Cycle 1
Health 2023-04-25 · Fire 2023-04-25
7 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (2 deficiencies)
2 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Tucson, AZ
Pueblo Springs Rehabilitation Center
3-star overall rating with 2-star inspections with 7 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
5545 East Lee Street, Tucson, AZ
(520) 296-2306
Overall
3 / 5
CMS overall stars
Health inspections
2 / 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
129
Certified beds
Average residents
83
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
The Ensign Group
Operator or chain grouping
Approved since
1981-01-16
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
0.29
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
1.74
Nurse aide staffing · state 2.36 · national 2.35
Total nurse hours
2.99
All reported nurse hours · state 4.12 · national 3.89
Licensed hours
1.25
RN + LPN hours · state 1.76 · national 1.54
Weekend hours
2.65
Weekend nurse staffing · state 3.62 · national 3.43
Weekend RN hours
0.15
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
0.32
CMS adjusted RN staffing hours
Adjusted total hours
3.35
CMS adjusted total nurse staffing hours
Case-mix index
1.22
Higher values indicate more complex resident acuity
RN turnover
43%
Annual RN turnover · state 45% · national 45%
Total nurse turnover
52%
Annual nurse turnover · state 48% · national 46%
SNF VBP
Value-based purchasing
Program rank
8,616
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
26.19
Composite VBP score used to determine payment impact.
Payment multiplier
0.9841
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 21.60% · Performance 21.77% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
4.07
Baseline 6.44% · Performance 6.62% · Measure score 4.07 · Achievement 4.07 · Improvement 0
Total nurse turnover
3.85
Baseline 59.09% · Performance 47.95% · Measure score 3.85 · Achievement 3.85 · Improvement 2.76
Adjusted total nurse staffing
2.55
Baseline 3.83 hours · Performance 3.80 hours · Measure score 2.55 · Achievement 2.55 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 15.36% |
10.72%
4.6 pts worse
|
No Different than the National Rate · Eligible stays 102 · Observed rate 24.51% · Lower 95% interval 10.16% |
| Discharge to community | 50.53% |
50.57%
About the same
|
No Different than the National Rate · Eligible stays 104 · Observed rate 41.35% · Lower 95% interval 40.33% |
| Medicare spending per beneficiary | 0.87 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 39 · Denominator 39 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 39 |
| Discharge self-care score | 73.91% |
53.69%
20.2 pts better
|
Numerator 17 · Denominator 23 |
| Discharge mobility score | 86.96% |
50.94%
36 pts better
|
Numerator 20 · Denominator 23 |
| Pressure ulcers or injuries, new or worsened | 2.56% |
2.29%
0.3 pts worse
|
Numerator 1 · Denominator 39 · Adjusted rate 2.58% |
| Healthcare-associated infections requiring hospitalization | 6.62% |
7.12%
0.5 pts better
|
No Different than the National Rate · Eligible stays 35 · Observed rate 5.71% · Lower 95% interval 3.56% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 99 |
| Staff flu vaccination coverage | 8.72% |
42%
33.3 pts worse
|
Numerator 15 · Denominator 172 |
| Discharge function score | 91.3% |
56.45%
34.8 pts better
|
Numerator 21 · Denominator 23 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 26 · Denominator 26 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 8 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 17 · 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 | 94.7% |
97.1%
2.4 pts worse
|
93.4%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 94.8% · Q2 95.0% · Q3 96.8% · Q4 92.2% · 4Q avg 94.7% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 93.7% |
94.6%
0.9 pts worse
|
95.5%
1.8 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 93.7% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.0% |
2.1%
2.1 pts better
|
3.3%
3.3 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 who have depressive symptoms | 17.0% |
4.2%
12.8 pts worse
|
11.4%
5.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 12.2% · Q3 21.1% · Q4 30.5% · 4Q avg 17.0% |
| Percentage of long-stay residents who lose too much weight | 1.3% |
5.3%
4 pts better
|
5.4%
4.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.6% · Q2 1.7% · Q3 0.0% · Q4 0.0% · 4Q avg 1.3% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 21.2% |
20.5%
0.7 pts worse
|
19.6%
1.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 22.8% · Q2 23.7% · Q3 19.0% · Q4 19.4% · 4Q avg 21.2% |
| Percentage of long-stay residents who received an antipsychotic medication | 1.3% |
11.8%
10.5 pts better
|
16.7%
15.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.9% · Q3 2.6% · Q4 0.0% · 4Q avg 1.3% · 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 | 13.6% |
14.5%
0.9 pts better
|
16.3%
2.7 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 13.6% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 3.4% |
10.8%
7.4 pts better
|
14.9%
11.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.8% · Q2 5.3% · Q3 3.3% · Q4 3.3% · 4Q avg 3.4% · 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 1.9% · Q2 1.4% · Q3 0.0% · Q4 0.0% · 4Q avg 0.8% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.4% |
1.2%
0.8 pts better
|
1.7%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.7% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 17.4% |
20.5%
3.1 pts better
|
19.8%
2.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 19.7% · Q2 18.5% · Q3 14.7% · Q4 17.1% · 4Q avg 17.4% |
