Montecito Post Acute Care and Rehabilitation
51 South 48th Street, Mesa, AZ 85206 · For profit - Corporation · 222 certified beds · (949) 487-9500 Medicare & Medicaid certified
The public record raises real questions here. Weigh the concerns below carefully.
- a middle-of-the-pack inspection score (3/5)
- a high payroll-based staffing rating (4/5)
- lower-than-typical staff turnover (34% vs 45% nationally) — better care continuity
- it has 1 actual-harm citation
- a high number of inspection citations overall (18) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $8,278 in federal fines (most recent 2025-05-20)
- its facility-reported quality-measure score sits well above its independent inspection score
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 3 of 5 |
| StaffingFrom payroll records (PBJ) | 4 of 5 |
| Quality measuresSelf-reported by the facility | 5 of 5 |
Worth a closer look. This home's quality-measure rating runs 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself — so a gap this large is worth reading the inspection record for.
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 5 of 5 |
| Long-stay residentspeople who live here | 5 of 5 |
| Short-stay residentsrehab / post-hospital | 5 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 2 to 5 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 1.0% | 10.7% | 15.4% | better |
| Long-stay residents who lose too much weight | 6.7% | 5.3% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 0.3% | 0.8% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 0.4% | 1.2% | 2.0% | better |
| Long-stay residents with depressive symptoms | 2.3% | 3.9% | 6.5% | better |
| Long-stay residents who were physically restrained | 2.7% | 0.3% | 0.1% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents with falls causing major injury | 1.0% | 2.1% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 1.4% | 12.8% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 30.3% | 21.0% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 99.4% | 94.6% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 8.7% | 4.4% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 20.8% | 20.6% | 21.2% | typical |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 2.8% | 10.6% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 0.1% | 1.2% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 98.8% | 87.3% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 14.9% | 23.7% | 22.6% | better |
| Short-stay residents with an outpatient ER visit | 6.0% | 10.4% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 1.60 | 1.47 | 1.67 | typical |
| Long-stay outpatient ER visits per 1,000 resident days | 0.63 | 1.42 | 1.80 | better |
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
56.2% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 203 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 71.1% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 45 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.
Therapy staffing: this home’s payroll records show 0.48 therapist hours per resident per day in 2026Q1 — more than 79% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 3% of this home’s weekday level — it runs therapy on weekdays, with essentially none at the weekend. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 56.2%CMS range 46.5–65.2 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 11.2%CMS range 8.1–14.7 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 71.1% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 75.6% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 60.0% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 99.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | 98.4% | 100.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 0.0% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 2.0% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 8.3%CMS range 5.5–12.6 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.17 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 222 beds and averages 201.7 residents a day — about 91% occupied, or roughly 20 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 4.21 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 1.23 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.13 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 3.48 hrs/resident/day on weekends vs 4.51 on weekdays — 23% thinner on weekends — a notable drop. RN hours go from 1.40 to 0.82 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 34% is below the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
18 citations, most serious first. The 11 most serious are shown; the remaining 7 are one tap away and print in full.
