Average — CMS composite of the measures below.
The next survey window likely opens around April 2027
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 Casas Adobes Post Acute Rehab Center during CMS and state inspections, most recent first.
Failure to Notify Ombudsman of Resident Transfers and Discharges: The facility did not notify the Ombudsman's office when multiple residents were discharged or transferred, including a resident with intact cognition who planned a home discharge after a NOMNC appeal, a resident sent to the hospital for surgery, and residents with dementia or severe cognitive impairment who were transferred to the hospital or another facility. Records showed no documentation of Ombudsman notification, and interviews confirmed the monthly transfer/discharge reporting process had not been completed for an extended period.
A resident with acute respiratory failure with hypoxia, CKD, and chronic pulmonary edema was observed using oxygen via NC at 2 lpm even though the prior oxygen order had been discontinued and no active order was in the chart. The resident said the oxygen helped her breathe better, while staff interviews confirmed the CNA believed she had used oxygen since admission and the RN, LPN, and DON verified there was no current physician order for oxygen despite the facility policy requiring oxygen to be administered only as ordered.
Two residents with significant behavioral and psychiatric histories, one severely cognitively impaired and one cognitively intact with poor impulse control, were involved in a physical altercation in the dining room after one resident’s wheelchair bumped the other’s chair. Witnesses, including an LPN and an activities aide, reported that the cognitively intact resident struck the other resident in the face, and documentation showed a resulting skin tear over the eyebrow and an additional skin tear on the elbow. The involved resident later stated that he was hit first and reacted by back-handing and slapping the other resident. This incident occurred despite existing care plans addressing behavioral disturbances and an abuse prevention policy stating that residents have the right to be free from abuse and mistreatment.
Multiple residents with severe cognitive and behavioral impairments engaged in repeated physical altercations, including slapping and hitting, in common areas and resident rooms. Staff witnessed and intervened in these incidents, but residents still experienced physical contact and, in some cases, visible injuries. Despite care plans addressing behavioral risks and staff awareness of abuse protocols, the facility did not prevent ongoing resident-to-resident abuse.
The facility did not ensure pharmaceutical services were provided to meet each resident's needs and failed to employ or obtain a licensed pharmacist, resulting in a lack of required pharmaceutical oversight.
A resident with a history of bipolar disorder, major depressive disorder, and dementia was involved in multiple aggressive incidents with other residents, despite being on psychotropic medications and having a care plan. The facility's interventions, including monitoring and medication adjustments, were ineffective in preventing these altercations. Staff interviews indicated that while strategies were in place to manage behavior, they were insufficient to prevent the incidents, leading to a deficiency in preventing resident-to-resident abuse.
The facility failed to protect five residents from abuse by other residents, leading to multiple altercations. Immediate interventions included 1:1 staffing, separating residents, and implementing 15-minute checks. The facility's policy on abuse prevention was reviewed, revealing deficiencies in protecting residents from abuse.
The facility failed to ensure controlled medications were properly administered and documented for several residents, leading to potential risks of medication diversion. A resident received Hydrocodone-Acetaminophen without proper documentation, and another resident's Tramadol administration was inaccurately recorded. Additionally, a resident with diabetes received Insulin Glargine outside of physician-ordered parameters, posing health risks. Staff interviews revealed inconsistencies in following protocols for medication wastage and administration.
A facility failed to complete a quarterly MDS assessment for a resident with dementia, Parkinson's Disease, and peripheral vascular disease. The MDS Coordinator and DON confirmed the assessment was missing due to a scheduling error, which did not meet facility expectations for timely resident assessments.
A resident with dementia and bipolar disorder was found with a cup of medications left on their bedside table, despite not having a physician's order for self-administration. Staff interviews revealed inconsistencies in medication administration practices, with some staff acknowledging that medications should not be left unattended. The facility's policy required staff to ensure medications were swallowed, highlighting a deficiency in maintaining a safe environment.
A resident with end-stage renal disease experienced significant weight fluctuations without appropriate follow-up or re-weighing, despite physician orders and facility policy. Staff interviews revealed inconsistencies in monitoring and communication processes, with differing opinions on what constituted a concerning weight change. The facility's policy required evaluation for any 5% weight change within 30 days, but this was not followed, potentially leading to inadequate care.
