Above average — CMS composite of the measures below.
A standard survey is most likely before around September 2026
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 Brookdale Santa Catalina during CMS and state inspections, most recent first.
Failure to Report and Document Alleged Neglect: A Nursing Student reported that a CNA did not provide cares to residents, including residents being left soaking wet and unchanged. The concern was relayed to facility leadership, but the allegation was not reported to the SA within the required timeframe and the investigation was not documented, despite the facility’s abuse/neglect policy requiring prompt reporting and a written investigation record.
Failure to timely report an allegation of neglect: a Nursing Student reported that a CNA had not provided cares and residents were left wet and unchanged, and the RN relayed the complaint to facility leadership. The DON and SSD acknowledged the complaint was shared internally, but the former Administrator denied receiving it and did not report it to the SA within the required 24-hour timeframe. The facility’s policy required prompt reporting of suspected neglect and a follow-up investigation report within 5 working days.
Failure to investigate and document an allegation of neglect: an RN received a Nursing Student’s report that a CNA was not providing cares and residents were left soaking wet and unchanged, and the complaint/grievance form was texted to the former ADM, DON, and SSD. The facility did not make its initial report to the SA until weeks later, the original grievance form could not be located, and no written investigation record was produced even though policy required prompt interviews of residents and staff and a written record.
A resident with spinal conditions, a history of lumbar compression fracture, and documented ADL self-care deficits was care planned and Kardexed for two-person maximum assist transfers for bathing and wheelchair transfers. Despite this, a CNA transferred the resident alone multiple times between a recliner, wheelchair, and shower chair using only a gait belt, during which the resident reported the CNA was rough, fast, and caused pain. An LPN received the resident’s complaint that the CNA was not caring and was the only staff present, while another CNA and a regional clinical specialist confirmed that the Kardex required two-person assist and that the CNA had performed the transfers without assistance, in violation of the plan of care and facility expectations.
The facility did not ensure that an area was free from accident hazards and failed to provide adequate supervision to prevent accidents. Surveyors observed environmental hazards and insufficient staff monitoring, increasing the risk of resident accidents.
A LPN worked 24 shifts without a valid license after her Texas-issued license was revoked, as ongoing license verification processes failed to detect the change. The DON and HR Director both described initial license checks and some random audits, but neither could confirm a consistent process for ongoing verification, and the facility was not promptly notified of the revocation.
A resident admitted with multiple health issues, including cognitive impairment and high fall risk, did not have a complete baseline care plan addressing all needs. While fall prevention measures were included, interventions for bladder incontinence were missing. Staff interviews confirmed the expectation for comprehensive care plans, highlighting the deficiency in meeting the facility's policy for addressing immediate health and safety needs within 48 hours of admission.
A resident with a history of falls was found on the floor without staff supervision, leading to a deficiency in monitoring post-fall. The resident's daughter reported that no staff were present to assist or provide instructions, and a video confirmed the lack of supervision. Staff interviews revealed that the protocol for unwitnessed falls was not fully followed, and the facility's policy lacked clear instructions on post-fall observation.
The facility failed to provide written notification to two residents and their representatives about hospital transfers. One resident with congestive heart failure was transferred for hypotension and hypoxia without written notice, and later passed away. Another resident with dementia was transferred, with only verbal notification to their son. Staff interviews confirmed the practice of verbal notifications, contrary to requirements.
An LPN in a long-term care facility failed to perform hand hygiene during medication administration for two residents, contrary to facility policies and CDC recommendations. The Director of Nursing confirmed the expectation for hand hygiene to prevent infection spread.
The facility failed to maintain kitchen equipment, specifically an electric meat slicer with a cracked plastic food contact plate identified in a January inspection. Observations in late April confirmed the slicer was still in disrepair, uncovered, and without an 'Out of Order' sign. Interviews revealed a lack of communication and follow-through, with the Head Chef unaware of repair delays and the Maintenance Director admitting the issue was overlooked. The facility's maintenance policy was not followed.
