Average — CMS composite of the measures below.
The next survey window likely opens around December 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 Villa Maria Post Acute And Rehabilitation during CMS and state inspections, most recent first.
Multiple residents with documented mental health diagnoses and active psychotropic treatment did not receive accurate PASRR Level I screenings or required Level II referrals. In several cases, PASRR forms from referring facilities and the facility itself marked "no" history of serious mental illness, omitted diagnoses such as PTSD, bipolar disorder, borderline personality disorder, schizophrenia, and depression, and failed to reflect recent inpatient psychiatric hospitalization or suicidal ideation, despite these being clearly documented in the clinical record, MDS assessments, psychiatric notes, and care plans. Some PASRR forms also incorrectly indicated that residents were not on psychotropic medications, or left the Level II referral determination section blank, even though the same records listed multiple psychotropic agents for mood, anxiety, and psychotic disorders. No Level II referrals were found for these residents. In interviews, the Social Services Director acknowledged that PASRRs were inaccurate or incomplete, that Level II referrals should have been submitted but were not, that the facility is responsible for PASRR accuracy, and that she lacked clear training and consistent oversight on PASRR update requirements and tracking.
A hospice resident with multiple chronic conditions experienced a decline marked by lethargy and decreasing O2 saturations, including documented hypoxia, but there was no corresponding physician order for oxygen or change-of-condition monitoring in the EMR when oxygen was applied at the bedside. Hospice notes indicated that oxygen was ordered and used, yet the facility lacked a hospice binder for the resident, did not upload hospice visit notes, and did not document O2 saturation checks for several days while other vital signs were recorded each shift. Observations showed an oxygen concentrator in use before a physician order was entered, and interviews with an LPN, ADON, DON, and hospice staff confirmed that required physician notification, oxygen orders, and care plan updates were not completed in accordance with facility policies on vital signs, change-of-condition reporting, oxygen administration, physician orders, and hospice care.
Surveyors found that the facility failed to maintain complete dual-nurse narcotic reconciliation logs for two medication carts, with multiple shifts lacking required nurse signatures despite a policy requiring incoming and outgoing licensed nurses to reconcile controlled medications at each shift change. An LPN confirmed that two nurses are required to complete the narcotic count and that missing signatures mean it cannot be proven that the counts were performed as required, and facility leadership acknowledged that the submitted logs did not meet their own expectations.
A resident with multiple psychiatric and pain diagnoses experienced distress and verbal altercations during two roommate changes, including reported threatening and mocking comments, crying, yelling, and behavioral escalation. Staff contacted the ADON and intervened, but did not document the behavioral episodes, roommate conflicts, or change-of-condition monitoring in the clinical record, despite facility policies and staff expectations that such events be charted. In a separate case, another resident with diabetes, chronic pain, cancer, and a stage 4 pressure ulcer was on hospice and had declining oxygen saturation, with hospice staff applying oxygen at 2L via nasal cannula and documenting hypoxia. However, the facility’s EMR lacked timely physician orders for oxygen, did not include a care plan for oxygen therapy until later, had no documented oxygen saturation monitoring for several days, and was missing hospice visit notes and a hospice binder, resulting in an incomplete and inaccurate medical record of the resident’s oxygen use and change in condition.
A resident with Type 2 DM, chronic kidney disease, and other comorbidities had a provider order for 20 units of Insulin Glargine daily, to be held if blood glucose was less than 110. Review of the MAR showed that insulin was administered on five occasions when the resident’s blood glucose was documented as below 110, without any provider authorization to give insulin under those conditions. Staff interviews confirmed that CMAs and CNAs are trained to follow ordered parameters, hold medications when parameters are not met, and notify nursing and the provider of abnormal values, and the DON acknowledged that the expectation for medication administration according to orders and facility policy was not met.
A resident with no cognitive impairment attempted to slap another resident, leading to a physical altercation where the second resident retaliated, causing injury. Despite staff intervention, the facility failed to prevent the incident, highlighting inadequate management of resident interactions and lack of de-escalation policies.
