Cycle 1
Health 2024-07-03 · Fire 2024-07-03
7 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Surprise, AZ
Sante Of Surprise
5-star overall rating with 4-star inspections with 7 recent health deficiencies
14775 West Yorkshire Drive, Surprise, AZ
(623) 594-5050
Overall
5 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
70
Certified beds
Average residents
67
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Sante
Operator or chain grouping
Approved since
2011-10-24
CMS approved date
Coverage
Medicare
Participation flags
Chain footprint
5 facilities
Chain averages 4 overall / 4 health / 4 staffing / 5 quality stars
Changed ownership
No
Within the last 12 months
Family council
No
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
1.17
Registered nurse staffing · state 0.72 · national 0.68
LPN hours / resident day
1.24
Licensed practical nurse staffing · state 1.04 · national 0.87
Aide hours / resident day
2.24
Nurse aide staffing · state 2.36 · national 2.35
Total nurse hours
4.65
All reported nurse hours · state 4.12 · national 3.89
Licensed hours
2.41
RN + LPN hours · state 1.76 · national 1.54
Weekend hours
3.93
Weekend nurse staffing · state 3.62 · national 3.43
Weekend RN hours
0.75
Weekend registered nurse coverage · state 0.51 · national 0.47
Physical therapist
0.21
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
1.09
CMS adjusted RN staffing hours
Adjusted total hours
4.33
CMS adjusted total nurse staffing hours
Case-mix index
1.47
Higher values indicate more complex resident acuity
RN turnover
36%
Annual RN turnover · state 45% · national 45%
Total nurse turnover
44%
Annual nurse turnover · state 48% · national 46%
SNF VBP
Value-based purchasing
Program rank
6,976
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
31.14
Composite VBP score used to determine payment impact.
Payment multiplier
0.9863
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
7.05
Baseline 23.26% · Performance 18.55% · Measure score 7.05 · Achievement 6.21 · Improvement 7.05
Healthcare-associated infections
0
Baseline 7.03% · Performance 8.00% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
2.49
Baseline 65.66% · Performance 53.49% · Measure score 2.49 · Achievement 2.49 · Improvement 2.48
Adjusted total nurse staffing
2.91
Baseline 3.68 hours · Performance 3.91 hours · Measure score 2.91 · Achievement 2.91 · Improvement 0.59
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.4% |
10.72%
0.7 pts worse
|
No Different than the National Rate · Eligible stays 993 · Observed rate 10.98% · Lower 95% interval 9.89% |
| Discharge to community | 68.85% |
50.57%
18.3 pts better
|
Better than the National Rate · Eligible stays 999 · Observed rate 65.07% · Lower 95% interval 65.92% |
| Medicare spending per beneficiary | 0.92 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 98.93% |
95.27%
3.7 pts better
|
Numerator 650 · Denominator 657 |
| Falls with major injury | 0.46% |
0.77%
0.3 pts better
|
Numerator 3 · Denominator 657 |
| Discharge self-care score | 61.44% |
53.69%
7.8 pts better
|
Numerator 247 · Denominator 402 |
| Discharge mobility score | 51% |
50.94%
0.1 pts better
|
Numerator 205 · Denominator 402 |
| Pressure ulcers or injuries, new or worsened | 1.37% |
2.29%
0.9 pts better
|
Numerator 9 · Denominator 655 · Adjusted rate 1.55% |
| Healthcare-associated infections requiring hospitalization | 8% |
7.12%
0.9 pts worse
|
No Different than the National Rate · Eligible stays 613 · Observed rate 7.99% · Lower 95% interval 6.25% |
| Staff COVID-19 vaccination coverage | 2.55% |
8.2%
5.6 pts worse
|
Numerator 4 · Denominator 157 |
| Staff flu vaccination coverage | 54.61% |
42%
12.6 pts better
|
Numerator 83 · Denominator 152 |
| Discharge function score | 56.97% |
56.45%
0.5 pts better
|
Numerator 229 · Denominator 402 |
| Transfer of health information to provider | 37.63% |
95.95%
58.3 pts worse
|
Numerator 70 · Denominator 186 |
| Transfer of health information to patient | 98.01% |
96.28%
1.7 pts better
|
Numerator 444 · Denominator 453 |
| Resident COVID-19 vaccinations up to date | 17.15% |
25.2%
8.1 pts worse
|
Numerator 59 · Denominator 344 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 95.0% |
91.1%
3.9 pts better
|
81.7%
