Cycle 1
Health 2025-05-30 · Fire 2025-05-30
2 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fountain Hills, AZ
Fountain Hills Post Acute
5-star overall rating with 5-star inspections with 2 recent health deficiencies
16300 East Keith Mcmahan Drive, Fountain Hills, AZ
(480) 836-4800
Overall
5 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
64
Certified beds
Average residents
46
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
The Ensign Group
Operator or chain grouping
Approved since
2001-11-26
CMS approved date
Coverage
Medicare
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
0.95
Registered nurse staffing · state 0.72 · national 0.68
LPN hours / resident day
1.11
Licensed practical nurse staffing · state 1.04 · national 0.87
Aide hours / resident day
1.66
Nurse aide staffing · state 2.36 · national 2.35
Total nurse hours
3.72
All reported nurse hours · state 4.12 · national 3.89
Licensed hours
2.06
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
0.27
Weekend registered nurse coverage · state 0.51 · national 0.47
Physical therapist
0.23
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.96
CMS adjusted RN staffing hours
Adjusted total hours
3.75
CMS adjusted total nurse staffing hours
Case-mix index
1.35
Higher values indicate more complex resident acuity
RN turnover
22%
Annual RN turnover · state 45% · national 45%
Total nurse turnover
44%
Annual nurse turnover · state 48% · national 46%
SNF VBP
Value-based purchasing
Program rank
4,202
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
40.94
Composite VBP score used to determine payment impact.
Payment multiplier
0.9938
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
3.33
Baseline 22.96% · Performance 20.69% · Measure score 3.33 · Achievement 1.61 · Improvement 3.33
Healthcare-associated infections
8.19
Baseline 8.08% · Performance 5.40% · Measure score 8.19 · Achievement 8.15 · Improvement 8.19
Total nurse turnover
3.60
Performance 48.98% · Measure score 3.60 · Achievement 3.60 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
1.26
Baseline 5.44 hours · Performance 3.44 hours · Measure score 1.26 · Achievement 1.26 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.52% |
10.72%
0.2 pts better
|
No Different than the National Rate · Eligible stays 379 · Observed rate 9.23% · Lower 95% interval 8.24% |
| Discharge to community | 63.87% |
50.57%
13.3 pts better
|
Better than the National Rate · Eligible stays 359 · Observed rate 60.17% · Lower 95% interval 59.45% |
| Medicare spending per beneficiary | 0.86 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 178 · Denominator 178 |
| Falls with major injury | 0.56% |
0.77%
0.2 pts better
|
Numerator 1 · Denominator 178 |
| Discharge self-care score | 64.41% |
53.69%
10.7 pts better
|
Numerator 76 · Denominator 118 |
| Discharge mobility score | 54.24% |
50.94%
3.3 pts better
|
Numerator 64 · Denominator 118 |
| Pressure ulcers or injuries, new or worsened | 2.29% |
2.29%
About the same
|
Numerator 4 · Denominator 175 · Adjusted rate 3.07% |
| Healthcare-associated infections requiring hospitalization | 5.4% |
7.12%
1.7 pts better
|
No Different than the National Rate · Eligible stays 182 · Observed rate 3.3% · Lower 95% interval 3.51% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 82 |
| Staff flu vaccination coverage | 21.55% |
42%
20.4 pts worse
|
Numerator 25 · Denominator 116 |
| Discharge function score | 73.73% |
56.45%
17.3 pts better
|
Numerator 87 · Denominator 118 |
| Transfer of health information to provider | 94.12% |
95.95%
1.8 pts worse
|
Numerator 112 · Denominator 119 |
| Transfer of health information to patient | 76.47% |
96.28%
19.8 pts worse
|
Numerator 39 · Denominator 51 |
| Resident COVID-19 vaccinations up to date | 52.13% |
25.2%
26.9 pts better
|
Numerator 49 · Denominator 94 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 97.5% |
97.1%
0.4 pts better
|
93.4%
4.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q3 95.5% · Q4 100.0% · 4Q avg 97.5% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 95.0% |
94.6%
0.4 pts better
|
95.5%
0.5 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 95.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 10.1% |
2.1%
8 pts worse
|
3.3%
6.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q3 13.6% · Q4 14.3% · 4Q avg 10.1% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 8.3% |
4.2%
4.1 pts worse
|
11.4%
3.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q3 5.0% · 4Q avg 8.3% |
| Percentage of long-stay residents who lose too much weight | 4.3% |
5.3%
1 pts better
|
5.4%
1.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q3 5.0% · 4Q avg 4.3% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 15.7% |
20.5%
4.8 pts better
|
19.6%
3.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q3 10.0% · 4Q avg 15.7% |
