Average — CMS composite of the measures below.
A standard survey is most likely before around November 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 Santa Rosa Care Center during CMS and state inspections, most recent first.
A resident with right-sided hemiplegia, contractures, and a documented need for two-person Hoyer lift transfers reported right shoulder pain, which led to imaging that showed a moderately displaced comminuted fracture of the surgical neck of the humerus. Staff interviews indicated the resident was always a two-person Hoyer lift transfer, while the resident later alleged that a CNA had manually lifted her from wheelchair to bed, during which she heard a crack and felt pain, and that she reported this pain and bruising to a CNA, an LPN, and the DON. The DON confirmed the resident reported shoulder pain and an incorrect transfer and that an investigation was initiated, but the DON did not notify the state agency, APS, Ombudsman, or police as required by facility policy for alleged abuse or serious bodily injury, delaying the report to the state agency until 26 days after the fracture was identified and only after APS contacted the facility.
A resident with cognitive impairment and behavioral issues was injured after being pushed by a roommate with dementia and a history of aggression, following a disagreement about a room light. Despite known behavioral risks and prior incidents, staff interventions were limited to medication and redirection, and the altercation resulted in a 4-cm head laceration.
Food storage and tray-line sanitation practices were not maintained according to professional standards. Staff observed sanitizer buckets and a dirty fan in the food prep area, multiple freezer and refrigerator items stored without labels or dates, and a dietary aide placing a cucumber that fell onto a tray back onto the plate with his hand. During puree prep, a blender lid was washed and sanitized after it was dropped, and the DON and dietitian stated it needed to air dry completely before use.
Food service safety practices were not followed during kitchen and tray-line operations. Sanitizer buckets, including one with a dish rag, were observed in the food preparation area where pudding/pie mix was being prepared, and a dirty fan was blowing across the tray line. During tray-line service, a Dietary Aide picked up a cucumber slice that fell off a plate and placed it back on the plate with his hand; staff stated this should not have occurred and identified the concern as food contamination.
A resident with stroke-related hemiplegia, schizoaffective disorder, depression, anxiety, and vascular dementia had an inaccurate PASARR Level I completed by the SSD. The pre-admission PASARR from the prior facility did not identify dementia as the primary diagnosis, but the facility’s post-admission PASARR listed dementia/Alzheimer’s disease without supporting documentation. Interviews showed staff disagreed on the primary diagnosis, and the SSD acknowledged the resident should have been referred to a Level II PASARR if schizophrenia and psychotropic use were present without a primary dementia diagnosis.
Failure to Provide Ordered Oxygen Therapy: A resident with COPD and respiratory failure was supposed to receive continuous O2, but staff found the concentrator and portable tank turned off while the cannula remained in place. The resident said he was SOB and could not feel air through the cannula. Staff gave conflicting explanations, including that the oxygen was off for a dental appointment and that the resident’s SOB was behavioral, while the DON stated O2 should only be given with a physician order. The record also showed no oxygen administration order in the chart despite documentation that the resident was to receive continuous supplemental oxygen.
Missing Current Physician Order for Dialysis: A resident with ESRD and cognitive intactness was documented as receiving dialysis, but the chart lacked a current physician order for the treatment. The care plan and appointment information referenced dialysis, and staff interviews confirmed the resident went to dialysis, yet the LPN and DON both verified that no active order was present in the physician order record at the time of review.
A resident with multiple chronic conditions, including COPD, heart disease, diabetes, and chronic respiratory failure, had a container of miconazole powder found at the bedside on an overhead shelf. The resident had no order for self-administration, and staff interviews confirmed that medications are expected to remain in locked carts unless specifically ordered. The LPN and DON both stated that bedside storage without an order did not meet expectations.
Multiple residents with cognitive and behavioral impairments were not adequately protected from abuse, resulting in incidents where one resident was bitten by another, a resident was struck in the face by a CNA, and several residents suffered injuries during altercations despite being on 1:1 supervision. Staff interviews and facility documentation confirmed that these events were substantiated as abuse or neglect, reflecting failures in supervision and intervention.
Two cognitively impaired residents with behavioral issues were involved in a physical altercation after one resident wandered into another's room and bed. The aggressor, who had a history of verbal and physical aggression, struck the other resident, resulting in visible injuries. Staff and documentation confirmed that monitoring was insufficient at the time, as the assigned hall monitor was assisting elsewhere, and both residents had known behavioral risks that were not adequately managed.
