Cycle 1
Health 2024-11-21 · Fire 2024-11-21
1 health deficiencies
Top issue: Resident Assessment and Care Planning (1 deficiency)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Tempe, AZ
Tempe Post Acute
5-star overall rating with 5-star inspections with 1 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
6100 South Rural Road, Tempe, AZ
(480) 831-8660
Overall
5 / 5
CMS overall stars
Health inspections
5 / 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
60
Certified beds
Average residents
68
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
The Ensign Group
Operator or chain grouping
Approved since
1985-07-29
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
0.55
Registered nurse staffing · state 0.72 · national 0.68
LPN hours / resident day
0.98
Licensed practical nurse staffing · state 1.04 · national 0.87
Aide hours / resident day
3.11
Nurse aide staffing · state 2.36 · national 2.35
Total nurse hours
4.64
All reported nurse hours · state 4.12 · national 3.89
Licensed hours
1.53
RN + LPN hours · state 1.76 · national 1.54
Weekend hours
3.96
Weekend nurse staffing · state 3.62 · national 3.43
Weekend RN hours
0.39
Weekend registered nurse coverage · state 0.51 · national 0.47
Physical therapist
0.15
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.56
CMS adjusted RN staffing hours
Adjusted total hours
4.74
CMS adjusted total nurse staffing hours
Case-mix index
1.34
Higher values indicate more complex resident acuity
RN turnover
33%
Annual RN turnover · state 45% · national 45%
Total nurse turnover
47%
Annual nurse turnover · state 48% · national 46%
SNF VBP
Value-based purchasing
Program rank
5,243
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
36.89
Composite VBP score used to determine payment impact.
Payment multiplier
0.9902
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
5.66
Baseline 22.44% · Performance 19.11% · Measure score 5.66 · Achievement 5.02 · Improvement 5.66
Healthcare-associated infections
2.65
Baseline 7.47% · Performance 7.04% · Measure score 2.65 · Achievement 2.65 · Improvement 1.22
Total nurse turnover
4.05
Baseline 69.56% · Performance 49.23% · Measure score 4.05 · Achievement 3.53 · Improvement 4.05
Adjusted total nurse staffing
2.40
Baseline 4.53 hours · Performance 3.76 hours · Measure score 2.40 · Achievement 2.40 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.88% |
10.72%
0.2 pts worse
|
No Different than the National Rate · Eligible stays 94 · Observed rate 11.7% · Lower 95% interval 8.24% |
| Discharge to community | 63.72% |
50.57%
13.1 pts better
|
Better than the National Rate · Eligible stays 76 · Observed rate 57.89% · Lower 95% interval 51.86% |
| Medicare spending per beneficiary | 0.98 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 75 · Denominator 75 |
| Falls with major injury | 1.33% |
0.77%
0.6 pts worse
|
Numerator 1 · Denominator 75 |
| Discharge self-care score | 57.14% |
53.69%
3.5 pts better
|
Numerator 28 · Denominator 49 |
| Discharge mobility score | 55.1% |
50.94%
4.2 pts better
|
Numerator 27 · Denominator 49 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 75 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 7.04% |
7.12%
0.1 pts better
|
No Different than the National Rate · Eligible stays 52 · Observed rate 5.77% · Lower 95% interval 3.86% |
| Staff COVID-19 vaccination coverage | 0.75% |
8.2%
7.4 pts worse
|
Numerator 1 · Denominator 133 |
| Staff flu vaccination coverage | 84.65% |
42%
42.7 pts better
|
Numerator 182 · Denominator 215 |
| Discharge function score | 73.47% |
56.45%
17 pts better
|
Numerator 36 · Denominator 49 |
| Transfer of health information to provider | 85.45% |
95.95%
10.5 pts worse
|
Numerator 47 · Denominator 55 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 11 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 16.67% |
25.2%
8.5 pts worse
|
Numerator 7 · Denominator 42 |
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 · 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 | 3.3% |
2.1%
1.2 pts worse
|
3.3%
About the same
|
Long Stay · 2024Q4-2025Q3 · Q2 4.5% · Q3 3.8% · Q4 0.0% · 4Q avg 3.3% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 4.8% |
4.2%
0.6 pts worse
|
11.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q2 0.0% · Q3 4.5% · Q4 4.8% · 4Q avg 4.8% |
| Percentage of long-stay residents who lose too much weight | 5.8% |
5.3%
0.5 pts worse
|
5.4%
0.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q3 10.0% · 4Q avg 5.8% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 17.1% |
20.5%
3.4 pts better
|
19.6%
2.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q3 20.0% · Q4 20.0% · 4Q avg 17.1% |