A resident with epilepsy experienced a seizure, but the facility failed to provide timely emergency response. The nurse delayed calling 911 and did not administer seizure medication, leaving the resident unattended and at risk. The Director of Nursing confirmed the delay was unacceptable, and the facility's policy was not followed.
The facility failed to provide catheter-related care as ordered for three residents, leading to missed opportunities for catheter care and emptying drainage bags. Staff interviews confirmed inconsistent care and documentation, and the facility was often understaffed, affecting the quality of care provided.
Failure to Accurately Complete PASRR Screenings and Level II Referrals for Multiple Residents With Mental Disorders
Penalty
Summary
The deficiency involves the facility’s failure to ensure accurate completion, updating, and referral of PASRR Level I screenings and Level II evaluations for multiple residents with serious mental illness (SMI) or other mental disorders. For one resident with borderline personality disorder, PTSD, recurrent depression, anxiety disorders, and factitious disorder, hospital-generated PASRRs repeatedly documented “no” history of SMI, mental disorders, or psychotropic medications, despite extensive behavioral health diagnoses and active psychotropic orders. The facility did not correct these PASRRs or complete a Level I PASRR after the 30‑day convalescent period ended, even though the resident’s MDS assessments, psychiatric notes, care plans, and social services assessments consistently documented anxiety, depression, PTSD, borderline personality disorder, and ongoing psychiatric treatment. Another resident with PTSD, depression, generalized anxiety disorder, bipolar disorder, polysubstance abuse, and recent inpatient psychiatric hospitalization for suicidal ideation had a PASRR Level I that omitted major depression and bipolar disorder and incorrectly indicated no recent psychiatric hospitalization or suicidal ideation. A subsequent PASRR Level I, completed after re‑admission, documented bipolar disorder and anxiety disorder but again indicated no recent psychiatric hospitalization or suicidal ideation and concluded that no Level II referral was necessary. The clinical record showed no evidence of any PASRR Level II referral for this resident. A separate resident with diabetes, depression, and later‑added bipolar disorder exhibited altered mental status and psychotic‑like behavior, prompting a psychiatric consult. However, the quarterly MDS did not list bipolar disorder as an active diagnosis, and the PASRR Level I documented major and mild/situational depression but stated the resident did not have bipolar disorder and did not require a Level II referral, with no Level II referral found in the record. For another resident admitted and re‑admitted with anxiety disorder, schizophrenia, recurrent depressive disorder, chronic PTSD, and polysubstance abuse in remission, multiple PASRR Level I tools were inconsistent with the clinical record. One hospital PASRR identified bipolar disorder and personality disorder and psychotropic use but did not document whether a Level II referral was needed. A subsequent facility PASRR Level I documented schizophrenia and anxiety disorder but stated the resident was not prescribed psychotropic medications, despite the admission MDS showing active anxiety, depression, schizophrenia, and use of antianxiety, antidepressant, antipsychotic, and anticonvulsant medications. A later PASRR Level I listed schizophrenia only, omitted depression, anxiety, and other mental disorders, and left the Level II referral determination section blank, even though the same form listed multiple psychotropic medications for depression, anxiety, and schizophrenia. No Level II referral was present in the record. Additional residents with multiple psychiatric diagnoses and psychotropic treatment also lacked accurate PASRR documentation and appropriate Level II referrals. One resident with anxiety disorder, bipolar disorder (current episode depressed), and schizophrenia had a PASRR Level I that correctly listed these diagnoses and related psychotropic medications but indicated no Level II referral; a later PASRR for the same resident omitted all mental illness diagnoses and psychotropic medications, again indicating no Level II referral, despite MDS documentation of anxiety disorder, bipolar disorder, schizophrenia, and use of antipsychotics and antidepressants. Another resident with aphasia, anxiety disorder, recurrent depressive disorder, mood disorder, personality and behavioral disorder due to physiological condition, and adjustment disorder had an initial PASRR listing anxiety and depression with no Level II referral, followed by a second PASRR that omitted all diagnoses and psychotropic medications, again indicating no Level II referral, despite orders and care plans for Depakote and anticonvulsant therapy for mood disorder. In interviews, the Director of Social Services acknowledged that PASRRs were inaccurate or incomplete, that required Level II referrals had not been submitted for several residents, that the facility was responsible for ensuring PASRR accuracy, and that she was uncertain about PASRR update requirements and tracking for residents needing Level II evaluations. The Director of Social Services further stated that the facility’s process for identifying residents with mental disorders or intellectual disabilities involved review of diagnoses such as depression, anxiety, bipolar disorder, and schizophrenia, and review of psychiatric medications, and that residents with more than one or two psychiatric diagnoses and stays longer than 30 days should automatically have a Level II PASRR referral submitted. She confirmed that she was responsible for completing Level I PASRRs and submitting Level II referrals, that PASRR resource reviews were infrequent and random, and that she had not received formal performance evaluation or sufficient training to identify knowledge gaps. She also stated that inaccurate or incomplete PASRR screening and referral processes could result in residents not receiving the services they need, and that accurate PASRR completion is critical to resident safety and quality of care.