| Percentage of long-stay residents with pressure ulcers | 5.1% |
4.8%
0.3 pts worse
|
5.1%
About the same
|
Long Stay · 2024Q4-2025Q3 · Q1 6.4% · Q2 5.6% · Q3 3.7% · Q4 4.9% · 4Q avg 5.1% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 91.4% |
91.1%
0.3 pts better
|
81.7%
9.7 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 95.4% · Q2 91.7% · Q3 89.8% · Q4 88.6% · 4Q avg 91.4% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 7.6% |
10.7%
3.1 pts better
|
12.0%
4.4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 7.6% · Observed 9.5% · Expected 14.0% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.6% |
1.1%
0.5 pts better
|
1.6%
1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 2.5% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.6% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 84.0% |
87.3%
3.3 pts worse
|
79.7%
4.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 84.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 27.1% |
24.6%
2.5 pts worse
|
23.9%
3.2 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 27.1% · Observed 33.3% · Expected 29.3% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-03-24 · Fire 2022-03-24
8 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2019-10-24 · Fire 2019-10-24
13 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2023-04-25
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2023-07-11
D · Potential for more than minimal harm
2023-04-25
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-07-11
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-06-06
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 2025-07-07
E · Potential for more than minimal harm
2025-06-06
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-07-07
D · Potential for more than minimal harm
2025-06-06
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2025-07-07
D · Potential for more than minimal harm
2025-06-06
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2025-07-07
D · Potential for more than minimal harm
2023-12-07
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 2024-01-26
D · Potential for more than minimal harm
2023-12-07
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 2024-01-26
E · Potential for more than minimal harm
2023-04-25
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2023-06-16
E · Potential for more than minimal harm
2023-04-25
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2023-06-16
D · Potential for more than minimal harm
2023-04-25
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2023-06-16
E · Potential for more than minimal harm
2023-03-30
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-05-26
E · Potential for more than minimal harm
2023-03-30
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 2023-05-26
D · Potential for more than minimal harm
2023-03-30
F727 · Nursing and Physician Services Deficiencies
Health
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Corrected 2023-05-26
E · Potential for more than minimal harm
2022-03-24
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2022-04-15
D · Potential for more than minimal harm
2022-03-24
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2022-04-15
D · Potential for more than minimal harm
2022-03-24
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 2022-04-15
D · Potential for more than minimal harm
2022-03-24
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 2022-04-15
D · Potential for more than minimal harm
2022-03-24
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2022-04-15
D · Potential for more than minimal harm
2022-03-24
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 2022-04-15
D · Potential for more than minimal harm
2022-03-24
F688 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected 2022-04-15
D · Potential for more than minimal harm
2022-03-24
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2022-04-15
E · Potential for more than minimal harm
2019-10-24
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2019-12-13
E · Potential for more than minimal harm
2019-10-24
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 2019-12-13
D · Potential for more than minimal harm
2019-10-24
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 2019-12-13
D · Potential for more than minimal harm
2019-10-24
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2019-12-13
D · Potential for more than minimal harm
2019-10-24
F625 · Resident Rights Deficiencies
Health
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Corrected 2019-12-13
D · Potential for more than minimal harm
2019-10-24
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2019-12-13
D · Potential for more than minimal harm
2019-10-24
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2019-12-13
D · Potential for more than minimal harm
2019-10-24
F791 · Quality of Life and Care Deficiencies
Health
Provide or obtain dental services for each resident.
Corrected 2019-12-13
Penalties and ownership
What sits behind the stars
Ownership
Bandera Healthcare LLC
5% Or Greater Direct Ownership Interest · Organization
Barnes, Jacob
Operational/Managerial Control · Individual
Burnam, Soon
Corporate Officer · Individual
Keetch, Chad
Corporate Director · Individual
Nearby options
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#3
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2-star overall rating with 1-star inspections with 13 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
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