The facility failed to protect residents from abuse by other residents, as evidenced by multiple incidents involving physical altercations. A cognitively intact resident and another resident pulled each other's hair, while a severely impaired resident was found in a physical altercation with his roommate. Additionally, a resident with severe cognitive impairment engaged in a verbal and physical altercation over seating in the dining room. Staff interventions were reactive, and inconsistencies in reporting were noted.
The facility failed to protect five residents from abuse by other residents, resulting in multiple incidents of physical altercations. Despite staff interventions and existing protocols, the incidents highlighted lapses in supervision and prevention measures.
Failure to Notify Ombudsman of Resident Transfers and Discharges
Penalty
Summary
The facility failed to ensure the Ombudsman's office was notified of resident transfers and discharges for four residents, including residents who were discharged to home, transferred to the hospital, or transferred to another facility. The record review showed that Resident #217, who had diagnoses including fracture of the right lower leg, difficulty walking, and polyneuropathy, had a planned discharge home after participating in discharge planning, receiving a NOMNC, and appealing that notice before losing the appeal and leaving the facility. Despite these events, there was no documentation that the Ombudsman was contacted about the discharge. Resident #150, who had diagnoses including fracture of the left femur, muscle weakness, major depressive disorder, and chronic kidney disease, had a BIMS score of 15 indicating intact cognition. A physician ordered transfer to the hospital, and a progress note documented that the resident was sent directly from an orthopedic appointment for surgery. The clinical record contained no documentation that the Ombudsman's office was notified of this transfer. Resident #211, who had dementia, COPD, and cognitive communication deficit, had a discharge MDS showing severely impaired cognitive skills for daily decision-making. Progress notes documented increased confusion, medication refusal, and a family request for hospital transfer, followed by the resident being sent to the hospital. Resident #215, who had COPD, interstitial pulmonary disease, suicidal ideations, and major depressive disorder, had severe cognitive impairment on the MDS and was discharged to another facility, but the record also lacked documentation of Ombudsman notification. Interviews with Social Services and the DON confirmed that transfer and discharge notifications had not been completed for months, and the facility policy reviewed did not include language requiring notification to the Ombudsman's office.
Oxygen Therapy Provided Without Current Physician Order
Penalty
Summary
The facility failed to ensure a resident received oxygen therapy in accordance with a current physician's order. The resident was admitted with diagnoses including acute respiratory failure with hypoxia, type 2 diabetes mellitus with diabetic chronic kidney disease, and chronic pulmonary edema. The admission MDS showed a BIMS score of 11, indicating moderate cognitive impairment, and also noted the resident was not short of breath but was on oxygen therapy. A physician's order had directed continuous oxygen at 2 liters per minute via nasal cannula, but that order was discontinued and no active oxygen order was found in the chart. Despite the absence of a current order, the resident was observed on multiple occasions with a nasal cannula in place and connected to an oxygen concentrator set at 2 liters per minute. The resident stated that the oxygen helped her breathe better. Staff interviews confirmed that the CNA believed the resident used oxygen since admission, while the RN and LPN both verified there was no active oxygen order in the record and stated the resident should not have been receiving oxygen without one. The DON also confirmed the prior oxygen order had been discontinued and could not locate documentation explaining the discontinuation. The facility policy stated that oxygen therapy is to be administered as ordered by the physician.
