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🔎 Estrella Health And Rehabilitation Center

Inspection Results


Inspection Overview

Estrella Health And Rehabilitation Center has been cited for a total of 28 deficiencies since we began saving each survey.

In Arizona, the average facility has **31.03 deficiencies** in our database. This profile shows the longer-term view.

Tip: Surveys happen throughout the year. Always check the official Medicare Care Compare site for the most recent data.



Understanding Deficiency Severity (A-L Scale)

The farther along in the alphabet (A through L) the Scope value is, the more severe the deficiency. **A through F means no actual harm has happened.**

Severity (Harm)Scope (Widespread?)Code Range
No Actual HarmIsolated to PatternA - C
No Actual HarmWidespreadD - F
**Actual Harm**IsolatedG
**Actual Harm**PatternH
**Actual Harm**WidespreadI
**Immediate Jeopardy**IsolatedJ
**Immediate Jeopardy**PatternK
**Immediate Jeopardy**WidespreadL


Detailed Deficiency List (Most Recent First)

Scope/Severity: E

Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

Survey Date: 2024-10-11
Correction Date: 2024-10-18
Category: Environmental Deficiencies
From Complaint: Y

Scope/Severity: D

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

Survey Date: 2024-03-29
Correction Date: 2024-05-08
Category: Nutrition and Dietary Deficiencies
From Complaint: N

Scope/Severity: D

Ensure services provided by the nursing facility meet professional standards of quality.

Survey Date: 2023-06-01
Correction Date: 2023-07-10
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: Y

Scope/Severity: D

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.

Survey Date: 2022-12-09
Correction Date: 2023-01-20
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: D

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

Survey Date: 2022-12-09
Correction Date: 2023-01-20
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: D

Keep residents' personal and medical records private and confidential.

Survey Date: 2022-12-09
Correction Date: 2023-01-20
Category: Resident Rights Deficiencies
From Complaint: Y

Scope/Severity: D

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.

Survey Date: 2022-12-09
Correction Date: 2023-01-20
Category: Resident Rights Deficiencies
From Complaint: Y

Scope/Severity: D

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Survey Date: 2022-12-09
Correction Date: 2023-01-20
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: D

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

Survey Date: 2022-08-18
Correction Date: 2022-09-29
Category: Resident Rights Deficiencies
From Complaint: Y

Scope/Severity: D

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Survey Date: 2022-08-18
Correction Date: 2022-09-29
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: D

Prepare residents for a safe transfer or discharge from the nursing home.

Survey Date: 2022-07-28
Correction Date: 2022-08-12
Category: Resident Rights Deficiencies
From Complaint: Y

Scope/Severity: B

Post nurse staffing information every day.

Survey Date: 2021-09-17
Correction Date: 2021-11-15
Category: Nursing and Physician Services Deficiencies
From Complaint: N

Scope/Severity: E

Provide timely, quality laboratory services/tests to meet the needs of residents.

Survey Date: 2021-09-17
Correction Date: 2021-11-15
Category: Administration Deficiencies
From Complaint: N

Scope/Severity: E

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Survey Date: 2021-09-17
Correction Date: 2021-11-15
Category: Nutrition and Dietary Deficiencies
From Complaint: N

Scope/Severity: E

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

Survey Date: 2021-09-17
Correction Date: 2021-11-15
Category: Nutrition and Dietary Deficiencies
From Complaint: N

Scope/Severity: D

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

Survey Date: 2021-04-12
Correction Date: 2021-05-04
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: D

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Survey Date: 2021-04-12
Correction Date: 2021-05-04
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: E

Ensure each resident’s drug regimen must be free from unnecessary drugs.

Survey Date: 2021-04-12
Correction Date: 2021-05-04
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: E

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

Survey Date: 2021-04-12
Correction Date: 2021-05-04
Category: Nutrition and Dietary Deficiencies
From Complaint: N

Scope/Severity: B

Post nurse staffing information every day.

Survey Date: 2021-01-21
Correction Date: 2021-01-27
Category: Nursing and Physician Services Deficiencies
From Complaint: N

Scope/Severity: E

Protect each resident from the wrongful use of the resident's belongings or money.

Survey Date: 2021-01-04
Correction Date: 2021-02-24
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: Y

Scope/Severity: E

Develop and implement policies and procedures to prevent abuse, neglect, and theft.

Survey Date: 2021-01-04
Correction Date: 2021-02-24
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: Y

Scope/Severity: E

Develop and implement policies and procedures to ensure (1) employees report any suspicion of a crime against any resident, according to timelines; (2) post the notice of employee rights; and (3) prohibit and prevent retaliation for reporting.

Survey Date: 2021-01-04
Correction Date: 2021-02-24
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: Y

Scope/Severity: E

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Survey Date: 2021-01-04
Correction Date: 2021-02-24
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: Y

Scope/Severity: E

Respond appropriately to all alleged violations.

Survey Date: 2021-01-04
Correction Date: 2021-02-24
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: Y

Scope/Severity: D

Provide and implement an infection prevention and control program.

Survey Date: 2020-09-23
Correction Date: 2020-10-12
Category: Infection Control Deficiencies
From Complaint: N

Scope/Severity: E

Report COVID19 data to residents and families.

Survey Date: 2020-08-26
Correction Date: 2020-09-18
Category: Infection Control Deficiencies
From Complaint: N

Scope/Severity: E

Provide and implement an infection prevention and control program.

Survey Date: 2020-07-16
Correction Date: 2020-08-17
Category: Infection Control Deficiencies
From Complaint: N


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All deficiency data is sourced directly from the **Centers for Medicare & Medicaid Services (CMS)**.
Data Aggregation and Review provided by **The Nursing Home Site.**