Cycle 1
Health 2025-02-21 · Fire 2025-02-21
4 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Mesa, AZ
Citadel Post Acute
5-star overall rating with 4-star inspections with 4 recent health deficiencies
5121 East Broadway Road, Mesa, AZ
(480) 832-5555
Overall
5 / 5
CMS overall stars
Health inspections
4 / 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
128
Certified beds
Average residents
107
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
The Ensign Group
Operator or chain grouping
Approved since
1985-03-01
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
0.51
Registered nurse staffing · state 0.72 · national 0.68
LPN hours / resident day
1.30
Licensed practical nurse staffing · state 1.04 · national 0.87
Aide hours / resident day
1.94
Nurse aide staffing · state 2.36 · national 2.35
Total nurse hours
3.75
All reported nurse hours · state 4.12 · national 3.89
Licensed hours
1.81
RN + LPN hours · state 1.76 · national 1.54
Weekend hours
3.35
Weekend nurse staffing · state 3.62 · national 3.43
Weekend RN hours
0.29
Weekend registered nurse coverage · state 0.51 · national 0.47
Physical therapist
0.17
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.52
CMS adjusted RN staffing hours
Adjusted total hours
3.79
CMS adjusted total nurse staffing hours
Case-mix index
1.35
Higher values indicate more complex resident acuity
RN turnover
44%
Annual RN turnover · state 45% · national 45%
Total nurse turnover
42%
Annual nurse turnover · state 48% · national 46%
SNF VBP
Value-based purchasing
Program rank
4,726
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
38.84
Composite VBP score used to determine payment impact.
Payment multiplier
0.9919
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
3.95
Baseline 18.04% · Performance 19.60% · Measure score 3.95 · Achievement 3.95 · Improvement 0
Healthcare-associated infections
3.22
Baseline 6.26% · Performance 6.87% · Measure score 3.22 · Achievement 3.22 · Improvement 0
Total nurse turnover
5.49
Baseline 60.30% · Performance 41.23% · Measure score 5.49 · Achievement 5.49 · Improvement 4.88
Adjusted total nurse staffing
2.87
Baseline 3.55 hours · Performance 3.90 hours · Measure score 2.87 · Achievement 2.87 · Improvement 1.04
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.35% |
10.72%
0.6 pts worse
|
No Different than the National Rate · Eligible stays 257 · Observed rate 11.67% · Lower 95% interval 8.92% |
| Discharge to community | 61.4% |
50.57%
10.8 pts better
|
Better than the National Rate · Eligible stays 206 · Observed rate 57.28% · Lower 95% interval 55.31% |
| Medicare spending per beneficiary | 0.8 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 96.91% |
95.27%
1.6 pts better
|
Numerator 157 · Denominator 162 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 162 |
| Discharge self-care score | 58.51% |
53.69%
4.8 pts better
|
Numerator 55 · Denominator 94 |
| Discharge mobility score | 53.19% |
50.94%
2.2 pts better
|
Numerator 50 · Denominator 94 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 162 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 6.87% |
7.12%
0.2 pts better
|
No Different than the National Rate · Eligible stays 128 · Observed rate 7.03% · Lower 95% interval 4.28% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 182 |
| Staff flu vaccination coverage | 8.63% |
42%
33.4 pts worse
|
Numerator 24 · Denominator 278 |
| Discharge function score | 64.89% |
56.45%
8.4 pts better
|
Numerator 61 · Denominator 94 |
| Transfer of health information to provider | 97.22% |
95.95%
1.3 pts better
|
Numerator 105 · Denominator 108 |
| Transfer of health information to patient | 94.12% |
96.28%
2.2 pts worse
|
Numerator 32 · Denominator 34 |
| Resident COVID-19 vaccinations up to date | 1.2% |
25.2%
24 pts worse
|
Numerator 1 · Denominator 83 |
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 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 75.8% |
94.6%
18.8 pts worse
|
95.5%
19.7 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 75.8% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.4% |
2.1%
0.7 pts better
|
3.3%
1.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.9% · Q3 2.1% · Q4 1.8% · 4Q avg 1.4% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.5% |
4.2%
3.7 pts better
|
11.4%
10.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 2.0% · 4Q avg 0.5% |
| Percentage of long-stay residents who lose too much weight | 2.3% |
5.3%
3 pts better
|
5.4%
3.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.3% · Q2 2.2% · Q3 0.0% · Q4 2.4% · 4Q avg 2.3% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 26.1% |
20.5%
5.6 pts worse
|
19.6%
