Above average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Estrella Health And Rehabilitation Center during CMS and state inspections, most recent first.
Two residents received medications outside physician-ordered parameters, resulting in drug regimens that were not free from unnecessary drugs. One resident with multiple comorbidities and intact cognition had PRN oxycodone ordered with specific tablet counts tied to pain-scale ranges, yet MARs showed repeated administrations of 2- and 3-tablet doses when documented pain scores fell outside the ordered ranges. Another resident with encephalopathy, respiratory failure, pneumonia, diabetes, and hypertension had midodrine ordered every 8 hours for hypotension with instructions to hold the dose if SBP exceeded 110, but MARs over several months showed the drug was given multiple times when SBP readings were above that threshold. In interviews, RNs, LPNs, and the DON confirmed that these administrations did not follow the written physician parameters, despite facility policies requiring medications to be given only as ordered and in clinically indicated doses and durations.
Failure to Provide Individualized Activity Programming: Two residents did not receive consistent, individualized activity services aligned with their preferences and needs. One resident with severe cognitive impairment and major mobility limits had minimal 1:1 activity documentation despite preferring music, reading, news, fresh air, and religious services, and was observed in bed with no activity items. Another Spanish-speaking resident with intact cognition had no documented activity participation, no TV or radio in the room, and reported boredom and lack of invitations to activities; staff were unclear about responsibility for room setup and activity engagement.
Confidential resident information was left visible on a medication cart laptop when an RN left the screen open facing the main hallway, exposing names, pictures, and room numbers for multiple residents. The RN said she was distracted and forgot to close the screen, while a CNA and the DON confirmed that resident records on hallway screens should not be left open and could be viewed by others.
Unlocked Medication Cart with Pills Left on Top: A medication cart was observed unlocked in a hallway with a clear cup containing 2 white pills left on top and no staff present. An RN stated the pills were Baclofen and Tylenol for a resident and admitted she forgot to lock the cart after getting busy. The DON confirmed carts must be locked when staff step away, and the facility policy required drugs and biologicals to be stored in locked compartments accessible only to authorized personnel.
Improper Food Storage and Soiled Dry Goods Scoops: An open container of ground beef was found in the walk-in refrigerator with unopened packages, without a label or date, and bulk dry goods scoops were stored openly on a shelf next to packaged food items while visibly soiled with dust. The Dietary Supervisor and ED acknowledged that opened refrigerated food should be labeled and dated and that scoops should be stored in a holder or washed beforehand.
Improper Linen Handling and Room Cleaning Practices: Staff were observed handling clean and soiled linens inconsistently, including an uncovered soiled linen cart parked in the hallway, clean linen touching the floor and not being rewashed, and a housekeeper sweeping contaminated gloves and wipes from a resident room toward the doorway. Interviews showed staff gave conflicting descriptions of linen bagging and transport practices, and the IPCP and DON stated staff were not following the facility’s infection control process.
Smoking Materials Kept in Resident’s Possession: A resident with cognitive intactness and a smoking eval allowing her to light her own cigarette was observed multiple times removing cigarettes and blue flame lighters from her purse and smoking on the designated patio. The facility’s smoking policy prohibited residents from keeping tobacco products or lighting materials on their person, and staff interviews confirmed that smoking items were supposed to be stored in lockers or secured by clinical staff.
The facility failed to maintain comfortable water and food temperatures, impacting residents' well-being. Several residents reported no hot water, affecting their ability to shower, while others noted cold food and coffee. A dietary manager confirmed food temperatures were below expected levels. The facility experienced a water backup, and ongoing kitchen remodeling was noted. Despite these issues, the director of nursing and executive director were unaware of plumbing problems.
The facility failed to ensure proper food storage, labeling, and handling practices. Observations revealed expired and improperly sealed food items in the refrigerator, freezer, and dry storage. Additionally, the cook used improper sanitizing methods and handled food without gloves, leading to potential foodborne illness risks.