Failure to Obtain Timely Oxygen Orders and Monitor Change in Condition for Hospice Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide timely care and services, including physician notification and obtaining a physician order for oxygen, in response to a resident’s change in condition. The resident was admitted with multiple diagnoses including type 2 diabetes mellitus, chronic pain syndrome, spinal stenosis, breast cancer, and a stage 4 sacral pressure ulcer. A care plan focus initiated shortly after admission identified an alteration in gastrointestinal status due to a colostomy, with an intervention to monitor vital signs as ordered and notify the provider of significant abnormalities. Despite this, the clinical record contained no physician order for vital sign monitoring, and the admission MDS showed no oxygen therapy in the 14 days prior to or at admission. Oxygen saturation logs for January showed readings in the mid-90s on room air on several dates, but hospice documentation later recorded a decline. Hospice notes indicated that on one visit the resident was lethargic and nonverbal with an oxygen saturation of 93% on room air, and on a subsequent visit the resident was difficult to awaken, lethargic, and reported not feeling well, with an oxygen saturation of 90% on room air. The hospice note for that visit stated that oxygen was ordered and that the resident was added to a decline list, but there was no evidence of a corresponding physician order for oxygen in either the hospice records or the facility’s medical record on that date. A physician order from that date only authorized emergent PRN nursing visits due to change in decline status. Later hospice documentation recorded an oxygen saturation of 87% on room air, noted that oxygen was applied at 2L via nasal cannula after staff filled the concentrator’s water reservoir, yet there was still no physician order for oxygen in the clinical record on that date. Surveyors found that the facility’s MAR/TAR documented blood pressure, temperature, pulse, and respirations every day and night shift, but did not include oxygen saturation monitoring until several days after the hospice note documenting hypoxia. The electronic medical record showed no oxygen saturation documentation between mid-January and the date when an oxygen order was finally entered. Observations showed the resident in bed with an oxygen concentrator present and turned on at 2L, initially with the nasal cannula draped over the concentrator and later with the cannula in place, before a physician order for oxygen was documented. Interviews with an LPN revealed there was no hospice binder for the resident, no oxygen order or oxygen care plan in the EMR at the time oxygen was observed in use, and that the nurse first became aware the resident was on oxygen during the surveyor’s observation. The ADON and DON both stated that any new need for oxygen or hypoxic episode should prompt immediate physician notification, a physician order for oxygen and change-of-condition monitoring, and oxygen saturation checks every shift, and that oxygen should only be administered with a physician order except as an emergency measure until an order is obtained. Review of facility policies on vital signs, change of condition reporting, oxygen administration, physician orders, and hospice/end-of-life care confirmed that changes in condition were to be promptly communicated to a physician, documented, and incorporated into the care plan, and that oxygen therapy was to be administered and documented only under appropriate physician orders, which did not occur in this case until several days after hypoxia and oxygen use were documented by hospice. Additionally, hospice staff interviews and records showed that hospice communicated via emailed documentation and that each hospice resident should have a hospice binder at the nurses’ station containing hospice notes and updates. For this resident, there was no hospice binder available, and hospice notes from key visits were not uploaded into the facility’s EMR at the time of review. The hospice RN who visited the resident on the date hypoxia was documented reported that the resident was hypoxic with oxygen saturation around 88–90%, that an oxygen concentrator was already at the bedside when she arrived, and that she notified facility staff that the concentrator’s distilled water reservoir was empty. The DON stated she believed the resident was placed on oxygen by hospice on the morning of the date the order was eventually written and that the oxygen was for comfort measures, and she was not aware of any hypoxic episodes. Review of the clinical record with the DON confirmed that there was no documentation that a provider was notified of a change in condition related to hypoxia and that the first oxygen order was not entered until that same day, despite earlier hospice documentation of hypoxia and oxygen use.
