Cycle 1
Health 2025-04-04 · Fire 2025-04-04
4 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Peoria, AZ
Az - Rio Vista Post Acute And Rehabilitation
5-star overall rating with 4-star inspections with 4 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
10323 West Olive Avenue, Peoria, AZ
(623) 875-0100
Overall
5 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
150
Certified beds
Average residents
137
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
The Ensign Group
Operator or chain grouping
Approved since
1988-08-05
CMS approved date
Coverage
Medicare + Medicaid
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
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.69
Registered nurse staffing · state 0.72 · national 0.68
LPN hours / resident day
0.89
Licensed practical nurse staffing · state 1.04 · national 0.87
Aide hours / resident day
1.97
Nurse aide staffing · state 2.36 · national 2.35
Total nurse hours
3.56
All reported nurse hours · state 4.12 · national 3.89
Licensed hours
1.58
RN + LPN hours · state 1.76 · national 1.54
Weekend hours
3.14
Weekend nurse staffing · state 3.62 · national 3.43
Weekend RN hours
0.45
Weekend registered nurse coverage · state 0.51 · national 0.47
Physical therapist
0.11
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.71
CMS adjusted RN staffing hours
Adjusted total hours
3.64
CMS adjusted total nurse staffing hours
Case-mix index
1.34
Higher values indicate more complex resident acuity
RN turnover
32%
Annual RN turnover · state 45% · national 45%
Total nurse turnover
50%
Annual nurse turnover · state 48% · national 46%
SNF VBP
Value-based purchasing
Program rank
4,220
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
40.85
Composite VBP score used to determine payment impact.
Payment multiplier
0.9938
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
5.46
Baseline 18.51% · Performance 18.90% · Measure score 5.46 · Achievement 5.46 · Improvement 0
Healthcare-associated infections
5.66
Baseline 6.48% · Performance 6.14% · Measure score 5.66 · Achievement 5.66 · Improvement 1.76
Total nurse turnover
3.23
Baseline 62.83% · Performance 50.47% · Measure score 3.23 · Achievement 3.23 · Improvement 2.76
Adjusted total nurse staffing
1.99
Baseline 3.24 hours · Performance 3.64 hours · Measure score 1.99 · Achievement 1.99 · Improvement 1.07
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.75% |
10.72%
1 pts better
|
No Different than the National Rate · Eligible stays 111 · Observed rate 8.11% · Lower 95% interval 6.49% |
| Discharge to community | 59.93% |
50.57%
9.4 pts better
|
No Different than the National Rate · Eligible stays 109 · Observed rate 58.72% · Lower 95% interval 50.35% |
| Medicare spending per beneficiary | 0.96 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 123 · Denominator 123 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 123 |
| Discharge self-care score | 54.88% |
53.69%
1.2 pts better
|
Numerator 45 · Denominator 82 |
| Discharge mobility score | 45.12% |
50.94%
5.8 pts worse
|
Numerator 37 · Denominator 82 |
| Pressure ulcers or injuries, new or worsened | 0.81% |
2.29%
1.5 pts better
|
Numerator 1 · Denominator 123 · Adjusted rate 0.73% |
| Healthcare-associated infections requiring hospitalization | 6.14% |
7.12%
1 pts better
|
No Different than the National Rate · Eligible stays 70 · Observed rate 4.29% · Lower 95% interval 3.18% |
| Staff COVID-19 vaccination coverage | 5.46% |
8.2%
2.7 pts worse
|
Numerator 10 · Denominator 183 |
| Staff flu vaccination coverage | 12.32% |
42%
29.7 pts worse
|
Numerator 34 · Denominator 276 |
| Discharge function score | 71.95% |
56.45%
15.5 pts better
|
Numerator 59 · Denominator 82 |
| Transfer of health information to provider | 97.59% |
95.95%
1.6 pts better
|
Numerator 81 · Denominator 83 |
| Transfer of health information to patient | 88% |
96.28%
8.3 pts worse
|
Numerator 22 · Denominator 25 |
| Resident COVID-19 vaccinations up to date | 1.56% |
25.2%
23.6 pts worse
|
Numerator 1 · Denominator 64 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
97.1%
2.9 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 98.8% |
94.6%
4.2 pts better
|
95.5%
3.3 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 98.8% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.1% |
2.1%
1 pts worse
|
3.3%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.9% · Q2 2.7% · Q3 4.1% · Q4 2.8% · 4Q avg 3.1% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
4.2%
4.2 pts better
|
11.4%
11.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents who lose too much weight | 5.3% |
5.3%
About the same
|
5.4%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.2% · Q2 7.5% · Q3 1.5% · Q4 3.1% · 4Q avg 5.3% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 24.6% |
20.5%
4.1 pts worse
|
19.6%
5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 26.2% · Q2 20.9% · Q3 26.9% · Q4 24.6% · 4Q avg 24.6% |
| Percentage of long-stay residents who received an antipsychotic medication | 4.6% |
11.8%
7.2 pts better
|
16.7%
12.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.8% · Q2 0.0% · Q3 6.0% · Q4 7.0% · 4Q avg 4.6% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.3%
