Cycle 1
Health 2024-06-14 · Fire 2024-06-14
1 health deficiencies
Top issue: Infection Control (1 deficiency)
3 fire-safety deficiencies
Top issue: Emergency Preparedness (3 deficiencies)
Mesa, AZ
Citrus Heights Respiratory and Rehabilitation
2-star overall rating with 3-star inspections with $5,324 in total fines with 1 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
3130 East Broadway Road, Mesa, AZ
(480) 924-7777
Overall
2 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
204
Certified beds
Average residents
89
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Allegiant Healthcare
Operator or chain grouping
Approved since
1989-02-15
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
3 facilities
Chain averages 2 overall / 2 health / 2 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
0.42
Registered nurse staffing · state 0.72 · national 0.68
LPN hours / resident day
1.21
Licensed practical nurse staffing · state 1.04 · national 0.87
Aide hours / resident day
2.36
Nurse aide staffing · state 2.36 · national 2.35
Total nurse hours
4.00
All reported nurse hours · state 4.12 · national 3.89
Licensed hours
1.64
RN + LPN hours · state 1.76 · national 1.54
Weekend hours
3.60
Weekend nurse staffing · state 3.62 · national 3.43
Weekend RN hours
0.20
Weekend registered nurse coverage · state 0.51 · national 0.47
Physical therapist
0.04
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.38
CMS adjusted RN staffing hours
Adjusted total hours
3.53
CMS adjusted total nurse staffing hours
Case-mix index
1.55
Higher values indicate more complex resident acuity
RN turnover
100%
Annual RN turnover · state 45% · national 45%
Total nurse turnover
96%
Annual nurse turnover · state 48% · national 46%
SNF VBP
Value-based purchasing
Program rank
12,044
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
14.20
Composite VBP score used to determine payment impact.
Payment multiplier
0.9813
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Healthcare-associated infections
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Total nurse turnover
0
Performance 73.53% · Measure score 0 · Achievement 0 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
2.84
Baseline 3.41 hours · Performance 3.89 hours · Measure score 2.84 · Achievement 2.84 · Improvement 1.50
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | Not Available |
10.72%
|
Not Available · Eligible stays 24 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays 15 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Medicare spending per beneficiary | Not Available |
1.02
|
Too few residents or stays to report publicly. |
| Drug regimen review with follow-up | Not Available |
95.27%
|
Numerator Not Available · Denominator 19 · Too few residents or stays to report publicly. |
| Falls with major injury | Not Available |
0.77%
|
Numerator Not Available · Denominator 19 · Too few residents or stays to report publicly. |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 10 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 10 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | Not Available |
2.29%
|
Numerator Not Available · Denominator 19 · Adjusted rate Not Available · Too few residents or stays to report publicly. |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 13 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 5.71% |
8.2%
2.5 pts worse
|
Numerator 8 · Denominator 140 |
| Staff flu vaccination coverage | 14.29% |
42%
27.7 pts worse
|
Numerator 21 · Denominator 147 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 10 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 9 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 6 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 7 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 91.1% |
97.1%
6 pts worse
|
93.4%
2.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 88.5% · Q2 87.5% · Q3 90.9% · Q4 98.6% · 4Q avg 91.1% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 97.7% |
94.6%
3.1 pts better
|
95.5%
2.2 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 97.7% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.6% |
2.1%
0.5 pts better
|
3.3%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.1% · Q2 2.5% · Q3 1.5% · Q4 1.4% · 4Q avg 1.6% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 3.3% |
4.2%
0.9 pts better
|
11.4%
8.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 3.5% · Q3 3.6% · Q4 6.2% · 4Q avg 3.3% |
| Percentage of long-stay residents who lose too much weight | 0.4% |
5.3%
4.9 pts better
|
5.4%
5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.4% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.4% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 23.9% |
20.5%
3.4 pts worse
|
19.6%
4.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 24.3% · Q2 27.7% · Q3 24.1% · Q4 19.4% · 4Q avg 23.9% |
| Percentage of long-stay residents who received an antipsychotic medication | 7.2% |
11.8%
4.6 pts better
|
16.7%
9.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.3% · Q2 9.8% · Q3 2.6% · Q4 7.7% · 4Q avg 7.2% · 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 | 31.1% |
14.5%
16.6 pts worse
|
16.3%
14.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 31.1% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 18.1% |
10.8%
7.3 pts worse
|
14.9%
3.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 35.3% · Q2 47.8% · Q3 9.8% · Q4 0.0% · 4Q avg 18.1% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 5.7% |
0.9%
4.8 pts worse
|
1.0%
4.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 11.4% · Q2 8.3% · Q3 0.0% · Q4 0.0% · 4Q avg 5.7% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.3% |
1.2%
0.1 pts worse
|
1.7%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.4% · Q2 1.2% · Q3 0.0% · Q4 0.0% · 4Q avg 1.3% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 21.3% |
20.5%
0.8 pts worse
|
19.8%
1.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 16.9% · Q2 35.7% · Q3 29.0% · Q4 4.1% · 4Q avg 21.3% |
| Percentage of long-stay residents with pressure ulcers | 4.7% |
4.8%
0.1 pts better
|
5.1%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.4% · Q2 6.1% · Q3 3.2% · Q4 2.5% · 4Q avg 4.7% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 76.5% |
91.1%
14.6 pts worse
|
81.7%
5.2 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 75.9% · Q2 67.2% · Q3 73.2% · Q4 85.6% · 4Q avg 76.5% |
| Percentage of short-stay residents who newly received an antipsychotic medication | 3.1% |
1.1%
2 pts worse
|
1.6%
1.5 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 4.5% · Q2 3.6% · Q3 2.8% · Q4 2.2% · 4Q avg 3.1% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 73.1% |
87.3%
14.2 pts worse
|
79.7%
6.6 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 73.1% |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-02-10 · Fire 2023-02-10
12 health deficiencies
Top issue: Resident Assessment and Care Planning (3 deficiencies)
3 fire-safety deficiencies
Top issue: Emergency Preparedness (2 deficiencies)
Cycle 3
Health 2021-11-18 · Fire 2021-11-18
14 health deficiencies
Top issue: Resident Assessment and Care Planning (5 deficiencies)
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2024-06-14
E13 · Emergency Preparedness Deficiencies
Fire Safety
Develop Emergency Preparedness policies and procedures.
