Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record

Estrella Health And Rehabilitation Center

AVONDALE, AZ · 161 certified beds · Last Life Safety survey April 10, 2026

CMS Certification Number 035166 · first certified July 1988

Ownership

Operated by THE ENSIGN GROUP · For profit - Corporation

  • Ownership changed January 1, 2022 (change of ownership)from SUNBRIDGE HEALTHCARE LLC
6
Citations on file
Rolling three-year window
3
Life Safety surveys
In the same window
1
Tags cited more than once
Across separate surveys
4
Inspection & testing records
Of the citations on file

Position within AZ

6 citations — more than 41% of the 140 certified nursing homes in AZ. Compared within AZ rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated

Improvingfewer citations at the latest survey than at its earlier surveys in the window.

The latest survey found 1 citation; the earlier surveys in the window averaged 2.5. With 3 surveys on file this is a direction of travel, not a conclusion.

When is the next survey likely?

The window opens June 2027 — about 8 months from now. This facility’s last Life Safety survey was April 2026. Facilities in AZ are typically surveyed 14–22 months after the last one (median 18), measured over 143 consecutive surveys in the last two years of CMS records.

A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to three years in Maryland. How the window is measured

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Which alerts

1 inspection-and-testing tag has been cited here at more than one survey. Nationally, that pattern is common: about three quarters of cited facilities have at least one repeated tag, and half of the facilities ever cited for sprinkler inspection and testing are cited for it again. A repeat is usually a recordkeeping gap rather than a new hazard.

Physical environment (health survey)

3 physical-environment citations on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 6 Life Safety citations above. The Physical Environment Index

  • F-0880 Provide and implement an infection prevention and control program.
  • F-0926 Have policies on smoking.
  • F-0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

How that compares

Citations on file over three years

Compared with the median facility in AZ, and nationally. Surveyors differ markedly between states, so the AZ figure is the meaningful one.

This facility6AZ median8National median11
Citations on file over three years, compared
MeasureCitations
This facility6
Median facility in AZ8
Median facility nationally11

Survey history

Citations at each Life Safety survey
22022-1232024-0312026-04
Citations at each Life Safety survey
Survey dateCitations
December 9, 20222
March 29, 20243
April 10, 20261

Most-cited tags

Most-cited tags at this facility
K-03632K-01331K-03721K-03211K-05211
Most-cited tags at this facility
TagWhat the surveyor checksTimes citedLast cited
K-0363Install corridor and hallway doors that block smoke.22026-04-10
K-0133Install a two-hour-resistant firewall separation.12024-03-29
K-0372Ensure smoke barriers are constructed to a 1 hour fire resistance rating.12024-03-29
K-0321Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.12022-12-09
K-0521Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.12022-12-09

What the citations cover

Citations by CMS category
  • Smoke Deficiencies 4
  • Services Deficiencies 1
  • Construction Deficiencies 1
Citations by CMS category
CategoryCitations
Smoke Deficiencies4
Services Deficiencies1
Construction Deficiencies1

Every citation on file

As published by CMS, newest survey first. Descriptions are CMS’s own wording.

April 10, 2026 — 1 citation

Citations issued on April 10, 2026
TagWhat the surveyor checksStatus
K-0363Install corridor and hallway doors that block smoke.Deficient, Provider has date of correction (February 24, 2026)

March 29, 2024 — 3 citations

Citations issued on March 29, 2024
TagWhat the surveyor checksStatus
K-0133Install a two-hour-resistant firewall separation.Deficient, Provider has date of correction (May 8, 2024)
K-0363Install corridor and hallway doors that block smoke.Deficient, Provider has date of correction (May 8, 2024)
K-0372Ensure smoke barriers are constructed to a 1 hour fire resistance rating.Deficient, Provider has date of correction (May 8, 2024)

December 9, 2022 — 2 citations

Citations issued on December 9, 2022
TagWhat the surveyor checksStatus
K-0321Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.Deficient, Provider has date of correction (January 23, 2023)
K-0521Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.Deficient, Provider has date of correction (January 23, 2023)

Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.