The facility failed to prevent resident-to-resident abuse, resulting in multiple altercations and injuries. A resident with schizophrenia exhibited aggressive behavior, hitting two others with a wheelchair part. Another resident was scratched during a verbal exchange, and a third altercation led to redness in a resident's eye. These incidents involved residents with cognitive impairments and highlight the facility's inability to manage aggressive behaviors effectively.
The facility failed to prevent abuse between residents, resulting in two incidents. One involved a resident with no cognitive impairment being attacked by a newly admitted resident with severe cognitive impairment, leading to injuries. Another incident involved a resident with severe cognitive impairment being kicked by a cognitively intact resident with a history of aggression. The facility did not implement adequate behavioral interventions or recognize warning signs, contributing to these deficiencies.
A resident with mild cognitive impairment was administered a Dulcolax suppository against their will, despite having had a bowel movement the previous day. The LPN involved did not adhere to the facility's protocol, which requires respecting a resident's decision to refuse medication. Interviews with staff, including the DON, confirmed that the practice was unacceptable, leading to the LPN's termination.
A resident with a history of sexual disinhibition kissed another resident without consent, leading to emotional distress. Despite previous incidents of sexual disinhibition, no additional interventions were implemented, and the lack of supervision on the patio contributed to the incident. The facility's policies on abuse and neglect were not adequately followed, resulting in a deficiency.
The facility failed to prevent resident-on-resident abuse, resulting in physical and psychosocial harm. In one incident, a resident with dementia and schizoaffective disorder struck another resident in the back after being touched. In another incident, a resident threw coffee at another resident's face during a disagreement. Both incidents involved residents with known behavioral issues, and the facility did not provide adequate supervision or implement effective strategies to manage these behaviors.
Two residents with severe cognitive impairments were involved in separate altercations with other residents, resulting in physical contact and injury. Staff interventions were insufficient to prevent these incidents, and the facility's abuse prevention policy was not effectively implemented.
Failure to Timely Report Serious Injury and Alleged Improper Transfer
Penalty
Summary
The deficiency involves the facility’s failure to timely report a serious injury and alleged improper transfer of a cognitively intact resident to the appropriate state agencies within the required timeframe. The resident had right-sided hemiplegia/hemiparesis due to cerebrovascular disease, contracture of the right wrist, muscle weakness, and required assistance with personal care. The care plan documented behaviors including false accusations and indicated the resident required two-person care and Hoyer lift transfers. A quarterly MDS showed a BIMS score of 15, indicating the resident was cognitively intact and had no documented mood or behavioral indicators. On one morning, the resident reported right shoulder pain to nursing staff, leading to physician notification and a STAT x-ray order. The x-ray later revealed a moderately displaced comminuted fracture of the surgical neck of the right humerus, and an orthopedic report documented swelling, bruising, and tenderness over the proximal humerus. The facility’s internal investigation, initiated the same day, included an interview with a CNA who stated that he and another CNA had transferred the resident from wheelchair to bed using a Hoyer lift per protocol and without incident. Other staff interviews indicated the resident reported arm soreness and pain, requested to see the doctor, and was known to be a two-person Hoyer lift transfer. The resident later reported that on the prior day a CNA had transferred her by wrapping his arms around her shoulders and lifting her from wheelchair to bed instead of using the Hoyer lift, that she heard a crack and felt pain, and that she informed the CNA and then an LPN and the DON about the pain and bruising. The DON acknowledged that the resident approached her and reported shoulder pain and an incorrect transfer, and that an investigation was started that same day. Despite the facility’s policy requiring that all alleged violations involving abuse, neglect, exploitation, mistreatment, including injuries of unknown source, be reported immediately but not later than two hours if the events involve abuse or result in serious bodily injury, the DON did not make required notifications to the state agency, APS, Ombudsman, or police. The DON stated she believed reporting was not required because the complainant was known to make false accusations, even though a major injury had occurred and an investigation into the cause of the injury was underway. The incident was not reported to the state agency until 26 days after the facility became aware of the fracture, and only after APS reported the incident to the facility.
