Cycle 1
Health 2024-09-18 · Fire 2024-09-18
7 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
2 fire-safety deficiencies
Top issue: Emergency Preparedness (1 deficiency)
Youngtown, AZ
Sunview Respiratory And Rehabilitation
4-star overall rating with 3-star inspections with 7 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
12207 North 113th Avenue, Youngtown, AZ
(623) 977-6532
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
127
Certified beds
Average residents
101
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
The Ensign Group
Operator or chain grouping
Approved since
1997-10-29
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
0.63
Registered nurse staffing · state 0.72 · national 0.68
LPN hours / resident day
1.72
Licensed practical nurse staffing · state 1.04 · national 0.87
Aide hours / resident day
2.64
Nurse aide staffing · state 2.36 · national 2.35
Total nurse hours
4.99
All reported nurse hours · state 4.12 · national 3.89
Licensed hours
2.35
RN + LPN hours · state 1.76 · national 1.54
Weekend hours
4.15
Weekend nurse staffing · state 3.62 · national 3.43
Weekend RN hours
0.57
Weekend registered nurse coverage · state 0.51 · national 0.47
Physical therapist
0.11
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.45
CMS adjusted RN staffing hours
Adjusted total hours
3.59
CMS adjusted total nurse staffing hours
Case-mix index
1.90
Higher values indicate more complex resident acuity
RN turnover
13%
Annual RN turnover · state 45% · national 45%
Total nurse turnover
31%
Annual nurse turnover · state 48% · national 46%
SNF VBP
Value-based purchasing
Program rank
5,302
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
36.66
Composite VBP score used to determine payment impact.
Payment multiplier
0.9900
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
4.89
Performance 19.16% · Measure score 4.89 · Achievement 4.89 · This facility did not have sufficient data to calculate a baseline period measure result.
Healthcare-associated infections
3.18
Baseline 7.54% · Performance 6.88% · Measure score 3.18 · Achievement 3.18 · Improvement 2.09
Total nurse turnover
6.59
Baseline 56.29% · Performance 36.75% · Measure score 6.59 · Achievement 6.59 · Improvement 5.71
Adjusted total nurse staffing
0
Baseline 3.03 hours · Performance 3.09 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.16% |
10.72%
0.6 pts better
|
No Different than the National Rate · Eligible stays 64 · Observed rate 12.5% · Lower 95% interval 6.97% |
| Discharge to community | 54.64% |
50.57%
4.1 pts better
|
No Different than the National Rate · Eligible stays 68 · Observed rate 41.18% · Lower 95% interval 39.1% |
| Medicare spending per beneficiary | 0.94 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 97.87% |
95.27%
2.6 pts better
|
Numerator 46 · Denominator 47 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 47 |
| Discharge self-care score | 70.83% |
53.69%
17.1 pts better
|
Numerator 17 · Denominator 24 |
| Discharge mobility score | 62.5% |
50.94%
11.6 pts better
|
Numerator 15 · Denominator 24 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 47 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 6.88% |
7.12%
0.2 pts better
|
No Different than the National Rate · Eligible stays 41 · Observed rate 9.76% · Lower 95% interval 3.65% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 178 |
| Staff flu vaccination coverage | 9.18% |
42%
32.8 pts worse
|
Numerator 19 · Denominator 207 |
| Discharge function score | 70.83% |
56.45%
14.4 pts better
|
Numerator 17 · Denominator 24 |
| Transfer of health information to provider | 87.88% |
95.95%
8.1 pts worse
|
Numerator 29 · Denominator 33 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 6 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 0% |
25.2%
25.2 pts worse
|
Numerator 0 · Denominator 25 |
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 | 85.4% |
94.6%
9.2 pts worse
|
95.5%
10.1 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 85.4% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.7% |
2.1%
1.4 pts better
|
3.3%
2.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.4% · Q2 1.4% · Q3 0.0% · Q4 0.0% · 4Q avg 0.7% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 1.3% |
4.2%
2.9 pts better
|
11.4%
10.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.8% · Q4 3.8% · 4Q avg 1.3% |
| Percentage of long-stay residents who lose too much weight | 6.2% |
5.3%
0.9 pts worse
|
5.4%
0.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.7% · Q2 9.2% · Q3 3.3% · Q4 6.6% · 4Q avg 6.2% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 32.7% |
20.5%
12.2 pts worse
|
19.6%
13.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 28.6% · Q2 35.8% · Q3 35.5% · Q4 31.1% · 4Q avg 32.7% |
| Percentage of long-stay residents who received an antipsychotic medication | 8.1% |
11.8%
3.7 pts better
|
16.7%
8.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.4% · Q2 8.9% · Q3 6.0% · Q4 7.0% · 4Q avg 8.1% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 4.0% |
0.3%
3.7 pts worse
|
