Cycle 1
Health 2024-03-29 · Fire 2024-03-29
1 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Avondale, AZ
Estrella Health And Rehabilitation Center
5-star overall rating with 5-star inspections with 1 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
350 East La Canada, Avondale, AZ
(623) 932-2282
Overall
5 / 5
CMS overall stars
Health inspections
5 / 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
161
Certified beds
Average residents
143
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
The Ensign Group
Operator or chain grouping
Approved since
1988-07-26
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
0.41
Registered nurse staffing · state 0.72 · national 0.68
LPN hours / resident day
0.98
Licensed practical nurse staffing · state 1.04 · national 0.87
Aide hours / resident day
2.04
Nurse aide staffing · state 2.36 · national 2.35
Total nurse hours
3.42
All reported nurse hours · state 4.12 · national 3.89
Licensed hours
1.38
RN + LPN hours · state 1.76 · national 1.54
Weekend hours
3.18
Weekend nurse staffing · state 3.62 · national 3.43
Weekend RN hours
0.38
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
0.43
CMS adjusted RN staffing hours
Adjusted total hours
3.62
CMS adjusted total nurse staffing hours
Case-mix index
1.29
Higher values indicate more complex resident acuity
RN turnover
21%
Annual RN turnover · state 45% · national 45%
Total nurse turnover
32%
Annual nurse turnover · state 48% · national 46%
SNF VBP
Value-based purchasing
Program rank
8,966
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
25.14
Composite VBP score used to determine payment impact.
Payment multiplier
0.9837
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 18.89% · Performance 22.64% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
1.55
Baseline 6.77% · Performance 7.37% · Measure score 1.55 · Achievement 1.55 · Improvement 0
Total nurse turnover
7.57
Performance 32.74% · Measure score 7.57 · Achievement 7.57 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
0.94
Baseline 3.51 hours · Performance 3.34 hours · Measure score 0.94 · Achievement 0.94 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.95% |
10.72%
0.2 pts worse
|
No Different than the National Rate · Eligible stays 100 · Observed rate 11% · Lower 95% interval 7.83% |
| Discharge to community | 62.44% |
50.57%
11.9 pts better
|
No Different than the National Rate · Eligible stays 94 · Observed rate 58.51% · Lower 95% interval 48.13% |
| Medicare spending per beneficiary | 0.84 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 93 · Denominator 93 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 93 |
| Discharge self-care score | 81.48% |
53.69%
27.8 pts better
|
Numerator 44 · Denominator 54 |
| Discharge mobility score | 62.96% |
50.94%
12 pts better
|
Numerator 34 · Denominator 54 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 93 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 7.37% |
7.12%
0.2 pts worse
|
No Different than the National Rate · Eligible stays 72 · Observed rate 8.33% · Lower 95% interval 3.64% |
| Staff COVID-19 vaccination coverage | 6.85% |
8.2%
1.3 pts worse
|
Numerator 15 · Denominator 219 |
| Staff flu vaccination coverage | 34.2% |
42%
7.8 pts worse
|
Numerator 92 · Denominator 269 |
| Discharge function score | 79.63% |
56.45%
23.2 pts better
|
Numerator 43 · Denominator 54 |
| Transfer of health information to provider | 95.52% |
95.95%
0.4 pts worse
|
Numerator 64 · Denominator 67 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 17 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 11.86% |
25.2%
13.3 pts worse
|
Numerator 7 · 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 | 99.7% |
97.1%
2.6 pts better
|
93.4%
6.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 98.9% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 99.7% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 96.2% |
94.6%
1.6 pts better
|
95.5%
0.7 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 96.2% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.4% |
2.1%
0.7 pts better
|
3.3%
1.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.1% · Q2 1.1% · Q3 1.1% · Q4 1.1% · 4Q avg 1.4% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 6.1% |
4.2%
1.9 pts worse
|
11.4%
5.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.9% · Q2 4.6% · Q3 4.7% · Q4 8.2% · 4Q avg 6.1% |
| Percentage of long-stay residents who lose too much weight | 3.3% |
5.3%
2 pts better
|
5.4%
2.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.0% · Q2 2.5% · Q3 2.4% · Q4 2.4% · 4Q avg 3.3% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 21.3% |
20.5%
0.8 pts worse
|
19.6%
1.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 26.7% · Q2 22.4% · Q3 17.9% · Q4 18.1% · 4Q avg 21.3% |
| Percentage of long-stay residents who received an antipsychotic medication | 4.8% |
11.8%
7 pts better
|
16.7%
11.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.8% · Q2 4.6% · Q3 3.4% · Q4 3.2% · 4Q avg 4.8% · 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 | 0.0% |
14.5%
14.5 pts better
|
16.3%
16.3 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 4.5% |
10.8%
6.3 pts better
|
14.9%
10.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.3% · Q2 3.8% · Q3 2.6% · Q4 6.7% · 4Q avg 4.5% · 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 | 0.8% |
