Casas Adobes Post Acute Rehab Center
1919 West Medical Street, Tucson, AZ 85704 · Pima County · 230 certified beds · avg 187 residents/day · certified since Apr 17, 1979
Abuse citation flag (CMS)
Part of chain: THE ENSIGN GROUP (342 facilities, chain avg rating 3.2★)
The abuse flag means inspectors cited this facility for abuse that caused harm to a resident within the past year, or potential for harm in each of the last two years. Source: CMS.
2/5
Health inspection rating (on-site)
0
Serious findings on record
$0
Fines, last 3 years
4.53
Nurse hours/resident/day (adjusted)
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★★☆☆☆2/5 · CMS overall rating: 3/5
The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.
All citations in the current public record (19)
CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.
| Date | Severity | What the facility was cited for |
|---|---|---|
| May 22, 2026 | D · Potential for harm, one-off | The facility did not provide required paperwork or notices about a resident's needs, their right to appeal a transfer or discharge, or the facility's bed-hold policy (how long a bed is saved during a hospital stay). · from a complaint |
| May 22, 2026 | D · Potential for harm, one-off | The facility did not provide safe and appropriate respiratory care — such as oxygen, breathing treatments, or care for residents on breathing equipment — for residents who needed it. |
| Apr 14, 2026 | D · Potential for harm, one-off | The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. · from a complaint |
| Jun 21, 2025 | D · Potential for harm, one-off | The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. · from a complaint |
| Jun 21, 2025 | D · Potential for harm, one-off | The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. · from a complaint |
| Jun 14, 2024 | D · Potential for harm, one-off | The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. · from a complaint |
| Apr 12, 2024 | E · Potential for harm, repeated | The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. · from a complaint |
| Mar 28, 2024 | E · Potential for harm, repeated | The facility provided care that did not meet professional standards of quality — the accepted standards that nurses and other clinicians are expected to follow. · from a complaint |
| Mar 28, 2024 | D · Potential for harm, one-off | The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. · from a complaint |
| Mar 28, 2024 | D · Potential for harm, one-off | The facility did not update each resident's care assessment at least once every 3 months. These regular check-ins keep the resident's care plan matched to their current condition. |
| Mar 28, 2024 | D · Potential for harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. |
| Mar 28, 2024 | D · Potential for harm, one-off | The facility did not provide safe, appropriate care for residents who need dialysis — the treatment that filters the blood when kidneys fail. |
| Feb 14, 2024 | E · Potential for harm, repeated | The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. · from a complaint |
| Nov 22, 2023 | D · Potential for harm, one-off | The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. · from a complaint |
| Dec 8, 2022 | E · Potential for harm, repeated | The facility provided care that did not meet professional standards of quality — the accepted standards that nurses and other clinicians are expected to follow. |
| Dec 8, 2022 | E · Potential for harm, repeated | The facility did not provide safe, appropriate care for residents who need dialysis — the treatment that filters the blood when kidneys fail. |
| Dec 8, 2022 | E · Potential for harm, repeated | The facility did not protect residents' personal information or did not keep complete, accurate medical records that meet professional standards. |
| Dec 8, 2022 | D · Potential for harm, one-off | The facility did not make sure residents were fully informed about their own health, care, and treatments in a way they could understand. |
| Dec 8, 2022 | D · Potential for harm, one-off | The facility allowed residents to lose the ability to do daily activities — like bathing, dressing, and eating — when there was no medical reason for the decline. Good care helps residents keep the abilities they have. |
Inspection trend by year
Citations from standard inspections decreased between the last two inspection cycles (5 → 2).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2022 | 5 | 0 | E |
| 2023 | 1 | 0 | D |
| 2024 | 8 | 0 | E |
| 2025 | 2 | 0 | D |
| 2026 | 3 | 0 | D |
Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.
Fines and enforcement (last 3 years)
No fines or payment denials in the published 3-year window.
Nurse staffing (from payroll records, adjusted for how much care residents need)
| Measure | This facility | Arizona avg | U.S. avg | Where it stands |
|---|---|---|---|---|
| Total nurse staffing (hours per resident per day) | 4.53 | 3.97 | 3.95 | top 21% in Arizona; top 22% in the U.S. |
| Registered Nurse hours | 0.53 | 0.69 | 0.69 | bottom 35% in Arizona; bottom 42% in the U.S. |
| Weekend total nurse staffing | 3.95 | 3.50 | 3.50 | top 23% in Arizona; top 25% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.34 | 0.49 | 0.48 | bottom 32% in Arizona; bottom 41% in the U.S. |
| Total nursing staff turnover (%) | 50.5 | 45.2 | 45.8 | bottom 34% in Arizona; bottom 36% in the U.S. |
| RN turnover (%) | 76.0 | 43.6 | 42.9 | bottom 5% in Arizona; bottom 7% in the U.S. |
Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 3.97, RN 0.46, weekend 3.46. Staffing rating: 3/5.
Self-reported quality measures
Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.
