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
Staffing
Hours and turnover
RN hours / resident day
0.41
Registered nurse staffing
LPN hours / resident day
0.98
Licensed practical nurse staffing
Aide hours / resident day
2.04
Nurse aide staffing
Weekend hours
3.18
Weekend nurse staffing
RN turnover
21%
Annual RN turnover
Total nurse turnover
32%
Annual nurse turnover
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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
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
Jump out