Failure to Prevent Resident-to-Resident Abuse Resulting in Injury
Penalty
Summary
The facility failed to protect a resident from abuse by another resident, resulting in physical injury. One resident, who had a history of schizoaffective disorder, bipolar type, and moderate cognitive impairment, was involved in a verbal disagreement with his roommate, who had dementia with behavioral disturbances and moderate cognitive impairment. The disagreement centered around the use of a room light, escalating to the point where the roommate pushed the resident, causing him to lose balance and fall. This resulted in a 4-centimeter laceration to the back of the resident's head, which required immediate attention from staff. Prior to the incident, both residents had documented behavioral issues, including agitation, restlessness, and difficulty with communication or redirection. The resident who initiated the physical contact had a recent history of behavioral escalation, including irritability and verbal aggression, and had previously been transferred from another facility after an assault on another resident. Despite these known risks, the facility's interventions were limited to medication management, monitoring, and attempts at redirection, without additional measures to prevent resident-to-resident altercations. Staff interviews confirmed that there had been ongoing disagreements between the two residents about the room environment, and that the resident who pushed had become increasingly agitated in the days leading up to the incident. The facility's policy defined resident-to-resident abuse as a form of abuse, and the Director of Nursing acknowledged that the incident constituted willful harm. The facility's failure to implement effective interventions to prevent the altercation directly led to the injury sustained by the resident.
Food Storage and Tray-Line Sanitation Deficiencies
Penalty
Summary
The facility failed to store food in accordance with professional standards for food service safety. During an initial kitchen observation, two sanitizer buckets, including one containing a dish rag, were observed in the food preparation area where a bowl of pudding/pie mix was being prepared. A portable blue plastic fan was also observed on a metal rack blowing across the food server’s side of the tray line, and its blades were caked with thick, brownish-gray dirt. Additional observations in the freezer and refrigerator showed multiple food items stored without labels or dates. Pork and turkey on the bottom shelf of the freezer were not labeled or dated, and two bags of frozen breadsticks and one bag of frozen fish patties were stored with no labels, including open or expiration dates. In the refrigerator, twenty-four packages of small corn tortillas, one package of cooked and peeled eggs, one bag of opened diced onions, one thirty-two-ounce bag of cauliflower, two bags of wilted brown shredded lettuce, one open box of mushrooms, one open box of carrots, and one partially peeled and used cucumber wrapped in plastic wrap were stored with no labels to include open or expiration dates. During pureed food preparation, pizza was prepared and pureed with tomato sauce, and ingredients were measured for each portion. When the lid of the blender was dropped, it was taken to the sink for washing and sanitizing, and the Dietary Director stated it was not permissible to dry the lid with a paper towel because it needed to air dry completely before use. During tray-line service, a slice of cucumber fell off a plate onto the tray, and a dietary aide picked it up with his hand and placed it back on the plate. The dietitian and Dietary Director both stated this did not meet their expectations because of contamination concerns. The report also noted that sanitizer buckets tested at 400 parts per million, temperatures for freezers and refrigerators were adequate, and food temperatures during preparation and service were within acceptable ranges.
Food Handling and Tray-Line Sanitation Breach
Penalty
Summary
The facility failed to ensure that food was served in accordance with professional standards of food service safety. During an initial kitchen observation with the Dietary Director, two sanitizer buckets, including one containing a dish rag, were observed in the food preparation area where a bowl of pudding/pie mix was being prepared. A portable blue plastic fan was also observed on a metal rack blowing across the food server's side of the tray line, and its blades were noted to be caked with thick, brownish-gray dirt. During tray-line service, a slice of cucumber fell off a plate onto the tray, and a Dietary Aide picked it up and placed it back onto the plate with his hand. The tray line was stopped, and staff stated that he should not have touched the food and returned it to the plate. The dietitian identified the concern as contamination of the food and possible infection, and the Dietary Director stated that picking up the food and putting it back on the plate did not meet his expectations. During interview, the Dietary Aide stated that he washed his hands when entering and exiting the kitchen, and that he did not think gloves were necessary on the tray line because he did not touch residents' food, although he acknowledged he should not have touched the item that fell off the plate.