Failure to Follow Physician-Ordered Medication Parameters for Pain and Hypotension
Penalty
Summary
The deficiency involves the facility’s failure to ensure medications were administered in accordance with physician‑ordered parameters, resulting in drug regimens that were not free from unnecessary drugs for two residents. For one resident with diagnoses including atherosclerotic heart disease, shoulder pain, type II diabetes, depression, muscle weakness, and a complete rotator cuff tear, the physician ordered oxycodone 5 mg with specific PRN dosing tied to a pain scale: 1 tablet every 4 hours as needed for mild pain (1–3), 2 tablets every 4 hours as needed for moderate pain (4–7), and 3 tablets every 4 hours as needed for severe pain (8–10). The resident’s care plan directed staff to administer the opioid as prescribed, and the resident’s MDS showed intact cognition with a BIMS score of 14. Despite these clear parameters, MAR reviews for November and December showed repeated administrations of oxycodone that did not match the ordered pain‑score ranges. For this resident, the November MAR documented that the 2‑tablet oxycodone dose for moderate pain (4–7) was given when the recorded pain level was 8 on one occasion and 3 on another, both outside the ordered range. The 3‑tablet oxycodone dose for severe pain (8–10) was administered multiple times when the documented pain level was below 8, including pain scores of 7, 6, and even 1. These out‑of‑parameter administrations occurred on numerous dates throughout November, and continued into December, when the 3‑tablet dose was again given for pain scores of 6 and 7 instead of the ordered 8–10 range. In interviews, an LPN who administered medications reviewed the record and confirmed that the oxycodone doses had been given outside the ordered parameters on multiple occasions, and stated that pain levels documented on the MAR reflected the resident’s pain before medication administration. The DON also reviewed the MARs, confirmed that the oxycodone orders were not followed on multiple dates in November and December, and acknowledged that physician orders were not followed, characterizing the issue as a documentation error. The second resident involved had diagnoses including encephalopathy, respiratory failure with hypoxia, pneumonia, type 2 diabetes, essential hypertension, cognitive communication deficit, and a need for assistance with personal care, and had a BIMS score of 13 indicating intact cognition. A physician order dated in December directed that midodrine 10 mg be given by mouth every 8 hours for hypotension, with a specific parameter to hold the medication if the systolic blood pressure (SBP) was greater than 110. Review of the MARs for January through April showed that midodrine was administered multiple times when the recorded SBP exceeded 110, including readings such as 112/73, 120/69, 132/68, 142/69, and other values above the ordered hold parameter. These administrations were carried out by multiple RNs and LPNs across morning, midday, and evening medication passes. In interviews, nursing staff described the facility policy as requiring adherence to physician‑ordered parameters and contacting the provider when parameters were outside the administration window, and acknowledged that giving medications outside those parameters constituted a medication error. The DON reviewed the March MAR and confirmed that the midodrine order parameters were not followed and that the physician’s orders were not adhered to. Facility policies titled "Physicians Orders," "Administration of Drugs," and "Unnecessary Drugs" stated that drugs are to be administered only upon the order of a licensed prescriber, that medications must be administered in accordance with written physician orders, and that residents are to receive only those medications, in doses and for durations clinically indicated to treat assessed conditions. The documented practice for both residents, as evidenced by MAR reviews and staff and DON interviews, showed that medications were repeatedly administered outside the specific parameters set by the prescribing physicians, contrary to these policies.