- Actual harm · Gcited before2025-05-20 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observations of practice, staff and representative interviews the facility failed to ensure adequate supervision for 1 of 2 sampled residents (#39) while smoking. The deficient practice resulted in the resident sustaining life-threatening injuries. Findings include: Resident #39 was admitted originally on March 3, 2014 and readmitted on [DATE] with diagnoses that include hemiplegia and hemiparesis, peripheral vascular disease, dementia, long QT syndrome, cognitive communication disorder, anemia and major depressive disorder. Review of resident #39 's clinical record revealed a smoking policy/consent dated December 6, 2018 with the resident ' s signature. Review of the resident ' s clinical record revealed a care plan focus of ' potential for injury related to smoking ' created on August 25, 2014 and last revised September 12, 2022. The goal was that the resident will have no injuries related to smoking and will be compliant with smoking protocols and individual smoking plan until the next…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-09-04 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure adequate assessment, monitoring, and supervision to prevent elopement for 2 (residents #22 and #19) of 5 sampled residents. The deficient practice could result in injury to residents.-Regarding Resident #22Resident #22 was readmitted to the facility on [DATE] with diagnoses including: Metabolic encephalopathy, cognitive communication deficit, restlessness and agitation, chronic kidney disease, , muscle weakness, difficulty in walking, protein-calorie malnutrition, altered mental status, seizures, type 2 diabetes mellitus with hyperglycemia, unspecified mood affective disorder, anxiety disorder, tobacco use, major depressive disorder, dementia, severe, without behavioral disturbance, psychotic disturbance, and mood disturbance.An admission minimum data set (MDS) assessment dated [DATE] revealed the resident had a brief interview for mental status (BIMS) score of 8, indicating moderate cognitive impairment.A care plan focus initiated…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2025-02-14 · tag F0725 — failed to have enough nursing staff — patternProvide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interviews, and policy review, the facility failed to ensure adequate staffing was provided on weekends to meet the needs of multiple residents (#59, and #162). The deficient practice could result in residents' care needs not being met. Findings Include: -Regarding Resident #59 Resident #59 was admitted to the facility on [DATE] with diagnoses that included chronic respiratory failure and quadriplegia. A Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 14, which indicated intact cognition. The assessment also indicated that the resident was dependent on staff assistance when moving from a laying to sitting position, and that the ability to get on and off the toilet was not assessed due to a medical condition or safety concern. An interview was conducted on February 11, 2024, at 10:05 a.m. with Resident #59's Representative, who stated that the facility had been understaffed the last couple weeks, with just…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-02-14 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, resident and staff interviews and observations The facility failed to ensure proper nail care for one of thirty-six sampled residents (#104) was performed. This deficient practice could result in resident grooming and hygiene needs not being met. Findings include: Resident #104 was admitted to the facility on [DATE] with diagnoses including hydrocephalus, muscle weakness, and hyperlipidemia. Review of resident #104's Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview of Mental Status (BIMS) score of 7, which indicates severe cognitive impairment. The MDS assessment also revealed the resident needed substantial/maximal assistance for showering/bathing and personal hygiene. Review of the facility's shower sheets dated January 3, 7, 10, 13, 14, 15, 17, 18, 21, 24, 27, 28, 30, and 31, 2025, and February 4, 7, and 11, 2025, reveal that the resident #104 did not need their fingernails or toenails clipped and no clipping was performed. Resident #104 was observed on…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-02-14 · tag F0757 — failed to avoid unnecessary drugs — isolatedEnsure each resident’s drug regimen must be free from unnecessary drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on review of clinical records and policy, and staff interviews the facility failed to ensure an order for pain medication was followed as prescribed for one Resident (#288). The deficient practice of administering unnecessary medication may result in undesirable medication-induced harm. Finding includes: Resident #288 was admitted into the facility on February 03, 2025 with diagnoses that included chronic atrial fibrillation, dysphagia, type 2 diabetes mellitus and a stage III pressure ulcer. Review of the physician orders revealed the following: - Acetaminophen Oral Tablet 325 milligrams (Acetaminophen) to give 2 tablets by mouth every 6 hours as needed for pain between 1-3 with a start date of February 03, 2025. - Oxycodone HCl oral tablet 10 milligrams (Oxycodone HCl) to give 1 tablet by mouth every 6 hours as needed for pain between 4-10 with a start date of February 03, 2025. Review of progress note signed by Licensed Practical Nurse (staff # 93) on February 09, 2025 at 12:01 p.m. and at 09:35 p.m. showed that resident was given Oxycodone HCl oral tablet 10 milligrams…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2023-11-22 · tag F0842 — failed to keep accurate, complete