Cycle 1
Health 2023-07-06 · Fire 2023-07-06
18 health deficiencies
Top issue: Resident Rights (5 deficiencies)
2 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Phoenix, AZ
Phoenix Mountain Post Acute
2-star overall rating with 1-star inspections with $8,018 in total fines with 18 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
13232 North Tatum Blvd, Phoenix, AZ
(602) 996-5200
Overall
2 / 5
CMS overall stars
Health inspections
1 / 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
130
Certified beds
Average residents
113
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
The Ensign Group
Operator or chain grouping
Approved since
1979-11-25
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
0.53
Registered nurse staffing · state 0.72 · national 0.68
LPN hours / resident day
0.75
Licensed practical nurse staffing · state 1.04 · national 0.87
Aide hours / resident day
2.26
Nurse aide staffing · state 2.36 · national 2.35
Total nurse hours
3.54
All reported nurse hours · state 4.12 · national 3.89
Licensed hours
1.28
RN + LPN hours · state 1.76 · national 1.54
Weekend hours
3.39
Weekend nurse staffing · state 3.62 · national 3.43
Weekend RN hours
0.54
Weekend registered nurse coverage · state 0.51 · national 0.47
Physical therapist
0.04
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.53
CMS adjusted RN staffing hours
Adjusted total hours
3.53
CMS adjusted total nurse staffing hours
Case-mix index
1.37
Higher values indicate more complex resident acuity
RN turnover
69%
Annual RN turnover · state 45% · national 45%
Total nurse turnover
59%
Annual nurse turnover · state 48% · national 46%
SNF VBP
Value-based purchasing
Program rank
13,198
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
7.59
Composite VBP score used to determine payment impact.
Payment multiplier
0.9807
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0.89
Baseline 19.22% · Performance 21.02% · Measure score 0.89 · Achievement 0.89 · Improvement 0
Healthcare-associated infections
0
Baseline 7.29% · Performance 7.86% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
0
Baseline 58.54% · Performance 68.86% · Measure score 0 · Achievement 0 · Improvement 0
Adjusted total nurse staffing
2.14
Baseline 3.39 hours · Performance 3.69 hours · Measure score 2.14 · Achievement 2.14 · Improvement 0.73
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.77% |
10.72%
About the same
|
No Different than the National Rate · Eligible stays 141 · Observed rate 10.64% · Lower 95% interval 7.88% |
| Discharge to community | 66.87% |
50.57%
16.3 pts better
|
Better than the National Rate · Eligible stays 134 · Observed rate 63.43% · Lower 95% interval 59.28% |
| Medicare spending per beneficiary | 0.83 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 58 · Denominator 58 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 58 |
| Discharge self-care score | 69.77% |
53.69%
16.1 pts better
|
Numerator 30 · Denominator 43 |
| Discharge mobility score | 39.53% |
50.94%
11.4 pts worse
|
Numerator 17 · Denominator 43 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 58 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 7.86% |
7.12%
0.7 pts worse
|
No Different than the National Rate · Eligible stays 67 · Observed rate 8.96% · Lower 95% interval 4.6% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 167 |
| Staff flu vaccination coverage | 31.78% |
42%
10.2 pts worse
|
Numerator 82 · Denominator 258 |
| Discharge function score | 72.09% |
56.45%
15.6 pts better
|
Numerator 31 · Denominator 43 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 35 · Denominator 35 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 14 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 8% |
25.2%
17.2 pts worse
|
Numerator 2 · Denominator 25 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 98.1% |
97.1%
1 pts better
|
93.4%
4.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 95.7% · Q4 97.0% · 4Q avg 98.1% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 89.5% |
94.6%
5.1 pts worse
|
95.5%
6 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 89.5% |
| 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 0.0% · Q2 1.1% · Q3 2.1% · Q4 2.0% · 4Q avg 1.3% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
4.2%
4.2 pts better
|
11.4%
11.4 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 lose too much weight | 5.2% |
5.3%
0.1 pts better
|
5.4%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.3% · Q2 5.7% · Q3 3.4% · Q4 5.3% · 4Q avg 5.2% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 19.8% |
20.5%
0.7 pts better
|
19.6%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 16.5% · Q2 15.9% · Q3 25.3% · Q4 21.3% · 4Q avg 19.8% |
| Percentage of long-stay residents who received an antipsychotic medication | 1.2% |
11.8%
10.6 pts better
|
16.7%
15.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.6% · Q3 0.0% · Q4 2.9% · 4Q avg 1.2% · 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 | 13.6% |
14.5%
0.9 pts better
|
16.3%
2.7 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 13.6% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 11.4% |
10.8%
0.6 pts worse
|
14.9%
3.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.2% · Q2 6.3% · Q3 20.0% · Q4 14.3% · 4Q avg 11.4% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.4% |
0.9%
0.5 pts worse
|
1.0%
0.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.5% · Q2 2.3% · Q3 1.1% · Q4 0.0% · 4Q avg 1.4% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.5% |
1.2%
0.7 pts better
|
1.7%
1.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.1% · Q3 0.0% · Q4 1.0% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 20.8% |
20.5%
0.3 pts worse
|
19.8%
1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 21.6% · Q2 12.7% · Q3 22.0% · Q4 26.8% · 4Q avg 20.8% |
