Cycle 1
Health 2024-10-02 · Fire 2024-10-02
0 health deficiencies
No concentrated health issue counts in this cycle.
2 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Gilbert, AZ
Wellsprings Of Gilbert
5-star overall rating with 5-star inspections with 2 fire-safety deficiencies in the latest cycle
3319 South Mercy Road, Gilbert, AZ
(480) 729-6500
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
32
Certified beds
Average residents
27
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
The Ensign Group
Operator or chain grouping
Approved since
2012-03-08
CMS approved date
Coverage
Medicare
Participation flags
Staffing
Hours and turnover
RN hours / resident day
1.10
Registered nurse staffing
LPN hours / resident day
1.04
Licensed practical nurse staffing
Aide hours / resident day
2.07
Nurse aide staffing
Weekend hours
3.55
Weekend nurse staffing
RN turnover
25%
Annual RN turnover
Total nurse turnover
58%
Annual nurse turnover
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 93.7% |
91.1%
2.6 pts better
|
81.7%
12 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who had an outpatient emergency department visit | 3.0% |
10.7%
7.7 pts better
|
12.0%
9 pts better
|
Short Stay · 20240701-20250630 |
| 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 |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 89.8% |
87.3%
2.5 pts better
|
79.7%
10.1 pts better
|
Short Stay · 2024Q3-2025Q2 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 22.7% |
24.6%
1.9 pts better
|
23.9%
1.2 pts better
|
Short Stay · 20240701-20250630 |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-08-11 · Fire 2023-08-11
4 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
2 fire-safety deficiencies
Top issue: Emergency Preparedness (1 deficiency)
Cycle 3
Health 2022-06-22 · Fire 2022-06-22
0 health deficiencies
No concentrated health issue counts in this cycle.
3 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2024-10-02
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2024-11-14
E · Potential for more than minimal harm
2024-10-02
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-10-14
E · Potential for more than minimal harm
2023-08-11
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2023-10-06
E · Potential for more than minimal harm
2023-08-11
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-10-06
D · Potential for more than minimal harm
2022-06-22
K223 · Egress Deficiencies
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2022-07-08
D · Potential for more than minimal harm
2022-06-22
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2022-07-08
D · Potential for more than minimal harm
2022-06-22
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2022-07-08
Inspection history
Recent health citations
E · Potential for more than minimal harm
2023-08-11
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-08-14
E · Potential for more than minimal harm
2023-08-11
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 2023-08-14
E · Potential for more than minimal harm
2023-08-11
F887 · Infection Control Deficiencies
Health
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.
Corrected 2023-08-14
D · Potential for more than minimal harm
2023-08-11
F552 · Resident Rights Deficiencies
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2023-08-14
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
Bermeo, Cezanne
Operational/Managerial Control · Individual
Burnam, Soon
Corporate Officer · Individual
Keetch, Chad
Corporate Officer · Individual
Peterson, Forrest
Corporate Director · Individual
Petty, Scott
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
The Center At Val Vista, LLC
Gilbert, AZ
5-star overall rating with 5-star inspections with 3 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#2
Sante Of Mesa
Mesa, AZ
5-star overall rating with 4-star inspections with $3,146 in total fines with 4 recent health deficiencies
#3
Desert Cove Nursing Center
Chandler, AZ
2-star overall rating with 1-star inspections with abuse icon flag with 17 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
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