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
Staffing
Hours and turnover
RN hours / resident day
0.56
Registered nurse staffing
LPN hours / resident day
0.96
Licensed practical nurse staffing
Aide hours / resident day
1.98
Nurse aide staffing
Weekend hours
2.94
Weekend nurse staffing
RN turnover
60%
Annual RN turnover
Total nurse turnover
47%
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 | 99.3% |
97.1%
2.2 pts better
|
93.4%
5.9 pts better
|
Long Stay · 2024Q4-2025Q3 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 | 13.8% |
14.5%
0.7 pts better
|
16.3%
2.5 pts better
|
Long Stay · 2024Q4-2025Q3 |
| 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 |
| 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 | 0.3% |
1.2%
0.9 pts better
|
1.7%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
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
Jump out