Failure to Provide Individualized Activity Programming
Penalty
Summary
The facility failed to ensure that an individualized ongoing program of activities that met residents’ interests and supported their well-being was consistently provided for two sampled residents. The deficiency involved Resident #134 and Resident #59, both of whom had care plans identifying limited activity involvement and the need for individualized programming. The report states that the facility’s policy required activities to meet resident needs and interests and support physical, mental, and psychosocial well-being, with attempts made to accommodate resident preferences. Resident #134 was admitted with diagnoses including cerebrovascular disease, spinal stenosis, dysphagia, cerebral infarction, muscle weakness, and fusion of the spine. The care plan identified the resident as dependent on staff for activities, unable to physically participate because of poor mobility, and in need of one-on-one programming for cognitive stimulation and social interaction. A quarterly MDS showed a BIMS score of 7, indicating severe cognitive impairment. The resident’s stated preferences included books, newspapers, magazines, music, news, animals, favorite activities, fresh air, and religious services. However, the 1:1 activity logs documented only a 5-minute game on January 28 and a 5-minute pet visit on February 20, with no other 1:1 visits documented for January through March. EMR review showed limited activity documentation, and the resident stated staff did not get him out of bed, that he had been in bed for approximately 3 or more months except for showers, that he could only watch English-language TV, and that he wanted to go outside for sun and fresh air. Observations found the resident in bed with English TV on and no activity items in the room. Resident #59 was admitted with diagnoses including chronic kidney disease, gastrointestinal hemorrhage, hyperlipidemia, hypertension, muscle weakness, and need for assistance with personal care under LTC. The care plan noted little or no activity involvement related to immobility and disinterest, with interventions to explain the importance of social interaction and invite the resident to scheduled activities. The resident had a BIMS score of 14 and no severe mood or behavior issues on MDS. Review of activity records showed no 1:1 contact or interaction by the Activities team during March and no documented 1:1 contact between January and March. The resident, who was Spanish-speaking only, stated she was very bored, had no TV or radio in her room, had no activities visible, and was not invited to scheduled activities unless her son and daughter-in-law visited and took her out. Her son confirmed he had not been informed about providing a TV, had not been invited to participate in care planning, and had not received communication from Social Services about her care or activities. Staff interviews showed confusion among departments about responsibility for providing a TV and setting up the room, and the DON acknowledged there was an issue with how the process was conducted and that the facility missed the opportunity to provide a TV.
Confidential Resident Information Left Visible on Medication Cart Laptop
Penalty
Summary
The facility failed to keep resident personal and medical records private and confidential for 16 of 148 residents. During observation on April 9, 2026 at 3:41 p.m., a laptop on a medication cart located by room [ROOM NUMBER] had an open computer screen facing the main hallway, and resident confidential information for 16 residents was visible. The information displayed included the resident's name, resident's picture, and room number. Health information for Resident #39 was identified because two medications were left on the top of the medication cart in a medication cup when the nurse went into room [ROOM NUMBER]. During interviews, the RN/staff #51 stated she was distracted and forgot to close the computer screen, and that the process would be to close out the screen if she leaves the medication cart so no one can see resident information. The CNA/staff #34 stated that resident records on hallway screens should be closed when staff walk away and that medication cart laptop screens could be seen if not closed. The DON/staff #147 stated the nurse would need to lock the medication cart and make sure the laptop is closed so resident information is not displayed and viewed. Review of the facility policy titled Health Insurance Portability and Accountability Act Compliance Policy and Procedure, revised December 2024, stated that the HIPAA Privacy Rule requires appropriate safeguards to protect the privacy of personal health information.
Unlocked Medication Cart with Pills Left on Top
Penalty
Summary
The facility failed to ensure medications were stored according to regulation and facility policy when a medication cart was observed unlocked in the hallway by a resident room. During the observation, a clear medication cup containing 2 white pills was sitting on top of the cart, and no staff member was present at the cart. The cart remained unlocked for 6 minutes while 2 staff members and 1 resident walked by it before the RN returned to the cart. When interviewed, the RN stated the pills were Baclofen and Tylenol for resident #39 and said she got busy and forgot to lock the medication cart. The RN stated that leaving the cart unlocked and medications on top of it could allow someone to steal the medications or take another resident's medication and become sick. The DON stated that medication carts need to be locked when staff step away from them and that leaving the cart unlocked created the potential for someone walking by to take the medications. The facility policy stated that all drugs and biologicals are to be stored in locked compartments and accessible only to authorized personnel.