6.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.5% · Q2 31.1% · Q3 28.9% · Q4 19.6% · 4Q avg 26.1% |
| Percentage of long-stay residents who received an antipsychotic medication | 3.4% |
11.8%
8.4 pts better
|
16.7%
13.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.2% · Q2 0.0% · Q3 7.4% · Q4 2.9% · 4Q avg 3.4% · 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 | 16.1% |
14.5%
1.6 pts worse
|
16.3%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 16.1% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 12.7% |
10.8%
1.9 pts worse
|
14.9%
2.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.9% · Q2 7.1% · Q3 11.1% · Q4 15.9% · 4Q avg 12.7% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.6% |
0.9%
0.7 pts worse
|
1.0%
0.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.3% · Q2 0.0% · Q3 2.1% · Q4 1.9% · 4Q avg 1.6% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.5% |
1.2%
0.7 pts better
|
1.7%
1.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.9% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 22.2% |
20.5%
1.7 pts worse
|
19.8%
2.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 24.6% · Q2 20.0% · Q3 25.6% · Q4 18.8% · 4Q avg 22.2% |
| Percentage of long-stay residents with pressure ulcers | 2.0% |
4.8%
2.8 pts better
|
5.1%
3.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.7% · Q2 0.0% · Q3 3.6% · Q4 3.0% · 4Q avg 2.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 95.7% |
91.1%
4.6 pts better
|
81.7%
14 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 92.2% · Q2 94.4% · Q3 97.5% · Q4 99.0% · 4Q avg 95.7% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 8.7% |
10.7%
2 pts better
|
12.0%
3.3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 8.7% · Observed 8.9% · Expected 11.5% · 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 0.6% · Q2 0.0% · Q3 0.0% · Q4 0.3% · 4Q avg 0.2% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 85.6% |
87.3%
1.7 pts worse
|
79.7%
5.9 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 85.6% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 22.2% |
24.6%
2.4 pts better
|
23.9%
1.7 pts better
|
Short Stay · 20240701-20250630 · Adjusted 22.2% · Observed 22.8% · Expected 24.4% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-04-14 · Fire 2023-04-14
1 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
3 fire-safety deficiencies
Top issue: Emergency Preparedness (1 deficiency)
Cycle 3
Health 2022-02-17 · Fire 2022-02-17
0 health deficiencies
No concentrated health issue counts in this cycle.
4 fire-safety deficiencies
Top issue: Services (2 deficiencies)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2023-04-14
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2023-05-19
D · Potential for more than minimal harm
2023-04-14
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-05-19
D · Potential for more than minimal harm
2023-04-14
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2023-05-19
D · Potential for more than minimal harm
2022-02-17
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2022-03-09
D · Potential for more than minimal harm
2022-02-17
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2022-03-09
D · Potential for more than minimal harm
2022-02-17
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2022-03-09
D · Potential for more than minimal harm
2022-02-17
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2022-03-09
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-07-18
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 2025-08-28
D · Potential for more than minimal harm
2025-02-21
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2025-04-04
D · Potential for more than minimal harm
2025-02-21
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 2025-04-04
D · Potential for more than minimal harm
2025-02-21
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-04-04
D · Potential for more than minimal harm
2023-04-14
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 2023-05-19
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
Albrechtsen, John
Corporate Officer · Individual
Burnam, Soon
Corporate Officer · Individual
Fitch, Craig
Corporate Officer · Individual
Peterson, Forrest
Corporate Director · Individual
Speth, Terry
Operational/Managerial Control · Individual
Speth, Terry
W-2 Managing Employee · Individual
Nearby options
Other facilities in reach
#1
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
#2
Montecito Post Acute Care and Rehabilitation
Mesa, AZ
4-star overall rating with 3-star inspections with $8,278 in total fines with 4 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#3
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
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