A facility failed to provide a bed-hold policy to a resident with dementia and moderate cognitive impairment before a hospital transfer. Despite a signed agreement upon admission, there was no evidence of communication at the time of transfer. Staff interviews revealed inconsistencies in the process, highlighting a deficiency in the facility's procedures.
A resident with severe cognitive impairment was not provided with a summary of their baseline care plan upon admission, as required by facility policy. Interviews revealed that the RAI Coordinator, new to the position, had not been providing residents with copies of their baseline care plans, contrary to the expectations set by the DON.
Failure to Report and Document Alleged Neglect
Penalty
Summary
The facility failed to implement its Abuse, Neglect, & Exploitation Policy after an allegation of neglect was made by a Nursing Student and relayed to RN/Staff #2. The allegation stated that a CNA did not provide cares to residents on the unit, including residents being left soaking wet and not changed. Staff #2 reported the concern to the former Administrator, and a complaint/grievance form was completed and texted to facility leadership, but the original form later could not be located in the abuse binder. The facility did not report the allegation of neglect to the State Agency within the required timeframe. The report indicates the initial allegation was made on March 27, 2026, but the facility’s first report to the SA was not made until April 17, 2026, approximately 21 days later. Staff #41 stated allegations of neglect are to be reported to the SA within 24 hours, and Staff #44 confirmed the allegation was not reported until after corporate office became involved. The investigation of the alleged neglect was also not documented. Staff #9 reportedly told Staff #44 that he had investigated by speaking with residents and staff and concluded the neglect had not occurred, but no written documentation of that investigation was produced. Staff #44 stated the standard process requires the investigation to be documented. The facility policy required the administrator or supervisor to protect residents from continued neglect, investigate the incident as soon as practicable, maintain a written record of the investigation, and report the allegation externally to the SA.
Failure to Timely Report Allegation of Neglect
Penalty
Summary
The facility failed to ensure an allegation of neglect was reported to the State Agency within the required timeframe. A Nursing Student reported to an RN that several nursing students were upset because a CNA had not changed residents on her unit and that residents were soaking wet and remained unchanged. The RN notified the former Administrator, took a picture of the completed complaint/grievance form, and texted it to him after the initial report was made to her. The RN stated she later received a call from the former Administrator that same night and relayed what had been reported by the Nursing Student. The Social Services Director and the DON both acknowledged that the complaint/grievance form was sent by text message to facility leadership in March 2026 and that the allegation involved residents not being provided cares. The DON stated she did not follow up after returning to the facility, and the Social Services Director stated she was not assigned to investigate because the former Administrator said he would handle it. The former Administrator denied receiving the texted complaint/grievance form and denied being notified of the allegation in March 2026, although he acknowledged that if the statement on the form was read aloud, it sounded like an allegation of neglect and would need to be reported to the SA. The facility’s policy required allegations of suspected neglect to be reported to the SA within 24 hours and the follow-up investigation report within 5 working days, but the initial report to the SA was not made until approximately 21 days after the allegation was first made.