PASARR Screening Incorrectly Completed for Resident with Mental Health Diagnoses
Penalty
Summary
The facility failed to ensure that a PASARR Level I screening was accurately completed for one resident. Resident #41 was admitted with diagnoses including hemiplegia and hemiparesis following a cerebrovascular infarction, schizoaffective disorder bipolar type, major depressive disorder, anxiety disorder, and vascular dementia. The quarterly MDS showed a BIMS score of 15, indicating the resident was cognitively intact, and also noted verbal behaviors, wandering, antidepressant use, and no antipsychotic use. The resident’s pre-admission PASARR, completed by the previous facility, identified schizoaffective disorder, major depressive disorder, and anxiety disorder, and stated the resident did not have a primary diagnosis of dementia or Alzheimer’s disease. It also noted the resident had been receiving mental health services from an inpatient Behavioral Health Team and was taking psychotropic medications. The post-admission PASARR completed by the facility’s Social Services Director listed the resident’s primary diagnosis as dementia or Alzheimer’s disease and stated this was verified by a comprehensive mental status exam, but the SSD later stated she could not locate documentation supporting that diagnosis and did not have a copy of the exam. Interviews showed the SSD determined dementia as the primary diagnosis by reviewing the History and Physical, the pre-admission PASARR, and the reason for admission, despite acknowledging the resident was admitted with a primary diagnosis of stroke. The DON stated the primary diagnosis was hemiplegia and hemiparesis following cerebrovascular disease, and the Admissions staff member also identified stroke-related hemiplegia as the primary diagnosis. The SSD stated that a resident with schizophrenia and psychotropic medication use without a primary diagnosis of dementia should have been referred to a Level II PASARR, and the facility policy stated Social Services was responsible for reviewing PASARR for new admissions and identifying PASARR II criteria triggers.
Failure to Provide Ordered Oxygen Therapy
Penalty
Summary
The facility failed to ensure that necessary respiratory care was provided for one resident with diagnoses including acute respiratory failure with hypoxia and COPD. The resident’s comprehensive assessment showed moderate cognitive impairment, limited mobility, dependence for most ADLs, bowel and bladder incontinence, a stage 3 pressure ulcer, and use of a wheelchair. The care plan identified COPD and stated that the resident was to receive aerosol or bronchodilator treatments as ordered, be monitored for respiratory symptoms, and receive oxygen via nasal prongs as ordered. The physician progress note documented that the resident was to receive continuous supplemental oxygen at 2 liters per minute at rest and with exertion, with a goal oxygen saturation above 88 percent. The record also showed that the resident had been reporting shortness of breath and later developed positive infiltrates on chest x-ray, after which antibiotics were ordered for community-acquired pneumonia. However, the physician orders reviewed did not identify an oxygen administration order, although an order dated January 23, 2025, referenced changing oxygen tubing and mask monthly. During observation, the resident was seated in a wheelchair with the nasal cannula in place, but the concentrator was turned off and the portable oxygen tank connected to the tubing was also turned off. The resident stated that he was short of breath and could not feel any air flowing through the cannula. A CNA turned on the tank after being called to the room and stated she had been helping the resident prepare for an off-site appointment. An LPN stated the oxygen was off because the resident was getting ready for a dental evaluation and said the resident’s shortness of breath was behavioral, while also stating that continuous oxygen should be on and working at all times. Interviews with other staff showed differing understanding of oxygen administration, and the DON stated oxygen should only be administered when ordered by a physician. The facility policy required staff to verify a physician’s order and review the care plan before oxygen administration.
Missing Current Physician Order for Dialysis
Penalty
Summary
The facility failed to ensure that Resident #16 had a current physician order for dialysis. The resident was admitted with diagnoses including ESRD, unspecified atrial fibrillation, and chronic pain syndrome. The MDS indicated a BIMS score of 14 and showed that the resident was receiving dialysis. The care plan, initiated on October 14, 2024 and revised on October 21, 2024, identified the need for hemodialysis related to renal failure and ESRD and listed dialysis days as Tuesdays, Thursdays, and Saturdays. Review of the physician orders, TAR, and MAR revealed no current order for dialysis, although there was an order to hold blood pressure medications on dialysis days that was identified as Mondays, Wednesdays, and Fridays. Staff interviews showed that the CNA did not know whether the resident received dialysis, the resident stated he went to dialysis on Mondays, Wednesdays, and Fridays, and staff observed transportation information in the appointment book. The LPN confirmed he did not see a current dialysis order, and the DON confirmed there was no current order in the system and stated the prior dialysis order had not been put back after the resident returned from the hospital. A later review of the physician orders showed a new dialysis order for Mondays, Wednesdays, and Fridays that had been transcribed by the ADON.