medical records — patternSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interviews, and review of facility policies and practices, the facility failed to ensure accurate documentation of showers/baths in the clinical record for two residents (#190 and #193). The deficient practice could result in an inaccurate documentation resulting in the potential of needed cares not being provided. Findings include: -Resident #193 was admitted on [DATE] with diagnoses of that included displaced fracture of the first cervical vertebra, repeated falls, and acute urinary tract infection without hematuria. The shower sheets record revealed the resident received a bath or shower on March 3,7,10, 14, 17, 18, 21, 24, 28 and 31, 2022. These shower sheets were signed by the CNA and the nurse. contained both CNA and nurse signatures for each shower or bath recorded. However, the March 2022 CNA documentation for showers/bathing revealed that resident #193 received a bath or shower on March 3, 7, 17, 21, 24, 28, and 31, 2022. The documentation did not include that…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-11-22 · tag F0757 — failed to avoid unnecessary drugs — isolatedEnsure each resident’s drug regimen must be free from unnecessary drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interviews and policy review, the facility failed to ensure one resident was free from unnecessary medication by failing to ensure there was a adequate indication for the use of antibiotic medication for one resident (#193). The deficient practice could result in residents receiving unnecessary antibiotics which could result in infectious microorganisms with increased drug resistance and/or superinfection. Findings include: Resident #193 was admitted on [DATE] with diagnoses of that included displaced fracture of the first cervical vertebra, repeated falls, and acute urinary tract infection without hematuria. The IDT (interdisciplinary team) note dated December 27, 2021 included that the resident had a cystitis and was on Cefdinir (antibiotic) for 7 days. The antibiotic therapy care plan dated December 28, 2021 included that the resident was on antibiotic therapy related to UTI (urinary tract infection) prophylaxis for 7 days. Intervention included to administer medication…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-08-18 · tag F0561 — failed to honor residents' choices — isolatedHonor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical documentation, resident and staff interviews, and facility policy, the facility failed to ensure preferences regarding meals were honored for one resident (#287). The deficient practice could result in resident's autonomy not exercised. Findings include: Resident #287 was admitted on [DATE] with diagnoses of toxic encephalopathy and protein calorie malnutrition. A care plan initiated on August 8, 2023 included the resident had a potential nutritional problem related to diagnoses of protein calorie malnutrition and had increased protein needs related to wound healing due to a pressure ulcer. Interventions included to honor resident rights to make personal dietary choices and provide dietary education as needed. A nursing note dated August 8, 2023 revealed the resident was alert and oriented x 4. The mini nutritional assessment dated [DATE] revealed the resident had a score of 10 indicating the resident at risk of malnutrition. The nutrition admission evaluation dated August 14, 2023 revealed an…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-08-18 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical documentation, resident and staff interviews, and facility policy, the facility failed to ensure treatment was administered as ordered by the physician for one resident (#27). The deficient practice could result in resident not receiving care and services based on his assessed needs. Findings include: Resident #27 was admitted on [DATE] with diagnoses of spinal stenosis cervical region, spondylosis with myopathy cervical region and functional quadriplegia. An admission Minimum Data Set (MDS) assessment dated [DATE] included the resident had moderately cognitive impairment and required extensive assistance one-person physical assistance for most activities of daily living. The assessment also included the resident rejected care 1-3 days during the last 7 days of the look back period. A care plan dated July 25, 2023 included the resident had an alteration in neurological status related to spinal stenosis and spondylosis, status post repeat spinal surgeries. It also included the resident was a…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2022-07-01 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — patternProvide appropriate pressure ulcer care and prevent new ulcers from developing.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, observations, staff interviews, and policies and procedures, the facility failed to ensure that one resident (#162) received the necessary care to prevent and to promote the healing of pressure ulcers. The sample size was 3 residents. The deficient practice could result in formation or worsening of pressure ulcers. Findings include: Resident #162 was admitted on [DATE] with diagnoses that included Hemiplegia, Hemiparesis r/t cerebral infarction affecting right dominant side, type 2 diabetes mellitus, diabetic chronic kidney disease, and morbid obesity. Review of the care plan initiated on August 23, 2021 revealed an ADL (activities of daily living) self-care performance deficit care plan with interventions that included restorative nursing assistant (RNA) to don/doff bilateral PRAFO (pressure relief ankle foot orthosis) x 6 hours as tolerated and out of bed in Geri-chair as tolerated by the resident to promote functional