Pueblo Springs Rehabilitation Center

5545 East Lee Street · Tucson, AZ · 85712 · 5202962306

129 certified beds For profit - Limited Liability company Chain: The Ensign Group

Why this verdict

  • Inspection results are getting worse cycle over cycle, not better.
  • No federal fines or payment denials in CMS’s 3-year window.

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Red flags

Cited under the freedom-from-abuse rule

Cited 2 times under F600 (freedom from abuse/neglect) below the actual-harm level — worth asking about on a tour.

Score breakdown

Inspection record 30% of score 61
Serious harm & abuse 20% 100
Staffing 20% 45
Federal penalties 15% 100
Trend 10% 43
Context 5% 100

Quality-measure stars are deliberately excluded — they're largely self-reported by facilities. Full method.

CMS ratings & staffing

Overall: 1 of 5 Inspections: 2 of 5 Staffing: 1 of 5 Quality measures: 4 of 5

Total nurse hours / resident-day3.013.48 min · 4.1 strong
RN hours / resident-day0.300.55–0.75
Weekend hours / resident-day2.54≈ weekday level
Nursing turnover / year57%median 45%
Fines (3-yr window)none

Inspection citations (20 in the current record)

  • Potential for harm · E June 6, 2025 · found via complaint

    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

    Corrected July 7, 2025 · Freedom from Abuse, Neglect, and Exploitation

  • Potential for harm · D June 6, 2025 · found via complaint

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

    Corrected July 7, 2025 · Freedom from Abuse, Neglect, and Exploitation

  • Potential for harm · E June 6, 2025 · found via complaint

    Provide and implement an infection prevention and control program.

    Corrected July 7, 2025 · Infection Control

  • Potential for harm · D June 6, 2025

    Provide enough food/fluids to maintain a resident's health.

    Corrected July 7, 2025 · Quality of Life and Care

  • Potential for harm · E June 6, 2025

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

    Corrected July 7, 2025 · Nutrition and Dietary

  • Potential for harm · E June 6, 2025

    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

    Corrected July 7, 2025 · Resident Assessment and Care Planning

  • Potential for harm · D June 6, 2025 · found via complaint

    PASARR screening for Mental disorders or Intellectual Disabilities

    Corrected July 7, 2025 · Resident Assessment and Care Planning

  • Potential for harm · D December 7, 2023 · found via complaint

    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

    Corrected January 26, 2024 · Freedom from Abuse, Neglect, and Exploitation

  • Potential for harm · D December 7, 2023 · found via complaint

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

    Corrected January 26, 2024 · Quality of Life and Care

  • Potential for harm · E April 25, 2023

    PASARR screening for Mental disorders or Intellectual Disabilities

    Corrected June 16, 2023 · Resident Assessment and Care Planning

  • Potential for harm · E April 25, 2023

    Provide safe, appropriate pain management for a resident who requires such services.

    Corrected June 16, 2023 · Quality of Life and Care

  • Potential for harm · D April 25, 2023

    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

    Corrected June 16, 2023 · Pharmacy Service

  • Potential for harm · D March 24, 2022

    Allow residents to self-administer drugs if determined clinically appropriate.

    Corrected April 15, 2022 · Resident Rights

  • Potential for harm · D March 24, 2022

    Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

    Corrected April 15, 2022 · Resident Rights

  • Potential for harm · D March 24, 2022

    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

    Corrected April 15, 2022 · Resident Rights

  • Potential for harm · D March 24, 2022

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

    Corrected April 15, 2022 · Resident Assessment and Care Planning

  • Potential for harm · D March 24, 2022

    Provide care and assistance to perform activities of daily living for any resident who is unable.

    Corrected April 15, 2022 · Quality of Life and Care

  • Potential for harm · D March 24, 2022

    Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.

    Corrected April 15, 2022 · Quality of Life and Care

  • Potential for harm · D March 24, 2022

    Provide safe and appropriate respiratory care for a resident when needed.

    Corrected April 15, 2022 · Quality of Life and Care

  • Potential for harm · E March 24, 2022

    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

    Corrected April 15, 2022 · Pharmacy Service

Family & resident reviews — a separate signal, never mixed into the score

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Source: CMS Care Compare (public domain), data as of June 1, 2026 · CCN 035068 · certified since January 16, 1981. The score is a screen, not a verdict on any one resident's experience — read how it's computed, then visit in person.