Failure to Maintain Complete Dual-Nurse Narcotic Reconciliation Logs
Penalty
Summary
The facility failed to ensure accurate reconciliation and accounting of controlled substances on two of three sampled medication carts. During review of the narcotic reconciliation log for the 100 medication cart, surveyors and an LPN identified missing nurse signature entries on six shifts within a specified date range, despite the expectation that these entries not be left blank. A similar review of the 300 medication cart narcotic reconciliation log revealed missing nurse signature entries on five shifts in the same period. The facility’s policy, revised in June 2025, instructed staff to reconcile controlled medications every shift by both incoming and outgoing licensed nurses at change of shift, but the documentation did not show that this process was consistently followed. Interviews with nursing staff and leadership confirmed that two nurses are required to complete the narcotic count and reconciliation log at each shift change to ensure accountability and verify that residents receive required medications. An LPN stated that there should be no missing signature entries for the dates in question because, without signatures, it cannot be proven that two nurses performed the narcotic counts for those shifts. The ADON and DON acknowledged that the narcotic reconciliation logs contained missing entries that did not meet facility expectations and that the logs with these deficiencies were provided to the survey team. The deficient practice was identified through observations, interviews, and review of facility documentation and policy.
Failure to Maintain Accurate Clinical Records for Behavioral Events and Oxygen Therapy
Penalty
Summary
The deficiency involves the facility’s failure to maintain accurate, complete, and readily available clinical records that reflected residents’ actual experiences and care. For one resident with borderline personality disorder, PTSD, chronic pain, insomnia, depression, anxiety, and factitious disorder, the record did not contain documentation of significant behavioral events and roommate conflicts that occurred during room changes, despite facility policies requiring documentation of changes of condition and related nursing actions. This resident was cognitively intact, had a care plan addressing confabulation and false accusations, and had a grievance on file about room placement. A facility-reported incident later concluded that an allegation of resident-to-resident abuse was unverified and characterized the event as a verbal disagreement, but there was no corresponding documentation in the clinical record of the verbal disagreement or room-change-related distress during the 72-hour significant change-of-condition period. The resident reported to surveyors that she was placed in two different roommate situations that she felt compromised her mental health and safety, including one roommate who required the door to remain open, which she stated exacerbated her neurological condition and pain, and another roommate who allegedly mocked her and threatened to suffocate her. She described repeated verbal altercations, a screaming match, and subsequent night terrors related to her PTSD. Staff interviews confirmed that the ADON received calls about the resident crying and hollering during room changes, that staff reported the roommate’s comments such as questioning if the resident was a child and saying she would die there anyway, and that staff intervened and moved the resident. The LPN acknowledged hearing the resident yelling, receiving CNA reports that the conflict was related to the roommate’s comments about the resident’s dolls and behavior, and contacting the ADON, but admitted he did not document the episode, despite recognizing in hindsight that it met criteria for a behavioral incident and change-of-condition documentation. Other staff, including the DSS and DON, stated they expected documentation of these events in the clinical record and that such documentation is used for assessments, grievances, and investigations. For another resident with type 2 diabetes, chronic pain syndrome, spinal stenosis, breast cancer, and a stage 4 sacral pressure ulcer, the facility failed to ensure the clinical record accurately reflected vital sign monitoring, oxygen therapy, hospice involvement, and related physician orders. The care plan included an intervention to monitor vital signs as ordered and record them, but there was no physician order for vital sign monitoring. The MAR/TAR showed routine documentation of blood pressure, temperature, pulse, and respirations, but no oxygen saturation entries until later in the month, and the EMR lacked oxygen saturation documentation for several days. The resident was observed with an oxygen concentrator at bedside, initially turned on without the nasal cannula in place and later with the cannula in use, yet there was no corresponding physician order for oxygen therapy until a later date, no oxygen therapy care plan until that order, and no evidence of change-of-condition