| Percentage of long-stay residents who received an antipsychotic medication | 2.0% |
11.8%
9.8 pts better
|
16.7%
14.7 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 2.0% · 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 · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 11.0% |
14.5%
3.5 pts better
|
16.3%
5.3 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 11.0% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 8.6% |
10.8%
2.2 pts better
|
14.9%
6.3 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 8.6% · 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 · Q3 0.0% · 4Q avg 0.0% · 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 · 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 | 18.6% |
20.5%
1.9 pts better
|
19.8%
1.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q3 21.2% · 4Q avg 18.6% |
| Percentage of long-stay residents with pressure ulcers | 3.0% |
4.8%
1.8 pts better
|
5.1%
2.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q2 3.1% · Q3 2.7% · Q4 3.1% · 4Q avg 3.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 95.2% |
91.1%
4.1 pts better
|
81.7%
13.5 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 98.0% · Q2 95.5% · Q3 93.0% · Q4 94.6% · 4Q avg 95.2% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 10.8% |
10.7%
0.1 pts worse
|
12.0%
1.2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 10.8% · Observed 11.9% · Expected 12.3% · 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 1.6% · Q2 1.0% · Q3 0.9% · Q4 0.5% · 4Q avg 1.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 83.6% |
87.3%
3.7 pts worse
|
79.7%
3.9 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 83.6% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 18.2% |
24.6%
6.4 pts better
|
23.9%
5.7 pts better
|
Short Stay · 20240701-20250630 · Adjusted 18.2% · Observed 18.6% · Expected 24.4% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-12-15 · Fire 2023-12-15
1 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2022-11-10 · Fire 2022-11-10
7 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
E · Potential for more than minimal harm
2024-11-21
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2024-12-13
E · Potential for more than minimal harm
2024-11-21
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2024-12-13
E · Potential for more than minimal harm
2024-11-21
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-12-13
D · Potential for more than minimal harm
2022-11-10
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2022-12-14
D · Potential for more than minimal harm
2022-11-10
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2022-12-14
Inspection history
Recent health citations
E · Potential for more than minimal harm
2024-11-21
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-12-27
E · Potential for more than minimal harm
2023-12-15
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 2024-01-29
D · Potential for more than minimal harm
2023-05-02
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2023-06-21
D · Potential for more than minimal harm
2022-11-10
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 2022-12-18
D · Potential for more than minimal harm
2022-11-10
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2022-12-18
D · Potential for more than minimal harm
2022-11-10
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2022-12-18
D · Potential for more than minimal harm
2022-11-10
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 2022-12-18
D · Potential for more than minimal harm
2022-11-10
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2022-12-18
D · Potential for more than minimal harm
2022-11-10
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2022-12-18
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, John
Corporate Officer · Individual
Burnam, Soon
Corporate Officer · Individual
Fitch, Craig
Corporate Officer · Individual
Ortega, Amador
Operational/Managerial Control · Individual
Ortega, Amador
W-2 Managing Employee · Individual
Peterson, Forrest
Corporate Director · Individual
Nearby options
Other facilities in reach
#1
River Park Post Acute
Chandler, AZ
5-star overall rating with 4-star inspections with 5 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#2
Friendship Village Of Tempe
Tempe, AZ
2-star overall rating with 1-star inspections with 18 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#3
Mirabella At Asu
Tempe, AZ
5-star overall rating with 4-star inspections with 2 recent health deficiencies
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