Failure to Investigate and Document Allegation of Neglect
Penalty
Summary
The facility failed to ensure an allegation of neglect was thoroughly investigated and documented after a Nursing Student reported that a CNA had not provided cares to residents on her unit. The allegation was first made to an RN, who described neglect as delayed care, staff isolation of residents, not giving medications, or not implementing interventions. The RN stated she notified the former Administrator, instructed the Nursing Student to complete a complaint/grievance form, took a picture of it, and texted it to the former Administrator. The RN also stated she later spoke with him by phone and relayed what had been reported, but she did not receive any status updates on the outcome of the investigation. The facility’s records showed the allegation was initially made on March 27, 2026, but the facility did not make its initial report of neglect to the State Agency until April 17, 2026, about 21 days later, and then initiated an investigation. Review of the State Agency complaint portal found no other self-report or 5-day investigation report for the alleged timeframe. The SSD stated that suspected neglect is reported to her as the abuse coordinator, that the grievance form was completed and sent by text to her, the DON, and the former Administrator, but she was unable to locate the specific form in the binder and said she was not assigned to investigate because the former Administrator said he would conduct the investigation. The DON acknowledged receiving the texted grievance form stating that residents were soaking wet all day and remained unchanged. She recalled speaking with the former Administrator and said he assumed responsibility for follow-up, but when asked to produce the original complaint/grievance form, it was missing. The former Administrator denied being notified of the allegation and denied receiving the texted form, though he acknowledged he was the abuse coordinator and expected to be available while traveling. A senior corporate clinical leader stated the former Administrator said he investigated by speaking with residents and staff, but no documentation of that investigation was provided. The facility policy required suspected neglect to be investigated as soon as practicable by interviewing residents and staff and maintaining a written record of the investigation.
Improper Single-Staff Transfer During Shower Contrary to Two-Person Assist Plan
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident was transferred in accordance with the care plan and transfer orders during bathing and showering. The resident had diagnoses including a wedge compression fracture of the 3rd lumbar vertebra, surgical aftercare, cauda equina syndrome, spinal stenosis, and a need for assistance with personal care. A care plan initiated on April 10, 2026 documented that the resident required assistance with bathing and showering and had an ADL self-care performance deficit. Interventions initiated on April 20, 2026 and resident task documentation revised on April 14, 2026 indicated that the resident required a two-person maximum assist for transfers to the wheelchair. Despite these documented requirements, a facility investigation dated April 22, 2026 revealed that a CNA (Staff #79) transferred the resident alone from a recliner to a wheelchair, from the wheelchair to a shower chair, and then back from the shower chair to the wheelchair and into bed, using only a gait belt and without a second staff member. The resident reported that the CNA was alone during all transfers, was very rough, and that the transfers were painful, and also stated that the CNA did not speak to him during the shower. An LPN (Staff #96) confirmed receiving a complaint from the resident that the CNA was not caring and was very fast during the shower, and that the CNA was the only staff member present. Another CNA (Staff #72) stated that the Kardex identifies the resident as a two-person assist and that she always obtains another person to help with transfers, noting that transferring the resident alone could cause pain and injury. The Regional Clinical Specialist (Staff #102) stated that CNAs are expected to follow the Kardex for transfer assistance levels and confirmed that the investigation determined the CNA had transferred the resident without assistance, contrary to policy and the plan of care.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
The facility failed to ensure that an area was free from accident hazards and did not provide adequate supervision to prevent accidents. Surveyors observed that the environment contained hazards that could lead to resident accidents, and staff did not implement sufficient measures to monitor or protect residents from these risks. This deficiency was identified based on direct observations and findings during the survey, which indicated lapses in maintaining a safe environment and in providing necessary supervision to prevent accidents.
LPN Worked Without Valid License Due to Lapses in Ongoing Verification
Penalty
Summary
The facility failed to ensure that a Licensed Practical Nurse (LPN) had a valid license to practice in the State of Arizona. Personnel records showed that the LPN was hired with a valid license originating from Texas, but the license was later revoked. Despite this, the LPN continued to work 24 shifts after the revocation. The facility's records and the National Council of State Boards of Nursing (NCSBN) licensing portal confirmed the revocation, and the LPN only informed the facility of the revocation after working these shifts, at which point she was removed from the schedule and suspended. Interviews with the Director of Nursing (DON) and the Director of Human Resources (HR) revealed gaps in the ongoing verification process for professional licenses. The DON was unsure how the facility ensured continued license validity after initial hire, and the HR Director described a process involving spreadsheets and random audits, but acknowledged that the facility was not immediately notified of the license revocation due to the license originating in another state. The facility's policy required HR and management to ensure personnel files were compliant and complete, but did not specify procedures for ongoing license verification.