monitoring orders or documentation of provider notification when the resident was hypoxic according to hospice records. Hospice documentation, obtained after a formal request, showed that the resident’s oxygen saturation had declined on room air and that oxygen was ordered and applied by hospice staff prior to the facility obtaining a physician order. The hospice notes indicated hypoxic readings and use of oxygen at 2L via nasal cannula, but these details were not present in the facility’s EMR at the time of survey, and hospice visit notes for specific dates were not available in the record or in a hospice binder. Facility staff, including an LPN, the ADON, the medical records director, and the DON, confirmed that there was no hospice binder for the resident, no oxygen order in the EMR until later, no care plan for oxygen therapy before that order, and no documented oxygen saturation monitoring for several days. The DON acknowledged that the clinical record did not show provider notification of a change of condition or oxygen saturation monitoring and stated that if the clinical record did not accurately reflect a resident’s current status or capture a change of condition, the resident could have an adverse outcome. Facility policies on documentation, change-of-condition reporting, abuse reporting, and comprehensive care planning required complete, timely, and accurate records to support care, assessments, and investigations, which were not met in these cases.
Insulin Administered Outside Ordered Blood Glucose Parameters
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident’s insulin regimen was administered according to the provider’s parameters, resulting in the use of insulin when it was not ordered to be given. A cognitively intact resident with Type 2 DM, chronic kidney disease, moderate protein-calorie malnutrition, generalized muscle weakness, and sequelae of cerebral infarction had a physician order for 20 units of Insulin Glargine once daily unless the blood sugar was less than 110. The resident’s care plan indicated noncompliance with a therapeutic diet and directed that diabetes medications be given as ordered by the physician. Review of the MAR for a specified month showed that Insulin Glargine was administered on five occasions when the documented blood glucose levels were below 110, despite no evidence in the clinical record that the provider had authorized insulin administration when blood sugars were under that threshold. During interviews, a CMA stated that staff are expected to follow medication orders with parameters as written and that administering medications outside those parameters can overmedicate a resident and must be reported to the charge nurse and physician. The DON stated that insulin lowers blood glucose and that administering it outside prescribed parameters can cause hypoglycemia, and staff are expected to notify the provider when blood glucose values fall outside ordered parameters. A CNA reported being trained to perform finger-stick blood glucose monitoring, to notify the nurse immediately for low readings or signs of hypoglycemia, and to follow provider orders. The DON-by-proxy confirmed that documentation showed five instances where Insulin Glargine was given when blood glucose was below 110 and acknowledged that the expectation for medications to be administered in accordance with provider orders was not met. Facility policies on medication administration and MRR required holding medications when parameters are not met and obtaining clarification when there is any question about dosage, as well as identifying medication-related errors and unnecessary drugs.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect a resident from abuse by another resident, resulting in a physical altercation. Resident #1, who had no cognitive impairment, was involved in an incident where he attempted to slap Resident #2, who then retaliated by striking Resident #1. This altercation led to Resident #1 sustaining a laceration on the forehead, requiring hospital treatment. The incident occurred despite staff attempts to intervene, highlighting a failure in preventing resident-to-resident abuse. Resident #1 had been moved to a different unit prior to the incident due to feeling threatened by Resident #2, following an earlier conflict where Resident #1 had defecated on the floor of their shared room. Resident #2, who also had no cognitive impairment, expressed dissatisfaction with Resident #1's behavior and had previously threatened to keep his TV volume high until Resident #1 was moved. This ongoing tension between the two residents was not adequately managed by the facility, leading to the altercation. Interviews with staff revealed that they were not fully aware of the history between the two residents, and there was no policy in place for de-escalation management with aggressive residents. The facility's policy on resident rights emphasized freedom from physical abuse, yet the lack of effective intervention and management of resident interactions contributed to the failure to uphold these rights.