Medication Stored at Bedside Without Order
Penalty
Summary
The facility failed to ensure that medications were stored in accordance with professional standards for one resident out of a sample of 23. Resident #66 had multiple diagnoses including COPD, heart disease, morbid obesity, diabetes with neuropathy, heart failure, chronic respiratory failure, dementia related to alcohol use, and was non-ambulatory, incontinent of bowel and bladder, and dependent on staff for most activities of daily living. The resident’s MDS showed intact cognition with a BIMS score of 15, visual impairment, and significant physical limitations. During observation, a container of miconazole powder 25% was found at the resident’s bedside on an overhead shelf behind and above the bed. There was no physician order for self-administration of medications. The resident’s orders included Nystatin powder to be applied topically to the peri-area and abdominal folds twice daily for candidiasis, with use after incontinence episodes, but no order allowed bedside storage or self-administration. The resident’s care plan addressed self-care deficits, risk for skin breakdown related to limited mobility, incontinence, disease processes, and morbid obesity, and noted that the resident could be resistant to care. Staff interviews confirmed that medications were expected to be kept in locked medication carts and not in resident rooms unless specifically ordered. An LPN stated that a medication at the bedside without an order did not meet expectations and checked the electronic record, finding no self-administration order. The DON also stated that self-administration requires a physician’s order and assessment of the resident’s ability, and that finding a medication at the bedside without such an order would not meet expectations. The facility policy stated that residents may self-administer medications only if the attending physician and interdisciplinary care planning team determine that the resident has the decision-making capacity to do so safely.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
The facility failed to protect multiple residents from abuse, including both resident-to-resident and staff-to-resident incidents. In one case, a resident with severe cognitive impairment and multiple comorbidities was bitten on the hand by another resident, resulting in injury. The incident was observed by staff, and the injured resident was found to have puncture wounds on the left hand. The biting resident was subsequently relocated, but the initial failure to prevent the altercation constituted a deficiency in protecting residents from abuse. Another incident involved a staff member physically abusing a resident with severe cognitive impairment and behavioral issues. The resident, who was known to wander and sometimes be combative, was struck in the face by a CNA after the resident allegedly grabbed the staff member. The abuse was witnessed by another CNA, who intervened and reported the incident. The staff member involved was terminated, but the event highlighted a lapse in ensuring residents were free from staff abuse. Additional deficiencies were identified in cases where residents with histories of aggression and cognitive impairment engaged in repeated altercations, resulting in physical injuries such as bruises and lacerations. In several instances, residents who were supposed to be under 1:1 supervision still managed to physically harm others, indicating that the supervision was inadequate. Facility documentation and interviews confirmed that these incidents were substantiated as abuse, and in one case, a staff member assigned to 1:1 supervision was terminated for neglect after failing to prevent an assault. The facility's actions and inactions in these cases failed to ensure residents were protected from all forms of abuse and neglect.
