Cycle 1
Health 2023-08-25 · Fire 2023-08-25
6 health deficiencies
Top issue: Resident Rights (3 deficiencies)
2 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Tucson, AZ
Sabino Canyon Rehabilitation & Care Center
4-star overall rating with 3-star inspections with 6 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
5830 East Pima Street, Tucson, AZ
(520) 722-5515
Overall
4 / 5
CMS overall stars
Health inspections
3 / 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
112
Certified beds
Average residents
94
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
The Ensign Group
Operator or chain grouping
Approved since
1987-10-07
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
0.68
Registered nurse staffing · state 0.72 · national 0.68
LPN hours / resident day
0.73
Licensed practical nurse staffing · state 1.04 · national 0.87
Aide hours / resident day
2.11
Nurse aide staffing · state 2.36 · national 2.35
Total nurse hours
3.52
All reported nurse hours · state 4.12 · national 3.89
Licensed hours
1.41
RN + LPN hours · state 1.76 · national 1.54
Weekend hours
3.04
Weekend nurse staffing · state 3.62 · national 3.43
Weekend RN hours
0.38
Weekend registered nurse coverage · state 0.51 · national 0.47
Physical therapist
0.05
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.69
CMS adjusted RN staffing hours
Adjusted total hours
3.55
CMS adjusted total nurse staffing hours
Case-mix index
1.35
Higher values indicate more complex resident acuity
RN turnover
47%
Annual RN turnover · state 45% · national 45%
Total nurse turnover
51%
Annual nurse turnover · state 48% · national 46%
SNF VBP
Value-based purchasing
Program rank
8,850
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
25.48
Composite VBP score used to determine payment impact.
Payment multiplier
0.9838
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
1.26
Baseline 17.34% · Performance 20.85% · Measure score 1.26 · Achievement 1.26 · Improvement 0
Healthcare-associated infections
4.02
Baseline 7.42% · Performance 6.63% · Measure score 4.02 · Achievement 4.02 · Improvement 2.76
Total nurse turnover
3.21
Baseline 44.93% · Performance 50.56% · Measure score 3.21 · Achievement 3.21 · Improvement 0
Adjusted total nurse staffing
1.69
Baseline 3.50 hours · Performance 3.56 hours · Measure score 1.69 · Achievement 1.69 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.84% |
10.72%
1.1 pts worse
|
No Different than the National Rate · Eligible stays 226 · Observed rate 12.39% · Lower 95% interval 8.97% |
| Discharge to community | 60.06% |
50.57%
9.5 pts better
|
Better than the National Rate · Eligible stays 208 · Observed rate 56.25% · Lower 95% interval 54.01% |
| 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 145 · Denominator 145 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 145 |
| Discharge self-care score | 76.92% |
53.69%
23.2 pts better
|
Numerator 60 · Denominator 78 |
| Discharge mobility score | 70.51% |
50.94%
19.6 pts better
|
Numerator 55 · Denominator 78 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 145 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 6.63% |
7.12%
0.5 pts better
|
No Different than the National Rate · Eligible stays 125 · Observed rate 5.6% · Lower 95% interval 4.17% |
| Staff COVID-19 vaccination coverage | 78.13% |
8.2%
69.9 pts better
|
Numerator 100 · Denominator 128 |
| Staff flu vaccination coverage | 23.96% |
42%
18 pts worse
|
Numerator 46 · Denominator 192 |
| Discharge function score | 82.05% |
56.45%
25.6 pts better
|
Numerator 64 · Denominator 78 |
| Transfer of health information to provider | 97.46% |
95.95%
1.5 pts better
|
Numerator 115 · Denominator 118 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 13 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 15.48% |
25.2%
9.7 pts worse
|
Numerator 13 · Denominator 84 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
97.1%
2.9 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| 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 | 2.2% |
2.1%
0.1 pts worse
|
3.3%
1.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 4.5% · Q3 0.0% · Q4 4.1% · 4Q avg 2.2% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 7.1% |
4.2%
2.9 pts worse
|
11.4%
4.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.0% · Q2 5.7% · Q3 7.3% · Q4 10.0% · 4Q avg 7.1% |
| Percentage of long-stay residents who lose too much weight | 4.2% |
5.3%
1.1 pts better
|
5.4%
1.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.5% · Q2 2.4% · Q3 0.0% · Q4 4.4% · 4Q avg 4.2% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 5.4% |
20.5%
15.1 pts better
|
19.6%
14.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.3% · Q2 4.9% · Q3 2.7% · Q4 4.3% · 4Q avg 5.4% |
| Percentage of long-stay residents who received an antipsychotic medication | 4.7% |
11.8%
7.1 pts better
|
16.7%
