Federal inspection record · CMS data as of October 1, 2026
Wellsprings of Gilbert
3319 South Mercy Road, Gilbert, AZ · (480) 729-6500
- Certified beds
- 32
- Residents per day
- 31
- Ownership
- For-Profit
- Chain
- The Ensign Group
- Medicare / Medicaid
- Medicare
- Certified since
- March 8, 2012
1
How this home got 5 stars
The overall rating isn't an average. CMS starts from the inspection rating and nudges it at most two steps. Here is the arithmetic for this home, using CMS's own rules.
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Health inspections
★★★★★starting point
Everything starts from what state inspectors found on site. This is a ranking against other homes in Arizona.
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Staffing
★★★★★no change
Only a 5-star staffing rating adds a star, and only a 1-star rating removes one. Ratings of 2 to 4 change nothing.
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Quality measures
★★★★★no change (already 5)
Same rule: 5 stars adds one, 1 star takes one away. These measures are mostly reported by the home itself.
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Overall
★★★★★5 of 5
Matches the rating CMS publishes on Care Compare.
2
Where it sits among Arizona homes
Wellsprings of Gilbert carries 7 inspection points. That is fewer than 92% of Arizona's 139 rated homes.
Inspectors' citations earn points by how serious and how widespread they were (the grid below). CMS then ranks every home in Arizona: the 10% with the fewest points get 5 stars, the 20% with the most get 1 star, and the middle 70% split evenly into 2, 3 and 4.
- 5★ 0–9.5 pts
- 4★ 9.5–23 pts
- 3★ 23–38 pts
- 2★ 38–59 pts
- 1★ over 59 pts
Bars show every rated home in Arizona by its weighted inspection score. CMS recalibrates the cut points monthly but holds a home's rating until its own score changes, so a home can sit just outside today's band.
3
What inspectors found
4 health citations on record since 2023. Each one gets a letter: the row says how badly residents were affected, the column how many.
Immediate jeopardyResidents at risk of serious injury or death
Actual harmA resident was hurt
Potential for harmNo one was hurt, but could have been
Minimal harmPaperwork-level problems
Read the rows, not the total. Most citations nationwide are a D: one problem, nobody hurt. Rows G–I mean a resident was harmed; J–L mean inspectors found residents in immediate danger of serious injury or death.
Small numbers in each cell are the inspection points CMS assigns per citation. Those points are what the state curve above ranks.
No citation on record at the harm or immediate-jeopardy level.
Everything else, by area of care
Quality of Life and Care2E
- E
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
- E
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Infection Control1E
- E
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
Resident Rights1D
- D
Ensure that residents are fully informed and understand their health status, care and treatments.
Inspection history
2024-10-02
0 health deficiencies · 2 fire-safety deficiencies
No concentrated health issue counts in this cycle.
2023-08-11
4 health deficiencies · 2 fire-safety deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
2022-06-22
0 health deficiencies · 3 fire-safety deficiencies
No concentrated health issue counts in this cycle.
4
Nursing time per resident, per day
Each resident here gets about 4 h 13 min of nursing staff time a day, 58 min of it from a registered nurse.
This home
4 h 13 min
Arizona average
4 h 5 min
U.S. average
3 h 54 min
- Registered nurse
- Licensed practical nurse
- Nurse aide
Turnover: 30% of nursing staff and 29% of registered nurses left in the past year.
Reported hours from payroll data the home submits to CMS, divided by its daily resident count. Not adjusted for how sick residents are.
5
Resident outcomes
Quality measures compared with state and national averages. Most come from assessments the home itself reports.
| Measure | This home | State | U.S. |
|---|---|---|---|
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine3.3 pts better | 95.9% | 92.6% | 82.3% |
| Percentage of short-stay residents who had an outpatient emergency department visit4.4 pts better | 5.6% | 10.0% | 11.8% |
| Percentage of short-stay residents who newly received an antipsychotic medication1.1 pts better | 0.0% | 1.1% | 1.5% |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine4.5 pts better | 92.4% | 87.9% | 80.1% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission7.1 pts better | 16.4% | 23.5% | 23.4% |
·
Who owns and runs it
15 owners and managers reported to CMS. The last column counts how many nursing homes each one is tied to.
Show ownership list
| Name | Role | Share | Homes |
|---|---|---|---|
| Bermeo, Cezanne | Managing Control - Governing Body · Individual | 0% | 1 facilities |
| Bermeo, Cezanne | Operational/Managerial Control · Individual | 0% | 1 facilities |
| Bermeo, Cezanne | Adp Of The SNF · Individual | 0% | 1 facilities |
| Burnam, Soon | Managing Control - Governing Body · Individual | 0% | 353 facilities |
| Burnam, Soon | Corporate Officer · Individual | 0% | 353 facilities |
| Creed Health Holdings LLC | Adp Of The SNF · Organization | 0% | 1 facilities |
| Ensign Services Inc | Adp Of The SNF · Organization | 0% | 299 facilities |
| Keetch, Chad | Corporate Officer · Individual | 0% | 301 facilities |
| Peterson, Forrest | Corporate Director · Individual | 0% | 42 facilities |
| Petty, Scott | Managing Control - Governing Body · Individual | 0% | 2 facilities |
| Petty, Scott | Operational/Managerial Control · Individual | 0% | 2 facilities |
| Petty, Scott | Adp Of The SNF · Individual | 0% | 2 facilities |
| Port, Barry | Individual Is An Owner, Partner Or Trustee Of Any Adp Of The SNF · Individual | 0% | 203 facilities |
| Standard Bearer Healthcare Op, LP | Adp Of The SNF · Organization | 0% | 78 facilities |
| The Ensign Group Inc | Adp Of The SNF · Organization | 0% | 135 facilities |
·
Fire safety
7 life-safety citations (sprinklers, exits, alarms). These don't count toward the star rating.
Smoke3E
- E
Install an approved automatic sprinkler system.
- E
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
- E
Provide properly protected cooking facilities.
Emergency Preparedness1E
- E
Conduct testing and exercise requirements.
Egress1D
- D
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Services1D
- D
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Gas, Vacuum, and Electrical Systems1D
- D
Have proper medical gas storage and administration areas.
·
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