Quality measures rating: 5/5 · long-stay residents: 5/5 · short-stay residents: 5/5
Who owns this facility
For profit - Limited Liability company
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Bandera Healthcare LLC | Organization | Direct Ownership Interest | NOT APPLICABLE | 02/25/2014 |
| The Ensign Group INC | Organization | Indirect Ownership Interest | NOT APPLICABLE | 09/25/2006 |
| Burnam, Soon | Individual | Operational/Managerial Control | NOT APPLICABLE | 02/25/2014 |
| Eagar, Robert | Individual | Managing Control - Governing Body | NOT APPLICABLE | 06/15/2019 |
| Eagar, Robert | Individual | Operational/Managerial Control | NOT APPLICABLE | 06/15/2019 |
| Eagar, Robert | Individual | ADP of the SNF | NOT APPLICABLE | 06/15/2019 |
| Ensign Services INC | Organization | ADP of the SNF | NOT APPLICABLE | 05/01/2014 |
| Favorite Healthcare Staffing LLC | Organization | Operational/Managerial Control | NOT APPLICABLE | 05/01/2014 |
| Frefer, Mosab | Individual | Managing Control - Governing Body | NOT APPLICABLE | 11/01/2023 |
| Frefer, Mosab | Individual | Operational/Managerial Control | NOT APPLICABLE | 11/01/2023 |
| Frefer, Mosab | Individual | ADP of the SNF | NOT APPLICABLE | 11/01/2023 |
| Keetch, Chad | Individual | Operational/Managerial Control | NOT APPLICABLE | 03/01/2011 |
| Montebella Health Holdings LLC | Organization | ADP of the SNF | NOT APPLICABLE | 01/01/2022 |
| Nursa INC | Organization | Operational/Managerial Control | NOT APPLICABLE | 05/01/2014 |
| Onshift INC | Organization | Operational/Managerial Control | NOT APPLICABLE | 05/01/2014 |
| Peterson, Forrest | Individual | Operational/Managerial Control | NOT APPLICABLE | 02/18/2020 |
| Port, Barry | Individual | Individual Is an Owner, Partner or Trustee of Any ADP of the SNF | NOT APPLICABLE | 03/20/2026 |
| Prestige Health Staffing LLC | Organization | Operational/Managerial Control | NOT APPLICABLE | 05/01/2014 |
| Standard Bearer Healthcare Op, LP | Organization | ADP of the SNF | NOT APPLICABLE | 01/01/2022 |
| The Ensign Group INC | Organization | ADP of the SNF | NOT APPLICABLE | 01/01/2022 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "What written notices do we get before any transfer or discharge, and what is your bed-hold policy?"
- "How many residents here use oxygen or breathing equipment, and who checks that equipment each shift?"
- "Tell me about this abuse or neglect citation — what happened, and what specific changes did you make afterward?"
- "How does your pharmacist review residents' medications, and how quickly can you fill new or urgent prescriptions?"
- "Can you tell me what this citation involved and what steps you took to bring care back up to standard?"
- "How do you track that every resident's quarterly assessment happens on time?"
- "What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
- "How do you coordinate and monitor care for residents who receive dialysis?"
- "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
- "Can I see the results and plan of correction from your most recent state inspection?"
Nearby facilities (within 20 miles)
| Facility | Distance | City | Overall | Inspection | Flags |
|---|---|---|---|---|---|
| Life Care Center of Tucson | 0.6 mi | Tucson, AZ | ★☆☆☆☆ | 1/5 | |
| La Canada Care Center | 2.0 mi | Tucson, AZ | ★★☆☆☆ | 1/5 | |
| Mountain View Care Center | 2.1 mi | Tucson, AZ | ★★★★☆ | 3/5 | |
| Brookdale Santa Catalina | 4.4 mi | Tucson, AZ | ★★★★☆ | 3/5 | |
| Catalina Post Acute and Rehabilitation | 5.5 mi | Tucson, AZ | ★★★★☆ | 3/5 | |
| Park Avenue Health and Rehabilitation Center | 5.8 mi | Tucson, AZ | ★★★★☆ | 3/5 | |
| Haven of Tucson | 7.3 mi | Tucson, AZ | ★★☆☆☆ | 2/5 | |
| Skilled Nursing Unit at Oro Valley Hospital | 7.5 mi | Oro Valley, AZ | ★★★★★ | 5/5 | |
| Villa Maria Post Acute and Rehabilitation | 7.7 mi | Tucson, AZ | ★★★☆☆ | 2/5 | |
| The Center at Tucson | 7.8 mi | Tucson, AZ | ★★★★★ | 5/5 | |
| Santa Rosa Care Center | 8.4 mi | Tucson, AZ | ★★★☆☆ | 2/5 | abuse |
| Foothills Rehabilitation Center | 8.7 mi | Tucson, AZ | ★★☆☆☆ | 1/5 |
Compare this facility with the 3 closest →
Facility data as of CMS processing date 2026-08-01. CCN 035070.