body position. Review of physician's orders revealed an…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2022-07-01 · tag F0812 — failed to store, cook, and serve food safely — patternProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, staff interviews, and policy reviews, the facility failed to ensure staff members wore hair restraints and food items were stored in accordance with professional standards for food service safety. The deficient practice could increase the risk of foodborne illness. Findings include: Regarding hair restraints During the initial kitchen observation conducted on June 27, 2022 at 8:30 a.m., a staff member who had a long, bushy beard, approximately 4 inches in length was observed with his beard unrestrained while putting away supplies around the kitchen. Another observation of the kitchen was conducted on June 29, 2022 at 10:05 a.m. During this observation, a staff member without a hair restraint was walking around the kitchen to include the walk-in fridge putting away supplies. In an interview conducted with the dietary manager (staff #318) on June 29, 2022 at 1:46 p.m., she stated that part of the staff's attire/grooming standards is that hair including facial hair is restrained while working in the kitchen. The facility policy titled Personal Hygiene dated 2018…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 7 citations
- Potential for harm · Ecited before2022-07-01 · tag F0842 — failed to keep accurate, complete medical records — patternSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record reviews, staff interviews, and policy review, the facility failed to maintain accurate, complete, and readily accessible medical records in accordance with professional standards and practices for four residents (#101, #39, #70, & #487). The sample size was 35 residents. The deficient practice could result in additional medical records being inaccessible and unavailable to reflect the care and services provided to residents. Findings include: -Resident #101 was admitted on [DATE] with diagnoses that included end stage renal disease, tracheostomy, morbid obesity, diabetes mellitus, and anemia. Review of the admission Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. Further review revealed no behaviors occurred during the admission assessment review dates. Review of the medical record on [DATE] at 9:35 AM revealed no Advance Directive form. An interview was conducted on [DATE]…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2022-07-01 · tag F0880 — failed to prevent and control infections — patternProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, staff interviews, policy review, and the Center for Disease Control and Prevention (CDC) guidelines, the facility failed to implement their infection control and prevention program related to perineal/catheter care. The deficient practice could result in transmission of infection to staff and residents. Findings include: An observation of perineal/catheter care for a resident was conducted on June 29, 2022 at 12:15 p.m. with Certified Nursing Assistants (CNA/staff #52 and staff #123) and the Director of Staff Development/Registered Nurse (RN/staff #86). There was white signage outside the resident's room that indicated the resident was on strict enhanced barrier precautions. The CNA staff in the room were wearing a gown, mask, gloves, and a face shield. The RN was wearing a mask, gown, and gloves. The CNA (staff #52) performed perineal/catheter care from the front of the body. While staff #52 and staff #123 were repositioning the resident onto the left side, the tracheostomy/airway connection became disconnected. Staff #123 held the tubing in her hands and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2022-07-01 · tag F0561 — failed to honor residents' choices — isolatedHonor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff and resident interviews, and review of policy and procedure, the facility failed to ensure one sampled resident's (#133) right to self-determination. The deficient practice could result in infringement of resident rights. Findings include: Resident #133 admitted to the facility on [DATE] with diagnoses that included osteomyelitis of vertebra, right femur, right ankle and foot, cellulitis of right lower limb, and spina bifida. Review of the physician's orders dated June 4, 2022 included the resident had been informed of their medical condition and that the resident was capable of giving informed consent and/or able to participate in the treatment plan. Review of a Communication Method Request form dated June 4, 2022 revealed the resident wanted information shared with the resident's parent. The Initial admission Record form signed June 6, 2022 included the resident was fully oriented with no confusion, made self-understood and had clear comprehension. Review of the Social…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-07-01 · tag F0625 — isolatedNotify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interviews, and policy review, the facility failed to ensure one resident (#39) was provided written notification for a bed hold when transferred to the hospital. The sample size was 2 residents. The deficient practice could result in residents that are transferred or discharged not being informed of the facility's bed hold policy in writing. Findings include: Resident #39 was admitted to the facility on [DATE] with diagnoses that included acute/chronic respiratory failure with hypercapnia, morbid obesity, and dependence on renal dialysis. Review of the admissions Minimum Data Set assessment dated [DATE], revealed a brief interview for mental status score of 14, which indicated the resident had intact cognition. Review of the resident census report revealed