Corrected 2024-07-30
D · Potential for more than minimal harm
2024-06-14
E34 · Emergency Preparedness Deficiencies
Fire Safety
Provide a means of sharing information on occupancy/needs.
Corrected 2024-07-30
D · Potential for more than minimal harm
2024-06-14
E7 · Emergency Preparedness Deficiencies
Fire Safety
Address patient/client population and determine types of services needed.
Corrected 2024-07-30
D · Potential for more than minimal harm
2023-02-10
E37 · Emergency Preparedness Deficiencies
Fire Safety
Establish staff and initial training requirements.
Corrected 2023-05-01
D · Potential for more than minimal harm
2023-02-10
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2023-05-01
D · Potential for more than minimal harm
2023-02-10
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-05-01
D · Potential for more than minimal harm
2021-11-18
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2021-12-16
D · Potential for more than minimal harm
2021-11-18
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2021-12-16
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-02-20
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 2025-03-12
E · Potential for more than minimal harm
2024-06-14
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-07-30
E · Potential for more than minimal harm
2023-08-17
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 2023-09-20
E · Potential for more than minimal harm
2023-08-17
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2023-09-20
E · Potential for more than minimal harm
2023-08-17
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 2023-09-20
G · Actual harm
2023-07-03
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2023-08-24
E · Potential for more than minimal harm
2023-03-22
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 2023-05-05
E · Potential for more than minimal harm
2023-02-10
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 2023-05-01
E · Potential for more than minimal harm
2023-02-10
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2023-05-01
E · Potential for more than minimal harm
2023-02-10
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-05-01
E · Potential for more than minimal harm
2023-02-10
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 2023-05-01
E · Potential for more than minimal harm
2023-02-10
F725 · Nursing and Physician Services Deficiencies
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2023-05-01
E · Potential for more than minimal harm
2023-02-10
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 2023-05-01
D · Potential for more than minimal harm
2023-02-10
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2023-05-01
D · Potential for more than minimal harm
2023-02-10
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 2023-05-01
D · Potential for more than minimal harm
2023-02-10
F602 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from the wrongful use of the resident's belongings or money.
Corrected 2023-05-01
D · Potential for more than minimal harm
2023-02-10
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 2023-05-01
D · Potential for more than minimal harm
2023-02-10
F803 · Nutrition and Dietary Deficiencies
Health
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Corrected 2023-05-01
E · Potential for more than minimal harm
2021-11-18
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2021-12-09
D · Potential for more than minimal harm
2021-11-18
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2021-12-09
D · Potential for more than minimal harm
2021-11-18
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 2021-12-09
D · Potential for more than minimal harm
2021-11-18
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2021-12-09
D · Potential for more than minimal harm
2021-11-18
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 2021-12-09
D · Potential for more than minimal harm
2021-11-18
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 2021-12-09
D · Potential for more than minimal harm
2021-11-18
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2021-12-09
D · Potential for more than minimal harm
2021-11-18
F688 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected 2021-12-09
D · Potential for more than minimal harm
2021-11-18
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2021-12-09
Penalties and ownership
What sits behind the stars
$5,324
2023-07-03
Fine
Fine · fine $5,324
Fine
Ownership
Allegiant Holding C LLC
5% Or Greater Direct Ownership Interest · Organization
Berger, Eliot
5% Or Greater Indirect Ownership Interest · Individual
Fein, Ariel
5% Or Greater Indirect Ownership Interest · Individual
Langer, Irving
5% Or Greater Indirect Ownership Interest · Individual
Weintraub, Jake
5% Or Greater Indirect Ownership Interest · Individual
Bargar, Tieg
W-2 Managing Employee · Individual
Berger, Eliot
Corporate Officer · Individual
Browning, Catalina
W-2 Managing Employee · Individual
Cibc Bank Usa
5% Or Greater Security Interest · Organization
Weintraub, Jake
Corporate Officer · Individual
Nearby options
Other facilities in reach
#1
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
#2
Citadel Post Acute
Mesa, AZ
5-star overall rating with 4-star inspections with 4 recent health deficiencies
#3
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
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