Cycle 1
Health 2024-12-13 · Fire 2024-12-13
1 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.
Scottsdale, AZ
Shea Post Acute Rehabilitation Center
5-star overall rating with 4-star inspections with 1 recent health deficiencies
11150 North 92nd Street, Scottsdale, AZ
(480) 860-1766
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
120
Certified beds
Average residents
106
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
The Ensign Group
Operator or chain grouping
Approved since
1985-04-09
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
0.68
Registered nurse staffing · state 0.72 · national 0.68
LPN hours / resident day
0.94
Licensed practical nurse staffing · state 1.04 · national 0.87
Aide hours / resident day
1.83
Nurse aide staffing · state 2.36 · national 2.35
Total nurse hours
3.45
All reported nurse hours · state 4.12 · national 3.89
Licensed hours
1.62
RN + LPN hours · state 1.76 · national 1.54
Weekend hours
3.00
Weekend nurse staffing · state 3.62 · national 3.43
Weekend RN hours
0.46
Weekend registered nurse coverage · state 0.51 · national 0.47
Physical therapist
0.14
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.73
CMS adjusted RN staffing hours
Adjusted total hours
3.70
CMS adjusted total nurse staffing hours
Case-mix index
1.27
Higher values indicate more complex resident acuity
RN turnover
47%
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
9,230
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
24.35
Composite VBP score used to determine payment impact.
Payment multiplier
0.9834
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 21.58% · Performance 21.69% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
4.29
Baseline 6.14% · Performance 6.55% · Measure score 4.29 · Achievement 4.29 · Improvement 0
Total nurse turnover
3.49
Baseline 42.31% · Performance 49.41% · Measure score 3.49 · Achievement 3.49 · Improvement 0
Adjusted total nurse staffing
1.96
Baseline 3.54 hours · Performance 3.64 hours · Measure score 1.96 · Achievement 1.96 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 12.98% |
10.72%
2.3 pts worse
|
No Different than the National Rate · Eligible stays 164 · Observed rate 15.85% · Lower 95% interval 9.85% |
| Discharge to community | 57.65% |
50.57%
7.1 pts better
|
No Different than the National Rate · Eligible stays 150 · Observed rate 52% · Lower 95% interval 50.17% |
| Medicare spending per beneficiary | 1.08 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 119 · Denominator 119 |
| Falls with major injury | 0.84% |
0.77%
0.1 pts worse
|
Numerator 1 · Denominator 119 |
| Discharge self-care score | 63.95% |
53.69%
10.3 pts better
|
Numerator 55 · Denominator 86 |
| Discharge mobility score | 65.12% |
50.94%
14.2 pts better
|
Numerator 56 · Denominator 86 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 117 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 6.55% |
7.12%
0.6 pts better
|
No Different than the National Rate · Eligible stays 89 · Observed rate 4.49% · Lower 95% interval 3.86% |
| Staff COVID-19 vaccination coverage | 0.72% |
8.2%
7.5 pts worse
|
Numerator 1 · Denominator 138 |
| Staff flu vaccination coverage | 30.06% |
42%
11.9 pts worse
|
Numerator 49 · Denominator 163 |
| Discharge function score | 72.09% |
56.45%
15.6 pts better
|
Numerator 62 · Denominator 86 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 80 · Denominator 80 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 24 · Denominator 24 |
| Resident COVID-19 vaccinations up to date | 10.96% |
25.2%
14.2 pts worse
|
Numerator 8 · Denominator 73 |
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 | 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 | 2.5% |
2.1%
0.4 pts worse
|
3.3%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.3% · Q2 4.1% · Q3 1.4% · Q4 0.0% · 4Q avg 2.5% · 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 | 3.5% |
5.3%
1.8 pts better
|
5.4%
1.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.5% · Q2 4.5% · Q3 3.1% · Q4 0.0% · 4Q avg 3.5% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 25.5% |
20.5%
5 pts worse
|
19.6%
5.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 22.6% · Q2 26.9% · Q3 27.7% · Q4 24.6% · 4Q avg 25.5% |
| Percentage of long-stay residents who received an antipsychotic medication | 4.1% |
11.8%
7.7 pts better
|
16.7%
12.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.9% · Q2 4.5% · Q3 2.4% · Q4 0.0% · 4Q avg 4.1% · 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 | 12.3% |
14.5%
2.2 pts better
|
16.3%
4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.6% · Q2 21.5% · Q3 15.3% · Q4 4.4% · 4Q avg 12.3% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 9.3% |
10.8%
1.5 pts better
|
14.9%
5.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.1% · Q2 10.8% · Q3 11.1% · Q4 10.2% · 4Q avg 9.3% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.9% |
0.9%
About the same
|
1.0%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.7% · Q2 1.7% · Q3 0.0% · Q4 0.0% · 4Q avg 0.9% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.4% |
1.2%
0.2 pts worse
|
1.7%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.9% · Q2 0.0% · Q3 1.4% · Q4 1.5% · 4Q avg 1.4% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 13.8% |
20.5%
6.7 pts better
|
19.8%
6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.6% · Q2 11.3% · Q3 15.6% · Q4 18.8% · 4Q avg 13.8% |
| Percentage of long-stay residents with pressure ulcers | 5.2% |
4.8%
0.4 pts worse
|
5.1%
0.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.6% · Q2 4.0% · Q3 3.2% · Q4 7.2% · 4Q avg 5.2% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.5% |
91.1%
8.4 pts better
|
81.7%
17.8 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 99.1% · Q4 99.0% · 4Q avg 99.5% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 2.6% |
10.7%
8.1 pts better
|
12.0%
9.4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 2.6% · Observed 3.0% · Expected 12.9% · 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 | 99.4% |
87.3%
12.1 pts better
|
79.7%
19.7 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 99.4% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 26.8% |
24.6%
2.2 pts worse
|
23.9%
2.9 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 26.8% · Observed 27.3% · Expected 24.2% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-06-02 · Fire 2023-06-02
6 health deficiencies
Top issue: Resident Assessment and Care Planning (3 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2022-04-14 · Fire 2022-04-14
5 health deficiencies
Top issue: Resident Rights (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Inspection history
Recent health citations
D · Potential for more than minimal harm
2024-12-13
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 2025-01-10
E · Potential for more than minimal harm
2023-06-02
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2023-07-13
D · Potential for more than minimal harm
2023-06-02
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 2023-07-13
D · Potential for more than minimal harm
2023-06-02
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 2023-07-13
D · Potential for more than minimal harm
2023-06-02
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2023-07-13
D · Potential for more than minimal harm
2023-06-02
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2023-07-13
D · Potential for more than minimal harm
2023-06-02
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 2023-07-13
D · Potential for more than minimal harm
2023-03-20
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 2023-05-09
E · Potential for more than minimal harm
2022-04-14
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2022-05-05
E · Potential for more than minimal harm
2022-04-14
F886 · Infection Control Deficiencies
Health
Perform COVID19 testing on residents and staff.
Corrected 2022-05-05
D · Potential for more than minimal harm
2022-04-14
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 2022-05-05
D · Potential for more than minimal harm
2022-04-14
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2022-05-05
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
Albrechtsen, Joshua
Operational/Managerial Control · Individual
Burnam, Soon
Corporate Officer · Individual
Keetch, Chad
Corporate Officer · Individual
Mal, Himmat
Operational/Managerial Control · Individual
Monks, Chandler
Corporate Officer · Individual
Peterson, Forrest
Corporate Director · Individual
Port, Barry
Corporate Officer · Individual
Sato, Ami
Corporate Officer · Individual
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