Incomplete Baseline Care Plan for Resident
Penalty
Summary
The facility failed to develop a complete baseline care plan for a resident who was admitted with multiple diagnoses, including a displaced fracture of the left femur, pain in the left hip, hypertension, Alzheimer's disease, major depressive disorder, fibromyalgia, dementia, and heart disease. The resident was identified as having moderate cognitive impairment with a BIMS score of 11 and was noted to be a high fall risk. The baseline care plan included several interventions for fall prevention but lacked any interventions for the resident's bladder incontinence. Interviews with staff members, including the Social Services Director, an LPN, and the Assistant Director of Nursing, revealed that the baseline care plan was expected to include interventions for all identified needs, including bladder incontinence. The absence of such interventions was acknowledged as a deficiency, with staff expressing concerns about the potential risks of not having a complete care plan, such as inadequate monitoring and oversight of the resident's needs. The facility's policy required a baseline care plan to be developed within 48 hours of admission to address immediate health and safety needs, which was not fully met in this case.
Failure to Monitor Resident Post-Fall
Penalty
Summary
The facility failed to ensure appropriate monitoring of a resident following a fall, which could result in injury to residents. The resident, who had a history of a displaced fracture of the left femur, Alzheimer's disease, and other conditions, was identified as a high fall risk. The care plan included several interventions for fall prevention, but there was no evidence of interventions for bladder incontinence. On the day of the incident, staff responded to noise from the resident's room and found the resident on the floor. It was noted that the resident was impulsive and had poor safety awareness, and staff were conducting frequent observations and toileting every two hours. The resident's daughter reported visiting her mother and finding her on the floor, with no staff present to provide assistance or instructions. The daughter stated that she was left alone with her mother and husband for about five minutes, during which time no staff returned to the room. The daughter also mentioned that her mother had expressed a need to use the bathroom and that no one had come to help her. A video recording provided by the daughter confirmed that the resident and family members were left alone without instructions not to move the resident post-fall. Interviews with staff revealed that the protocol for an unwitnessed fall includes assessing the resident for injuries, initiating neurological checks, and ensuring the resident's safety by staying in the room until they can be safely moved or emergency personnel arrive. However, it was acknowledged that the resident was left unsupervised on the floor for a short time, and staff were occupied with making calls and completing paperwork. The facility's policy did not provide clear instructions regarding direct observation and resident movement after a fall, contributing to the deficiency.
Failure to Provide Written Notification of Hospital Transfers
Penalty
Summary
The facility failed to provide written notification to two residents and their representatives regarding the reason for their transfer to the hospital. Resident #26, who had diagnoses including congestive heart failure and acute respiratory failure, was transferred to the hospital for evaluation of hypotension and hypoxia. Despite a progress note indicating the transfer, there was no evidence that the resident or their representative was notified in writing. The resident's wife was contacted about the resident's behavior prior to the transfer, but not about the transfer itself. Unfortunately, the resident passed away in the hospital shortly after the transfer. Resident #79, diagnosed with dementia and a femur fracture, was also transferred to the hospital. A progress note mentioned that the resident's son was informed of the transfer, but it did not specify the method of communication. Interviews with facility staff revealed that the standard practice was to notify residents and their representatives verbally, rather than in writing, which is a requirement. This lack of written notification could lead to inappropriate transfers or discharges and disrupt continuity of care.
Infection Control Breach During Medication Administration
Penalty
Summary
The facility failed to adhere to infection control protocols during medication administration for two residents. On April 30, 2024, a licensed practical nurse (LPN) was observed administering medications to a resident without performing hand hygiene before entering the resident's room, during the medication administration, or after exiting the room. The LPN then proceeded to dispense medications for another resident without performing hand hygiene, repeating the same oversight during the administration process. Interviews with the LPN and the Director of Nursing (DON) revealed that the facility's policy required hand hygiene to be performed between resident care and during medication administration. The DON emphasized the importance of hand hygiene in preventing infection and cross-contamination. The facility's policies, including the Bloodborne Pathogens Exposure Control Plan and Handwashing/Hand Hygiene guidelines, were reviewed and indicated that hand hygiene should be practiced to prevent the spread of infections.