13.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 90.4% · Q2 95.7% · Q3 96.8% · Q4 97.3% · 4Q avg 95.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 7.6% |
10.7%
3.1 pts better
|
12.0%
4.4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 7.6% · Observed 7.7% · Expected 11.3% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.5% |
1.1%
0.6 pts better
|
1.6%
1.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.5% · Q2 0.7% · Q3 0.2% · Q4 0.7% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 82.1% |
87.3%
5.2 pts worse
|
79.7%
2.4 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 82.1% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 25.4% |
24.6%
0.8 pts worse
|
23.9%
1.5 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 25.4% · Observed 26.0% · Expected 24.3% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-02-24 · Fire 2023-02-24
1 health deficiencies
Top issue: Pharmacy Service (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2022-01-27 · Fire 2022-01-27
5 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2022-01-27
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2022-02-22
Inspection history
Recent health citations
D · Potential for more than minimal harm
2024-07-03
F638 · Resident Assessment and Care Planning Deficiencies
Health
Assure that each resident’s assessment is updated at least once every 3 months.
Corrected 2024-08-09
D · Potential for more than minimal harm
2024-07-03
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 2024-08-09
D · Potential for more than minimal harm
2024-07-03
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-08-09
D · Potential for more than minimal harm
2024-07-03
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 2024-08-09
D · Potential for more than minimal harm
2024-07-03
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-08-09
D · Potential for more than minimal harm
2024-07-03
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2024-08-09
D · Potential for more than minimal harm
2024-07-03
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-08-09
D · Potential for more than minimal harm
2023-02-24
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 2023-04-27
E · Potential for more than minimal harm
2022-01-27
F885 · Infection Control Deficiencies
Health
Report COVID19 data to residents and families.
Corrected 2022-03-04
D · Potential for more than minimal harm
2022-01-27
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2022-03-04
D · Potential for more than minimal harm
2022-01-27
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2022-03-04
D · Potential for more than minimal harm
2022-01-27
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 2022-03-04
D · Potential for more than minimal harm
2022-01-27
F908 · Environmental Deficiencies
Health
Keep all essential equipment working safely.
Corrected 2022-03-04
Penalties and ownership
What sits behind the stars
Ownership
Hansen, Charles
5% Or Greater Direct Ownership Interest · Individual
Ingels, Shannon
Contracted Managing Employee · Individual
Munch Tooke, LLC
5% Or Greater Direct Ownership Interest · Organization
Munch, Michael
5% Or Greater Direct Ownership Interest · Individual
Rdw Arizona LLC
5% Or Greater Direct Ownership Interest · Organization
Schaefer, Jacob
5% Or Greater Direct Ownership Interest · Individual
Sp Re Surprise LLC
5% Or Greater Direct Ownership Interest · Organization
Sp Surprise LLC
5% Or Greater Direct Ownership Interest · Organization
Sterling & Jacqueline Holdings,llc
5% Or Greater Direct Ownership Interest · Organization
Tooke, Arthur
5% Or Greater Direct Ownership Interest · Individual
Wasser & Winters Co
5% Or Greater Direct Ownership Interest · Organization
Winters, Jess
5% Or Greater Direct Ownership Interest · Individual
Nearby options
Other facilities in reach
#1
Sun Health Grandview Care Center
Sun City West, AZ
5-star overall rating with 4-star inspections with 3 recent health deficiencies
#2
Surprise Health And Rehabilitation Center
Surprise, AZ
5-star overall rating with 5-star inspections with 2 recent health deficiencies
#3
Sun West Choice Healthcare & Rehab
Sun City West, AZ
5-star overall rating with 4-star inspections with $4,838 in total fines with 3 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
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