10-31
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-12-16
D · Potential for more than minimal harm
2024-09-16
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 2024-09-23
D · Potential for more than minimal harm
2024-09-10
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 2024-09-11
E · Potential for more than minimal harm
2023-08-24
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-09-14
E · Potential for more than minimal harm
2022-02-10
F552 · Resident Rights Deficiencies
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2022-03-31
E · Potential for more than minimal harm
2022-02-10
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2022-03-31
E · Potential for more than minimal harm
2022-02-10
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2022-03-31
D · Potential for more than minimal harm
2022-02-10
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2022-03-31
D · Potential for more than minimal harm
2022-02-10
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2022-03-31
D · Potential for more than minimal harm
2022-02-10
F726 · Nursing and Physician Services Deficiencies
Health
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Corrected 2022-03-31
D · Potential for more than minimal harm
2022-02-10
F758 · Pharmacy Service Deficiencies
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 2022-03-31
D · Potential for more than minimal harm
2022-02-10
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-03-31
Penalties and ownership
What sits behind the stars
$12,735
2025-11-06
Fine
Fine · fine $12,735
Fine
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
Haney, Doug
Operational/Managerial Control · Individual
Jones, Christine
Corporate Director · Individual
Srivastava, Vinee
Operational/Managerial Control · Individual
Nearby options
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#2
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#3
Haven Of Phoenix
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4-star overall rating with 3-star inspections with 5 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
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