Cycle 1
Health 2024-09-03 · Fire 2024-09-03
3 health deficiencies
Top issue: Administration (1 deficiency)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Sun City West, AZ
Sun West Choice Healthcare & Rehab
5-star overall rating with 4-star inspections with $4,838 in total fines with 3 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
14002 West Meeker Blvd, Sun City West, AZ
(623) 584-6161
Overall
5 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
140
Certified beds
Average residents
133
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
The Ensign Group
Operator or chain grouping
Approved since
1985-07-25
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
0.59
Registered nurse staffing · state 0.72 · national 0.68
LPN hours / resident day
0.89
Licensed practical nurse staffing · state 1.04 · national 0.87
Aide hours / resident day
2.19
Nurse aide staffing · state 2.36 · national 2.35
Total nurse hours
3.67
All reported nurse hours · state 4.12 · national 3.89
Licensed hours
1.48
RN + LPN hours · state 1.76 · national 1.54
Weekend hours
3.10
Weekend nurse staffing · state 3.62 · national 3.43
Weekend RN hours
0.37
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
0.63
CMS adjusted RN staffing hours
Adjusted total hours
3.93
CMS adjusted total nurse staffing hours
Case-mix index
1.28
Higher values indicate more complex resident acuity
RN turnover
39%
Annual RN turnover · state 45% · national 45%
Total nurse turnover
37%
Annual nurse turnover · state 48% · national 46%
SNF VBP
Value-based purchasing
Program rank
6,353
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
33.18
Composite VBP score used to determine payment impact.
Payment multiplier
0.9875
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
1.03
Baseline 22.59% · Performance 21.74% · Measure score 1.03 · Achievement 0 · Improvement 1.03
Healthcare-associated infections
3.93
Baseline 7.82% · Performance 6.66% · Measure score 3.93 · Achievement 3.93 · Improvement 3.61
Total nurse turnover
5.37
Baseline 69.12% · Performance 43.12% · Measure score 5.37 · Achievement 5.03 · Improvement 5.37
Adjusted total nurse staffing
2.94
Baseline 3.78 hours · Performance 3.91 hours · Measure score 2.94 · Achievement 2.94 · Improvement 0.17
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 12.86% |
10.72%
2.1 pts worse
|
No Different than the National Rate · Eligible stays 119 · Observed rate 15.97% · Lower 95% interval 9.16% |
| Discharge to community | 58.53% |
50.57%
8 pts better
|
No Different than the National Rate · Eligible stays 99 · Observed rate 52.53% · Lower 95% interval 49.69% |
| 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 68 · Denominator 68 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 68 |
| Discharge self-care score | 58.14% |
53.69%
4.5 pts better
|
Numerator 25 · Denominator 43 |
| Discharge mobility score | 51.16% |
50.94%
0.2 pts better
|
Numerator 22 · Denominator 43 |
| Pressure ulcers or injuries, new or worsened | 1.47% |
2.29%
0.8 pts better
|
Numerator 1 · Denominator 68 · Adjusted rate 1.62% |
| Healthcare-associated infections requiring hospitalization | 6.66% |
7.12%
0.5 pts better
|
No Different than the National Rate · Eligible stays 59 · Observed rate 5.08% · Lower 95% interval 3.84% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 191 |
| Staff flu vaccination coverage | 8.2% |
42%
33.8 pts worse
|
Numerator 20 · Denominator 244 |
| Discharge function score | 62.79% |
56.45%
6.3 pts better
|
Numerator 27 · Denominator 43 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 52 · Denominator 52 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 12 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 19.44% |
25.2%
5.8 pts worse
|
Numerator 7 · Denominator 36 |
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 | 98.3% |
94.6%
3.7 pts better
|
95.5%
2.8 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 98.3% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.7% |
2.1%
0.6 pts worse
|
3.3%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.8% · Q2 2.9% · Q3 2.9% · Q4 1.0% · 4Q avg 2.7% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 2.5% |
4.2%
1.7 pts better
|
11.4%
8.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.2% · Q2 0.0% · Q3 1.1% · Q4 6.9% · 4Q avg 2.5% |
| Percentage of long-stay residents who lose too much weight | 6.9% |
5.3%
1.6 pts worse
|
5.4%
1.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.6% · Q2 4.8% · Q3 7.0% · Q4 8.2% · 4Q avg 6.9% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 38.5% |
20.5%
18 pts worse
|
19.6%
18.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 34.4% · Q2 36.5% · Q3 37.9% · Q4 45.3% · 4Q avg 38.5% |
| Percentage of long-stay residents who received an antipsychotic medication | 18.5% |
11.8%
6.7 pts worse
|
16.7%
1.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.0% · Q2 25.0% · Q3 24.6% · Q4 4.1% · 4Q avg 18.5% · 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 | 7.3% |
14.5%
7.2 pts better
|
16.3%
9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.0% · Q2 5.6% · Q3 12.0% · Q4 6.8% · 4Q avg 7.3% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 5.4% |
10.8%
5.4 pts better
|
14.9%
9.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.0% · Q2 6.6% · Q3 5.3% · Q4 3.9% · 4Q avg 5.4% · 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 | 0.2% |
1.2%