0.1%
3.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.7% · Q2 2.9% · Q3 6.2% · Q4 4.6% · 4Q avg 4.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 6.3% |
14.5%
8.2 pts better
|
16.3%
10 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 6.3% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 6.2% |
10.8%
4.6 pts better
|
14.9%
8.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.3% · Q2 7.7% · Q3 5.0% · Q4 2.3% · 4Q avg 6.2% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.4% |
0.9%
0.5 pts better
|
1.0%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.4% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.4% · 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 4.1% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 1.1% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 19.0% |
20.5%
1.5 pts better
|
19.8%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.2% · Q2 16.1% · Q3 28.8% · Q4 19.3% · 4Q avg 19.0% |
| Percentage of long-stay residents with pressure ulcers | 9.8% |
4.8%
5 pts worse
|
5.1%
4.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 14.5% · Q2 8.4% · Q3 5.4% · Q4 10.1% · 4Q avg 9.8% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 93.6% |
91.1%
2.5 pts better
|
81.7%
11.9 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 92.6% · Q2 95.5% · Q3 93.7% · Q4 92.7% · 4Q avg 93.6% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 5.6% |
10.7%
5.1 pts better
|
12.0%
6.4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 5.6% · Observed 7.1% · Expected 14.3% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.3% |
1.1%
0.8 pts better
|
1.6%
1.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.7% · Q3 0.7% · Q4 0.0% · 4Q avg 0.3% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 88.9% |
87.3%
1.6 pts better
|
79.7%
9.2 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 88.9% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 24.8% |
24.6%
0.2 pts worse
|
23.9%
0.9 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 24.8% · Observed 38.1% · Expected 36.6% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-08-25 · Fire 2023-08-25
1 health deficiencies
Top issue: Resident Assessment and Care Planning (1 deficiency)
2 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Cycle 3
Health 2022-06-24 · Fire 2022-06-24
7 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
D · Potential for more than minimal harm
2024-09-18
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2024-10-17
D · Potential for more than minimal harm
2024-09-18
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-11-03
D · Potential for more than minimal harm
2023-08-25
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 2023-10-16
D · Potential for more than minimal harm
2023-08-25
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-10-16
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-03-07
F836 · Administration Deficiencies
Health
Ensure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards.
Corrected 2025-04-21
E · Potential for more than minimal harm
2024-09-18
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2024-11-03
E · Potential for more than minimal harm
2024-09-18
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-11-03
E · Potential for more than minimal harm
2024-09-18
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 2024-11-03
E · Potential for more than minimal harm
2024-09-18
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-11-03
D · Potential for more than minimal harm
2024-09-18
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 2024-11-03
D · Potential for more than minimal harm
2024-09-18
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-11-03
D · Potential for more than minimal harm
2023-11-09
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 2023-12-17
D · Potential for more than minimal harm
2023-11-09
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 2023-12-17
D · Potential for more than minimal harm
2023-08-25
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2023-10-03
E · Potential for more than minimal harm
2023-03-14
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-04-28
D · Potential for more than minimal harm
2023-03-14
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2023-04-28
E · Potential for more than minimal harm
2022-06-24
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2022-08-16
D · Potential for more than minimal harm
2022-06-24
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2022-08-16
D · Potential for more than minimal harm
2022-06-24
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 2022-08-16
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
Albrechtsen, John
Operational/Managerial Control · Individual
Albrechtsen, John
W-2 Managing Employee · Individual
Burnam, Soon
Corporate Officer · Individual
Christensen, Christopher
Corporate Director · Individual
Wittekind, Beverly
Corporate Officer · Individual
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#3
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