Cycle 1
Health 2025-01-31 · Fire 2025-01-31
11 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (7 deficiencies)
5 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Peoria, AZ
Immanuel Campus Of Care
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
11301 North 99th Avenue, Peoria, AZ
(623) 977-8373
Overall
2 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
228
Certified beds
Average residents
164
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1998-11-18
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
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
0.54
Registered nurse staffing · state 0.72 · national 0.68
LPN hours / resident day
1.26
Licensed practical nurse staffing · state 1.04 · national 0.87
Aide hours / resident day
3.18
Nurse aide staffing · state 2.36 · national 2.35
Total nurse hours
4.98
All reported nurse hours · state 4.12 · national 3.89
Licensed hours
1.81
RN + LPN hours · state 1.76 · national 1.54
Weekend hours
4.51
Weekend nurse staffing · state 3.62 · national 3.43
Weekend RN hours
0.51
Weekend registered nurse coverage · state 0.51 · national 0.47
Physical therapist
0.02
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.64
CMS adjusted RN staffing hours
Adjusted total hours
5.89
CMS adjusted total nurse staffing hours
Case-mix index
1.16
Higher values indicate more complex resident acuity
RN turnover
24%
Annual RN turnover · state 45% · national 45%
Total nurse turnover
24%
Annual nurse turnover · state 48% · national 46%
SNF VBP
Value-based purchasing
Program rank
29
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
96.25
Composite VBP score used to determine payment impact.
Payment multiplier
1.0276
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Healthcare-associated infections
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Total nurse turnover
9.25
Baseline 23.27% · Performance 25.87% · Measure score 9.25 · Achievement 9.25 · Improvement 0
Adjusted total nurse staffing
10
Baseline 5.39 hours · Performance 6.09 hours · Measure score 10 · Achievement 10 · Improvement 9
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | Not Available |
10.72%
|
Not Available · Eligible stays 4 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays 3 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Medicare spending per beneficiary | Not Available |
1.02
|
Too few residents or stays to report publicly. |
| Drug regimen review with follow-up | Not Available |
95.27%
|
Numerator Not Available · Denominator 1 · Too few residents or stays to report publicly. |
| Falls with major injury | Not Available |
0.77%
|
Numerator Not Available · Denominator 1 · Too few residents or stays to report publicly. |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator Not Available · Newly certified or not enough cases to report. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator Not Available · Newly certified or not enough cases to report. |
| Pressure ulcers or injuries, new or worsened | Not Available |
2.29%
|
Numerator Not Available · Denominator 1 · Adjusted rate Not Available · Too few residents or stays to report publicly. |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 3 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 2.03% |
8.2%
6.2 pts worse
|
Numerator 6 · Denominator 296 |
| Staff flu vaccination coverage | 36.99% |
42%
5 pts worse
|
Numerator 155 · Denominator 419 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator Not Available · Newly certified or not enough cases to report. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator Not Available · Newly certified or not enough cases to report. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 1 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 1 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 98.0% |
97.1%
0.9 pts better
|
93.4%
4.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 97.3% · Q2 98.6% · Q3 98.7% · Q4 97.4% · 4Q avg 98.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 99.4% |
94.6%
4.8 pts better
|
95.5%
3.9 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 99.4% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.3% |
2.1%
0.8 pts better
|
3.3%
2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.0% · Q2 1.4% · Q3 1.3% · Q4 0.6% · 4Q avg 1.3% · 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 3.5% · Q2 2.9% · Q3 7.6% · Q4 6.8% · 4Q avg 5.3% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 47.7% |
20.5%
27.2 pts worse
|
19.6%
28.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 47.5% · Q2 47.4% · Q3 49.3% · Q4 46.6% · 4Q avg 47.7% |
| Percentage of long-stay residents who received an antipsychotic medication | 58.3% |
11.8%
46.5 pts worse
|
16.7%
41.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 59.0% · Q2 56.4% · Q3 62.2% · Q4 56.4% · 4Q avg 58.3% · 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 | 18.3% |
14.5%
3.8 pts worse
|
16.3%
2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 19.6% · Q2 9.2% · Q3 2.9% · Q4 39.1% · 4Q avg 18.3% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 12.9% |
10.8%
2.1 pts worse
|
14.9%
2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.4% · Q2 11.0% · Q3 8.9% · Q4 22.8% · 4Q avg 12.9% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.8% |
0.9%
0.1 pts better
|
1.0%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.7% · Q2 1.5% · Q3 0.6% · Q4 0.5% · 4Q avg 0.8% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.3% |
1.2%
0.1 pts worse
|
1.7%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.4% · Q2 0.0% · Q3 1.3% · Q4 2.6% · 4Q avg 1.3% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 16.0% |
20.5%
4.5 pts better
|
19.8%
3.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 16.9% · Q2 15.8% · Q3 17.2% · Q4 14.0% · 4Q avg 16.0% |
| Percentage of long-stay residents with pressure ulcers | 5.2% |
4.8%
0.4 pts worse
|
5.1%
0.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.3% · Q2 5.4% · Q3 6.6% · Q4 4.3% · 4Q avg 5.2% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 88.2% |
91.1%
2.9 pts worse
|
81.7%
6.5 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 83.1% · Q2 83.9% · Q3 94.4% · Q4 93.8% · 4Q avg 88.2% |
| Percentage of short-stay residents who newly received an antipsychotic medication | 11.3% |
1.1%
10.2 pts worse
|
1.6%
9.7 pts worse
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 11.3% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 84.6% |
87.3%
2.7 pts worse
|
79.7%
4.9 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 84.6% |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-11-03 · Fire 2023-11-03
13 health deficiencies
Top issue: Resident Rights (5 deficiencies)
6 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Cycle 3
Health 2022-09-02 · Fire 2022-09-02
14 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (9 deficiencies)
2 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2025-01-31
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2025-03-03
E · Potential for more than minimal harm
2025-01-31
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-03-21
E · Potential for more than minimal harm
2025-01-31
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2025-03-21
E · Potential for more than minimal harm
2025-01-31
K911 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2025-03-02
E · Potential for more than minimal harm
2025-01-31
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-03-21
E · Potential for more than minimal harm
2023-11-03
K133 · Construction Deficiencies
Fire Safety
Install a two-hour-resistant firewall separation.
