Cycle 1
Health 2024-04-12 · Fire 2024-04-12
2 health deficiencies
Top issue: Administration (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Surprise, AZ
Surprise Health And Rehabilitation Center
5-star overall rating with 5-star inspections with 2 recent health deficiencies
14660 West Parkwood Drive, Surprise, AZ
(623) 546-5030
Overall
5 / 5
CMS overall stars
Health inspections
5 / 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
100
Certified beds
Average residents
100
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
The Ensign Group
Operator or chain grouping
Approved since
2019-10-04
CMS approved date
Coverage
Medicare
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
0.90
Registered nurse staffing · state 0.72 · national 0.68
LPN hours / resident day
1.48
Licensed practical nurse staffing · state 1.04 · national 0.87
Aide hours / resident day
2.71
Nurse aide staffing · state 2.36 · national 2.35
Total nurse hours
5.09
All reported nurse hours · state 4.12 · national 3.89
Licensed hours
2.38
RN + LPN hours · state 1.76 · national 1.54
Weekend hours
4.24
Weekend nurse staffing · state 3.62 · national 3.43
Weekend RN hours
0.67
Weekend registered nurse coverage · state 0.51 · national 0.47
Physical therapist
0.16
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.54
CMS adjusted RN staffing hours
Adjusted total hours
3.03
CMS adjusted total nurse staffing hours
Case-mix index
2.30
Higher values indicate more complex resident acuity
RN turnover
55%
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
3,593
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
43.60
Composite VBP score used to determine payment impact.
Payment multiplier
0.9966
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
5.67
Baseline 20.73% · Performance 18.80% · Measure score 5.67 · Achievement 5.67 · Improvement 4.70
Healthcare-associated infections
7.29
Baseline 7.29% · Performance 5.66% · Measure score 7.29 · Achievement 7.29 · Improvement 6.63
Total nurse turnover
4.48
Baseline 55.04% · Performance 45.38% · Measure score 4.48 · Achievement 4.48 · Improvement 2.70
Adjusted total nurse staffing
0
Baseline 3.40 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 | 11.22% |
10.72%
0.5 pts worse
|
No Different than the National Rate · Eligible stays 460 · Observed rate 11.96% · Lower 95% interval 9.56% |
| Discharge to community | 64.99% |
50.57%
14.4 pts better
|
Better than the National Rate · Eligible stays 462 · Observed rate 59.52% · Lower 95% interval 58.88% |
| Medicare spending per beneficiary | 0.98 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 284 · Denominator 284 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 284 |
| Discharge self-care score | 71.1% |
53.69%
17.4 pts better
|
Numerator 123 · Denominator 173 |
| Discharge mobility score | 57.23% |
50.94%
6.3 pts better
|
Numerator 99 · Denominator 173 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 283 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 5.66% |
7.12%
1.5 pts better
|
No Different than the National Rate · Eligible stays 216 · Observed rate 5.09% · Lower 95% interval 3.32% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 242 |
| Staff flu vaccination coverage | 15.96% |
42%
26 pts worse
|
Numerator 49 · Denominator 307 |
| Discharge function score | 76.88% |
56.45%
20.4 pts better
|
Numerator 133 · Denominator 173 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 235 · Denominator 235 |
| Transfer of health information to patient | 84.85% |
96.28%
11.4 pts worse
|
Numerator 28 · Denominator 33 |
| Resident COVID-19 vaccinations up to date | 18.98% |
25.2%
6.2 pts worse
|
Numerator 26 · Denominator 137 |
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 | 97.1% |
94.6%
2.5 pts better
|
95.5%
1.6 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 97.1% |
| 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 | 6.7% |
4.2%
2.5 pts worse
|
11.4%
4.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.3% · Q3 9.1% · Q4 8.0% · 4Q avg 6.7% |
| Percentage of long-stay residents who lose too much weight | 1.7% |
5.3%
3.6 pts better
|
5.4%
3.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.1% · Q2 0.0% · Q3 3.7% · Q4 0.0% · 4Q avg 1.7% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 41.5% |
20.5%
21 pts worse
|
19.6%
21.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 43.8% · Q2 40.7% · Q3 35.7% · Q4 45.2% · 4Q avg 41.5% |
