Cycle 1
Health 2025-09-16 · Fire 2025-09-16
5 health deficiencies
Top issue: Resident Assessment and Care Planning (2 deficiencies)
6 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Tucson, AZ
Catalina Post Acute And Rehabilitation
4-star overall rating with 3-star inspections with 5 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
2611 North Warren Avenue, Tucson, AZ
(520) 795-9574
Overall
4 / 5
CMS overall stars
Health inspections
3 / 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
102
Certified beds
Average residents
94
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
The Ensign Group
Operator or chain grouping
Approved since
1988-10-20
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
0.82
Registered nurse staffing · state 0.72 · national 0.68
LPN hours / resident day
1.01
Licensed practical nurse staffing · state 1.04 · national 0.87
Aide hours / resident day
2.30
Nurse aide staffing · state 2.36 · national 2.35
Total nurse hours
4.13
All reported nurse hours · state 4.12 · national 3.89
Licensed hours
1.83
RN + LPN hours · state 1.76 · national 1.54
Weekend hours
3.43
Weekend nurse staffing · state 3.62 · national 3.43
Weekend RN hours
0.61
Weekend registered nurse coverage · state 0.51 · national 0.47
Physical therapist
0.07
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.68
CMS adjusted RN staffing hours
Adjusted total hours
3.42
CMS adjusted total nurse staffing hours
Case-mix index
1.65
Higher values indicate more complex resident acuity
RN turnover
29%
Annual RN turnover · state 45% · national 45%
Total nurse turnover
36%
Annual nurse turnover · state 48% · national 46%
SNF VBP
Value-based purchasing
Program rank
5,430
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
36.21
Composite VBP score used to determine payment impact.
Payment multiplier
0.9897
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
4.22
Baseline 19.72% · Performance 19.48% · Measure score 4.22 · Achievement 4.22 · Improvement 0.41
Healthcare-associated infections
5.74
Baseline 5.20% · Performance 6.12% · Measure score 5.74 · Achievement 5.74 · Improvement 0
Total nurse turnover
3.73
Baseline 52.17% · Performance 48.45% · Measure score 3.73 · Achievement 3.73 · Improvement 0.86
Adjusted total nurse staffing
0.8
Baseline 3.01 hours · Performance 3.31 hours · Measure score 0.8 · Achievement 0.8 · Improvement 0.56
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.04% |
10.72%
0.7 pts better
|
No Different than the National Rate · Eligible stays 110 · Observed rate 10% · Lower 95% interval 7.03% |
| Discharge to community | 71.66% |
50.57%
21.1 pts better
|
Better than the National Rate · Eligible stays 113 · Observed rate 60.18% · Lower 95% interval 59.56% |
| Medicare spending per beneficiary | 0.85 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 101 · Denominator 101 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 101 |
| Discharge self-care score | 60.42% |
53.69%
6.7 pts better
|
Numerator 29 · Denominator 48 |
| Discharge mobility score | 62.5% |
50.94%
11.6 pts better
|
Numerator 30 · Denominator 48 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 101 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 6.12% |
7.12%
1 pts better
|
No Different than the National Rate · Eligible stays 68 · Observed rate 4.41% · Lower 95% interval 3.28% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 161 |
| Staff flu vaccination coverage | 22.56% |
42%
19.4 pts worse
|
Numerator 44 · Denominator 195 |
| Discharge function score | 79.17% |
56.45%
22.7 pts better
|
Numerator 38 · Denominator 48 |
| Transfer of health information to provider | 97.65% |
95.95%
1.7 pts better
|
Numerator 83 · Denominator 85 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 15 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 1.69% |
25.2%
23.5 pts worse
|
Numerator 1 · Denominator 59 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.5% |
97.1%
2.4 pts better
|
93.4%
6.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 97.7% · Q3 100.0% · Q4 100.0% · 4Q avg 99.5% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 90.9% |
94.6%
3.7 pts worse
|
95.5%
4.6 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 90.9% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.0% |
2.1%
2.1 pts better
|
3.3%
3.3 pts better
|
Long 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 long-stay residents who have depressive symptoms | 11.6% |
4.2%
7.4 pts worse
|
11.4%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.3% · Q2 20.0% · Q3 15.2% · Q4 3.3% · 4Q avg 11.6% |
| Percentage of long-stay residents who lose too much weight | 0.6% |
5.3%
4.7 pts better
|
5.4%
4.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 2.2% · 4Q avg 0.6% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 16.5% |
20.5%
4 pts better
|
19.6%
3.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.2% · Q2 16.3% · Q3 11.9% · Q4 22.2% · 4Q avg 16.5% |
| Percentage of long-stay residents who received an antipsychotic medication | 7.3% |
11.8%
4.5 pts better
|
16.7%
9.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.3% · Q2 9.5% · Q3 3.6% · Q4 6.2% · 4Q avg 7.3% · 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 | 24.5% |
14.5%
10 pts worse
|
16.3%
8.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 24.5% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 16.7% |
10.8%
5.9 pts worse
|
14.9%
1.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 23.1% · Q2 18.4% · Q3 13.9% · Q4 10.8% · 4Q avg 16.7% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
0.9%
0.9 pts better
|
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% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.1% |
1.2%
0.1 pts better
|
1.7%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 4.3% · 4Q avg 1.1% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 15.5% |
20.5%
5 pts better
|
19.8%
4.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 21.8% · Q2 23.8% · Q3 11.1% · Q4 5.4% · 4Q avg 15.5% |
| Percentage of long-stay residents with pressure ulcers | 6.7% |
4.8%
1.9 pts worse
|
5.1%
1.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 9.7% · Q2 6.1% · Q3 4.7% · Q4 6.2% · 4Q avg 6.7% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.3% |