Corrected 2023-12-22
E · Potential for more than minimal harm
2023-11-03
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2023-12-22
E · Potential for more than minimal harm
2023-11-03
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-12-22
E · Potential for more than minimal harm
2023-11-03
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2023-12-22
D · Potential for more than minimal harm
2023-11-03
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2023-12-22
D · Potential for more than minimal harm
2023-11-03
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-12-22
D · Potential for more than minimal harm
2022-09-02
E20 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures including evacuation.
Corrected 2022-10-14
D · Potential for more than minimal harm
2022-09-02
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 2022-10-14
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-12-02
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 2025-12-12
D · Potential for more than minimal harm
2025-07-15
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2025-08-15
D · Potential for more than minimal harm
2025-07-15
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2025-08-15
D · Potential for more than minimal harm
2025-07-15
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2025-08-15
D · Potential for more than minimal harm
2025-07-03
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2025-08-01
D · Potential for more than minimal harm
2025-05-27
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2025-06-06
G · Actual harm
2025-03-24
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 2025-04-24
D · Potential for more than minimal harm
2025-03-20
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2025-03-25
E · Potential for more than minimal harm
2025-01-31
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2025-03-20
D · Potential for more than minimal harm
2025-01-31
F557 · Resident Rights Deficiencies
Health
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
Corrected 2025-03-20
D · Potential for more than minimal harm
2025-01-31
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2025-03-20
D · Potential for more than minimal harm
2024-12-20
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2024-12-23
D · Potential for more than minimal harm
2024-12-20
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2024-12-23
D · Potential for more than minimal harm
2024-12-20
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 2024-12-23
D · Potential for more than minimal harm
2024-09-05
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2024-10-18
D · Potential for more than minimal harm
2024-07-10
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2024-08-01
G · Actual harm
2024-04-19
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2024-04-24
D · Potential for more than minimal harm
2024-03-08
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-04-28
D · Potential for more than minimal harm
2024-03-08
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 2024-04-28
E · Potential for more than minimal harm
2023-11-03
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2023-12-22
E · Potential for more than minimal harm
2023-11-03
F576 · Resident Rights Deficiencies
Health
Ensure residents have reasonable access to and privacy in their use of communication methods.
Corrected 2023-12-22
E · Potential for more than minimal harm
2023-11-03
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2023-12-22
D · Potential for more than minimal harm
2023-11-03
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2023-12-22
D · Potential for more than minimal harm
2023-11-03
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2023-12-22
D · Potential for more than minimal harm
2023-11-03
F644 · Resident Assessment and Care Planning Deficiencies
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2023-12-22
D · Potential for more than minimal harm
2023-10-20
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2023-12-04
D · Potential for more than minimal harm
2023-09-14
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2023-09-11
D · Potential for more than minimal harm
2023-08-28
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 2023-09-15
E · Potential for more than minimal harm
2023-07-27
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2023-09-11
E · Potential for more than minimal harm
2023-06-14
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2023-07-29
E · Potential for more than minimal harm
2023-06-14
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2023-07-29
D · Potential for more than minimal harm
2023-06-14
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2023-07-29
D · Potential for more than minimal harm
2023-04-11
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2023-06-08
E · Potential for more than minimal harm
2022-09-02
F567 · Resident Rights Deficiencies
Health
Honor the resident's right to manage his or her financial affairs.
Corrected 2022-10-31
D · Potential for more than minimal harm
2022-09-02
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2022-10-31
D · Potential for more than minimal harm
2022-09-02
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2022-10-31
D · Potential for more than minimal harm
2022-09-02
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2022-10-31
D · Potential for more than minimal harm
2022-09-02
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2022-10-31
Penalties and ownership
What sits behind the stars
$9,110
2025-01-31
Fine
Fine · fine $9,110
Fine
$9,419
2024-03-07
Fine
Fine · fine $9,419
Fine
Ownership
Immanuel Caring Ministries, Inc.
Operational/Managerial Control · Organization
Litman, Lawrence
Operational/Managerial Control · Individual
Litman, Lawrence
Corporate Officer · Individual
Mccarthy-Robinson, Susan
Operational/Managerial Control · Individual
Mccarthy-Robinson, Susan
Corporate Director · Individual
Mcnellis, Gregory
Corporate Officer · Individual
Nassour, William
Operational/Managerial Control · Individual
Trautman, Ray
Operational/Managerial Control · Individual
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