Failure to Prevent Resident-to-Resident Abuse Due to Inadequate Monitoring
Penalty
Summary
The facility failed to protect a resident from abuse by another resident, resulting in a physical altercation. One resident, who had diagnoses including alcohol-induced dementia and major depressive disorder and was noted to be cognitively impaired, was found in another resident's room with visible injuries, including blood on his face and neck. Documentation and staff interviews confirmed that this resident had a history of wandering, restlessness, and irritability, and his care plan included monitoring and removing him from situations when he began to escalate. On the day of the incident, he was found in another resident's bed, and the other resident admitted to striking him after becoming upset by the intrusion. The second resident involved had diagnoses of dementia, schizoaffective disorder, and bipolar disorder, and was also cognitively impaired. His care plan noted behaviors such as physical and verbal aggression, delusions, and hallucinations, with interventions including medication administration and redirection. Staff interviews and progress notes indicated that this resident became agitated when the first resident entered his room and bed, leading to the physical altercation. Staff observed blood on the aggressor's knuckles and confirmed that he admitted to hitting the other resident. At the time of the incident, a hall monitor assigned to observe residents was not present in the hallway, as they were assisting another resident. Staff interviews revealed that the first resident had a pattern of wandering into other residents' rooms, and the second resident had a history of verbal threats but no prior physical aggression. The facility's policy required monitoring for aggressive behaviors and recognized that wandering into others' rooms could provoke reactions, but the monitoring in place was insufficient to prevent the altercation.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect four residents from physical abuse, resulting in incidents of resident-to-resident altercations. Resident #1, who was admitted with schizophrenia and other behavioral issues, exhibited aggressive behavior towards other residents. On December 4, 2024, Resident #1 threatened and attempted to hit another resident, and later in the day, hit two residents with a part of his wheelchair hidden in a sock. This incident was witnessed by staff, and the Tucson Police Department was called. Resident #1 was taken to the hospital for psychiatric treatment. The facility's investigation confirmed the occurrence of the altercation. Resident #11, with severe cognitive impairment, and Resident #111, also with severe cognitive impairment, were involved in the altercation with Resident #1. Resident #111 sustained a small bruise on the left forearm as a result of the incident. Staff interviews revealed that Resident #1 had been agitated throughout the day, possibly triggered by personal belongings being dropped off by his sister. Despite being regularly followed for behavioral health needs, Resident #1's aggression was not effectively managed, leading to the physical altercation. Another incident involved Resident #2, who was scratched by Resident #22 after a verbal exchange. Resident #22, with moderate cognitive impairment, had a history of behavioral issues that were reportedly managed with medication. The facility's investigation noted that Resident #2 had a small scratch on the face. Additionally, Resident #3 and Resident #33 were involved in a verbal altercation that escalated to physical contact, resulting in redness to Resident #3's eye. These incidents highlight the facility's failure to prevent resident-to-resident abuse, as evidenced by multiple altercations and injuries among residents with cognitive impairments.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect residents from abuse, resulting in incidents involving four residents. Resident #4, who had no cognitive impairment, was attacked by Resident #5, who had severe cognitive impairment and was newly admitted to the facility. The altercation occurred in Resident #4's room and continued in the hallway, resulting in Resident #4 sustaining a laceration on the right eyebrow and a scratch on the back. Staff witnessed the second altercation and intervened, but the facility had not implemented any behavioral interventions for Resident #5, who was known to be easily triggered. In another incident, Resident #1, who had severe cognitive impairment, was kicked by Resident #2, who was cognitively intact but had a history of fluctuating aggressive behaviors. The incident occurred after Resident #2 returned from a smoke break and became agitated. Staff witnessed the altercation, but there were no injuries reported. The facility had identified Resident #2's potential for aggression but failed to prevent the incident by not recognizing the warning signs of increased agitation. The facility's policy defines abuse as including physical actions such as hitting and kicking, and acknowledges that abuse can occur between residents. Despite this, the facility did not adequately address the behavioral issues of Residents #5 and #2, leading to the incidents of resident-to-resident abuse. The lack of appropriate interventions and failure to recognize warning signs contributed to the deficiencies observed by the surveyors.
Resident's Right to Refuse Medication Not Honored
Penalty
Summary
The facility failed to honor a resident's right to refuse medication, specifically a Dulcolax suppository, which was administered despite the resident's explicit refusal. The resident, who had mild cognitive impairment, was admitted with diagnoses including Parkinson's disease, type 2 diabetes, and major depressive disorder. The incident occurred after the resident had a bowel movement, and the suppository was administered the following day by an LPN, contrary to the resident's wishes. The resident's Power of Attorney was notified after the medication was given. Interviews with various staff members, including LPNs and the Director of Nursing, revealed a consensus that administering a suppository against a resident's will is not acceptable practice. Staff members indicated that they would typically educate the resident on the medication's purpose and respect their decision if they refused. The Director of Nursing confirmed that the staff member involved did not meet the facility's expectations, leading to the staff member's termination. The facility's bowel movement protocol was reviewed, which outlines steps to be taken if a resident does not have a bowel movement in more than three days, including obtaining an order for a bowel regimen protocol and discussing additional interventions with the resident's physician.
