Cycle 1
Health 2024-08-09 · Fire 2024-08-09
5 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Phoenix, AZ
South Mountain Post Acute
4-star overall rating with 4-star inspections with 5 recent health deficiencies
8008 S. Jesse Owens Parkway, Phoenix, AZ
(602) 243-2780
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
124
Certified beds
Average residents
107
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
The Ensign Group
Operator or chain grouping
Approved since
1997-03-25
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
0.44
Registered nurse staffing · state 0.72 · national 0.68
LPN hours / resident day
1.39
Licensed practical nurse staffing · state 1.04 · national 0.87
Aide hours / resident day
2.18
Nurse aide staffing · state 2.36 · national 2.35
Total nurse hours
4.01
All reported nurse hours · state 4.12 · national 3.89
Licensed hours
1.83
RN + LPN hours · state 1.76 · national 1.54
Weekend hours
3.60
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
0.06
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.32
CMS adjusted RN staffing hours
Adjusted total hours
2.90
CMS adjusted total nurse staffing hours
Case-mix index
1.89
Higher values indicate more complex resident acuity
RN turnover
77%
Annual RN turnover · state 45% · national 45%
Total nurse turnover
52%
Annual nurse turnover · state 48% · national 46%
SNF VBP
Value-based purchasing
Program rank
10,963
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
18.49
Composite VBP score used to determine payment impact.
Payment multiplier
0.9820
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
1.29
Baseline 20.46% · Performance 20.83% · Measure score 1.29 · Achievement 1.29 · Improvement 0
Healthcare-associated infections
0
Baseline 6.54% · Performance 7.97% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
6.10
Baseline 47.25% · Performance 38.74% · Measure score 6.10 · Achievement 6.10 · Improvement 3.30
Adjusted total nurse staffing
0
Baseline 3.03 hours · Performance 2.69 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.05% |
10.72%
0.3 pts worse
|
No Different than the National Rate · Eligible stays 93 · Observed rate 11.83% · Lower 95% interval 7.25% |
| Discharge to community | 47.93% |
50.57%
2.6 pts worse
|
No Different than the National Rate · Eligible stays 81 · Observed rate 39.51% · Lower 95% interval 36.73% |
| Medicare spending per beneficiary | 1.07 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 74 · Denominator 74 |
| Falls with major injury | 1.35% |
0.77%
0.6 pts worse
|
Numerator 1 · Denominator 74 |
| Discharge self-care score | 68.42% |
53.69%
14.7 pts better
|
Numerator 26 · Denominator 38 |
| Discharge mobility score | 39.47% |
50.94%
11.5 pts worse
|
Numerator 15 · Denominator 38 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 74 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 7.97% |
7.12%
0.8 pts worse
|
No Different than the National Rate · Eligible stays 52 · Observed rate 11.54% · Lower 95% interval 4.29% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 201 |
| Staff flu vaccination coverage | 27.17% |
42%
14.8 pts worse
|
Numerator 72 · Denominator 265 |
| Discharge function score | 57.89% |
56.45%
1.4 pts better
|
Numerator 22 · Denominator 38 |
| Transfer of health information to provider | 96.67% |
95.95%
0.7 pts better
|
Numerator 58 · Denominator 60 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 5 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 2.44% |
25.2%
22.8 pts worse
|
Numerator 1 · Denominator 41 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.1% |
97.1%
2 pts better
|
93.4%
5.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 98.0% · Q2 98.2% · Q3 100.0% · Q4 100.0% · 4Q avg 99.1% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 93.4% |
94.6%
1.2 pts worse
|
95.5%
2.1 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 93.4% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.0% |
2.1%
2.1 pts better
|
3.3%
3.3 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 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 | 6.2% |
5.3%
0.9 pts worse
|
5.4%
0.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.0% · Q2 3.8% · Q3 11.1% · Q4 3.7% · 4Q avg 6.2% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 33.3% |
20.5%
12.8 pts worse
|
19.6%
13.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 38.0% · Q2 34.6% · Q3 33.3% · Q4 27.8% · 4Q avg 33.3% |
| Percentage of long-stay residents who received an antipsychotic medication | 1.5% |
11.8%
10.3 pts better
|
16.7%
15.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.9% · Q3 3.2% · Q4 0.0% · 4Q avg 1.5% · 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 | 12.0% |
14.5%
2.5 pts better
|
16.3%
4.3 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 12.0% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 6.3% |
10.8%
4.5 pts better
|
14.9%
