Park Avenue Health and Rehabilitation Center
2001 North Park Avenue, Tucson, AZ 85719 · Pima County · 200 certified beds · avg 150 residents/day · certified since Aug 3, 1988
Part of chain: THE ENSIGN GROUP (342 facilities, chain avg rating 3.2★)
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★★★☆☆3/5 · CMS overall rating: 4/5
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.
Most serious findings (actual harm or immediate jeopardy)
▲ Actual harm, one-off · Aug 1, 2024 · F-0689 · triggered by a complaint
The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Sep 12, 2024 (Deficient, Provider has date of correction)
All citations in the current public record (23)
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 |
|---|---|---|
| Oct 24, 2025 | D · Potential for harm, one-off | The facility did not protect residents' personal information or did not keep complete, accurate medical records that meet professional standards. · from a complaint |
| Aug 22, 2025 | E · Potential for harm, repeated | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Aug 22, 2025 | D · Potential for harm, one-off | The facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights. |
| Aug 1, 2025 | D · Potential for harm, one-off | The facility did not immediately notify the resident, their doctor, and a family member when something significant happened — such as an injury, a decline in health, or a room change. Families and doctors are entitled to know right away. · from a complaint |
| Aug 1, 2025 | D · Potential for harm, one-off | The facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation. · from a complaint |
| Jun 11, 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 11, 2025 | D · Potential for harm, one-off | 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 |
| Aug 1, 2024 | ▲ G · Actual 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. · from a complaint |
| May 19, 2023 | E · Potential for harm, repeated | The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving. |
| May 19, 2023 | D · Potential for harm, one-off | The facility did not immediately notify the resident, their doctor, and a family member when something significant happened — such as an injury, a decline in health, or a room change. Families and doctors are entitled to know right away. |
| May 19, 2023 | D · Potential for harm, one-off | The facility used physical restraints — devices that limit a resident's movement — when they weren't needed for medical treatment. |
| May 19, 2023 | D · Potential for harm, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. |
| May 19, 2023 | D · Potential for harm, one-off | The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. |
| May 19, 2023 | D · Potential for harm, one-off | The facility did not provide routine dental care and 24-hour emergency dental care for residents. |
| Apr 1, 2022 | E · Potential for harm, repeated | The facility did not create and follow a basic care plan covering a new resident's most immediate needs within 48 hours of admission. The first days are when a new resident is most vulnerable. |
| Apr 1, 2022 | E · Potential for harm, repeated | The facility did not keep residents' medications free from unnecessary drugs. Residents should only take medicines they truly need, at the right dose, for a clear reason. |
| Apr 1, 2022 | E · Potential for harm, repeated | The facility did not serve food and drinks that were appetizing, attractive, and at a safe and pleasant temperature. |
| Apr 1, 2022 | E · Potential for harm, repeated | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| Apr 1, 2022 | D · Potential for harm, one-off | The facility did not properly complete the required screening (called PASARR) that identifies whether a person entering a nursing home has a mental illness or intellectual disability and needs specialized services. |
| Apr 1, 2022 | D · Potential for harm, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. |
| Apr 1, 2022 | D · Potential for harm, one-off | The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving. |
| Apr 1, 2022 | D · Potential for harm, one-off | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Apr 1, 2022 | D · Potential for harm, one-off | The facility did not have a working call system — the button or cord residents use to summon help — in each resident's bathroom and bathing area. |
Inspection trend by year
Citations from standard inspections decreased between the last two inspection cycles (6 → 2).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2022 | 9 | 0 | E |
| 2023 | 6 | 0 | E |
| 2024 | 1 | 1 | G ▲ |
| 2025 | 7 | 0 | E |
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)
1 fine totaling $25,116.
