Cycle 1
Health 2024-12-05 · Fire 2024-12-05
4 health deficiencies
Top issue: Resident Assessment and Care Planning (2 deficiencies)
3 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Phoenix, AZ
Ridgecrest Post Acute
4-star overall rating with 3-star inspections with 4 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
16640 North 38th Street, Phoenix, AZ
(602) 482-6671
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
200
Certified beds
Average residents
163
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Pacs Group
Operator or chain grouping
Approved since
1986-02-28
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
264 facilities
Chain averages 3 overall / 3 health / 2 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
0.27
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
2.79
Nurse aide staffing · state 2.36 · national 2.35
Total nurse hours
4.09
All reported nurse hours · state 4.12 · national 3.89
Licensed hours
1.29
RN + LPN hours · state 1.76 · national 1.54
Weekend hours
3.81
Weekend nurse staffing · state 3.62 · national 3.43
Weekend RN hours
0.17
Weekend registered nurse coverage · state 0.51 · national 0.47
Physical therapist
0.02
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.29
CMS adjusted RN staffing hours
Adjusted total hours
4.38
CMS adjusted total nurse staffing hours
Case-mix index
1.28
Higher values indicate more complex resident acuity
RN turnover
56%
Annual RN turnover · state 45% · national 45%
Total nurse turnover
63%
Annual nurse turnover · state 48% · national 46%
SNF VBP
Value-based purchasing
Program rank
6,333
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
33.26
Composite VBP score used to determine payment impact.
Payment multiplier
0.9876
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
5.29
Baseline 18.69% · Performance 18.98% · Measure score 5.29 · Achievement 5.29 · Improvement 0
Healthcare-associated infections
1.37
Baseline 7.85% · Performance 7.42% · Measure score 1.37 · Achievement 1.37 · Improvement 0.99
Total nurse turnover
1.38
Baseline 58.97% · Performance 58.05% · Measure score 1.38 · Achievement 1.38 · Improvement 0
Adjusted total nurse staffing
5.27
Baseline 5.39 hours · Performance 4.58 hours · Measure score 5.27 · Achievement 5.27 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 12.03% |
10.72%
1.3 pts worse
|
No Different than the National Rate · Eligible stays 179 · Observed rate 13.41% · Lower 95% interval 8.73% |
| Discharge to community | 60.42% |
50.57%
9.9 pts better
|
Better than the National Rate · Eligible stays 168 · Observed rate 54.17% · Lower 95% interval 51.7% |
| Medicare spending per beneficiary | 1.01 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 98 · Denominator 98 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 98 |
| Discharge self-care score | 74.14% |
53.69%
20.5 pts better
|
Numerator 43 · Denominator 58 |
| Discharge mobility score | 58.62% |
50.94%
7.7 pts better
|
Numerator 34 · Denominator 58 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 98 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 7.42% |
7.12%
0.3 pts worse
|
No Different than the National Rate · Eligible stays 113 · Observed rate 7.96% · Lower 95% interval 4.57% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 202 |
| Staff flu vaccination coverage | 59.73% |
42%
17.7 pts better
|
Numerator 132 · Denominator 221 |
| Discharge function score | 82.76% |
56.45%
26.3 pts better
|
Numerator 48 · Denominator 58 |
| Transfer of health information to provider | 98.46% |
95.95%
2.5 pts better
|
Numerator 64 · Denominator 65 |
| Transfer of health information to patient | 82.14% |
96.28%
14.1 pts worse
|
Numerator 23 · Denominator 28 |
| Resident COVID-19 vaccinations up to date | 26.53% |
25.2%
1.3 pts better
|
Numerator 13 · Denominator 49 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 0.8 |
1.7
0.9 pts better
|
1.9
1.1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.8 · Observed 0.5 · Expected 1.1 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.2 |
1.5
0.3 pts better
|
1.8
0.6 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.2 · Observed 0.8 · Expected 1.1 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 98.4% |
97.1%
1.3 pts better
|
93.4%
5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 98.4% · Q3 99.2% · Q4 96.0% · 4Q avg 98.4% |
| 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 | 1.4% |
2.1%
0.7 pts better
|
3.3%
1.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.5% · Q2 2.4% · Q3 0.8% · Q4 0.0% · 4Q avg 1.4% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 17.6% |
4.2%
13.4 pts worse
|
11.4%
6.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 14.3% · Q2 11.3% · Q3 13.7% · Q4 31.5% · 4Q avg 17.6% |
| Percentage of long-stay residents who lose too much weight | 1.2% |
5.3%
4.1 pts better
|
5.4%
4.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.0% · Q3 0.0% · Q4 3.9% · 4Q avg 1.2% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 30.9% |
20.5%
10.4 pts worse
|
19.6%
11.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 32.3% · Q2 30.4% · Q3 30.7% · Q4 30.1% · 4Q avg 30.9% |
| Percentage of long-stay residents who received an antipsychotic medication | 7.0% |
11.8%
4.8 pts better
|
16.7%
9.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.6% · Q2 8.9% · Q3 4.8% · Q4 0.0% · 4Q avg 7.0% · 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 | 5.5% |
14.5%
9 pts better
|
16.3%
10.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.1% · Q2 8.2% · Q3 5.1% · Q4 2.4% · 4Q avg 5.5% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 4.8% |
10.8%
6 pts better
|
14.9%
10.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.6% · Q2 3.1% · Q3 1.1% · Q4 6.3% · 4Q avg 4.8% · 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 0.9% · Q3 0.0% · Q4 0.0% · 4Q avg 0.2% · 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 | 23.3% |