Failure to Prevent Resident-to-Resident Physical Altercation Resulting in Injury
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from physical abuse during a resident-to-resident altercation in the dining room. One resident with severe cognitive impairment, vascular dementia, major depressive disorder, anxiety disorder, and a history of behavioral disturbances such as yelling, abusive language, threatening behaviors, and physical aggression was care planned for behavioral issues related to dementia and cerebrovascular accident. Another resident, cognitively intact, had diagnoses including adjustment disorder, bipolar disorder, anxiety disorder, schizoaffective disorder, epilepsy, and traumatic brain injury, with care-planned behavioral disturbances including poor impulse control and verbal aggression. Both residents were present in the dining room when the incident occurred. According to nursing and activities staff accounts, the cognitively impaired resident was in a self-propelled wheelchair and bumped the other resident’s wheelchair in the dining room. Witnesses reported that the cognitively intact resident then struck out and slapped the cognitively impaired resident in the face. There were differing accounts as to whether the cognitively impaired resident first made contact with the other resident’s face after bumping the chair, but staff consistently described that the cognitively intact resident responded by striking the other resident in the face. The DON confirmed that the cognitively intact resident turned around, raised his voice, and made contact with the other resident’s face after the wheelchair bump. Clinical documentation showed that the cognitively impaired resident sustained a skin tear over the right eyebrow/eye area associated with the altercation, with a weekly skin evaluation also noting a skin tear on the right elbow. Staff interviews confirmed that a mark over the right eyebrow was found and treated. The cognitively intact resident reported that someone hit him in the face and that he automatically back-handed and slapped the other resident, stating he did not mean to hit him and that he felt safe in the facility. The facility’s abuse prevention policy states that each resident has the right to be free from abuse, neglect, misappropriation of resident property, exploitation, and mistreatment, yet a physical altercation resulting in injury occurred between these two residents.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect residents from abuse by not preventing resident-to-resident physical altercations. Multiple incidents were documented in which residents with severe cognitive impairments and behavioral disturbances engaged in physical aggression toward each other. These incidents included slapping, hitting, and grabbing, often occurring in common areas such as hallways and dining rooms, as well as in resident rooms. Staff members witnessed these altercations and intervened to separate the residents, but the events still resulted in physical contact and, in some cases, visible injuries such as redness to the face. Several residents involved had diagnoses including Alzheimer's disease, dementia with behavioral disturbances, schizoaffective disorder, and other psychiatric or cognitive conditions. Care plans for these residents noted behavioral symptoms such as physical aggression, wandering, and poor impulse control. Despite these documented risks, altercations occurred repeatedly, with staff sometimes present in the area but unable to prevent the incidents. In some cases, residents were placed on increased monitoring, such as fifteen-minute checks, following altercations, but the report details that the aggressive behaviors persisted over time. Staff interviews confirmed awareness that resident-to-resident abuse can occur and that such incidents are considered abuse. Staff described monitoring public areas and intervening when altercations occurred, but also acknowledged challenges in preventing these events, especially given the behavioral profiles of the residents involved. Documentation and investigations were completed after each incident, and law enforcement was notified in several cases. However, the repeated nature of the incidents and the direct observations of physical aggression between residents demonstrate a failure to ensure all residents were protected from abuse and physical harm by others.
Failure to Provide Pharmaceutical Services and Licensed Pharmacist Oversight
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of each resident and did not employ or obtain the services of a licensed pharmacist. This deficiency was identified during the survey process, indicating that the required pharmaceutical oversight and services were not in place for residents as mandated by regulations.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to prevent resident-to-resident abuse involving Resident #55 as the aggressor and Resident #44 as the victim. Resident #55, who had a history of bipolar disorder, major depressive disorder, and dementia, was involved in multiple altercations with other residents. Despite being on psychotropic medications and having a care plan in place to manage potential psychosocial well-being problems, Resident #55 exhibited physical aggression on several occasions, including hitting and pushing other residents. The facility's interventions, such as monitoring for psychosis and adjusting medications, were not effective in preventing these incidents. Resident #55's history of aggression included several documented incidents where they physically attacked other residents. These incidents were recorded in progress notes, highlighting a pattern of behavior that was not adequately addressed by the facility. The care plan for Resident #55 included interventions like removing them to a calm environment and monitoring the effectiveness of psychotropic medications. However, these measures did not prevent further aggressive behavior, as evidenced by multiple altercations occurring over several months. Interviews with staff revealed that while there were strategies in place to manage resident behavior, such as engaging residents in activities and monitoring for signs of agitation, these were not sufficient to prevent the incidents involving Resident #55. The facility's Director of Nursing acknowledged the history of altercations and the steps taken, such as moving Resident #55 to a high-acuity behavioral unit and implementing 15-minute checks. Despite these efforts, the facility's failure to prevent resident-to-resident abuse resulted in a deficiency, as the interventions were not effective in ensuring the safety of all residents.