8.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.6% · Q2 5.7% · Q3 2.8% · Q4 8.3% · 4Q avg 6.3% · 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 | 0.9% |
1.2%
0.3 pts better
|
1.7%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.8% · Q3 1.6% · Q4 0.0% · 4Q avg 0.9% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 20.3% |
20.5%
0.2 pts better
|
19.8%
0.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 21.4% · Q2 15.1% · Q3 23.7% · Q4 21.2% · 4Q avg 20.3% |
| Percentage of long-stay residents with pressure ulcers | 4.8% |
4.8%
About the same
|
5.1%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.8% · Q2 0.0% · Q3 6.8% · Q4 6.3% · 4Q avg 4.8% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 92.4% |
91.1%
1.3 pts better
|
81.7%
10.7 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 95.1% · Q2 94.5% · Q3 88.2% · Q4 91.4% · 4Q avg 92.4% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 2.7% |
10.7%
8 pts better
|
12.0%
9.3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 2.7% · Observed 2.9% · Expected 12.2% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.1% |
1.1%
1 pts better
|
1.6%
1.5 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.5% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.1% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 88.7% |
87.3%
1.4 pts better
|
79.7%
9 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 88.7% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 39.3% |
24.6%
14.7 pts worse
|
23.9%
15.4 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 39.3% · Observed 38.2% · Expected 23.2% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-01-06 · Fire 2023-01-06
8 health deficiencies
Top issue: Nutrition and Dietary (3 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2021-12-16 · Fire 2021-12-16
3 health deficiencies
Top issue: Pharmacy Service (1 deficiency)
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
2025-12-29
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2026-01-29
D · Potential for more than minimal harm
2025-07-21
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2025-08-14
D · Potential for more than minimal harm
2024-12-18
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-12-30
D · Potential for more than minimal harm
2024-11-08
F808 · Nutrition and Dietary Deficiencies
Health
Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.
Corrected 2024-12-16
D · Potential for more than minimal harm
2024-08-09
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 2024-08-17
D · Potential for more than minimal harm
2024-08-09
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 2024-08-17
D · Potential for more than minimal harm
2024-08-09
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2024-08-17
D · Potential for more than minimal harm
2024-06-27
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 2024-08-05
E · Potential for more than minimal harm
2023-01-06
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 2023-02-20
D · Potential for more than minimal harm
2023-01-06
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 2023-02-20
D · Potential for more than minimal harm
2023-01-06
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-02-20
D · Potential for more than minimal harm
2023-01-06
F814 · Nutrition and Dietary Deficiencies
Health
Dispose of garbage and refuse properly.
Corrected 2023-02-20
D · Potential for more than minimal harm
2023-01-06
F919 · Environmental Deficiencies
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected 2023-02-20
D · Potential for more than minimal harm
2021-12-16
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2022-01-25
D · Potential for more than minimal harm
2021-12-16
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2022-01-25
D · Potential for more than minimal harm
2021-12-16
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 2022-01-25
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
Fischbeck, Courtney
Operational/Managerial Control · Individual
Fischbeck, Courtney
Corporate Officer · Individual
Hasan, Omair
Operational/Managerial Control · Individual
Keetch, Chad
Corporate Officer · Individual
Peterson, Forrest
Corporate Director · Individual
Sato, Ami
Corporate Officer · Individual
Ventura Medstaff, LLC
Operational/Managerial Control · Organization
Nearby options
Other facilities in reach
#1
Desert Peak Care Center
Phoenix, AZ
1-star overall rating with 1-star inspections with abuse icon flag with $64,873 in total fines with 16 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
#2
Suncrest Healthcare Center
Phoenix, AZ
2-star overall rating with 1-star inspections with abuse icon flag with 23 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#3
Haven Health Sky Harbor, LLC
Phoenix, AZ
2-star overall rating with 1-star inspections with $43,628 in total fines with 19 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
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