Cycle 1
Health 2024-10-10 · Fire 2024-10-10
4 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Scottsdale, AZ
Osborn Health And Rehabilitation
5-star overall rating with 4-star inspections with 3 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
3333 North Civic Center Plaza, Scottsdale, AZ
(480) 994-1333
Overall
5 / 5
CMS overall stars
Health inspections
4 / 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
130
Certified beds
Average residents
112
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
The Ensign Group
Operator or chain grouping
Approved since
1981-05-07
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
0.61
Registered nurse staffing · state 0.72 · national 0.68
LPN hours / resident day
1.02
Licensed practical nurse staffing · state 1.04 · national 0.87
Aide hours / resident day
2.58
Nurse aide staffing · state 2.36 · national 2.35
Total nurse hours
4.21
All reported nurse hours · state 4.12 · national 3.89
Licensed hours
1.63
RN + LPN hours · state 1.76 · national 1.54
Weekend hours
3.65
Weekend nurse staffing · state 3.62 · national 3.43
Weekend RN hours
0.45
Weekend registered nurse coverage · state 0.51 · national 0.47
Physical therapist
0.11
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.59
CMS adjusted RN staffing hours
Adjusted total hours
4.09
CMS adjusted total nurse staffing hours
Case-mix index
1.41
Higher values indicate more complex resident acuity
RN turnover
41%
Annual RN turnover · state 45% · national 45%
Total nurse turnover
54%
Annual nurse turnover · state 48% · national 46%
SNF VBP
Value-based purchasing
Program rank
2,062
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
52.01
Composite VBP score used to determine payment impact.
Payment multiplier
1.0065
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
9.32
Baseline 25.82% · Performance 17.11% · Measure score 9.32 · Achievement 9.32 · Improvement 9
Healthcare-associated infections
5.87
Baseline 7.37% · Performance 6.08% · Measure score 5.87 · Achievement 5.87 · Improvement 4.94
Total nurse turnover
2.91
Baseline 65.62% · Performance 51.79% · Measure score 2.91 · Achievement 2.91 · Improvement 2.89
Adjusted total nurse staffing
2.70
Baseline 4 hours · Performance 3.85 hours · Measure score 2.70 · Achievement 2.70 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.55% |
10.72%
0.2 pts better
|
No Different than the National Rate · Eligible stays 149 · Observed rate 10.07% · Lower 95% interval 7.61% |
| Discharge to community | 57.24% |
50.57%
6.7 pts better
|
Better than the National Rate · Eligible stays 138 · Observed rate 53.62% · Lower 95% interval 51% |
| Medicare spending per beneficiary | 0.96 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 118 · Denominator 118 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 118 |
| Discharge self-care score | 64.86% |
53.69%
11.2 pts better
|
Numerator 48 · Denominator 74 |
| Discharge mobility score | 55.41% |
50.94%
4.5 pts better
|
Numerator 41 · Denominator 74 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 118 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 6.08% |
7.12%
1 pts better
|
No Different than the National Rate · Eligible stays 80 · Observed rate 3.75% · Lower 95% interval 3.6% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 181 |
| Staff flu vaccination coverage | 9.31% |
42%
32.7 pts worse
|
Numerator 27 · Denominator 290 |
| Discharge function score | 68.92% |
56.45%
12.5 pts better
|
Numerator 51 · Denominator 74 |
| Transfer of health information to provider | 97.33% |
95.95%
1.4 pts better
|
Numerator 73 · Denominator 75 |
| Transfer of health information to patient | 93.33% |
96.28%
3 pts worse
|
Numerator 28 · Denominator 30 |
| Resident COVID-19 vaccinations up to date | 0% |
25.2%
25.2 pts worse
|
Numerator 0 · Denominator 67 |
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 | 98.8% |
94.6%
4.2 pts better
|
95.5%
3.3 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 98.8% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.8% |
2.1%
0.3 pts better
|
3.3%
1.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.5% · Q3 2.9% · Q4 2.7% · 4Q avg 1.8% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 20.4% |
4.2%
16.2 pts worse
|
11.4%
9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.3% · Q2 21.7% · Q3 18.5% · Q4 21.2% · 4Q avg 20.4% |
| Percentage of long-stay residents who lose too much weight | 6.4% |
5.3%
1.1 pts worse
|
5.4%
1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.1% · Q2 6.2% · Q3 4.5% · Q4 11.4% · 4Q avg 6.4% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 26.0% |
20.5%
5.5 pts worse
|
19.6%
6.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 27.7% · Q2 25.0% · Q3 21.2% · Q4 30.0% · 4Q avg 26.0% |
| Percentage of long-stay residents who received an antipsychotic medication | 0.0% |
11.8%
11.8 pts better
|
16.7%
16.7 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 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 | 9.8% |
14.5%
4.7 pts better
|
16.3%
