Cycle 1
Health 2023-11-17 · Fire 2023-11-17
9 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Mesa, AZ
Mission Palms Post Acute
3-star overall rating with 3-star inspections with 9 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
6461 East Baywood Avenue, Mesa, AZ
(480) 832-5160
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
160
Certified beds
Average residents
154
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
The Ensign Group
Operator or chain grouping
Approved since
1979-07-05
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
0.00
Registered nurse staffing
LPN hours / resident day
0.00
Licensed practical nurse staffing
Aide hours / resident day
0.00
Nurse aide staffing
Total nurse hours
0.00
All reported nurse hours
Licensed hours
0.00
RN + LPN hours
Weekend hours
0.00
Weekend nurse staffing
Weekend RN hours
0.00
Weekend registered nurse coverage
Physical therapist
0.00
Reported PT staffing
Adjusted RN hours
0.00
CMS adjusted RN staffing hours
Adjusted total hours
0.00
CMS adjusted total nurse staffing hours
Case-mix index
0.00
Higher values indicate more complex resident acuity
RN turnover
11%
Annual RN turnover · state 45% · national 45%
Total nurse turnover
38%
Annual nurse turnover · state 48% · national 46%
SNF VBP
Value-based purchasing
Program rank
2,489
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
49.48
Composite VBP score used to determine payment impact.
Payment multiplier
1.0034
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
5.93
Baseline 18.34% · Performance 18.68% · Measure score 5.93 · Achievement 5.93 · Improvement 0
Healthcare-associated infections
7.05
Baseline 9.41% · Performance 6.08% · Measure score 7.05 · Achievement 5.88 · Improvement 7.05
Total nurse turnover
6.23
Baseline 42.98% · Performance 38.21% · Measure score 6.23 · Achievement 6.23 · Improvement 2.13
Adjusted total nurse staffing
0.58
Baseline 3.33 hours · Performance 3.24 hours · Measure score 0.58 · Achievement 0.58 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 12.08% |
10.72%
1.4 pts worse
|
No Different than the National Rate · Eligible stays 221 · Observed rate 14.93% · Lower 95% interval 9.25% |
| Discharge to community | 64.14% |
50.57%
13.6 pts better
|
Better than the National Rate · Eligible stays 204 · Observed rate 56.37% · Lower 95% interval 55.88% |
| Medicare spending per beneficiary | 0.84 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 110 · Denominator 110 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 110 |
| Discharge self-care score | 70.51% |
53.69%
16.8 pts better
|
Numerator 55 · Denominator 78 |
| Discharge mobility score | 56.41% |
50.94%
5.5 pts better
|
Numerator 44 · Denominator 78 |
| Pressure ulcers or injuries, new or worsened | 1.82% |
2.29%
0.5 pts better
|
Numerator 2 · Denominator 110 · Adjusted rate 1.67% |
| Healthcare-associated infections requiring hospitalization | 6.08% |
7.12%
1 pts better
|
No Different than the National Rate · Eligible stays 108 · Observed rate 4.63% · Lower 95% interval 3.37% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 256 |
| Staff flu vaccination coverage | 8.14% |
42%
33.9 pts worse
|
Numerator 24 · Denominator 295 |
| Discharge function score | 73.08% |
56.45%
16.6 pts better
|
Numerator 57 · Denominator 78 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 84 · Denominator 84 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 10 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 1.85% |
25.2%
23.3 pts worse
|
Numerator 1 · Denominator 54 |
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 | 99.1% |
94.6%
4.5 pts better
|
95.5%
3.6 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 99.1% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.3% |
2.1%
0.8 pts better
|
3.3%
2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.0% · Q2 1.0% · Q3 1.1% · Q4 2.2% · 4Q avg 1.3% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 34.4% |
4.2%
30.2 pts worse
|
11.4%
23 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 38.4% · Q2 34.5% · Q3 31.6% · Q4 32.5% · 4Q avg 34.4% |
| Percentage of long-stay residents who lose too much weight | 0.0% |
5.3%
5.3 pts better
|
5.4%
5.4 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 who received an antianxiety or hypnotic medication | 23.0% |
20.5%
2.5 pts worse
|
19.6%
3.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 19.1% · Q2 21.4% · Q3 24.1% · Q4 27.8% · 4Q avg 23.0% |
| Percentage of long-stay residents who received an antipsychotic medication | 6.9% |
11.8%
4.9 pts better
|
16.7%
9.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.1% · Q2 7.0% · Q3 5.0% · Q4 8.2% · 4Q avg 6.9% · 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 | 13.0% |
14.5%
1.5 pts better
|
16.3%
3.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 22.2% · Q3 5.6% · Q4 9.4% · 4Q avg 13.0% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 2.5% |
10.8%
8.3 pts better
|
14.9%
12.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.2% · Q2 1.2% · Q3 3.8% · Q4 3.9% · 4Q avg 2.5% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.9% |
0.9%
About the same
|