91.1%
8.2 pts better
|
81.7%
17.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 99.4% · Q2 99.4% · Q3 99.1% · Q4 99.5% · 4Q avg 99.3% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 9.9% |
10.7%
0.8 pts better
|
12.0%
2.1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 9.9% · Observed 11.5% · Expected 13.0% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.0% |
1.1%
0.1 pts better
|
1.6%
0.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.8% · Q2 1.2% · Q3 0.7% · Q4 1.2% · 4Q avg 1.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 88.1% |
87.3%
0.8 pts better
|
79.7%
8.4 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 88.1% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 23.6% |
24.6%
1 pts better
|
23.9%
0.3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 23.6% · Observed 28.7% · Expected 29.0% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-07-07 · Fire 2023-07-07
9 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
2 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Cycle 3
Health 2022-07-21 · Fire 2022-07-21
8 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2025-09-16
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2025-09-24
E · Potential for more than minimal harm
2025-09-16
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2025-10-12
E · Potential for more than minimal harm
2025-09-16
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-12-22
E · Potential for more than minimal harm
2025-09-16
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2025-12-12
E · Potential for more than minimal harm
2025-09-16
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-10-01
E · Potential for more than minimal harm
2025-09-16
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2025-12-08
E · Potential for more than minimal harm
2023-07-07
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 2023-08-21
E · Potential for more than minimal harm
2023-07-07
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2023-08-21
D · Potential for more than minimal harm
2022-07-21
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-09-12
D · Potential for more than minimal harm
2022-07-21
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2022-09-12
D · Potential for more than minimal harm
2022-07-21
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2022-09-12
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-10-29
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-11-20
E · Potential for more than minimal harm
2025-09-16
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-09-26
D · Potential for more than minimal harm
2025-09-16
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2025-09-26
D · Potential for more than minimal harm
2025-09-16
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-09-26
D · Potential for more than minimal harm
2025-06-23
F726 · Nursing and Physician Services Deficiencies
Health
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Corrected 2025-07-14
D · Potential for more than minimal harm
2024-08-08
F676 · Quality of Life and Care Deficiencies
Health
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Corrected 2024-08-15
E · Potential for more than minimal harm
2024-07-09
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2024-07-13
D · Potential for more than minimal harm
2023-12-27
F678 · Quality of Life and Care Deficiencies
Health
Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
Corrected 2024-02-16
E · Potential for more than minimal harm
2023-07-07
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-08-28
E · Potential for more than minimal harm
2023-07-07
F814 · Nutrition and Dietary Deficiencies
Health
Dispose of garbage and refuse properly.
Corrected 2023-08-28
D · Potential for more than minimal harm
2023-07-07
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2023-08-28
D · Potential for more than minimal harm
2023-07-07
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-08-28
D · Potential for more than minimal harm
2023-07-07
F693 · Quality of Life and Care Deficiencies
Health
Ensure 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.
Corrected 2023-08-28
D · Potential for more than minimal harm
2023-07-07
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-08-28
D · Potential for more than minimal harm
2023-07-07
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2023-08-28
D · Potential for more than minimal harm
2023-03-24
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2023-05-15
E · Potential for more than minimal harm
2022-07-21
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2022-09-02
E · Potential for more than minimal harm
2022-07-21
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-09-02
D · Potential for more than minimal harm
2022-07-21
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2022-09-02
D · Potential for more than minimal harm
2022-07-21
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2022-09-02
D · Potential for more than minimal harm
2022-07-21
F688 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected 2022-09-02
D · Potential for more than minimal harm
2022-07-21
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 2022-09-02
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
Eagar, Robert
Operational/Managerial Control · Individual
Eagar, Robert
W-2 Managing Employee · Individual
Fitch, Craig
Corporate Officer · Individual
Jones, Christine
Corporate Officer · Individual
Peterson, Forrest
Corporate Director · Individual
Nearby options
Other facilities in reach
#1
Park Avenue Health And Rehabilitation Center
Tucson, AZ
4-star overall rating with 3-star inspections with $25,116 in total fines with 7 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#2
Villa Maria Post Acute And Rehabilitation
Tucson, AZ
3-star overall rating with 2-star inspections with $8,018 in total fines with 9 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#3
The Center At Tucson
Tucson, AZ
5-star overall rating with 5-star inspections with 3 recent health deficiencies
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