| Percentage of long-stay residents with pressure ulcers | 2.6% |
4.8%
2.2 pts better
|
5.1%
2.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.5% · Q2 3.5% · Q3 3.1% · Q4 1.4% · 4Q avg 2.6% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 97.4% |
91.1%
6.3 pts better
|
81.7%
15.7 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 98.4% · Q2 98.1% · Q3 96.2% · Q4 96.4% · 4Q avg 97.4% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 4.1% |
10.7%
6.6 pts better
|
12.0%
7.9 pts better
|
Short Stay · 20240701-20250630 · Adjusted 4.1% · Observed 4.2% · Expected 11.3% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.0% |
1.1%
0.1 pts better
|
1.6%
0.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.9% · Q3 1.2% · Q4 2.3% · 4Q avg 1.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 78.5% |
87.3%
8.8 pts worse
|
79.7%
1.2 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 78.5% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 18.9% |
24.6%
5.7 pts better
|
23.9%
5 pts better
|
Short Stay · 20240701-20250630 · Adjusted 18.9% · Observed 20.8% · Expected 26.3% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-05-12 · Fire 2022-05-12
4 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Cycle 3
Health 2020-01-17 · Fire 2020-01-17
6 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2023-07-06
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2023-10-06
D · Potential for more than minimal harm
2023-07-06
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-10-06
D · Potential for more than minimal harm
2022-05-12
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2022-06-09
D · Potential for more than minimal harm
2020-01-17
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2020-03-10
D · Potential for more than minimal harm
2020-01-17
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2020-03-10
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-07-11
F908 · Environmental Deficiencies
Health
Keep all essential equipment working safely.
Corrected 2025-08-08
D · Potential for more than minimal harm
2025-07-11
F557 · Resident Rights Deficiencies
Health
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
Corrected 2025-08-08
D · Potential for more than minimal harm
2025-06-17
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 2025-07-16
D · Potential for more than minimal harm
2025-06-17
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 2025-07-16
G · Actual harm
2024-06-11
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 2024-07-25
E · Potential for more than minimal harm
2023-07-06
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2023-08-13
E · Potential for more than minimal harm
2023-07-06
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 2023-08-13
E · Potential for more than minimal harm
2023-07-06
F625 · Resident Rights Deficiencies
Health
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Corrected 2023-08-13
E · Potential for more than minimal harm
2023-07-06
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 2023-08-13
E · Potential for more than minimal harm
2023-07-06
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 2023-08-13
E · Potential for more than minimal harm
2023-07-06
F770 · Administration Deficiencies
Health
Provide timely, quality laboratory services/tests to meet the needs of residents.
Corrected 2023-08-13
E · Potential for more than minimal harm
2023-07-06
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 2023-08-13
D · Potential for more than minimal harm
2023-07-06
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 2023-08-13
D · Potential for more than minimal harm
2023-07-06
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2023-08-13
D · Potential for more than minimal harm
2023-07-06
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 2023-08-13
D · Potential for more than minimal harm
2023-07-06
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2023-08-13
D · Potential for more than minimal harm
2023-07-06
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2023-08-13
D · Potential for more than minimal harm
2023-07-06
F814 · Nutrition and Dietary Deficiencies
Health
Dispose of garbage and refuse properly.
Corrected 2023-08-13
D · Potential for more than minimal harm
2023-07-06
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-08-13
E · Potential for more than minimal harm
2022-05-12
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2022-06-16
D · Potential for more than minimal harm
2022-05-12
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 2022-06-16
D · Potential for more than minimal harm
2022-05-12
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2022-06-16
G · Actual harm
2020-01-17
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2020-03-11
E · Potential for more than minimal harm
2020-01-17
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2020-03-11
D · Potential for more than minimal harm
2020-01-17
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2020-03-11
D · Potential for more than minimal harm
2020-01-17
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2020-03-11
D · Potential for more than minimal harm
2020-01-17
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2020-03-11
D · Potential for more than minimal harm
2020-01-17
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 2020-03-11
Penalties and ownership
What sits behind the stars
$8,018
2024-06-11
Fine
Fine · fine $8,018
Fine
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
Haerter, Charlton
Operational/Managerial Control · Individual
Keetch, Chad
Corporate Officer · Individual
Peterson, Forrest
Corporate Officer · Individual
Wagner, Clayton
Operational/Managerial Control · Individual
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