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
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
No
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
1.10
Registered nurse staffing · state 0.72 · national 0.68
LPN hours / resident day
1.04
Licensed practical nurse staffing · state 1.04 · national 0.87
Aide hours / resident day
2.07
Nurse aide staffing · state 2.36 · national 2.35
Total nurse hours
4.21
All reported nurse hours · state 4.12 · national 3.89
Licensed hours
2.14
RN + LPN hours · state 1.76 · national 1.54
Weekend hours
3.55
Weekend nurse staffing · state 3.62 · national 3.43
Weekend RN hours
0.49
Weekend registered nurse coverage · state 0.51 · national 0.47
Physical therapist
0.20
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.98
CMS adjusted RN staffing hours
Adjusted total hours
3.73
CMS adjusted total nurse staffing hours
Case-mix index
1.54
Higher values indicate more complex resident acuity
RN turnover
25%
Annual RN turnover · state 45% · national 45%
Total nurse turnover
58%
Annual nurse turnover · state 48% · national 46%
SNF VBP
Value-based purchasing
Program rank
7,912
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
28.40
Composite VBP score used to determine payment impact.
Payment multiplier
0.9850
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
3.10
Baseline 18.49% · Performance 20.00% · Measure score 3.10 · Achievement 3.10 · Improvement 0
Healthcare-associated infections
2.59
Baseline 7.69% · Performance 7.06% · Measure score 2.59 · Achievement 2.59 · Improvement 1.84
Total nurse turnover
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Adjusted total nurse staffing
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.27% |
10.72%
0.5 pts better
|
No Different than the National Rate · Eligible stays 285 · Observed rate 10.18% · Lower 95% interval 8.04% |
| Discharge to community | 66.46% |
50.57%
15.9 pts better
|
Better than the National Rate · Eligible stays 286 · Observed rate 63.99% · Lower 95% interval 61.34% |
| Medicare spending per beneficiary | 1.02 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 195 · Denominator 195 |
| Falls with major injury | 1.03% |
0.77%
0.3 pts worse
|
Numerator 2 · Denominator 195 |
| Discharge self-care score | 76.53% |
53.69%
22.8 pts better
|
Numerator 75 · Denominator 98 |
| Discharge mobility score | 61.22% |
50.94%
10.3 pts better
|
Numerator 60 · Denominator 98 |
| Pressure ulcers or injuries, new or worsened | 1.03% |
2.29%
1.3 pts better
|
Numerator 2 · Denominator 194 · Adjusted rate 1.04% |
| Healthcare-associated infections requiring hospitalization | 7.06% |
7.12%
0.1 pts better
|
No Different than the National Rate · Eligible stays 162 · Observed rate 6.79% · Lower 95% interval 4.69% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 68 |
| Staff flu vaccination coverage | 11.22% |
42%
30.8 pts worse
|
Numerator 11 · Denominator 98 |
| Discharge function score | 75.51% |
56.45%
19.1 pts better
|
Numerator 74 · Denominator 98 |
| Transfer of health information to provider | 99.35% |
95.95%
3.4 pts better
|
Numerator 152 · Denominator 153 |
| Transfer of health information to patient | 97.44% |
96.28%
1.2 pts better
|
Numerator 38 · Denominator 39 |
| Resident COVID-19 vaccinations up to date | 0% |
25.2%
25.2 pts worse
|
Numerator 0 · Denominator 118 |
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 · Q1 88.0% · Q2 96.7% · Q3 96.7% · Q4 92.5% · 4Q avg 93.7% |
| 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 · Adjusted 3.0% · Observed 3.4% · Expected 12.8% · 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 | 89.8% |
87.3%
2.5 pts better
|
79.7%
10.1 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 89.8% |
| 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 · Adjusted 22.7% · Observed 26.3% · Expected 27.6% · Used in QM five-star |
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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