0.3 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 14.6% |
14.5%
0.1 pts worse
|
16.3%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 9.8% · Q3 28.4% · Q4 18.8% · 4Q avg 14.6% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 3.9% |
10.8%
6.9 pts better
|
14.9%
11 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 3.1% · Q3 4.6% · Q4 8.1% · 4Q avg 3.9% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.6% |
0.9%
0.3 pts better
|
1.0%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 2.3% · 4Q avg 0.6% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 4.2% |
1.2%
3 pts worse
|
1.7%
2.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.9% · Q2 4.0% · Q3 4.1% · Q4 5.7% · 4Q avg 4.2% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 32.8% |
20.5%
12.3 pts worse
|
19.8%
13 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 27.5% · Q2 38.5% · Q3 28.8% · Q4 35.6% · 4Q avg 32.8% |
| Percentage of long-stay residents with pressure ulcers | 4.4% |
4.8%
0.4 pts better
|
5.1%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.1% · Q2 4.8% · Q3 4.5% · Q4 3.0% · 4Q avg 4.4% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.1% |
91.1%
8 pts better
|
81.7%
17.4 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 98.9% · Q2 98.9% · Q3 99.1% · Q4 99.5% · 4Q avg 99.1% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 4.0% |
10.7%
6.7 pts better
|
12.0%
8 pts better
|
Short Stay · 20240701-20250630 · Adjusted 4.0% · Observed 4.7% · Expected 13.1% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.3% |
1.1%
0.8 pts better
|
1.6%
1.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.7% · Q2 0.3% · Q3 0.0% · Q4 0.0% · 4Q avg 0.3% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 97.7% |
87.3%
10.4 pts better
|
79.7%
18 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 97.7% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 24.3% |
24.6%
0.3 pts better
|
23.9%
0.4 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 24.3% · Observed 28.1% · Expected 27.6% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-05-26 · Fire 2023-05-26
4 health deficiencies
Top issue: Resident Assessment and Care Planning (2 deficiencies)
1 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Cycle 3
Health 2022-03-04 · Fire 2022-03-04
4 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2025-04-04
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-05-14
D · Potential for more than minimal harm
2023-05-26
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2023-07-20
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-05-07
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-05-23
D · Potential for more than minimal harm
2025-05-07
F561 · Resident Rights Deficiencies
Health
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected 2025-05-23
D · Potential for more than minimal harm
2025-05-07
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-05-23
E · Potential for more than minimal harm
2025-04-04
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-05-09
D · Potential for more than minimal harm
2025-02-05
F660 · Resident Assessment and Care Planning Deficiencies
Health
Plan the resident's discharge to meet the resident's goals and needs.
Corrected 2025-03-07
D · Potential for more than minimal harm
2023-05-26
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2023-07-05
D · Potential for more than minimal harm
2023-05-26
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-07-05
D · Potential for more than minimal harm
2023-05-26
F802 · Nutrition and Dietary Deficiencies
Health
Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
Corrected 2023-07-05
G · Actual harm
2022-03-04
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2022-04-15
E · Potential for more than minimal harm
2022-03-04
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-04-15
D · Potential for more than minimal harm
2022-03-04
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2022-04-15
D · Potential for more than minimal harm
2022-03-04
F685 · Quality of Life and Care Deficiencies
Health
Assist a resident in gaining access to vision and hearing services.
Corrected 2022-04-15
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
Burnam, Soon
Corporate Officer · Individual
Keetch, Chad
Corporate Officer · Individual
Majors, Megan
Operational/Managerial Control · Individual
Nassour, William
Operational/Managerial Control · Individual
Peterson, Forrest
Corporate Officer · Individual
Port, Barry
Corporate Officer · Individual
Nearby options
Other facilities in reach
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Immanuel Campus Of Care
Peoria, AZ
2-star overall rating with 1-star inspections with abuse icon flag with $18,529 in total fines with 11 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
#2
Sunview Respiratory And Rehabilitation
Youngtown, AZ
4-star overall rating with 3-star inspections with 7 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#3
Boswell Transitional Care Of Cascadia
Sun City, AZ
5-star overall rating with 4-star inspections with 2 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
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