Failure to Protect Resident from Abuse
Penalty
Summary
The facility failed to protect a resident from abuse, specifically a non-consensual kiss by another resident. Resident #28, who has diagnoses of Major Depressive Disorder and Schizoaffective Disorder, reported that Resident #6 kissed her on the patio in front of the building after dark. Resident #28 expressed that she still experiences nightmares from the incident and feels uncomfortable seeing Resident #6 during activities. The incident was corroborated by Resident #6, who admitted to kissing Resident #28 and mentioned that he was moved to another unit following the incident. Resident #6, who has diagnoses of sexual disinhibition, Major Depressive Disorder, and cerebral ischemia, was noted to have exhibited sexual disinhibition on previous occasions, as documented in the Medication Administration Record. Despite this, no additional interventions were implemented to address these behaviors. Interviews with staff revealed that Resident #6 was moved to a lockdown unit after the incident, but there was a lack of supervision on the patio during the evening, which contributed to the occurrence of the incident. The facility's policy on identifying sexual abuse defines non-consensual sexual contact as abuse, and the policy on neglect indicates that failure to provide necessary supervision can result in emotional distress. The report highlights that the facility did not adequately monitor or intervene in Resident #6's behavior, leading to the incident with Resident #28. The lack of supervision and failure to implement additional interventions for Resident #6's known behaviors contributed to the deficiency.
Resident-on-Resident Abuse Due to Inadequate Supervision
Penalty
Summary
The facility failed to prevent resident-on-resident abuse, resulting in physical and psychosocial harm. An altercation occurred between two residents in the dining room, where one resident, diagnosed with dementia and schizoaffective disorder, struck another resident in the back after being touched. The aggressive resident had a history of psychiatric behaviors and aggression, which were documented in multiple nursing notes. Despite being aware of these behaviors, the facility did not implement adequate measures to prevent the incident. Another incident involved a resident throwing a cup of coffee at another resident's face during a disagreement in the dining room. The aggressive resident, diagnosed with major depressive disorder and schizoaffective disorder, had a history of verbal aggression and impulsive behavior. The facility's records did not include notes regarding this incident, indicating a lack of proper documentation and monitoring of the resident's behavior. Interviews with staff and residents revealed that the facility's interventions were insufficient to prevent these incidents. Staff members reported that the residents involved in the altercations had known behavioral issues, yet the facility did not provide adequate supervision or implement effective strategies to manage these behaviors. The facility's failure to protect residents from abuse and neglect is a significant deficiency in their care practices.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect the rights of two residents to be free from abuse by other residents. Resident #4, who has severe cognitive impairment and a history of aggressive behavior, was involved in an altercation with Resident #6, who also has severe cognitive impairment and a history of aggression. During an argument on the patio, Resident #6 was being redirected by a CNA when they encountered Resident #4 in the hallway. Resident #4 verbally taunted Resident #6, leading to a physical altercation where Resident #6 made contact with Resident #4, resulting in redness to Resident #4's left eye. In another incident, Resident #1, who has severe cognitive impairment, was involved in an altercation with Resident #5, who also has severe cognitive impairment and a history of being resistive to care. Resident #1 was seated on Resident #5's walker in the dining room, and when Resident #5 attempted to use the walker, Resident #1 did not move. This led to Resident #5 pushing and striking Resident #1 on the cheek. The incident resulted in initial redness on Resident #1's cheek, which subsided by the following day. Interviews with staff revealed that there were no immediate interventions to prevent these incidents, and staff training on abuse prevention was mentioned but not effectively implemented. The facility's policy on abuse prevention was not adhered to, as both verbal and physical abuse occurred. The facility's failure to ensure the safety and protection of residents from abuse by other residents was evident in these incidents.
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Illustrative
What surveyors actually found near you
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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.
Illustrative
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Tucson
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Handmaker Home For The Aging | 0.7 mi | ★★★★★ | 12 | 1 |
| Foothills Rehabilitation Center | 0.7 mi | ★★★★★ | 26 | 0 |
| Villa Maria Post Acute And Rehabilitation | 0.8 mi | ★★★★★ | 5 | 0 |
| The Center At Tucson | 1.1 mi | ★★★★★ | 0 | 0 |
| Sabino Canyon Rehabilitation & Care Center | 1.2 mi | ★★★★★ | 3 | 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.