1 pts better
|
1.7%
1.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.0% · Q4 0.0% · 4Q avg 0.2% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 19.4% |
20.5%
1.1 pts better
|
19.8%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 24.4% · Q2 19.5% · Q3 16.8% · Q4 16.9% · 4Q avg 19.4% |
| Percentage of long-stay residents with pressure ulcers | 3.3% |
4.8%
1.5 pts better
|
5.1%
1.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.7% · Q2 3.7% · Q3 4.7% · Q4 0.0% · 4Q avg 3.3% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 96.5% |
91.1%
5.4 pts better
|
81.7%
14.8 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 95.7% · Q2 97.2% · Q3 95.3% · Q4 97.9% · 4Q avg 96.5% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 7.8% |
10.7%
2.9 pts better
|
12.0%
4.2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 7.8% · Observed 8.1% · Expected 11.6% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.2% |
1.1%
0.9 pts better
|
1.6%
1.4 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 1.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.2% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 93.8% |
87.3%
6.5 pts better
|
79.7%
14.1 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 93.8% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 22.8% |
24.6%
1.8 pts better
|
23.9%
1.1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 22.8% · Observed 21.6% · Expected 22.6% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-02-03 · Fire 2023-02-03
3 health deficiencies
Top issue: Resident Assessment and Care Planning (2 deficiencies)
2 fire-safety deficiencies
Top issue: Services (1 deficiency)
Cycle 3
Health 2022-01-07 · Fire 2022-01-07
9 health deficiencies
Top issue: Resident Rights (3 deficiencies)
6 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (3 deficiencies)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2024-09-03
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-10-11
D · Potential for more than minimal harm
2023-02-03
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-04-27
D · Potential for more than minimal harm
2023-02-03
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2023-04-27
E · Potential for more than minimal harm
2022-01-07
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 2022-02-07
D · Potential for more than minimal harm
2022-01-07
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2022-02-07
D · Potential for more than minimal harm
2022-01-07
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2022-02-07
D · Potential for more than minimal harm
2022-01-07
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2022-02-07
D · Potential for more than minimal harm
2022-01-07
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2022-02-07
D · Potential for more than minimal harm
2022-01-07
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2022-02-07
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-08-29
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 2025-10-07
D · Potential for more than minimal harm
2024-09-03
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-10-11
D · Potential for more than minimal harm
2024-09-03
F773 · Administration Deficiencies
Health
Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.
Corrected 2024-10-11
G · Actual harm
2023-08-28
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 2023-11-22
D · Potential for more than minimal harm
2023-02-03
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2023-04-27
D · Potential for more than minimal harm
2023-02-03
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2023-04-27
D · Potential for more than minimal harm
2023-02-03
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2023-04-27
E · Potential for more than minimal harm
2022-01-07
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 2022-02-17
E · Potential for more than minimal harm
2022-01-07
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 2022-02-17
E · Potential for more than minimal harm
2022-01-07
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2022-02-17
E · Potential for more than minimal harm
2022-01-07
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 2022-02-17
D · Potential for more than minimal harm
2022-01-07
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 2022-02-17
D · Potential for more than minimal harm
2022-01-07
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 2022-02-17
D · Potential for more than minimal harm
2022-01-07
F637 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident when there is a significant change in condition
Corrected 2022-02-17
D · Potential for more than minimal harm
2022-01-07
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-02-17
Penalties and ownership
What sits behind the stars
$4,838
2023-08-28
Fine
Fine · fine $4,838
Fine
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
Christensen, Christopher
Corporate Officer · Individual
Granger, Terry
Operational/Managerial Control · Individual
Granger, Terry
W-2 Managing Employee · Individual
Wittekind, Beverly
Corporate Officer · Individual
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#3
Surprise Health And Rehabilitation Center
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5-star overall rating with 5-star inspections with 2 recent health deficiencies
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