| Date | Type | Amount / length |
|---|---|---|
| Aug 1, 2024 | Fine | $25,116 |
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) | 3.47 | 3.97 | 3.95 | bottom 36% in Arizona; bottom 35% in the U.S. |
| Registered Nurse hours | 0.35 | 0.69 | 0.69 | bottom 9% in Arizona; bottom 15% in the U.S. |
| Weekend total nurse staffing | 3.07 | 3.50 | 3.50 | bottom 36% in Arizona; bottom 35% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.19 | 0.49 | 0.48 | bottom 8% in Arizona; bottom 11% in the U.S. |
| Total nursing staff turnover (%) | 41.4 | 45.2 | 45.8 | top 33% in Arizona; top 40% in the U.S. |
| RN turnover (%) | 27.3 | 43.6 | 42.9 | top 18% in Arizona; top 24% 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 3.13, RN 0.31, weekend 2.78. Staffing rating: 2/5.
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 |
|---|---|---|---|---|
| Burnam, Soon | Individual | Corporate Officer | NOT APPLICABLE | 10/18/2006 |
| Cote, Ellen | Individual | Operational/Managerial Control | NOT APPLICABLE | 11/12/2008 |
| Cote, Ellen | Individual | ADP of the SNF | NOT APPLICABLE | 11/12/2008 |
| Ensign Services INC | Organization | ADP of the SNF | NOT APPLICABLE | 08/01/2003 |
| Keetch, Chad | Individual | Corporate Officer | NOT APPLICABLE | 03/01/2011 |
| Peterson, Forrest | Individual | Corporate Director | NOT APPLICABLE | 01/01/2019 |
| Port, Barry | Individual | Individual Is an Owner, Partner or Trustee of Any ADP of the SNF | NOT APPLICABLE | 07/30/2025 |
| Vo, Elise | Individual | Operational/Managerial Control | NOT APPLICABLE | 03/05/2021 |
| Vo, Elise | Individual | ADP of the SNF | NOT APPLICABLE | 03/05/2021 |
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 is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
- "How do you keep residents' medical records accurate, complete, and secure?"
- "Who leads your infection prevention program, and how do you make sure staff follow practices like hand hygiene every day?"
- "Can you give me examples of how your staff protect residents' dignity in everyday care, like bathing and dressing?"
- "If my family member falls or their condition changes, exactly when and how will I be notified?"
- "When abuse or theft is suspected, who do you notify, how fast, and how do you inform the family?"
- "Tell me about this abuse or neglect citation — what happened, and what specific changes did you make afterward?"
- "Can you tell me what this citation involved and what steps you took to bring care back up to standard?"
- "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 |
|---|---|---|---|---|---|
| Catalina Post Acute and Rehabilitation | 0.8 mi | Tucson, AZ | ★★★★☆ | 3/5 | |
| Villa Maria Post Acute and Rehabilitation | 3.5 mi | Tucson, AZ | ★★★☆☆ | 2/5 | |
| Santa Rosa Care Center | 4.1 mi | Tucson, AZ | ★★★☆☆ | 2/5 | abuse |
| The Center at Tucson | 4.2 mi | Tucson, AZ | ★★★★★ | 5/5 | |
| Haven of Tucson | 4.5 mi | Tucson, AZ | ★★☆☆☆ | 2/5 | |
| Handmaker Home for the Aging | 4.7 mi | Tucson, AZ | ★★★☆☆ | 2/5 | abuse |
| Foothills Rehabilitation Center | 4.7 mi | Tucson, AZ | ★★☆☆☆ | 1/5 | |
| Arizona State Veteran Home-Tucson | 4.7 mi | Tucson, AZ | ★★★☆☆ | 3/5 | |
| Sabino Canyon Rehabilitation & Care Center | 5.3 mi | Tucson, AZ | ★★★★☆ | 3/5 | |
| Pueblo Springs Rehabilitation Center | 5.3 mi | Tucson, AZ | ★★☆☆☆ | 3/5 |
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Facility data as of CMS processing date 2026-08-01. CCN 035174.