12 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.1% · Q2 6.5% · Q3 3.3% · Q4 5.7% · 4Q avg 4.7% · 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 | 12.1% |
14.5%
2.4 pts better
|
16.3%
4.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q4 13.6% · 4Q avg 12.1% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 5.2% |
10.8%
5.6 pts better
|
14.9%
9.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.3% · Q2 0.0% · Q3 0.0% · Q4 9.3% · 4Q avg 5.2% · 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 3.1% · Q2 0.0% · 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 | 1.1% |
1.2%
0.1 pts better
|
1.7%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 2.4% · Q4 2.1% · 4Q avg 1.1% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 23.9% |
20.5%
3.4 pts worse
|
19.8%
4.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 14.6% · Q2 19.4% · Q3 31.7% · Q4 28.8% · 4Q avg 23.9% |
| 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 0.0% · Q2 0.0% · Q3 3.0% · Q4 3.0% · 4Q avg 1.5% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.6% |
91.1%
8.5 pts better
|
81.7%
17.9 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 98.9% · Q2 99.8% · Q3 99.8% · Q4 100.0% · 4Q avg 99.6% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 13.2% |
10.7%
2.5 pts worse
|
12.0%
1.2 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 13.2% · Observed 12.5% · Expected 10.6% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.4% |
1.1%
0.7 pts better
|
1.6%
1.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.9% · Q4 0.9% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 97.1% |
87.3%
9.8 pts better
|
79.7%
17.4 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 97.1% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 27.9% |
24.6%
3.3 pts worse
|
23.9%
4 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 27.9% · Observed 26.2% · Expected 22.4% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-07-28 · Fire 2022-07-28
6 health deficiencies
Top issue: Resident Assessment and Care Planning (2 deficiencies)
1 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Cycle 3
Health 2020-02-27 · Fire 2020-02-27
0 health deficiencies
No concentrated health issue counts in this cycle.
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2023-08-25
K342 · Smoke Deficiencies
Fire Safety
Have a complete alarm system manually initiated and initiated by fire sprinkler system connection.
Corrected 2023-10-23
D · Potential for more than minimal harm
2023-08-25
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2023-10-23
D · Potential for more than minimal harm
2022-07-28
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 2022-09-12
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-10-22
F628 · Resident Rights Deficiencies
Health
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Corrected 2025-10-27
D · Potential for more than minimal harm
2025-09-26
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 2025-09-27
D · Potential for more than minimal harm
2025-07-11
F628 · Resident Rights Deficiencies
Health
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Corrected 2025-08-01
E · Potential for more than minimal harm
2023-08-25
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 2023-10-16
E · Potential for more than minimal harm
2023-08-25
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 2023-10-16
D · Potential for more than minimal harm
2023-08-25
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 2023-10-16
E · Potential for more than minimal harm
2022-07-28
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2022-09-06
E · Potential for more than minimal harm
2022-07-28
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-09-06
D · Potential for more than minimal harm
2022-07-28
F585 · Resident Rights Deficiencies
Health
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Corrected 2022-09-06
D · Potential for more than minimal harm
2022-07-28
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2022-09-06
D · Potential for more than minimal harm
2022-07-28
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2022-09-06
D · Potential for more than minimal harm
2022-07-28
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 2022-09-06
Penalties and ownership
What sits behind the stars
Ownership
Burnam, Soon
Corporate Officer · Individual
Jones, Christine
Operational/Managerial Control · Individual
Keetch, Chad
Corporate Officer · Individual
Milani, Ramin
Operational/Managerial Control · Individual
Peterson, Forrest
Corporate Director · Individual
Nearby options
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#2
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#3
Sandstone Estates Rehab Centre
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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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