Improper Food Storage and Soiled Dry Goods Scoops
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in a manner that prevents foodborne illness to residents. During a kitchen observation with the Dietary Manager, an open container of ground beef was found on the bottom shelf of the walk-in refrigerator, stored in the same cardboard box with unopened ground beef packages. The open container had no label or date, and about 50% of the ground beef remained in the original plastic container/tubing, which was tied in a knot and kept next to unopened packages. In the dry goods storage room, scoops used for bulk items such as oats and beans were observed stored in the open on a metal shelf next to packaged food items. The scoops were visibly soiled with dust from previous use. During interviews, the Dietary Supervisor stated that ground beef should be dated after opening and that not dating and labeling it could cause foodborne illness if used outside applicable dates. The Dietary Supervisor also stated that scoops should be stored in a tub when not in use and that cross contamination and foodborne illness could occur from not storing the dry goods scoops correctly. The Executive Director later stated that every food item in the refrigerator should be labeled and dated and that the bulk dry goods scoops should be stored in a holder or washed beforehand.
Improper Linen Handling and Room Cleaning Practices
Penalty
Summary
The facility failed to ensure that clean and soiled linens were handled and transported according to policy. During an observation of the laundry room, the Housekeeping Supervisor was helping a resident get his clothes while racks of hung clothing were uncovered and touching the floor. A Floor Tech was also observed transporting soiled linen in a cart that was parked outside the soiled linen laundry room door with the door open to the hallway; the cart had a soiled linen bag placed on top and was otherwise not closed. The Floor Tech stated the soiled linen bag should have been placed inside the cart with the lid on, not on top of the cart without a cover. Interviews with staff showed inconsistent understanding of the linen handling process. The Housekeeping Supervisor stated that soiled linen carts should always be covered with a lid and that parking an uncovered cart outside the laundry room could cause contamination. She also stated that soiled linen from blood or contact isolation rooms should be transported in red bags within a lidded cart, but she was unsure how to handle trash in a resident room for a resident diagnosed with C. diff. Other staff gave differing descriptions of how soiled linens were bagged and transported, including use of clear bags, biohazard bags, and covered bins, and one LPN stated contaminated trash was disposed of the same way as regular trash. On another observation, a Lead Housekeeper was folding and hanging clean linen that touched the floor, and the linens were not placed back into soiled linens to be rewashed. The Lead Housekeeper stated the linens should have been placed back into soiled linens or a resident could get ill. In a separate room-cleaning observation, a Housekeeper swept dirty gloves and wipes with brown matter that appeared to be fecal matter from inside the room toward the doorway. Staff stated the items should have been picked up and bagged rather than swept. The Infection Control Preventionist and the DON both stated that staff were not following the facility's process for handling soiled linen and cleaning contaminated items in resident rooms.
Smoking Materials Kept in Resident’s Possession
Penalty
Summary
The facility failed to ensure its smoking policy was followed for one resident who had been readmitted with diagnoses including a displaced fracture of the medial condyle of the right tibia, chronic pain syndrome, schizoaffective disorder, bipolar type, and depression. The resident’s care plan identified a focus for potential injury related to smoking and included interventions for education on safe smoking practices, keeping smoking materials in designated areas, and monitoring compliance with the smoking policy. The resident’s MDS showed a BIMS score of 14, indicating cognitive intactness, and the smoking evaluation stated the resident could light her own cigarette and had received education on safe smoking practices. Despite the smoking policy stating that residents may not keep lighting materials, tobacco products, e-cigarettes, or smoking devices on their person or in their possession, observations showed the resident repeatedly removed cigarettes and a blue flame lighter from her purse. On the smoking patio, the resident took a lighter and pack of cigarettes from her purse, lit a cigarette, and returned the items to her purse. In a later observation in her room, she again removed two packs of cigarettes and two blue flame lighters from her purse. The resident stated she kept her smoking materials in her purse at all times and said there were no set smoking times and she could go out whenever she wanted. Staff interviews confirmed the facility expectation that residents are not allowed to keep smoking materials in their possession and that such items should be stored in lockers or secured by clinical staff. A housekeeping assistant filling in as a smoking attendant stated residents should not keep smoking materials on their person because it posed a safety risk. The RN and DON both stated residents are not allowed to keep lighters or cigarettes in their possession, and that if a resident were found with such items, they should be confiscated and reported immediately. The Activities Supervisor stated independent residents were required to store smoking materials in assigned lockers and were not permitted to keep them on their person, yet the resident was observed with cigarettes and lighters in her purse during the survey.
