Cycle 1
Health 2023-09-01 · Fire 2023-09-01
1 health deficiencies
Top issue: Infection Control (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Phoenix, AZ
North Mountain Medical And Rehabilitation Center
5-star overall rating with 5-star inspections with 1 recent health deficiencies
9155 North Third Street, Phoenix, AZ
(602) 944-1666
Overall
5 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
155
Certified beds
Average residents
157
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
The Ensign Group
Operator or chain grouping
Approved since
1983-11-02
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
1.03
Registered nurse staffing · state 0.72 · national 0.68
LPN hours / resident day
1.79
Licensed practical nurse staffing · state 1.04 · national 0.87
Aide hours / resident day
3.24
Nurse aide staffing · state 2.36 · national 2.35
Total nurse hours
6.06
All reported nurse hours · state 4.12 · national 3.89
Licensed hours
2.82
RN + LPN hours · state 1.76 · national 1.54
Weekend hours
5.50
Weekend nurse staffing · state 3.62 · national 3.43
Weekend RN hours
0.82
Weekend registered nurse coverage · state 0.51 · national 0.47
Physical therapist
0.13
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.52
CMS adjusted RN staffing hours
Adjusted total hours
3.06
CMS adjusted total nurse staffing hours
Case-mix index
2.71
Higher values indicate more complex resident acuity
RN turnover
57%
Annual RN turnover · state 45% · national 45%
Total nurse turnover
43%
Annual nurse turnover · state 48% · national 46%
SNF VBP
Value-based purchasing
Program rank
10,497
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
20.17
Composite VBP score used to determine payment impact.
Payment multiplier
0.9823
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
0
Baseline 6.98% · Performance 8.46% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
5.32
Baseline 47.06% · Performance 41.94% · Measure score 5.32 · Achievement 5.32 · Improvement 1.81
Adjusted total nurse staffing
0.73
Baseline 2.63 hours · Performance 3.02 hours · Measure score 0.73 · Achievement 0 · Improvement 0.73
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | Not Available |
10.72%
|
Not Available · Eligible stays 16 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Discharge to community | 46.8% |
50.57%
3.8 pts worse
|
No Different than the National Rate · Eligible stays 31 · Observed rate 19.35% · Lower 95% interval 26.13% |
| Medicare spending per beneficiary | 1.29 |
1.02
0.3 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 49 · Denominator 49 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 49 |
| Discharge self-care score | 84.62% |
53.69%
30.9 pts better
|
Numerator 22 · Denominator 26 |
| Discharge mobility score | 69.23% |
50.94%
18.3 pts better
|
Numerator 18 · Denominator 26 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 49 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 8.46% |
7.12%
1.3 pts worse
|
No Different than the National Rate · Eligible stays 27 · Observed rate 25.93% · Lower 95% interval 5.32% |
| Staff COVID-19 vaccination coverage | 4.24% |
8.2%
4 pts worse
|
Numerator 17 · Denominator 401 |
| Staff flu vaccination coverage | 23.64% |
42%
18.4 pts worse
|
Numerator 130 · Denominator 550 |
| Discharge function score | 92.31% |
56.45%
35.9 pts better
|
Numerator 24 · Denominator 26 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 34 · Denominator 34 |
| 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 | 14.29% |
25.2%
10.9 pts worse
|
Numerator 4 · Denominator 28 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.2 |
1.7
0.5 pts better
|
1.9
0.7 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.2 · Observed 2.7 · Expected 4.4 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.6 |
1.5
0.9 pts better
|
1.8
1.2 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.6 · Observed 1.0 · Expected 2.6 · Used in QM five-star |
| 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 | 100.0% |
94.6%
5.4 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.2% |
2.1%
0.9 pts better
|
3.3%
2.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.8% · Q3 2.3% · Q4 1.6% · 4Q avg 1.2% · 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 1.0% · Q2 0.0% · Q3 1.0% · Q4 0.0% · 4Q avg 0.5% |
| Percentage of long-stay residents who lose too much weight | 4.0% |
5.3%
1.3 pts better
|
5.4%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.8% · Q2 1.7% · Q3 5.4% · Q4 7.9% · 4Q avg 4.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 47.8% |
20.5%
27.3 pts worse
|
19.6%
28.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 47.5% · Q2 47.5% · Q3 50.4% · Q4 45.7% · 4Q avg 47.8% |
| Percentage of long-stay residents who received an antipsychotic medication | 14.4% |
11.8%
2.6 pts worse
|
16.7%
2.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 16.3% · Q2 14.3% · Q3 15.3% · Q4 12.0% · 4Q avg 14.4% · 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 | 0.0% |
14.5%
14.5 pts better
|
16.3%
16.3 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 5.6% |
10.8%
5.2 pts better
|
14.9%
9.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.7% · Q2 7.1% · Q3 2.1% · Q4 6.1% · 4Q avg 5.6% · 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 · 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 a urinary tract infection | 0.6% |
1.2%
0.6 pts better
|
1.7%
1.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.8% · Q2 0.0% · Q3 0.8% · Q4 0.8% · 4Q avg 0.6% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 20.4% |
20.5%
0.1 pts better
|
19.8%
0.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 26.7% · Q2 29.1% · Q3 10.8% · Q4 15.9% · 4Q avg 20.4% |
| Percentage of long-stay residents with pressure ulcers | 10.2% |
4.8%
5.4 pts worse
|
5.1%
5.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 9.6% · Q2 9.6% · Q3 12.5% · Q4 8.8% · 4Q avg 10.2% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.6% |
91.1%
8.5 pts better
|
81.7%
17.9 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 98.4% · Q2 100.0% · Q3 100.0% · Q4 99.5% · 4Q avg 99.6% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 8.8% |
10.7%
1.9 pts better
|
12.0%
3.2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 8.8% · Observed 12.2% · Expected 15.5% · 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 | 97.6% |
87.3%
10.3 pts better
|
79.7%
17.9 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 97.6% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 12.1% |
24.6%
12.5 pts better
|
23.9%
11.8 pts better
|
Short Stay · 20240701-20250630 · Adjusted 12.1% · Observed 19.5% · Expected 38.3% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-07-14 · Fire 2022-07-14
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 2020-02-07 · Fire 2020-02-07
0 health deficiencies
No concentrated health issue counts in this cycle.
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2020-02-07
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2020-03-06
D · Potential for more than minimal harm
2020-02-07
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2020-03-06
D · Potential for more than minimal harm
2020-02-07
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2020-03-06
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-11-25
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2026-01-09
D · Potential for more than minimal harm
2024-12-02
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 2025-01-16
E · Potential for more than minimal harm
2022-07-14
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 2022-08-31
Penalties and ownership
What sits behind the stars
Ownership
Burnam, Soon
Corporate Officer · Individual
Gandhi, Hemang
Operational/Managerial Control · Individual
Keetch, Chad
Corporate Officer · Individual
Peterson, Forrest
Corporate Officer · Individual
Postl, Jason
Operational/Managerial Control · Individual
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#3
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