Citadel Post Acute
5121 East Broadway Road, Mesa, AZ 85206 · Maricopa County · 128 certified beds · avg 120 residents/day · certified since Mar 1, 1985
Part of chain: THE ENSIGN GROUP (342 facilities, chain avg rating 3.2★)
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★★★★★5/5 · CMS overall rating: 5/5
The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.
All citations in the current public record (5)
CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.
| Date | Severity | What the facility was cited for |
|---|---|---|
| Jul 18, 2025 | D · Potential for harm, one-off | The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. · from a complaint |
| Feb 21, 2025 | D · Potential for harm, one-off | The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. |
| Feb 21, 2025 | D · Potential for harm, one-off | The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. |
| Feb 21, 2025 | D · Potential for harm, one-off | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Apr 14, 2023 | D · Potential for harm, one-off | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
Inspection trend by year
Citations from standard inspections increased between the last two inspection cycles (1 → 3).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2023 | 1 | 0 | D |
| 2025 | 4 | 0 | D |
Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.
Fines and enforcement (last 3 years)
No fines or payment denials in the published 3-year window.
Nurse staffing (from payroll records, adjusted for how much care residents need)
| Measure | This facility | Arizona avg | U.S. avg | Where it stands |
|---|---|---|---|---|
| Total nurse staffing (hours per resident per day) | 3.74 | 3.97 | 3.95 | top 49% in Arizona; bottom 49% in the U.S. |
| Registered Nurse hours | 0.46 | 0.69 | 0.69 | bottom 29% in Arizona; bottom 32% in the U.S. |
| Weekend total nurse staffing | 3.16 | 3.50 | 3.50 | bottom 41% in Arizona; bottom 40% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.24 | 0.49 | 0.48 | bottom 15% in Arizona; bottom 19% in the U.S. |
| Total nursing staff turnover (%) | 43.8 | 45.2 | 45.8 | top 43% in Arizona; top 47% in the U.S. |
| RN turnover (%) | 37.5 | 43.6 | 42.9 | top 32% in Arizona; top 42% in the U.S. |
Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 3.55, RN 0.44, weekend 3.00. Staffing rating: 3/5.
Self-reported quality measures
Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.
Quality measures rating: 5/5 · long-stay residents: 5/5 · short-stay residents: 5/5
Who owns this facility
For profit - Corporation
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Burnam, Soon | Individual | Corporate Officer | NOT APPLICABLE | 03/25/2015 |
| Ensign Services INC | Organization | ADP of the SNF | NOT APPLICABLE | 07/01/2015 |
| Keetch, Chad | Individual | Corporate Officer | NOT APPLICABLE | 03/01/2011 |
| Monks, Chandler | Individual | Corporate Officer | NOT APPLICABLE | 03/01/2024 |
| Peterson, Forrest | Individual | Corporate Director | NOT APPLICABLE | 01/01/2019 |
| Port, Barry | Individual | Individual Is an Owner, Partner or Trustee of Any ADP of the SNF | NOT APPLICABLE | 06/23/2025 |
| Sato, Ami | Individual | Corporate Officer | NOT APPLICABLE | 09/09/2024 |
| Speth, Terry | Individual | Managing Control - Governing Body | NOT APPLICABLE | 11/11/2015 |
| Speth, Terry | Individual | Operational/Managerial Control | NOT APPLICABLE | 11/11/2015 |
| Speth, Terry | Individual | ADP of the SNF | NOT APPLICABLE | 06/23/2025 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "Tell me about this abuse or neglect citation — what happened, and what specific changes did you make afterward?"
- "How does your pharmacist review residents' medications, and how quickly can you fill new or urgent prescriptions?"
- "Can you show me how medications are stored and secured on the units, including controlled drugs?"
- "Who leads your infection prevention program, and how do you make sure staff follow practices like hand hygiene every day?"
- "What did your most recent kitchen inspection find, and can I see how food is stored and prepared?"
- "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
- "Can I see the results and plan of correction from your most recent state inspection?"
Nearby facilities (within 20 miles)
| Facility | Distance | City | Overall | Inspection | Flags |
|---|---|---|---|---|---|
| Desert Blossom Health & Rehab Center | 0.7 mi | Mesa, AZ | ★★★★★ | 4/5 | |
| Montecito Post Acute Care and Rehabilitation | 0.7 mi | Mesa, AZ | ★★★★☆ | 3/5 | |
| Advanced Healthcare of Mesa | 0.8 mi | Mesa, AZ | ★★★★★ | 5/5 | |
| Alta Mesa Health and Rehabilitation | 1.1 mi | Mesa, AZ | ★★★★★ | 5/5 | |
| Mi Casa Nursing Center | 1.2 mi | Mesa, AZ | ★★★☆☆ | 2/5 | abuse |
| Mission Palms Post Acute | 1.7 mi | Mesa, AZ | ★★★★☆ | 3/5 | |
| Sante of Mesa | 2.0 mi | Mesa, AZ | ★★★★★ | 5/5 | |
| Citrus Heights Respiratory and Rehabilitation | 2.3 mi | Mesa, AZ | ★★★☆☆ | 2/5 | |
| Springdale Village Post Acute | 2.9 mi | Mesa, AZ | ★★★☆☆ | 2/5 | |
| Sandridge Post Acute | 7.2 mi | Mesa, AZ | ★★★☆☆ | 2/5 | |
| Wellsprings of Gilbert | 8.3 mi | Gilbert, AZ | ★★★★★ | 5/5 | |
| Apache Junction Health Center | 8.7 mi | Apache Junction, AZ | ★★★★☆ | 3/5 |
Compare this facility with the 3 closest →
Facility data as of CMS processing date 2026-08-01. CCN 035103.