Deficiencies in Water and Food Temperature Management
Penalty
Summary
The facility failed to maintain comfortable water temperatures and safe food temperatures, which could negatively impact residents' psychosocial well-being. Multiple residents reported the absence of hot water in their bathrooms, affecting their ability to shower. One resident mentioned not having a shower since September 30 due to the lack of hot water. Another resident's family member confirmed the absence of hot water, and a CNA acknowledged the ongoing water issues, particularly during the evening. Additionally, the facility experienced a water backup, and a plumber was working on the issue. The director of nursing and executive director were unaware of any plumbing issues, despite ongoing kitchen remodeling and pipe replacement. Residents also reported that their food, including soup and coffee, was served cold. A dietary manager confirmed that the food temperatures were below the expected level when reaching residents. The facility's policy on resident rights emphasizes the importance of treating residents with dignity and respect, which was compromised by these deficiencies. Observations included bathroom flooding and missing shower sheets for a resident, further indicating systemic issues with facility maintenance and resident care.
Improper Food Storage and Handling Practices
Penalty
Summary
The facility failed to ensure that food items were stored, labeled, and dated in accordance with professional standards for food service safety. During an initial kitchen observation, several food items in the refrigerator were found to be beyond their use-by dates, including grape jelly, mustard, and a package of impossible burgers that was also not sealed. Additionally, the refrigerator contained an open container of potato salad and a metal serving pan with caked grease containing cooked hotdogs in water, partially covered with plastic wrap. The freezer had open and unsealed bags of frozen green beans, impossible patties, and ground beef patties. The dry storage area had an open and unsealed package of Jet Puff Marshmallows. These deficiencies could result in food-borne related illnesses due to improper storage and handling of food items. Further observations revealed improper food handling practices by the cook. The cook was seen cleaning the meat preparation station with a cloth from a sanitizing bucket that contained pieces of raw ground beef and then using the same cloth to clean the station again. During the preparation of pureed macaroni and cheese, the cook used his ungloved hand to scoop cheese sauce and touched the cooked macaroni, then wiped his hands on his apron. The dietary supervisor had to repeatedly instruct the cook to blend the macaroni and cheese to the correct consistency and to use milk instead of chicken stock. After the preparation, the cook used the same contaminated cloth to clean the puree preparation surface until the dietary supervisor intervened. The dietary supervisor acknowledged the risks associated with improper sanitizing concentration and improper food storage, labeling, and dating practices, which could lead to foodborne illnesses such as E-Coli.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Avondale
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Palm Valley Post Acute | 1.3 mi | ★★★★★ | 4 | 0 |
| Sun Health La Loma Care Center | 4.5 mi | ★★★★★ | 1 | 0 |
| Northpark Health And Rehabilitation Of Cascadia | 5.4 mi | ★★★★★ | 3 | 0 |
| Diamondback Healthcare Center | 5.7 mi | ★★★★★ | 6 | 0 |
| Az - Rio Vista Post Acute And Rehabilitation | 9.2 mi | ★★★★★ | 0 | 0 |
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