ESTRELLA HEALTH AND REHABILITATION CENTER Nursing Home


ESTRELLA HEALTH AND REHABILITATION CENTER (CCN: 035166) is a For profit - Limited Liability company facility located in AVONDALE, AZ (85323). The facility has an overall rating of 4/5, health inspection rating of 3/5, and a staffing rating of 3/5. It offers 161 certified beds and maintains an average of 121. residents per day. The nursing staff includes Nurse Aides, LPNs, and RNs working 3.37597 total hours per resident per day. It has been certified since July 26, 1988 and the last listed health inspection was on December 9, 2022, The facility is located in Maricopa county and provides senior and nursing home care.

ESTRELLA HEALTH AND REHABILITATION CENTER Summary


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Provider Name: ESTRELLA HEALTH AND REHABILITATION CENTER

Address: 350 EAST LA CANADA, AVONDALE, AZ 85323

Phone: (623) 932-2282

County: Maricopa (060)

Ownership Type: For profit - Limited Liability company

Certified Beds: 161

Average Residents Per Day: 121. ()

Provider Type: Medicare and Medicaid, Resides in Hospital: No

Legal Business Name: COLDWATER SPRINGS HEALTHCARE, INC.

First Approved Date: July 26, 1988

Affiliated Entity: THE ENSIGN GROUP (507)

Retirement Community: N, Special Focus Status:

Ownership Change in Last 12 Months: N

Resident Family Council: Resident

Sprinkler System Status: Yes

Overall Rating: 4 ()

Health Inspection Rating: 3 ()

QM Rating: 5 ()

Long Stay QM Rating: 5 ()

Short Stay QM Rating: 5 ()

Staffing Rating: 3 ()

Staffing Report Note:

PT Staffing Note:

Nurse Aide Staff Hours Per Day, per resident: 2.00784, LPN Staff Hours Per Day: 0.9854, RN Staff Hours Per Day: 0.3827, Licensed Staff Hours Per Day: 1.3681

Total Nurse Staff Hours Per Day, per resident: 3.37597

Weekend Nurse Staff Hours: 3.04027, Weekend RN Staff Hours: 0.4012

PT Staff Hours Per Day, per resident: 0.0444

Nurse Staff Turnover: 46.2, Nurse Turnover Note:

RN Turnover: 30.0, RN Turnover Note:

Admin Left Number: 0, Admin Turnover Note:

Case Mix Nurse Aide Hours Per Day, per resident: 2.0182, Case Mix LPN Hours Per Day: 0.7075, Case Mix RN Hours Per Day: 0.3201

Adjusted Nurse Aide Hours Per Day, per resident: 2.02671, Adjusted LPN Hours Per Day: 1.0278, Adjusted RN Hours Per Day: 0.4505

Total Adjusted Nurse Hours Per Day, per resident: 3.49357

Adjusted Weekend Nurse Hours Per Day, per resident: 3.14617

Health Survey Dates and Scores: Cycle 1: 2022-12-09 (Score: 24), Cycle 2: 2021-09-17 (Score: 36), Cycle 3: 2021-04-12 (Score: 24)

Total Weighted Health Score: 28.000

Reported Incidents: 0, Substantiated Complaints: 8

Infection Control Citations: 0

Fines and Penalties: Number of Fines: 0, Total Fines in Dollars: 0.00, Payment Denials Number: 0, Total Penalties Number: 0

Location and GPS: 350 EAST LA CANADA,AVONDALE,AZ,85323 (33.4462, -112.346)

Process Date: 2024-03-01


Health Inspection Citations Details

Each record details specific health deficiencies found during inspections, categorized by type, severity, and whether they were corrected. Below are the severity levels and their implications:

Citation on 2023-06-01

Type: Health, Deficiency: Ensure services provided by the nursing facility meet professional standards of quality.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2023-07-10

Citation on 2022-12-09

Type: Health, Deficiency: 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.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2023-01-20

Citation on 2022-12-09

Type: Health, Deficiency: Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2023-01-20

Citation on 2022-12-09

Type: Health, Deficiency: Keep residents' personal and medical records private and confidential.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2023-01-20

Citation on 2022-12-09

Type: Health, Deficiency: Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2023-01-20

Citation on 2022-12-09

Type: Health, Deficiency: Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2023-01-20

Citation on 2022-08-18

Type: Health, Deficiency: Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2022-09-29

Citation on 2022-08-18

Type: Health, Deficiency: Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2022-09-29

Citation on 2022-07-28

Type: Health, Deficiency: Prepare residents for a safe transfer or discharge from the nursing home.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2022-08-12

Citation on 2021-09-17

Type: Health, Deficiency: Post nurse staffing information every day.

Severity: B - Level 1: No actual harm with potential for minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2021-11-15

Citation on 2021-09-17

Type: Health, Deficiency: Provide timely, quality laboratory services/tests to meet the needs of residents.

Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2021-11-15

Citation on 2021-09-17

Type: Health, Deficiency: Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2021-11-15

Citation on 2021-09-17

Type: Health, Deficiency: Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2021-11-15

Citation on 2021-04-12

Type: Health, Deficiency: Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2021-05-04

Citation on 2021-04-12

Type: Health, Deficiency: Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2021-05-04

Citation on 2021-04-12

Type: Health, Deficiency: Ensure each resident’s drug regimen must be free from unnecessary drugs.

Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2021-05-04

Citation on 2021-04-12

Type: Health, Deficiency: Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2021-05-04


Fire Safety Citations Details

Each record details specific fire safety deficiencies found during inspections, categorized by type, severity, and whether they were corrected. Below are the severity levels and their implications:

Citation on 2021-09-17

Type: Fire Safety, Tag: 0200, Version: New

Description: Meet other general requirements.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2021-10-22

Citation on 2021-09-17

Type: Fire Safety, Tag: 0355, Version: New

Description: Properly select, install, inspect, or maintain portable fire extinguishes.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2021-10-22

Citation on 2021-09-17

Type: Fire Safety, Tag: 0918, Version: New

Description: Have generator or other power source capable of supplying service within 10 seconds.

Severity: F - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2021-10-22

Citation on 2021-04-09

Type: Fire Safety, Tag: 0223, Version: New

Description: Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.

Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2021-05-03

Citation on 2021-04-09

Type: Fire Safety, Tag: 0511, Version: New

Description: Have properly installed electrical wiring and gas equipment.

Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2021-05-03

Citation on 2021-04-09

Type: Fire Safety, Tag: 0712, Version: New

Description: Have simulated fire drills held at unexpected times.

Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2021-05-03

Citation on 2021-04-09

Type: Fire Safety, Tag: 0918, Version: New

Description: Have generator or other power source capable of supplying service within 10 seconds.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2021-05-03

Citation on 2021-04-09

Type: Fire Safety, Tag: 0923, Version: New

Description: Have proper medical gas storage and administration areas.

Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2021-05-03