Cycle 1
Health 2023-12-07 · Fire 2023-12-07
7 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (5 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Chandler, AZ
Chandler Post Acute And Rehabilitation
4-star overall rating with 3-star inspections with 6 recent health deficiencies
2121 West Elgin Street, Chandler, AZ
(480) 899-6717
Overall
4 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
120
Certified beds
Average residents
106
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
The Ensign Group
Operator or chain grouping
Approved since
1985-01-24
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
1.19
Licensed practical nurse staffing · state 1.04 · national 0.87
Aide hours / resident day
2.10
Nurse aide staffing · state 2.36 · national 2.35
Total nurse hours
3.98
All reported nurse hours · state 4.12 · national 3.89
Licensed hours
1.88
RN + LPN hours · state 1.76 · national 1.54
Weekend hours
3.30
Weekend nurse staffing · state 3.62 · national 3.43
Weekend RN hours
0.47
Weekend registered nurse coverage · state 0.51 · national 0.47
Physical therapist
0.10
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.70
CMS adjusted RN staffing hours
Adjusted total hours
4.06
CMS adjusted total nurse staffing hours
Case-mix index
1.34
Higher values indicate more complex resident acuity
RN turnover
52%
Annual RN turnover · state 45% · national 45%
Total nurse turnover
50%
Annual nurse turnover · state 48% · national 46%
SNF VBP
Value-based purchasing
Program rank
5,860
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
34.79
Composite VBP score used to determine payment impact.
Payment multiplier
0.9886
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
3.58
Baseline 21.62% · Performance 19.77% · Measure score 3.58 · Achievement 3.58 · Improvement 3.52
Healthcare-associated infections
2.06
Baseline 5.70% · Performance 7.22% · Measure score 2.06 · Achievement 2.06 · Improvement 0
Total nurse turnover
4.26
Baseline 50.91% · Performance 46.28% · Measure score 4.26 · Achievement 4.26 · Improvement 1.28
Adjusted total nurse staffing
4.02
Baseline 3.70 hours · Performance 4.22 hours · Measure score 4.02 · Achievement 4.02 · Improvement 2.02
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.67% |
10.72%
0.1 pts better
|
No Different than the National Rate · Eligible stays 144 · Observed rate 11.81% · Lower 95% interval 8.24% |
| Discharge to community | 67.48% |
50.57%
16.9 pts better
|
Better than the National Rate · Eligible stays 115 · Observed rate 60% · Lower 95% interval 57.9% |
| Medicare spending per beneficiary | 0.92 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 91 · Denominator 91 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 91 |
| Discharge self-care score | 63.33% |
53.69%
9.6 pts better
|
Numerator 38 · Denominator 60 |
| Discharge mobility score | 61.67% |
50.94%
10.7 pts better
|
Numerator 37 · Denominator 60 |
| Pressure ulcers or injuries, new or worsened | 1.1% |
2.29%
1.2 pts better
|
Numerator 1 · Denominator 91 · Adjusted rate 1.17% |
| Healthcare-associated infections requiring hospitalization | 7.22% |
7.12%
0.1 pts worse
|
No Different than the National Rate · Eligible stays 62 · Observed rate 8.06% · Lower 95% interval 4.45% |
| Staff COVID-19 vaccination coverage | 6.64% |
8.2%
1.6 pts worse
|
Numerator 15 · Denominator 226 |
| Staff flu vaccination coverage | 47.75% |
42%
5.8 pts better
|
Numerator 106 · Denominator 222 |
| Discharge function score | 65% |
56.45%
8.5 pts better
|
Numerator 39 · Denominator 60 |
| Transfer of health information to provider | 96.97% |
95.95%
1 pts better
|
Numerator 64 · Denominator 66 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 15 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 4.62% |
25.2%
20.6 pts worse
|
Numerator 3 · Denominator 65 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.5% |
97.1%
2.4 pts better
|
93.4%
6.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 98.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 99.5% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 96.4% |
94.6%
1.8 pts better
|
95.5%
0.9 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 96.4% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.1% |
2.1%
1 pts better
|
3.3%
2.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.0% · Q2 0.0% · Q3 2.2% · Q4 0.0% · 4Q avg 1.1% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.6% |
4.2%
3.6 pts better
|
11.4%
10.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 2.3% · 4Q avg 0.6% |
| Percentage of long-stay residents who lose too much weight | 6.5% |
5.3%
1.2 pts worse
|
5.4%
1.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.7% · Q2 0.0% · Q3 15.0% · Q4 4.4% · 4Q avg 6.5% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 27.1% |
20.5%
6.6 pts worse
|
19.6%
7.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 24.4% · Q2 25.0% · Q3 30.0% · Q4 28.9% · 4Q avg 27.1% |
| Percentage of long-stay residents who received an antipsychotic medication | 11.0% |
11.8%
0.8 pts better
|
16.7%
5.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.0% · Q3 15.0% · Q4 8.7% · 4Q avg 11.0% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.5% |
0.3%
0.2 pts worse
|
0.1%
0.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 2.2% · Q4 0.0% · 4Q avg 0.5% |
| Percentage of long-stay residents whose ability to walk independently worsened | 9.8% |
14.5%
4.7 pts better
|
16.3%
6.5 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 9.8% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 6.2% |
10.8%
4.6 pts better
|
14.9%