20.5%
2.8 pts worse
|
19.8%
3.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.1% · Q2 25.1% · Q3 18.4% · Q4 24.6% · 4Q avg 23.3% |
| Percentage of long-stay residents with pressure ulcers | 1.9% |
4.8%
2.9 pts better
|
5.1%
3.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.0% · Q2 1.9% · Q3 1.8% · Q4 2.0% · 4Q avg 1.9% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.3% |
91.1%
8.2 pts better
|
81.7%
17.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 98.0% · Q2 99.1% · Q3 100.0% · Q4 100.0% · 4Q avg 99.3% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 6.2% |
10.7%
4.5 pts better
|
12.0%
5.8 pts better
|
Short Stay · 20240701-20250630 · Adjusted 6.2% · Observed 6.8% · Expected 12.2% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.9% |
1.1%
0.2 pts better
|
1.6%
0.7 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 1.0% · Q2 0.9% · Q3 0.9% · Q4 0.7% · 4Q avg 0.9% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 91.7% |
87.3%
4.4 pts better
|
79.7%
12 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 91.7% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 15.9% |
24.6%
8.7 pts better
|
23.9%
8 pts better
|
Short Stay · 20240701-20250630 · Adjusted 15.9% · Observed 15.9% · Expected 23.8% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-03-16 · Fire 2023-03-16
8 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (2 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Cycle 3
Health 2022-03-10 · Fire 2022-03-10
5 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2024-12-05
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2024-12-28
E · Potential for more than minimal harm
2024-12-05
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-12-28
E · Potential for more than minimal harm
2024-12-05
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-12-28
F · Potential for more than minimal harm
2023-03-16
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-05-26
D · Potential for more than minimal harm
2022-03-10
E20 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures including evacuation.
Corrected 2022-04-14
D · Potential for more than minimal harm
2022-03-10
K342 · Smoke Deficiencies
Fire Safety
Have a complete alarm system manually initiated and initiated by fire sprinkler system connection.
Corrected 2022-04-14
D · Potential for more than minimal harm
2022-03-10
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2022-04-14
D · Potential for more than minimal harm
2022-03-10
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2022-04-14
Inspection history
Recent health citations
E · Potential for more than minimal harm
2024-12-05
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-01-08
D · Potential for more than minimal harm
2024-12-05
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-01-08
D · Potential for more than minimal harm
2024-12-05
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 2025-01-08
D · Potential for more than minimal harm
2024-12-05
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 2025-01-08
D · Potential for more than minimal harm
2024-08-26
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 2024-10-06
D · Potential for more than minimal harm
2024-06-13
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 2024-07-15
D · Potential for more than minimal harm
2024-06-13
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 2024-07-15
D · Potential for more than minimal harm
2024-04-05
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 2024-05-31
D · Potential for more than minimal harm
2023-12-21
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 2024-03-01
E · Potential for more than minimal harm
2023-03-16
F774 · Administration Deficiencies
Health
Help the resident with transportation to and from laboratory services outside of the facility.
Corrected 2023-05-26
D · Potential for more than minimal harm
2023-03-16
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2023-05-26
D · Potential for more than minimal harm
2023-03-16
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 2023-05-26
D · Potential for more than minimal harm
2023-03-16
F814 · Nutrition and Dietary Deficiencies
Health
Dispose of garbage and refuse properly.
Corrected 2023-05-26
E · Potential for more than minimal harm
2022-03-10
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 2022-04-07
D · Potential for more than minimal harm
2022-03-10
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2022-04-07
D · Potential for more than minimal harm
2022-03-10
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2022-04-07
D · Potential for more than minimal harm
2022-03-10
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2022-04-07
Penalties and ownership
What sits behind the stars
Ownership
Providence Group Inc
5% Or Greater Direct Ownership Interest · Organization
Hancock, Mark
5% Or Greater Indirect Ownership Interest · Individual
Murray, Jason
5% Or Greater Indirect Ownership Interest · Individual
Apt, Frederick
Corporate Officer · Individual
Brenay, Scott
W-2 Managing Employee · Individual
Hancock, Mark
Corporate Officer · Individual
Jergensen, Joshua
Corporate Officer · Individual
Mitchell, John
Corporate Officer · Individual
Nassour, William
Contracted Managing Employee · Individual
Nearby options
Other facilities in reach
#1
Life Care Center Of Paradise Valley
Phoenix, AZ
3-star overall rating with 2-star inspections with $72,147 in total fines with 9 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#2
Phoenix Mountain Post Acute
Phoenix, AZ
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
#3
Acacia Health Center
Phoenix, AZ
5-star overall rating with 5-star inspections with 1 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
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