6.5 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 9.8% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 5.1% |
10.8%
5.7 pts better
|
14.9%
9.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.2% · Q2 4.8% · Q3 3.2% · Q4 8.8% · 4Q avg 5.1% · 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 | 2.5% |
1.2%
1.3 pts worse
|
1.7%
0.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.6% · Q2 0.0% · Q3 2.9% · Q4 1.4% · 4Q avg 2.5% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 34.8% |
20.5%
14.3 pts worse
|
19.8%
15 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 37.8% · Q2 44.0% · Q3 19.9% · Q4 37.4% · 4Q avg 34.8% |
| Percentage of long-stay residents with pressure ulcers | 1.0% |
4.8%
3.8 pts better
|
5.1%
4.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.9% · Q2 0.0% · Q3 1.1% · Q4 1.1% · 4Q avg 1.0% · 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 99.7% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 99.9% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 6.9% |
10.7%
3.8 pts better
|
12.0%
5.1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 6.9% · Observed 7.9% · Expected 12.8% · 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 0.5% · Q2 0.0% · Q3 0.5% · Q4 1.8% · 4Q avg 0.8% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 96.1% |
87.3%
8.8 pts better
|
79.7%
16.4 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 96.1% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 16.3% |
24.6%
8.3 pts better
|
23.9%
7.6 pts better
|
Short Stay · 20240701-20250630 · Adjusted 16.3% · Observed 17.1% · Expected 25.0% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-09-29 · Fire 2023-09-29
3 health deficiencies
Top issue: Pharmacy Service (1 deficiency)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Cycle 3
Health 2022-08-11 · Fire 2022-08-11
8 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (4 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
2024-10-10
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2025-01-14
E · Potential for more than minimal harm
2023-09-29
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-11-30
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-07-11
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 2025-08-25
E · Potential for more than minimal harm
2024-10-10
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 2024-11-24
E · Potential for more than minimal harm
2024-10-10
F676 · Quality of Life and Care Deficiencies
Health
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Corrected 2024-11-24
D · Potential for more than minimal harm
2024-10-10
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 2024-11-24
E · Potential for more than minimal harm
2023-09-29
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2023-11-13
E · Potential for more than minimal harm
2023-09-29
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2023-11-13
D · Potential for more than minimal harm
2023-09-29
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 2023-11-13
D · Potential for more than minimal harm
2023-04-06
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 2023-06-09
D · Potential for more than minimal harm
2023-04-06
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2023-06-09
D · Potential for more than minimal harm
2023-04-06
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 2023-06-09
D · Potential for more than minimal harm
2023-04-06
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2023-06-09
D · Potential for more than minimal harm
2022-08-11
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 2022-09-23
D · Potential for more than minimal harm
2022-08-11
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2022-09-23
D · Potential for more than minimal harm
2022-08-11
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 2022-09-23
B · Minimal harm
2022-08-11
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2022-09-23
Penalties and ownership
What sits behind the stars
Ownership
Bandera Healthcare LLC
5% Or Greater Direct Ownership Interest · Organization
The Ensign Group Inc
5% Or Greater Indirect Ownership Interest · Organization
Burnam, Soon
Corporate Officer · Individual
Keetch, Chad
Corporate Officer · Individual
Monks, Chandler
Corporate Officer · Individual
Peterson, Forrest
Corporate Director · Individual
Sato, Ami
Corporate Officer · Individual
Sessions, Troy
Operational/Managerial Control · Individual
Srivastava, Vinee
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
Haven Of Scottsdale
Scottsdale, AZ
2-star overall rating with 1-star inspections with abuse icon flag with 15 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#2
Heritage Court Post Acute Of Scottsdale
Scottsdale, AZ
5-star overall rating with 4-star inspections with 5 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#3
Rehab At Scottsdale Village Square
Scottsdale, AZ
2-star overall rating with 1-star inspections with Special Focus status with abuse icon flag with $199,344 in total fines with 16 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
Jump out