1.2%
0.4 pts better
|
1.7%
0.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.1% · Q2 0.0% · Q3 0.0% · Q4 2.2% · 4Q avg 0.8% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 29.1% |
20.5%
8.6 pts worse
|
19.8%
9.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 24.5% · Q2 26.3% · Q3 32.3% · Q4 33.8% · 4Q avg 29.1% |
| Percentage of long-stay residents with pressure ulcers | 3.5% |
4.8%
1.3 pts better
|
5.1%
1.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.6% · Q2 2.0% · Q3 3.0% · Q4 5.3% · 4Q avg 3.5% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 91.5% |
91.1%
0.4 pts better
|
81.7%
9.8 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 92.2% · Q2 91.3% · Q3 90.5% · Q4 91.8% · 4Q avg 91.5% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 9.1% |
10.7%
1.6 pts better
|
12.0%
2.9 pts better
|
Short Stay · 20240701-20250630 · Adjusted 9.1% · Observed 10.2% · Expected 12.5% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.7% |
1.1%
0.4 pts better
|
1.6%
0.9 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.9% · Q2 0.8% · Q3 0.4% · Q4 0.7% · 4Q avg 0.7% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 85.3% |
87.3%
2 pts worse
|
79.7%
5.6 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 85.3% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 30.7% |
24.6%
6.1 pts worse
|
23.9%
6.8 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 30.7% · Observed 35.6% · Expected 27.6% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-12-09 · Fire 2022-12-09
5 health deficiencies
Top issue: Resident Rights (3 deficiencies)
2 fire-safety deficiencies
Top issue: Services (1 deficiency)
Cycle 3
Health 2021-09-17 · Fire 2021-09-17
5 health deficiencies
Top issue: Nutrition and Dietary (2 deficiencies)
3 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2024-03-29
K133 · Construction Deficiencies
Fire Safety
Install a two-hour-resistant firewall separation.
Corrected 2024-05-08
E · Potential for more than minimal harm
2024-03-29
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-05-08
E · Potential for more than minimal harm
2024-03-29
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-05-08
D · Potential for more than minimal harm
2022-12-09
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2023-01-23
D · Potential for more than minimal harm
2022-12-09
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2023-01-23
F · Potential for more than minimal harm
2021-09-17
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2021-10-22
D · Potential for more than minimal harm
2021-09-17
K200 · Egress Deficiencies
Fire Safety
Meet other general requirements.
Corrected 2021-10-22
D · Potential for more than minimal harm
2021-09-17
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2021-10-22
Inspection history
Recent health citations
D · Potential for more than minimal harm
2024-03-29
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 2024-05-08
D · Potential for more than minimal harm
2023-06-01
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2023-07-10
D · Potential for more than minimal harm
2022-12-09
F578 · Resident Rights Deficiencies
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2023-01-20
D · Potential for more than minimal harm
2022-12-09
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2023-01-20
D · Potential for more than minimal harm
2022-12-09
F622 · Resident Rights Deficiencies
Health
Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
Corrected 2023-01-20
D · Potential for more than minimal harm
2022-12-09
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2023-01-20
D · Potential for more than minimal harm
2022-12-09
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 2023-01-20
E · Potential for more than minimal harm
2021-09-17
F770 · Administration Deficiencies
Health
Provide timely, quality laboratory services/tests to meet the needs of residents.
Corrected 2021-11-15
E · Potential for more than minimal harm
2021-09-17
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2021-11-15
E · Potential for more than minimal harm
2021-09-17
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 2021-11-15
B · Minimal harm
2021-09-17
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2021-11-15
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
Monks, Chandler
Corporate Officer · Individual
Moser, Matthew
Operational/Managerial Control · Individual
Nassour, William
Operational/Managerial Control · Individual
Peterson, Forrest
Corporate Officer · Individual
Sato, Ami
Corporate Officer · Individual
Nearby options
Other facilities in reach
#1
Palm Valley Post Acute
Goodyear, AZ
0-star overall rating with 0-star inspections with Special Focus status with abuse icon flag with $82,607 in total fines with 6 recent health deficiencies
#2
Sun Health La Loma Care Center
Litchfield Park, AZ
2-star overall rating with 2-star inspections with $12,735 in total fines with 10 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#3
Northpark Health And Rehabilitation Of Cascadia
Phoenix, AZ
5-star overall rating with 5-star inspections with $3,174 in total fines with 1 recent health deficiencies
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