1.0%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.3% · Q3 2.4% · Q4 0.0% · 4Q avg 0.9% · 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 · Q1 0.0% · Q2 0.0% · 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 | 23.2% |
20.5%
2.7 pts worse
|
19.8%
3.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 35.0% · Q2 16.5% · Q3 18.5% · Q4 21.9% · 4Q avg 23.2% |
| Percentage of long-stay residents with pressure ulcers | 4.3% |
4.8%
0.5 pts better
|
5.1%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.1% · Q2 4.3% · Q3 5.6% · Q4 3.2% · 4Q avg 4.3% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 98.1% |
91.1%
7 pts better
|
81.7%
16.4 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 95.8% · Q2 96.8% · Q3 99.3% · Q4 100.0% · 4Q avg 98.1% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 10.2% |
10.7%
0.5 pts better
|
12.0%
1.8 pts better
|
Short Stay · 20240701-20250630 · Adjusted 10.2% · Observed 11.3% · Expected 12.3% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.6% |
1.1%
0.5 pts better
|
1.6%
1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.9% · Q2 0.6% · Q3 0.0% · Q4 1.0% · 4Q avg 0.6% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 90.5% |
87.3%
3.2 pts better
|
79.7%
10.8 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 90.5% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 25.3% |
24.6%
0.7 pts worse
|
23.9%
1.4 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 25.3% · Observed 27.4% · Expected 25.8% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-09-16 · Fire 2022-09-16
2 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2021-04-02 · Fire 2021-04-02
8 health deficiencies
Top issue: Quality of Life and Care (3 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
2023-11-17
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 2024-03-01
D · Potential for more than minimal harm
2023-11-17
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-03-01
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-08-25
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-09-24
D · Potential for more than minimal harm
2025-08-20
F726 · Nursing and Physician Services Deficiencies
Health
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Corrected 2025-09-19
D · Potential for more than minimal harm
2025-05-16
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2025-06-30
D · Potential for more than minimal harm
2024-01-18
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 2024-03-03
D · Potential for more than minimal harm
2023-11-17
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2024-01-01
D · Potential for more than minimal harm
2023-11-17
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 2024-01-01
D · Potential for more than minimal harm
2023-11-17
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2024-01-01
D · Potential for more than minimal harm
2023-11-17
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2024-01-01
D · Potential for more than minimal harm
2023-11-17
F791 · Quality of Life and Care Deficiencies
Health
Provide or obtain dental services for each resident.
Corrected 2024-01-01
D · Potential for more than minimal harm
2023-11-17
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-01-01
D · Potential for more than minimal harm
2023-05-24
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2023-07-07
D · Potential for more than minimal harm
2022-09-16
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 2022-10-31
D · Potential for more than minimal harm
2022-09-16
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 2022-10-31
E · Potential for more than minimal harm
2021-04-02
F553 · Resident Rights Deficiencies
Health
Allow resident to participate in the development and implementation of his or her person-centered plan of care.
Corrected 2021-05-14
E · Potential for more than minimal harm
2021-04-02
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 2021-05-14
D · Potential for more than minimal harm
2021-04-02
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2021-05-14
D · Potential for more than minimal harm
2021-04-02
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2021-05-14
D · Potential for more than minimal harm
2021-04-02
F694 · Quality of Life and Care Deficiencies
Health
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Corrected 2021-05-14
D · Potential for more than minimal harm
2021-04-02
F881 · Infection Control Deficiencies
Health
Implement a program that monitors antibiotic use.
Corrected 2021-05-14
Penalties and ownership
What sits behind the stars
Ownership
Burnam, Soon
Corporate Officer · Individual
Gande, Lalith
Operational/Managerial Control · Individual
Keetch, Chad
Corporate Officer · Individual
Monks, Chandler
Corporate Officer · Individual
Peterson, Forrest
Corporate Officer · Individual
Wagner, Clayton
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
Mi Casa Nursing Center
Mesa, AZ
3-star overall rating with 2-star inspections with abuse icon flag with $6,510 in total fines with 8 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
#2
Springdale Village Post Acute
Mesa, AZ
1-star overall rating with 2-star inspections with 12 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#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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