| Percentage of long-stay residents who received an antipsychotic medication | 3.8% |
11.8%
8 pts better
|
16.7%
12.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q4 4.3% · 4Q avg 3.8% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 9.9% |
0.3%
9.6 pts worse
|
0.1%
9.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 9.4% · Q2 10.3% · Q3 10.3% · Q4 9.7% · 4Q avg 9.9% |
| Percentage of long-stay residents whose need for help with daily activities has increased | 0.0% |
10.8%
10.8 pts better
|
14.9%
14.9 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% · 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 · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 3.3% |
1.2%
2.1 pts worse
|
1.7%
1.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.1% · Q2 3.4% · Q3 3.6% · Q4 3.2% · 4Q avg 3.3% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 13.6% |
20.5%
6.9 pts better
|
19.8%
6.2 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 13.6% |
| Percentage of long-stay residents with pressure ulcers | 6.0% |
4.8%
1.2 pts worse
|
5.1%
0.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.9% · Q2 5.0% · Q3 5.7% · Q4 6.3% · 4Q avg 6.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.4% |
91.1%
8.3 pts better
|
81.7%
17.7 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 99.7% · Q2 99.4% · Q3 99.4% · Q4 99.4% · 4Q avg 99.4% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 4.2% |
10.7%
6.5 pts better
|
12.0%
7.8 pts better
|
Short Stay · 20240701-20250630 · Adjusted 4.2% · Observed 4.3% · Expected 11.2% · 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 0.2% · Q2 0.5% · Q3 0.2% · Q4 0.2% · 4Q avg 0.3% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 97.0% |
87.3%
9.7 pts better
|
79.7%
17.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 97.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 21.5% |
24.6%
3.1 pts better
|
23.9%
2.4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 21.5% · Observed 22.0% · Expected 24.3% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-12-23 · Fire 2022-12-23
3 health deficiencies
Top issue: Quality of Life and Care (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2021-11-04 · Fire 2021-11-04
6 health deficiencies
Top issue: Resident Assessment and Care Planning (2 deficiencies)
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
2025-03-11
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2025-04-18
D · Potential for more than minimal harm
2025-03-06
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 2025-03-19
D · Potential for more than minimal harm
2024-06-27
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-08-13
E · Potential for more than minimal harm
2022-12-23
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2023-01-23
D · Potential for more than minimal harm
2022-12-23
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 2023-01-23
E · Potential for more than minimal harm
2021-11-04
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2021-12-06
E · Potential for more than minimal harm
2021-11-04
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2021-12-06
D · Potential for more than minimal harm
2021-11-04
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 2021-12-06
D · Potential for more than minimal harm
2021-11-04
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2021-12-06
D · Potential for more than minimal harm
2021-11-04
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 2021-12-06
D · Potential for more than minimal harm
2021-11-04
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2021-12-06
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
Fitch, Craig
Corporate Officer · Individual
Glazier, Mark
Operational/Managerial Control · Individual
Glazier, Mark
W-2 Managing Employee · Individual
Lorenz, Brian
Corporate Officer · Individual
Peterson, Forrest
Corporate Director · Individual
Peterson, Forrest
Corporate Officer · Individual
Snapper, Suzanne
Corporate Officer · Individual
Nearby options
Other facilities in reach
#1
Sante Of Surprise
Surprise, AZ
5-star overall rating with 4-star inspections with 7 recent health deficiencies
#2
Sun Health Grandview Care Center
Sun City West, AZ
5-star overall rating with 4-star inspections with 3 recent health deficiencies
#3
Sun West Choice Healthcare & Rehab
Sun City West, AZ
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
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