8.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.5% · Q2 15.6% · Q3 3.0% · Q4 5.1% · 4Q avg 6.2% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 4.5% |
0.9%
3.6 pts worse
|
1.0%
3.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.8% · Q2 6.5% · Q3 5.9% · Q4 4.3% · 4Q avg 4.5% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.1% |
1.2%
0.1 pts better
|
1.7%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.3% · Q3 0.0% · Q4 2.2% · 4Q avg 1.1% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 18.5% |
20.5%
2 pts better
|
19.8%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 19.8% · Q2 24.1% · Q3 10.2% · Q4 19.2% · 4Q avg 18.5% |
| Percentage of long-stay residents with pressure ulcers | 5.8% |
4.8%
1 pts worse
|
5.1%
0.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 9.2% · Q2 9.7% · Q3 2.0% · Q4 2.0% · 4Q avg 5.8% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 98.4% |
91.1%
7.3 pts better
|
81.7%
16.7 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 98.6% · Q2 98.2% · Q3 98.0% · Q4 98.8% · 4Q avg 98.4% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 13.7% |
10.7%
3 pts worse
|
12.0%
1.7 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 13.7% · Observed 14.9% · Expected 12.1% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.8% |
1.1%
0.3 pts better
|
1.6%
0.8 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.7% · Q2 0.9% · Q3 0.9% · Q4 0.6% · 4Q avg 0.8% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 90.6% |
87.3%
3.3 pts better
|
79.7%
10.9 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 90.6% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 19.3% |
24.6%
5.3 pts better
|
23.9%
4.6 pts better
|
Short Stay · 20240701-20250630 · Adjusted 19.3% · Observed 19.1% · Expected 23.6% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-10-20 · Fire 2022-10-20
8 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Cycle 3
Health 2021-06-17 · Fire 2021-06-17
7 health deficiencies
Top issue: Quality of Life and Care (2 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
2022-10-20
K321 · Smoke Deficiencies
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 2022-11-21
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-12-12
F919 · Environmental Deficiencies
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected 2026-02-12
D · Potential for more than minimal harm
2025-12-12
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2026-02-12
D · Potential for more than minimal harm
2025-11-20
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 2025-12-21
D · Potential for more than minimal harm
2025-11-20
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 2025-12-21
D · Potential for more than minimal harm
2025-11-20
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2025-12-21
D · Potential for more than minimal harm
2025-11-17
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 2025-11-16
D · Potential for more than minimal harm
2025-11-17
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2025-11-16
D · Potential for more than minimal harm
2024-11-01
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-12-16
D · Potential for more than minimal harm
2024-04-02
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-05-17
D · Potential for more than minimal harm
2023-12-07
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-03-04
D · Potential for more than minimal harm
2023-10-17
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-11-17
D · Potential for more than minimal harm
2023-05-04
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 2023-06-16
D · Potential for more than minimal harm
2022-10-20
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2022-12-02
D · Potential for more than minimal harm
2022-10-20
F578 · Resident Rights Deficiencies
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2022-10-20
D · Potential for more than minimal harm
2022-10-20
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2022-12-02
D · Potential for more than minimal harm
2022-10-20
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2022-12-02
D · Potential for more than minimal harm
2022-10-20
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 2022-12-02
D · Potential for more than minimal harm
2022-10-20
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2022-12-02
E · Potential for more than minimal harm
2021-06-17
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2021-07-30
E · Potential for more than minimal harm
2021-06-17
F761 · Pharmacy Service Deficiencies
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 2021-07-30
D · Potential for more than minimal harm
2021-06-17
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2021-07-30
D · Potential for more than minimal harm
2021-06-17
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2021-07-30
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
Jones, Brett
Operational/Managerial Control · Individual
Keetch, Chad
Corporate Officer · Individual
Monks, Chandler
Corporate Officer · Individual
Peterson, Forrest
Corporate Director · Individual
Sato, Ami
Corporate Officer · Individual
Uy, Marietta
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
Sante Of Chandler
Chandler, AZ
5-star overall rating with 4-star inspections with 5 recent health deficiencies
#2
Archstone Care Center
Chandler, AZ
5-star overall rating with 4-star inspections with 3 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#3
Desert Cove Nursing Center
Chandler, AZ
2-star overall rating with 1-star inspections with abuse icon flag with 17 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
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