Failure to Protect Residents from Abuse by Other Residents
Penalty
Summary
The facility failed to protect the rights of five residents to be free from abuse from other residents. Resident #5, who had moderate cognitive impairment and exhibited verbal behavioral symptoms, was thrown to the floor by Resident #4 after an altercation involving a wheelchair. Resident #4, who also had dementia and behavioral disturbances, was placed on 1:1 staff supervision and later transferred to the hospital due to his aggression. The incident was witnessed by a CNA who intervened and separated the residents. Resident #2, who had moderate cognitive impairment, was involved in an altercation with Resident #3, resulting in Resident #2 hitting Resident #3 on the cheek. Immediate interventions included 1:1 staffing and moving Resident #2 to another unit. Resident #3, who had a history of cognitive communication deficit and muscle weakness, was later involved in another incident where he was hit on the head by Resident #1 after bumping wheelchairs. Both residents were separated, and 15-minute checks were implemented. Resident #1, who had severe cognitive impairment, was involved in a verbal altercation with Resident #3, resulting in Resident #3 hitting Resident #1 on the jaw. Immediate interventions included checking for injuries, implementing 15-minute checks, and separating the residents. The facility's policy on abuse prevention was reviewed, and it was found that the facility failed to protect residents from abuse by other residents, leading to an unsafe environment.
Controlled Medication and Insulin Administration Deficiencies
Penalty
Summary
The facility failed to ensure controlled medications were provided and accounted for in accordance with professional standards for four residents. Resident #52, who was cognitively intact, was on a scheduled pain regimen with Oxycodone-Acetaminophen, which was documented as administered as ordered. However, for Resident #358, who was moderately cognitively impaired, Hydrocodone-Acetaminophen was not administered as ordered on a specific date, and there was an issue with the documentation of medication wastage. The controlled drug record showed discrepancies in the wastage documentation, with one entry not signed by a second nurse. Resident #27, who was cognitively intact, had a prescription for Tramadol to be taken as needed. The medication administration record indicated discrepancies in the administration of Tramadol, with an incorrect number of tablets documented as given. Interviews with staff revealed that controlled medications should be wasted in the presence of two nurses, but this protocol was not consistently followed, leading to potential risks of medication diversion. Additionally, Resident #118, who had diabetes mellitus, received Insulin Glargine outside of the physician-ordered parameters on multiple occasions. The medication was administered despite fasting blood sugar levels being below the threshold set by the physician. Interviews with nursing staff confirmed that medications should be administered according to physician orders, and deviations from these orders were not communicated to the physician, posing risks to the resident's health. The facility's policies on medication administration and controlled medications were not adhered to, contributing to these deficiencies.
Failure to Complete Timely Quarterly MDS Assessment
Penalty
Summary
The facility failed to complete a quarterly Minimum Data Set (MDS) assessment within the required timeframe for a resident diagnosed with dementia, Parkinson's Disease, and peripheral vascular disease. The resident was admitted on a specific date, and the admission MDS was completed on November 16, 2023. However, there was no evidence of a quarterly MDS assessment being completed after this date, which is a requirement to ensure timely identification of potential risks and care needs. During an interview, the MDS Coordinator acknowledged that the quarterly MDS assessment for the resident was missing and not completed on time. The coordinator noted that the resident should have appeared on the schedule for an assessment, but the schedule was cleared, resulting in the omission. The Director of Nursing also confirmed that the quarterly MDS assessment was missing and should have been completed in February to meet facility expectations. The facility's policies and the RAI manual emphasize the importance of timely and accurate assessments to reflect the resident's status and address care problems in an individualized care plan.
Medication Administration Deficiency
Penalty
Summary
The facility failed to ensure that a resident was free from accident hazards, specifically regarding medication administration. A resident with diagnoses of dementia, bipolar disorder, and cognitive communication deficit was found to have a cup of medications left on their bedside table. These medications included glipizide, quetiapine fumarate, divalproex, and metformin, none of which had a physician's order for self-administration. The resident's care plan indicated poor safety awareness, and the facility's policy required staff to remain with the resident until all medication was swallowed. Interviews with staff revealed inconsistencies in medication administration practices. An LPN stated that it was not acceptable to leave medications at the bedside, while a CNA mentioned finding pills on the resident's bedside table before. Another LPN acknowledged that the resident was not capable of self-administering medication but noted that the resident was generally compliant. The Director of Nursing confirmed that medications left on the bedside table did not meet the facility's expectations and that the issue had been identified for quality improvement.