| Percentage of long-stay residents who received an antipsychotic medication | 20.4% |
11.8%
8.6 pts worse
|
16.7%
3.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 20.4% · 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 · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| 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 · 4Q avg 6.2% · Used in QM five-star |
| 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 · Q3 0.0% · 4Q avg 0.0% · Used in QM five-star |
| 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 · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 15.4% |
20.5%
5.1 pts better
|
19.8%
4.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q3 27.4% · 4Q avg 15.4% |
| Percentage of long-stay residents with pressure ulcers | 13.9% |
4.8%
9.1 pts worse
|
5.1%
8.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q3 8.6% · Q4 4.9% · 4Q avg 13.9% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 93.3% |
91.1%
2.2 pts better
|
81.7%
11.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 89.9% · Q2 90.2% · Q3 96.5% · Q4 96.9% · 4Q avg 93.3% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 9.1% |
10.7%
1.6 pts better
|
12.0%
2.9 pts better
|
Short Stay · 20240701-20250630 · Adjusted 9.1% · Observed 9.4% · Expected 11.4% · 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 0.6% · Q2 0.6% · Q3 0.6% · Q4 1.5% · 4Q avg 0.8% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 87.7% |
87.3%
0.4 pts better
|
79.7%
8 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 87.7% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 27.9% |
24.6%
3.3 pts worse
|
23.9%
4 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 27.9% · Observed 27.1% · Expected 23.2% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-01-25 · Fire 2024-01-25
3 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (1 deficiency)
1 fire-safety deficiencies
Top issue: Construction (1 deficiency)
Cycle 3
Health 2022-10-20 · Fire 2022-10-20
9 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (2 deficiencies)
2 fire-safety deficiencies
Top issue: Services (1 deficiency)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2024-01-25
K133 · Construction Deficiencies
Fire Safety
Install a two-hour-resistant firewall separation.
Corrected 2024-02-01
D · Potential for more than minimal harm
2022-10-20
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2022-12-05
D · Potential for more than minimal harm
2022-10-20
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2022-12-05
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-11-19
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 2025-12-01
D · Potential for more than minimal harm
2025-05-30
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 2025-07-06
D · Potential for more than minimal harm
2024-03-06
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 2024-05-08
D · Potential for more than minimal harm
2024-01-25
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-03-04
D · Potential for more than minimal harm
2024-01-25
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 2024-02-05
E · Potential for more than minimal harm
2022-10-20
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 2022-12-15
D · Potential for more than minimal harm
2022-10-20
F552 · Resident Rights Deficiencies
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2022-12-15
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 2022-12-15
D · Potential for more than minimal harm
2022-10-20
F608 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to ensure (1) employees report any suspicion of a crime against any resident, according to timelines; (2) post the notice of employee rights; and (3) prohibit and prevent retaliation for reporting.
Corrected 2022-12-15
D · Potential for more than minimal harm
2022-10-20
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2022-12-15
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 2022-12-15
D · Potential for more than minimal harm
2022-10-20
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2022-12-15
D · Potential for more than minimal harm
2022-10-20
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-12-15
D · Potential for more than minimal harm
2022-10-20
F919 · Environmental Deficiencies
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected 2022-12-15
Penalties and ownership
What sits behind the stars
Ownership
Bandera Healthcare LLC
5% Or Greater Direct Ownership Interest · Organization
Burnam, Soon
Corporate Officer · Individual
Dark Sky Holdings LLC
5% Or Greater Indirect Ownership Interest · Organization
Keetch, Chad
Corporate Officer · Individual
Monks, Conner
Operational/Managerial Control · Individual
Prabhakaran, Vinay
Operational/Managerial Control · Individual
The Ensign Group Inc
5% Or Greater Indirect Ownership Interest · Organization
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