Failure to Maintain Kitchen Equipment
Penalty
Summary
The facility failed to ensure that kitchen equipment was in proper working order, specifically the electric meat slicer. A Food Safety Inspection Report dated January 13, 2024, identified that the plastic food contact plate of the meat slicer was cracked. Observations conducted on April 29 and April 30, 2024, confirmed that the meat slicer remained in the same condition, uncovered, and without an 'Out of Order' sign. On May 1, 2024, a work order was requested, and the facility administrator provided a purchase order for a new food contact plate, along with a picture of the meat slicer now covered and marked as 'Out of Order.' However, the administrator was unaware if the slicer had been used after the initial inspection or before the sign was displayed. Interviews with the Head Chef and Maintenance Director revealed a lack of communication and follow-through regarding the repair of the meat slicer. The Head Chef had adjusted food ordering to compensate for the non-functional slicer but was unaware of why the repair had not been completed since January. The Maintenance Director admitted that the work order might have been overlooked due to other issues at the time and only became aware of the problem on the morning of May 1, 2024. The facility's maintenance policy, last revised in December 2009, states that the maintenance department is responsible for keeping equipment safe and operable, but this was not adhered to in this instance.
Failure to Provide Bed-Hold Policy Upon Hospital Transfer
Penalty
Summary
The facility failed to provide a bed-hold policy to a resident and their representative before a transfer to the hospital, which is a deficiency in their procedures. The resident, who was admitted with diagnoses including dementia, a fracture of the right femur, and heart disease, had a moderate cognitive impairment as indicated by a BIMS score of 8. Despite having a bed-hold agreement signed upon admission, there was no evidence that the policy was communicated to the resident or their representative at the time of the hospital transfer. This oversight was identified during a review of the resident's records and confirmed through staff interviews. Interviews with various staff members, including an LPN, the Director of Social Services, and the Administrator, revealed inconsistencies in the facility's process for communicating the bed-hold policy. The LPN could not confirm if the policy was provided at the time of transfer, while the Director of Social Services and the Administrator indicated that the policy should be reviewed with residents or their representatives both at admission and upon transfer. However, the lack of documentation in the resident's records suggests a failure in executing this procedure, leading to the deficiency noted in the report.
Failure to Provide Baseline Care Plan Summary
Penalty
Summary
The facility failed to ensure that a resident and their representative were provided with a summary of the baseline care plan upon admission. The resident, who was admitted with diagnoses including noninfective gastroenteritis and colitis, neurocognitive disorder with Lewy bodies, and type 2 diabetes mellitus, had a severe cognitive impairment as indicated by a BIMS score of 7. Despite participating in goal setting, there was no evidence that the resident or their representative received a summary of the baseline care plan, which is a requirement according to the facility's policy. Interviews with the social services director and the RAI Coordinator revealed that the interim care plan was created using nursing admission data, and residents were supposed to receive a copy of their care plan. However, the RAI Coordinator, who was new to the position, admitted that residents were not currently provided with a copy of their baseline care plan. The Director of Nursing confirmed that the expectation was for residents to receive a copy of their baseline care plan before the comprehensive care plan, but this was not documented in the resident's records.
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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 Tucson
How nearby facilities compare on the same public inspection record.
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| Mountain View Care Center | 3.5 mi | ★★★★★ | 0 | 0 |
| La Canada Care Center | 4.1 mi | ★★★★★ | 7 | 0 |
| Casas Adobes Post Acute Rehab Center | 4.4 mi | ★★★★★ | 3 | 0 |
| Life Care Center Of Tucson | 5 mi | ★★★★★ | 5 | 0 |
| Haven Of Tucson | 5.6 mi | ★★★★★ | 7 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.