that the resident had been discharged with return anticipated on May 5, 2022 and June 3, 2022. Review of the medical record revealed no written notification regarding bed holds for hospitalizations on June 3, 2022, and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-07-01 · tag F0641 — isolatedEnsure each resident receives an accurate assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interviews, policy review, and the Resident Assessment Instrument (RAI) manual, the facility failed to ensure the Minimum Data Set (MDS) assessment was accurate for one resident (#133). The sample size was 35 residents. The deficient practice could result in assessments that are not accurate and data that is not accurate for quality monitoring. Findings include: Resident #133 was admitted to the facility on [DATE] with diagnoses that included osteomyelitis of vertebra, right femur, right ankle and foot, cellulitis of right lower limb, and type two diabetes mellitus (DM). Review of the physician's orders revealed an order dated June 4, 2022 for Humalog Solution 100 units/milliliter (ml) inject subcutaneously before meals and at bedtime per sliding scale for DM. The sliding scale did not include insulin coverage for blood sugar levels under 201. Review of an admission MDS assessment dated [DATE] included coding that the resident had received 7 days of insulin injections…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-07-01 · tag F0692 — failed to prevent malnutrition and dehydration — isolatedProvide enough food/fluids to maintain a resident's health.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interviews, clinical record review, and review of policy, the facility failed to ensure one resident's (#178) weight was obtained as ordered. The sample size was 4 residents. Failure to obtain and monitor weights could result in weight loss and malnutrition. Findings include: Resident #178 was admitted [DATE] with diagnoses that included cervical vertebral fracture, traumatic brain injury, dysphagia and anemia. Review of the physician's orders dated 6/13/22 revealed weights were to be taken weekly. A review of the nutrition notes revealed dated 6/15/2022 at 9:36 AM revealed that per the RNA staff, the resident refused an admission weight. The note also revealed the resident weighed 209 pounds in the hospital on 6/11/22, that weight was entered, and that hospital weights ranged from 191 - 209 pounds. The note stated to continue to encourage, retrying on future dates. Review of the weights revealed the weight 209 pounds dated 6/15/22. No other weights were noted. Review of the Mini Nutritional…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-07-01 · tag F0693 — failed to provide proper feeding-tube care — isolatedEnsure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, observations, resident and staff interviews, and policy review, the facility failed to ensure percutaneous endoscopic gastrostomy (PEG) tube care was provided for one sampled resident (#70). The deficient practice could result in the resident's increased risk for infection. Findings include: Resident #70 was admitted to the facility on [DATE] with diagnoses that included chronic respiratory failure with hypoxia, other toxic encephalopathy, tracheostomy, pneumothorax, dysphagia, muscle weakness, gastronomy, type II diabetes mellitus with hyperglycemia, and protein-calorie malnutrition. Physician orders dated September 29, 2021 revealed to check the tube placement and patency prior to each feeding/flush/medication administration via air bolus auscultation or residual aspiration and to flush the tubing with 100 ml (milliliters) water three times a day for tube patency. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a score of 15 on the Brief Interview for…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
$8,278 in federal fines across 1 penalty.
- $8,278 — penalty dated 2025-05-20
Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.
Part of a chain
This home belongs to THE ENSIGN GROUP — 342 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 4 of 5 | 3.2 | +0.8 vs chain |
| Health inspection | 3 of 5 | 2.8 | +0.2 vs chain |
| Staffing | 4 of 5 | 2.7 | +1.3 vs chain |
| Quality measures | 5 of 5 | 4.4 | +0.6 vs chain |
The other 341 homes this chain runs (chain average 3.2★, per CMS)
Showing 40 of 341; lowest-rated first.
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Since |
|---|---|---|---|
| BOBBA, DHEERAJ | Individual | MANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 09/01/2015 |
| COOPER, KARL | Individual | MANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 09/01/2018 |
| PETERSON, FORREST | Individual | CORPORATE DIRECTOR | since 01/01/2019 |
| BURNAM, SOON | Individual | CORPORATE OFFICER | since 10/01/2006 |
| KEETCH, CHAD | Individual | CORPORATE OFFICER | since 03/01/2011 |
| PORT, BARRY | Individual | INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF | since 07/29/2025 |
| ENSIGN SERVICES INC | Organization | ADP OF THE SNF | since 08/01/2003 |
CMS files one row per role, so the 11 rows in the source record cover these 7 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.
1 organizational owner listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
This home reported $4.2M paid to related parties — landlords or management companies under common ownership — equal to about 12% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in AZ
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Arizona Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 035135. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-02-14, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →
Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →
Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.