Cycle 1
Health 2024-05-10 · Fire 2024-05-10
6 health deficiencies
Top issue: Infection Control (2 deficiencies)
1 fire-safety deficiencies
Top issue: Emergency Preparedness (1 deficiency)
Peoria, AZ
Lake Pleasant Post Acute Rehabilitation Center
4-star overall rating with 3-star inspections with 5 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
20625 North Lake Pleasant Road, Peoria, AZ
(623) 566-0642
Overall
4 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
128
Certified beds
Average residents
108
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
The Ensign Group
Operator or chain grouping
Approved since
1985-07-29
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
0.56
Registered nurse staffing · state 0.72 · national 0.68
LPN hours / resident day
0.96
Licensed practical nurse staffing · state 1.04 · national 0.87
Aide hours / resident day
1.98
Nurse aide staffing · state 2.36 · national 2.35
Total nurse hours
3.50
All reported nurse hours · state 4.12 · national 3.89
Licensed hours
1.52
RN + LPN hours · state 1.76 · national 1.54
Weekend hours
2.94
Weekend nurse staffing · state 3.62 · national 3.43
Weekend RN hours
0.42
Weekend registered nurse coverage · state 0.51 · national 0.47
Physical therapist
0.08
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.57
CMS adjusted RN staffing hours
Adjusted total hours
3.54
CMS adjusted total nurse staffing hours
Case-mix index
1.35
Higher values indicate more complex resident acuity
RN turnover
60%
Annual RN turnover · state 45% · national 45%
Total nurse turnover
47%
Annual nurse turnover · state 48% · national 46%
SNF VBP
Value-based purchasing
Program rank
4,325
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
40.42
Composite VBP score used to determine payment impact.
Payment multiplier
0.9933
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
6.41
Baseline 18.94% · Performance 18.46% · Measure score 6.41 · Achievement 6.41 · Improvement 1.99
Healthcare-associated infections
8.16
Baseline 7.38% · Performance 5.40% · Measure score 8.16 · Achievement 8.16 · Improvement 7.82
Total nurse turnover
0
Baseline 65.22% · Performance 63.57% · Measure score 0 · Achievement 0 · Improvement 0
Adjusted total nurse staffing
1.60
Baseline 3.66 hours · Performance 3.53 hours · Measure score 1.60 · Achievement 1.60 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.28% |
10.72%
0.4 pts better
|
No Different than the National Rate · Eligible stays 121 · Observed rate 9.09% · Lower 95% interval 7.6% |
| Discharge to community | 51.09% |
50.57%
0.5 pts better
|
No Different than the National Rate · Eligible stays 112 · Observed rate 48.21% · Lower 95% interval 43.14% |
| Medicare spending per beneficiary | 0.83 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 47 · Denominator 47 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 47 |
| Discharge self-care score | 55.88% |
53.69%
2.2 pts better
|
Numerator 19 · Denominator 34 |
| Discharge mobility score | 38.24% |
50.94%
12.7 pts worse
|
Numerator 13 · Denominator 34 |
| Pressure ulcers or injuries, new or worsened | 2.13% |
2.29%
0.2 pts better
|
Numerator 1 · Denominator 47 · Adjusted rate 1.94% |
| Healthcare-associated infections requiring hospitalization | 5.4% |
7.12%
1.7 pts better
|
No Different than the National Rate · Eligible stays 50 · Observed rate 0% · Lower 95% interval 2.46% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 138 |
| Staff flu vaccination coverage | 25.58% |
42%
16.4 pts worse
|
Numerator 44 · Denominator 172 |
| Discharge function score | 64.71% |
56.45%
8.3 pts better
|
Numerator 22 · Denominator 34 |
| Transfer of health information to provider | 82.76% |
95.95%
13.2 pts worse
|
Numerator 24 · Denominator 29 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 7 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 10.34% |
25.2%
14.9 pts worse
|
Numerator 3 · Denominator 29 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.3% |
97.1%
2.2 pts better
|
93.4%
5.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 98.6% · Q3 98.6% · Q4 100.0% · 4Q avg 99.3% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
94.6%
5.4 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.0% |
2.1%
1.1 pts better
|
3.3%
2.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.4% · Q4 2.6% · 4Q avg 1.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 3.7% |
4.2%
0.5 pts better
|
11.4%
7.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.1% · Q2 4.3% · Q3 1.5% · Q4 0.0% · 4Q avg 3.7% |
| 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 4.6% · Q2 4.8% · Q3 5.3% · Q4 6.3% · 4Q avg 5.3% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 41.3% |
20.5%
20.8 pts worse
|
19.6%
21.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 32.8% · Q2 34.9% · Q3 47.5% · Q4 50.8% · 4Q avg 41.3% |
| Percentage of long-stay residents who received an antipsychotic medication | 3.1% |
11.8%
8.7 pts better
|
16.7%
13.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.1% · Q2 2.5% · Q3 0.0% · Q4 0.0% · 4Q avg 3.1% · 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 | 13.8% |
14.5%
0.7 pts better
|
16.3%
2.5 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 13.8% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 5.9% |
10.8%
4.9 pts better
|
14.9%
9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.2% · Q2 8.6% · Q3 5.4% · Q4 6.7% · 4Q avg 5.9% · 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 | 0.3% |
1.2%
0.9 pts better
|
1.7%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.4% · Q3 0.0% · Q4 0.0% · 4Q avg 0.3% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 28.2% |
20.5%
7.7 pts worse
|
19.8%
