Cycle 1
Health 2024-04-05 · Fire 2024-04-05
3 health deficiencies
Top issue: Infection Control (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Peoria, AZ
Peoria Post Acute And Rehabilitation
5-star overall rating with 4-star inspections with 3 recent health deficiencies
13215 North 94th Drive, Peoria, AZ
(623) 933-7722
Overall
5 / 5
CMS overall stars
Health inspections
4 / 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
179
Certified beds
Average residents
169
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
The Ensign Group
Operator or chain grouping
Approved since
1987-06-10
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
0.79
Registered nurse staffing · state 0.72 · national 0.68
LPN hours / resident day
1.15
Licensed practical nurse staffing · state 1.04 · national 0.87
Aide hours / resident day
2.51
Nurse aide staffing · state 2.36 · national 2.35
Total nurse hours
4.44
All reported nurse hours · state 4.12 · national 3.89
Licensed hours
1.94
RN + LPN hours · state 1.76 · national 1.54
Weekend hours
3.99
Weekend nurse staffing · state 3.62 · national 3.43
Weekend RN hours
0.55
Weekend registered nurse coverage · state 0.51 · national 0.47
Physical therapist
0.07
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.58
CMS adjusted RN staffing hours
Adjusted total hours
3.30
CMS adjusted total nurse staffing hours
Case-mix index
1.84
Higher values indicate more complex resident acuity
RN turnover
25%
Annual RN turnover · state 45% · national 45%
Total nurse turnover
49%
Annual nurse turnover · state 48% · national 46%
SNF VBP
Value-based purchasing
Program rank
11,975
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
14.45
Composite VBP score used to determine payment impact.
Payment multiplier
0.9813
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
2.18
Baseline 18.92% · Performance 20.42% · Measure score 2.18 · Achievement 2.18 · Improvement 0
Healthcare-associated infections
0
Baseline 6.16% · Performance 8.39% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
3.60
Baseline 58.75% · Performance 48.95% · Measure score 3.60 · Achievement 3.60 · Improvement 2.39
Adjusted total nurse staffing
0
Baseline 3.62 hours · Performance 3.11 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.02% |
10.72%
0.7 pts better
|
No Different than the National Rate · Eligible stays 176 · Observed rate 10.23% · Lower 95% interval 7.43% |
| Discharge to community | 65.74% |
50.57%
15.2 pts better
|
Better than the National Rate · Eligible stays 173 · Observed rate 58.38% · Lower 95% interval 58.04% |
| Medicare spending per beneficiary | 0.85 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 134 · Denominator 134 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 134 |
| Discharge self-care score | 59.77% |
53.69%
6.1 pts better
|
Numerator 52 · Denominator 87 |
| Discharge mobility score | 40.23% |
50.94%
10.7 pts worse
|
Numerator 35 · Denominator 87 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 133 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 8.39% |
7.12%
1.3 pts worse
|
No Different than the National Rate · Eligible stays 97 · Observed rate 12.37% · Lower 95% interval 5.61% |
| Staff COVID-19 vaccination coverage | 10.96% |
8.2%
2.8 pts better
|
Numerator 39 · Denominator 356 |
| Staff flu vaccination coverage | 41.33% |
42%
0.7 pts worse
|
Numerator 174 · Denominator 421 |
| Discharge function score | 68.97% |
56.45%
12.5 pts better
|
Numerator 60 · Denominator 87 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 92 · Denominator 92 |
| Transfer of health information to patient | 88% |
96.28%
8.3 pts worse
|
Numerator 22 · Denominator 25 |
| Resident COVID-19 vaccinations up to date | 3.03% |
25.2%
22.2 pts worse
|
Numerator 2 · Denominator 66 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 95.9% |
97.1%
1.2 pts worse
|
93.4%
2.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 96.4% · Q2 93.8% · Q3 96.5% · Q4 96.7% · 4Q avg 95.9% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 89.3% |
94.6%
5.3 pts worse
|
95.5%
6.2 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 89.3% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.0% |
2.1%
0.9 pts worse
|
3.3%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.8% · Q2 3.5% · Q3 3.5% · Q4 3.3% · 4Q avg 3.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 11.9% |
4.2%
7.7 pts worse
|
11.4%
0.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.6% · Q2 10.4% · Q3 6.2% · Q4 7.0% · 4Q avg 11.9% |
| Percentage of long-stay residents who lose too much weight | 9.3% |
5.3%
4 pts worse
|
5.4%
3.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.6% · Q2 7.5% · Q3 13.1% · Q4 8.8% · 4Q avg 9.3% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 47.0% |
20.5%
26.5 pts worse
|
19.6%
27.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 41.0% · Q2 47.2% · Q3 51.4% · Q4 48.2% · 4Q avg 47.0% |
| Percentage of long-stay residents who received an antipsychotic medication | 15.2% |
11.8%
3.4 pts worse
|
16.7%
1.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.5% · Q2 11.3% · Q3 20.6% · Q4 13.3% · 4Q avg 15.2% · 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 | 22.4% |
14.5%
7.9 pts worse
|
16.3%
6.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q3 27.7% · 4Q avg 22.4% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 11.9% |
10.8%
1.1 pts worse
|
14.9%
3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.9% · Q2 12.9% · Q3 11.1% · Q4 10.5% · 4Q avg 11.9% · 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 | 0.0% |
1.2%
1.2 pts better
|
1.7%
1.7 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 new or worsened bowel or bladder incontinence | 26.9% |
20.5%
6.4 pts worse
|
19.8%
7.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 31.8% · Q2 28.2% · Q3 27.4% · Q4 20.3% · 4Q avg 26.9% |
| Percentage of long-stay residents with pressure ulcers | 5.6% |
4.8%
0.8 pts worse
|
5.1%
0.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.9% · Q2 4.5% · Q3 7.4% · Q4 7.3% · 4Q avg 5.6% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 91.2% |
91.1%
0.1 pts better
|
81.7%
9.5 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 92.6% · Q2 90.8% · Q3 88.8% · Q4 92.6% · 4Q avg 91.2% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 5.8% |
10.7%
4.9 pts better
|
12.0%
6.2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 5.8% · Observed 6.7% · Expected 12.7% · 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 0.3% · Q2 1.4% · Q3 1.1% · Q4 0.0% · 4Q avg 0.7% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 86.4% |
87.3%
0.9 pts worse
|
79.7%
6.7 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 86.4% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 24.0% |
24.6%
0.6 pts better
|
23.9%
0.1 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 24.0% · Observed 27.6% · Expected 27.4% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-12-15 · Fire 2022-12-15
1 health deficiencies
Top issue: Resident Assessment and Care Planning (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2021-10-28 · Fire 2021-10-28
1 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-09-11
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2025-10-07
D · Potential for more than minimal harm
2025-06-24
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 2025-07-22
E · Potential for more than minimal harm
2024-04-05
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-05-13
D · Potential for more than minimal harm
2022-12-15
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2023-02-04
D · Potential for more than minimal harm
2021-10-28
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 2021-11-09
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
Lorenz, Brian
Operational/Managerial Control · Individual
Lorenz, Brian
W-2 Managing Employee · Individual
Peterson, Forrest
Corporate Director · Individual
Nearby options
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#2
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5-star overall rating with 4-star inspections with 2 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#3
Immanuel Campus Of Care
Peoria, AZ
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
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