Failure to Monitor Dialysis Resident's Weight Changes
Penalty
Summary
The facility failed to ensure safe monitoring of vital signs and weights for a resident with end-stage renal disease, type 2 diabetes, epilepsy, and major depressive disorder. The resident was admitted with a physician's order to have vitals and weights taken before and after dialysis. However, a review of the electronic health record revealed significant weight fluctuations, including a 41-pound loss and a subsequent 20.4-pound gain within a short period, without evidence of re-weighing or appropriate follow-up. Interviews with various staff members, including LPNs, CNAs, nurse managers, and dietetic technicians, highlighted inconsistencies in the monitoring and communication processes regarding weight changes. Staff members had differing opinions on what constituted a concerning weight change, with some suggesting a 5-pound change should be reported, while others indicated a 10-pound change. Despite the IDT's recommendation to re-weigh the resident due to significant weight loss, this action was not documented or carried out. The facility's policy required evaluation by the interdisciplinary team for any weight change of 5% within 30 days, but this was not adhered to in the case of the resident. The director of nursing acknowledged the need for a more robust process to monitor weight changes and ensure recommendations are communicated and documented. The failure to re-weigh the resident and investigate the weight fluctuations could potentially result in complications and inadequate care for the resident.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect the rights of three residents from abuse by other residents, as evidenced by multiple incidents. Resident #92, who was cognitively intact, was involved in a physical altercation with Resident #117, where both pulled each other's hair. The facility documentation indicated that both residents were separated and placed on 15-minute checks, and Resident #117 was moved to a different room. However, the report highlights that the facility did not adequately prevent the initial incident from occurring. In another incident, Resident #71, who had severe cognitive impairment, was found on the floor in a physical altercation with his roommate. The staff intervened by separating the residents and moving Resident #71 to a new room. The report suggests that the facility's measures were reactive rather than preventive, as the altercation had already occurred before staff intervention. Additionally, Resident #1, with severe cognitive impairment, engaged in a verbal and physical altercation with Resident #460 over seating in the dining room. Staff intervened by physically separating the residents, but the incident indicates a failure to prevent the altercation. Interviews with staff revealed inconsistencies in reporting and handling such incidents, despite the facility's policy emphasizing the right of residents to be free from abuse.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to ensure that five residents were free from abuse by other residents. Resident #1, who had a moderate cognitive impairment, hit Resident #2, who was severely cognitively impaired, after an altercation involving their wheelchairs. Staff intervened and separated the residents, but the incident highlighted a lapse in supervision and prevention of resident-to-resident abuse. No injuries were reported, but the incident was documented, and notifications were made to relevant parties. Another incident involved Resident #3, who was cognitively intact, and Resident #9, who also had no cognitive impairments. Resident #9 blocked the doorway with his wheelchair and kicked Resident #3 in the abdomen when asked to move. Staff separated the residents, conducted skin assessments, and moved Resident #9 to a different room. This incident also pointed to a failure in preventing resident-to-resident abuse despite the facility's protocols. Additional incidents included Resident #4, who had moderate cognitive impairment, being kicked by Resident #5, who was cognitively intact, resulting in an abrasion. Resident #6, who was severely cognitively impaired, was hit by Resident #7, who was also severely cognitively impaired, during an episode of increased disorientation. These incidents further demonstrated the facility's failure to protect residents from abuse by other residents, despite having policies and training in place to prevent such occurrences.
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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.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Life Care Center Of Tucson | 0.6 mi | ★★★★★ | 5 | 0 |
| La Canada Care Center | 2 mi | ★★★★★ | 7 | 0 |
| Mountain View Care Center | 2.1 mi | ★★★★★ | 0 | 0 |
| Brookdale Santa Catalina | 4.4 mi | ★★★★★ | 4 | 0 |
| Catalina Post Acute And Rehabilitation | 5.5 mi | ★★★★★ | 12 | 0 |
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