Mesa, AZ

Montecito Post Acute Care and Rehabilitation

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

51 South 48th Street, Mesa, AZ

(949) 487-9500

Compare this facility

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

222

Certified beds

Average residents

193

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

The Ensign Group

Operator or chain grouping

Approved since

1986-09-17

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

1.19

Registered nurse staffing · state 0.72 · national 0.68

LPN hours / resident day

0.90

Licensed practical nurse staffing · state 1.04 · national 0.87

Aide hours / resident day

2.07

Nurse aide staffing · state 2.36 · national 2.35

Total nurse hours

4.16

All reported nurse hours · state 4.12 · national 3.89

Licensed hours

2.09

RN + LPN hours · state 1.76 · national 1.54

Weekend hours

3.58

Weekend nurse staffing · state 3.62 · national 3.43

Weekend RN hours

0.88

Weekend registered nurse coverage · state 0.51 · national 0.47

Physical therapist

0.09

Reported PT staffing · state 0.10 · national 0.07

Adjusted RN hours

0.90

CMS adjusted RN staffing hours

Adjusted total hours

3.16

CMS adjusted total nurse staffing hours

Case-mix index

1.80

Higher values indicate more complex resident acuity

RN turnover

26%

Annual RN turnover · state 45% · national 45%

Total nurse turnover

40%

Annual nurse turnover · state 48% · national 46%

SNF VBP

Value-based purchasing

Program rank

9,714

Lower is better among SNFs in the FY 2026 VBP program.

Performance score

22.74

Composite VBP score used to determine payment impact.

Payment multiplier

0.9830

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

1.73

Baseline 19.80% · Performance 20.63% · Measure score 1.73 · Achievement 1.73 · Improvement 0

Healthcare-associated infections

1.50

Baseline 9.17% · Performance 8.33% · Measure score 1.50 · Achievement 0 · Improvement 1.50

Total nurse turnover

4.98

Baseline 45.96% · Performance 43.32% · Measure score 4.98 · Achievement 4.98 · Improvement 0.75

Adjusted total nurse staffing

0.89

Baseline 2.59 hours · Performance 3.04 hours · Measure score 0.89 · Achievement 0 · Improvement 0.89

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	11.25%	10.72% 0.5 pts worse	No Different than the National Rate · Eligible stays 191 · Observed rate 15.71% · Lower 95% interval 8.05%
Discharge to community	56.19%	50.57% 5.6 pts better	No Different than the National Rate · Eligible stays 203 · Observed rate 37.93% · Lower 95% interval 46.5%
Medicare spending per beneficiary	1.17	1.02 0.1 pts worse
Drug regimen review with follow-up	98.4%	95.27% 3.1 pts better	Numerator 123 · Denominator 125
Falls with major injury	0.8%	0.77% About the same	Numerator 1 · Denominator 125
Discharge self-care score	64.06%	53.69% 10.4 pts better	Numerator 41 · Denominator 64
Discharge mobility score	53.13%	50.94% 2.2 pts better	Numerator 34 · Denominator 64
Pressure ulcers or injuries, new or worsened	1.6%	2.29% 0.7 pts better	Numerator 2 · Denominator 125 · Adjusted rate 1.04%
Healthcare-associated infections requiring hospitalization	8.33%	7.12% 1.2 pts worse	No Different than the National Rate · Eligible stays 92 · Observed rate 13.04% · Lower 95% interval 5.53%
Staff COVID-19 vaccination coverage	6.6%	8.2% 1.6 pts worse	Numerator 27 · Denominator 409
Staff flu vaccination coverage	22.79%	42% 19.2 pts worse	Numerator 98 · Denominator 430
Discharge function score	67.19%	56.45% 10.7 pts better	Numerator 43 · Denominator 64
Transfer of health information to provider	100%	95.95% 4 pts better	Numerator 74 · Denominator 74
Transfer of health information to patient	80.95%	96.28% 15.3 pts worse	Numerator 17 · Denominator 21
Resident COVID-19 vaccinations up to date	6.9%	25.2% 18.3 pts worse	Numerator 4 · Denominator 58

