Pueblo Springs Rehabilitation Center

Name: Pueblo Springs Rehabilitation Center
Address: 5545 EAST LEE STREET, Tucson, AZ, 85712, US
Telephone: 5202962306

5545 East Lee Street, Tucson, AZ 85712 · Pima County · 129 certified beds · avg 93 residents/day · certified since Jan 16, 1981

Part of chain: THE ENSIGN GROUP (342 facilities, chain avg rating 3.2★)

3/5

Health inspection rating (on-site)

Serious findings on record

Fines, last 3 years

3.40

Nurse hours/resident/day (adjusted)

What health inspectors found (on-site government inspections — the most independent evidence available)

Health inspection rating: ★★★☆☆3/5 · CMS overall rating: 2/5

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 (21)

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
Jun 12, 2026	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 6, 2025	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.
Jun 6, 2025	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.
Jun 6, 2025	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. · from a complaint
Jun 6, 2025	D · Potential for harm, one-off	The facility did not provide enough food and fluids to keep residents healthy, such as preventing unplanned weight loss or dehydration.
Jun 6, 2025	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
Jun 6, 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. · from a complaint
Jun 6, 2025	D · Potential for harm, one-off	The facility did not develop and follow policies and procedures to prevent abuse, neglect, and theft. These written safeguards are the foundation of resident protection. · from a complaint
Dec 7, 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 7, 2023	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. · from a complaint
Apr 25, 2023	E · Potential for harm, repeated	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 25, 2023	E · Potential for harm, repeated	The facility did not provide safe and appropriate pain management for a resident who needed it.
Apr 25, 2023	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.
Mar 24, 2022	E · Potential for harm, repeated	The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist.
Mar 24, 2022	D · Potential for harm, one-off	The facility did not allow residents to take their own medications when a clinical review showed they could do so safely. Residents have this right if their care team determines it's appropriate.
Mar 24, 2022	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.
Mar 24, 2022	D · Potential for harm, one-off	The facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs.
Mar 24, 2022	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.
Mar 24, 2022	D · Potential for harm, one-off	The facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own.
Mar 24, 2022	D · Potential for harm, one-off	The facility did not provide the care needed to maintain or improve residents' movement and flexibility — such as range-of-motion exercises — leading to avoidable decline.
Mar 24, 2022	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.

Inspection trend by year

Citations from standard inspections increased between the last two inspection cycles (3 → 4).

Year	Citations	Worst severity that year
2022	8	E
2023	5	E
2025	7	E
2026	1	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)	3.40	3.97	3.95	bottom 30% in Arizona; bottom 31% in the U.S.
Registered Nurse hours	0.24	0.69	0.69	bottom 2% in Arizona; bottom 4% in the U.S.
Weekend total nurse staffing	2.96	3.50	3.50	bottom 27% in Arizona; bottom 29% in the U.S.
Weekend RN hours (not acuity-adjusted)	0.14	0.49	0.48	bottom 1% in Arizona; bottom 4% in the U.S.
Total nursing staff turnover (%)	58.3	45.2	45.8	bottom 16% in Arizona; bottom 19% in the U.S.
RN turnover (%)	75.0	43.6	42.9	bottom 7% in Arizona; bottom 9% 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 3.03, RN 0.21, weekend 2.64. Staffing rating: 1/5.

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: 4/5 · long-stay residents: 5/5 · short-stay residents: 3/5