Failure to Provide Timely Emergency Response for Resident with Seizure
Penalty
Summary
The facility failed to provide timely treatment and care for a resident with a history of epilepsy, major depressive disorder, and hemiplegia following a stroke. The resident was found on the floor and later experienced a seizure, but the nurse in charge delayed calling emergency services and did not administer any seizure medication. The resident was left unattended while actively vomiting and unable to protect their airway, which was observed by the fire department upon their arrival. The nurse in charge, identified as staff #28, waited almost two hours to call 911 after the resident began experiencing seizure activity. The nurse did not have eyes on the resident when emergency services arrived and was unfamiliar with the resident's condition. The nurse practitioner was contacted late, and the order to send the resident to the hospital was delayed. Interviews with other staff members indicated that the situation was considered a medical emergency, and the delay in contacting emergency services was not acceptable. The Director of Nursing confirmed that the delay in care was not acceptable and that the expectation was for staff to contact a provider immediately in such emergencies. The facility's policy required licensed nurses to initiate appropriate first aid measures until emergency personnel arrived, which was not followed in this case. The deficiency in timely response and care had the potential to result in severe consequences for the resident.
Failure to Provide Catheter Care as Ordered
Penalty
Summary
The facility failed to ensure that three residents were provided catheter-related care as ordered, leading to missed opportunities for catheter care and emptying drainage bags. Resident #6, who was admitted with paraplegia and neuromuscular dysfunction of the bladder, had multiple missed opportunities for catheter care and emptying the drainage bag in November and December 2023. Additionally, orders for urinary analysis were not transcribed or implemented, and the resident reported having to change his own catheter due to staff unavailability. Interviews with staff confirmed that catheter care was not consistently performed or documented, and the facility was often understaffed, affecting the quality of care provided to residents with catheters. Resident #2, admitted with bladder neck obstruction and other diagnoses, also experienced missed opportunities for catheter care and emptying the drainage bag in December 2023, January 2024, and February 2024. The resident's care plan and physician's orders were not consistently followed, and interviews with staff revealed that catheter care was not performed every shift as required. The Director of Nursing acknowledged that the orders were not transcribed or implemented as expected, and the facility's policy for catheter care was not met. Resident #8, who had a suprapubic catheter and was at risk for recurring urinary tract infections, had missed opportunities for catheter care and emptying the drainage bag in November 2023, December 2023, and January 2024. The resident's care plan and physician's orders were not consistently followed, and staff interviews indicated that catheter care was not always provided or documented. The Director of Nursing confirmed that the facility's expectations for catheter care and documentation were not met, and the facility's policies and procedures were not adequately followed.
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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) |
|---|---|---|---|---|
| The Center At Tucson | 0.8 mi | ★★★★★ | 0 | 0 |
| Santa Rosa Care Center | 0.8 mi | ★★★★★ | 20 | 0 |
| Foothills Rehabilitation Center | 1.2 mi | ★★★★★ | 26 | 0 |
| Handmaker Home For The Aging | 1.2 mi | ★★★★★ | 12 | 1 |
| Haven Of Tucson | 1.7 mi | ★★★★★ | 7 | 0 |
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