8.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 27.6% · Q2 24.4% · Q3 26.2% · Q4 34.0% · 4Q avg 28.2% |
| Percentage of long-stay residents with pressure ulcers | 1.5% |
4.8%
3.3 pts better
|
5.1%
3.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.1% · Q2 1.1% · Q3 1.0% · Q4 1.7% · 4Q avg 1.5% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 98.7% |
91.1%
7.6 pts better
|
81.7%
17 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 98.0% · Q2 97.8% · Q3 99.0% · Q4 100.0% · 4Q avg 98.7% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 7.7% |
10.7%
3 pts better
|
12.0%
4.3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 7.7% · Observed 9.7% · Expected 14.0% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.1%
1.1 pts better
|
1.6%
1.6 pts better
|
Short 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 short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 97.2% |
87.3%
9.9 pts better
|
79.7%
17.5 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 97.2% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 25.0% |
24.6%
0.4 pts worse
|
23.9%
1.1 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 25.0% · Observed 32.3% · Expected 30.7% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-01-26 · Fire 2023-01-26
7 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
3 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Cycle 3
Health 2021-12-08 · Fire 2021-12-08
7 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (2 deficiencies)
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2024-05-10
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2024-06-24
D · Potential for more than minimal harm
2023-01-26
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-03-05
D · Potential for more than minimal harm
2023-01-26
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2023-03-05
D · Potential for more than minimal harm
2023-01-26
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-03-05
D · Potential for more than minimal harm
2021-12-08
K325 · Smoke Deficiencies
Fire Safety
Have properly installed hallway dispensers for alcohol-based hand rub.
Corrected 2022-01-10
D · Potential for more than minimal harm
2021-12-08
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2022-01-10
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-12-05
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2026-01-16
E · Potential for more than minimal harm
2024-05-10
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 2024-06-24
E · Potential for more than minimal harm
2024-05-10
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 2024-06-24
D · Potential for more than minimal harm
2024-05-10
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2024-06-24
D · Potential for more than minimal harm
2024-05-10
F696 · Quality of Life and Care Deficiencies
Health
Provide appropriate care/assistance for a resident with a prosthesis.
Corrected 2024-06-24
D · Potential for more than minimal harm
2024-05-10
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-06-24
E · Potential for more than minimal harm
2024-01-17
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2024-03-01
D · Potential for more than minimal harm
2023-12-13
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 2024-01-19
D · Potential for more than minimal harm
2023-12-13
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2024-01-19
E · Potential for more than minimal harm
2023-01-26
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2023-03-05
E · Potential for more than minimal harm
2023-01-26
F725 · Nursing and Physician Services Deficiencies
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2023-03-05
E · Potential for more than minimal harm
2023-01-26
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2023-03-05
D · Potential for more than minimal harm
2023-01-26
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 2023-03-05
D · Potential for more than minimal harm
2023-01-26
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2023-03-05
D · Potential for more than minimal harm
2023-01-26
F685 · Quality of Life and Care Deficiencies
Health
Assist a resident in gaining access to vision and hearing services.
Corrected 2023-03-05
D · Potential for more than minimal harm
2023-01-26
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2023-03-05
E · Potential for more than minimal harm
2021-12-08
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 2022-01-25
D · Potential for more than minimal harm
2021-12-08
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 2022-01-25
D · Potential for more than minimal harm
2021-12-08
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2022-01-25
D · Potential for more than minimal harm
2021-12-08
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2022-01-25
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
Fischbeck, Courtney
Corporate Officer · Individual
Hill, Sean
Operational/Managerial Control · Individual
Keetch, Chad
Corporate Officer · Individual
Nagle, Craig
Operational/Managerial Control · Individual
Peterson, Forrest
Corporate Director · Individual
Sato, Ami
Corporate Officer · Individual
Nearby options
Other facilities in reach
#1
Sun City Post Acute
Sun City, AZ
4-star overall rating with 3-star inspections with 4 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
#2
Center At Arrowhead, LLC
Glendale, AZ
5-star overall rating with 4-star inspections with 5 recent health deficiencies with 18 fire-safety deficiencies in the latest cycle
#3
Freedom Plaza Care Center
Peoria, AZ
5-star overall rating with 5-star inspections with 4 fire-safety deficiencies in the latest cycle
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