9 health deficiencies
Top issue: Nursing and Physician Services (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Phoenix, AZ
4-star overall rating with 3-star inspections with 9 recent health deficiencies
4635 North 14th Street, Phoenix, AZ
(602) 264-9039
Overall
4 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Beds
107
Certified beds
Average residents
82
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
The Ensign Group
Operator or chain grouping
Approved since
1984-01-06
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Staffing
RN hours / resident day
0.85
Registered nurse staffing
LPN hours / resident day
0.75
Licensed practical nurse staffing
Aide hours / resident day
1.75
Nurse aide staffing
Weekend hours
2.91
Weekend nurse staffing
RN turnover
23%
Annual RN turnover
Total nurse turnover
35%
Annual nurse turnover
Quality measures
| 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 |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 92.3% |
94.6%
2.3 pts worse
|
95.5%
3.2 pts worse
|
Long Stay · 2024Q3-2025Q2 |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.0% |
2.1%
2.1 pts better
|
3.3%
3.3 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who have depressive symptoms | 0.8% |
4.2%
3.4 pts better
|
11.4%
10.6 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who lose too much weight | 4.8% |
5.3%
0.5 pts better
|
5.4%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 17.7% |
20.5%
2.8 pts better
|
19.6%
1.9 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antipsychotic medication | 4.5% |
11.8%
7.3 pts better
|
16.7%
12.2 pts better
|
Long Stay · 2024Q4-2025Q3 |
| 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 |
| Percentage of long-stay residents whose need for help with daily activities has increased | 6.9% |
10.8%
3.9 pts better
|
14.9%
8 pts better
|
Long Stay · 2024Q4-2025Q3 |
| 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 |
| 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 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 28.5% |
20.5%
8 pts worse
|
19.8%
8.7 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with pressure ulcers | 2.6% |
4.8%
2.2 pts better
|
5.1%
2.5 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 93.2% |
91.1%
2.1 pts better
|
81.7%
11.5 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who had an outpatient emergency department visit | 8.2% |
10.7%
2.5 pts better
|
12.0%
3.8 pts better
|
Short Stay · 20240701-20250630 |
| 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 |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 86.5% |
87.3%
0.8 pts worse
|
79.7%
6.8 pts better
|
Short Stay · 2024Q3-2025Q2 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 26.7% |
24.6%
2.1 pts worse
|
23.9%
2.8 pts worse
|
Short Stay · 20240701-20250630 |
Survey summary
Top issue: Nursing and Physician Services (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Top issue: Environmental (1 deficiency)
2 fire-safety deficiencies
Top issue: Miscellaneous (1 deficiency)
Top issue: Quality of Life and Care (3 deficiencies)
3 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Fire safety
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-01-15
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 2023-01-20
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-01-20
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 2021-09-24
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2021-09-24
Inspection history
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Not marked corrected
Health
Provide and implement an infection prevention and control program.
Corrected 2024-06-08
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2024-06-08
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2024-06-08
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-06-08
Health
Provide and implement an infection prevention and control program.
Corrected 2024-06-08
Health
Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
Corrected 2024-06-08
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2024-06-08
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-06-08
Health
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
Corrected 2024-06-08
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 2024-06-08
Health
Post nurse staffing information every day.
Corrected 2024-06-08
Health
Ensure that residents are free from significant medication errors.
Corrected 2023-12-22
Health
Provide and implement an infection prevention and control program.
Corrected 2021-09-24
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2021-09-24
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2021-09-24
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2021-09-24
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2021-09-24
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2021-09-24
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2021-09-24
Penalties and ownership
5% Or Greater Direct Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Organization
Corporate Officer · Individual
Operational/Managerial Control · Individual
Corporate Director · Individual
Corporate Officer · Individual
Operational/Managerial Control · Individual
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