Who owns this facility

For profit - Limited Liability company

Owner / manager	Type	Role	Stake	Since
Singh, Jaspreet	Individual	Indirect Ownership Interest	NOT APPLICABLE	08/20/2023
The Ensign Group INC	Organization	Indirect Ownership Interest	NOT APPLICABLE	06/13/2017
Barnes, Jacob	Individual	Managing Control - Governing Body	NOT APPLICABLE	01/09/2026
Barnes, Jacob	Individual	Operational/Managerial Control	NOT APPLICABLE	01/09/2026
Barnes, Jacob	Individual	ADP of the SNF	NOT APPLICABLE	01/09/2026
Burnam, Soon	Individual	Managing Control - Governing Body	NOT APPLICABLE	06/13/2017
Burnam, Soon	Individual	Corporate Officer	NOT APPLICABLE	06/23/2017
Ensign Services INC	Organization	ADP of the SNF	NOT APPLICABLE	06/13/2017
Harlan Heights Health Holdings LLC	Organization	ADP of the SNF	NOT APPLICABLE	01/01/2022
Keetch, Chad	Individual	Corporate Director	NOT APPLICABLE	03/01/2011
Peterson, Forrest	Individual	Managing Control - Governing Body	NOT APPLICABLE	01/01/2022
Port, Barry	Individual	Managing Control - Governing Body	NOT APPLICABLE	07/26/2018
Singh, Jaspreet	Individual	Managing Control - Governing Body	NOT APPLICABLE	08/20/2023
Singh, Jaspreet	Individual	ADP of the SNF	NOT APPLICABLE	06/25/2025
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	09/01/2017

Questions to ask on your visit

Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.

"How does your pharmacist review residents' medications, and how quickly can you fill new or urgent prescriptions?"
"What did your most recent kitchen inspection find, and can I see how food is stored and prepared?"
"How do you keep residents' medical records accurate, complete, and secure?"
"How do you screen new residents for mental health and disability-related needs, and how do you provide the specialized services they require?"
"How do you monitor residents' weight and eating, and what happens when someone starts losing weight?"
"Tell me about this abuse or neglect citation — what happened, and what specific changes did you make afterward?"
"Who leads your infection prevention program, and how do you make sure staff follow practices like hand hygiene every day?"
"What specific steps do you take to prevent abuse and neglect, and how are staff trained on them?"
"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
Sabino Canyon Rehabilitation & Care Center	0.1 mi	Tucson, AZ	★★★★☆	3/5
Handmaker Home for the Aging	0.7 mi	Tucson, AZ	★★★☆☆	2/5	abuse
Sandstone Estates Rehab Centre	0.7 mi	Tucson, AZ	★☆☆☆☆	1/5
Foothills Rehabilitation Center	0.8 mi	Tucson, AZ	★★☆☆☆	1/5
Devon Gables Rehabilitation Center	0.9 mi	Tucson, AZ	★★☆☆☆	2/5	abuse
Santa Rosa Care Center	1.2 mi	Tucson, AZ	★★★☆☆	2/5	abuse
Haven of Saguaro Valley	1.6 mi	Tucson, AZ	★★★★★	4/5
The Center at Tucson	1.6 mi	Tucson, AZ	★★★★★	5/5
Villa Maria Post Acute and Rehabilitation	1.9 mi	Tucson, AZ	★★★☆☆	2/5
Haven of Tucson	2.5 mi	Tucson, AZ	★★☆☆☆	2/5

Compare this facility with the 3 closest →

All facilities in Tucson →

Facility data as of CMS processing date 2026-08-01. CCN 035068.

The Care File

Visit checklist — Pueblo Springs Rehabilitation Center

5545 East Lee Street, Tucson, AZ 85712 · 5202962306

Health inspection rating 3/5 · CMS overall 2/5· Fines (3y): $0

Questions for the administrator:

☐ "How does your pharmacist review residents' medications, and how quickly can you fill new or urgent prescriptions?"
☐ "What did your most recent kitchen inspection find, and can I see how food is stored and prepared?"
☐ "How do you keep residents' medical records accurate, complete, and secure?"
☐ "How do you screen new residents for mental health and disability-related needs, and how do you provide the specialized services they require?"
☐ "How do you monitor residents' weight and eating, and what happens when someone starts losing weight?"
☐ "Tell me about this abuse or neglect citation — what happened, and what specific changes did you make afterward?"
☐ "Who leads your infection prevention program, and how do you make sure staff follow practices like hand hygiene every day?"
☐ "What specific steps do you take to prevent abuse and neglect, and how are staff trained on them?"
☐ "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?"

While you're there, notice:

☐ Smell and cleanliness in hallways, not just the lobby
☐ How staff speak to residents; call lights answered promptly
☐ Residents up, dressed, and engaged (visit mealtimes and a weekend if you can)

Data: CMS Provider Data Catalog, version 2026-08-01 · CCN 035068 · Verify at medicare.gov/care-compare · Printed from The Care File (thecarefile.com)