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Number of hospitalizations per 1000 long-stay resident days	1.9	1.7 0.2 pts worse	1.9 About the same	Long Stay · 20240701-20250630 · Adjusted 1.9 · Observed 4.2 · Expected 4.2 · Used in QM five-star
Number of outpatient emergency department visits per 1000 long-stay resident days	0.7	1.5 0.8 pts better	1.8 1.1 pts better	Long Stay · 20240701-20250630 · Adjusted 0.7 · Observed 1.0 · Expected 2.5 · Used in QM five-star
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	99.4%	97.1% 2.3 pts better	93.4% 6 pts better	Long Stay · 2024Q4-2025Q3 · Q1 98.5% · Q2 99.2% · Q3 100.0% · Q4 100.0% · 4Q avg 99.4%
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine	99.4%	94.6% 4.8 pts better	95.5% 3.9 pts better	Long Stay · 2024Q3-2025Q2 · 4Q avg 99.4%
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 1.5% · Q2 1.5% · Q3 0.8% · Q4 1.6% · 4Q avg 1.3% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms	6.7%	4.2% 2.5 pts worse	11.4% 4.7 pts better	Long Stay · 2024Q4-2025Q3 · Q1 8.2% · Q2 11.3% · Q3 4.5% · Q4 2.9% · 4Q avg 6.7%
Percentage of long-stay residents who lose too much weight	7.8%	5.3% 2.5 pts worse	5.4% 2.4 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 7.2% · Q2 10.7% · Q3 7.4% · Q4 5.7% · 4Q avg 7.8%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	29.3%	20.5% 8.8 pts worse	19.6% 9.7 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 28.6% · Q2 28.1% · Q3 30.3% · Q4 30.1% · 4Q avg 29.3%
Percentage of long-stay residents who received an antipsychotic medication	5.2%	11.8% 6.6 pts better	16.7% 11.5 pts better	Long Stay · 2024Q4-2025Q3 · Q1 6.3% · Q2 4.2% · Q3 4.3% · Q4 5.8% · 4Q avg 5.2% · Used in QM five-star
Percentage of long-stay residents who were physically restrained	2.5%	0.3% 2.2 pts worse	0.1% 2.4 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 2.3% · Q2 3.1% · Q3 2.3% · Q4 2.4% · 4Q avg 2.5%
Percentage of long-stay residents whose ability to walk independently worsened	7.2%	14.5% 7.3 pts better	16.3% 9.1 pts better	Long Stay · 2024Q4-2025Q3 · Q4 0.0% · 4Q avg 7.2% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	1.3%	10.8% 9.5 pts better	14.9% 13.6 pts better	Long Stay · 2024Q4-2025Q3 · Q1 1.1% · Q2 2.1% · Q3 0.0% · Q4 2.0% · 4Q avg 1.3% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder	0.2%	0.9% 0.7 pts better	1.0% 0.8 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.7% · Q4 0.0% · 4Q avg 0.2% · Used in QM five-star
Percentage of long-stay residents with a urinary tract infection	0.2%	1.2% 1 pts better	1.7% 1.5 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.8% · Q4 0.0% · 4Q avg 0.2% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	24.1%	20.5% 3.6 pts worse	19.8% 4.3 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 21.7% · Q2 24.1% · Q3 27.2% · Q4 23.0% · 4Q avg 24.1%
Percentage of long-stay residents with pressure ulcers	7.5%	4.8% 2.7 pts worse	5.1% 2.4 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 5.6% · Q2 6.5% · Q3 11.5% · Q4 6.2% · 4Q avg 7.5% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	99.9%	91.1% 8.8 pts better	81.7% 18.2 pts better	Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 99.8% · Q3 99.8% · Q4 100.0% · 4Q avg 99.9%
Percentage of short-stay residents who had an outpatient emergency department visit	6.7%	10.7% 4 pts better	12.0% 5.3 pts better	Short Stay · 20240701-20250630 · Adjusted 6.7% · Observed 8.5% · Expected 14.1% · Used in QM five-star
Percentage of short-stay residents who newly received an antipsychotic medication	0.0%	1.1% 1.1 pts better	1.6% 1.6 pts better	Short 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 short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	98.8%	87.3% 11.5 pts better	79.7% 19.1 pts better	Short Stay · 2024Q3-2025Q2 · 4Q avg 98.8%
Percentage of short-stay residents who were rehospitalized after a nursing home admission	15.5%	24.6% 9.1 pts better	23.9% 8.4 pts better	Short Stay · 20240701-20250630 · Adjusted 15.5% · Observed 22.0% · Expected 34.0% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2025-02-14 · Fire 2025-02-14

5 health deficiencies

Top issue: Quality of Life and Care (3 deficiencies)

1 fire-safety deficiencies

Top issue: Smoke (1 deficiency)

Cycle 2 Health 2023-08-18 · Fire 2023-08-18

2 health deficiencies

Top issue: Quality of Life and Care (1 deficiency)

0 fire-safety deficiencies

No concentrated fire-safety issue counts in this cycle.

Cycle 3 Health 2022-07-01 · Fire 2022-07-01

11 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

E · Potential for more than minimal harm 2025-02-14

K363 · Smoke Deficiencies

Fire Safety

Install corridor and hallway doors that block smoke.

Corrected 2025-04-22

Inspection history

Recent health citations

D · Potential for more than minimal harm 2025-09-04

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 2025-10-03

G · Actual harm 2025-05-20

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 2025-06-13

E · Potential for more than minimal harm 2025-02-14

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 2025-03-28

D · Potential for more than minimal harm 2025-02-14

F677 · Quality of Life and Care Deficiencies

Health

Provide care and assistance to perform activities of daily living for any resident who is unable.

Corrected 2025-03-28

D · Potential for more than minimal harm 2025-02-14

F757 · Pharmacy Service Deficiencies

Health

Ensure each resident’s drug regimen must be free from unnecessary drugs.

Corrected 2025-03-28

E · Potential for more than minimal harm 2023-11-22

F842 · Resident Assessment and Care Planning Deficiencies

Health

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Corrected 2023-12-28

D · Potential for more than minimal harm 2023-11-22

F757 · Pharmacy Service Deficiencies

Health

Ensure each resident’s drug regimen must be free from unnecessary drugs.

Corrected 2023-12-28

D · Potential for more than minimal harm 2023-08-18

F561 · Resident Rights Deficiencies

Health

Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.

Corrected 2023-09-29

D · Potential for more than minimal harm 2023-08-18

F684 · Quality of Life and Care Deficiencies

Health

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected 2023-09-29

E · Potential for more than minimal harm 2022-07-01

F686 · Quality of Life and Care Deficiencies

Health

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Corrected 2022-08-08

E · Potential for more than minimal harm 2022-07-01

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 2022-08-08

E · Potential for more than minimal harm 2022-07-01

F842 · Resident Assessment and Care Planning Deficiencies

Health

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Corrected 2022-08-08

E · Potential for more than minimal harm 2022-07-01