Cycle 1
Health 2024-05-01 · Fire 2024-05-01
7 health deficiencies
Top issue: Resident Rights (3 deficiencies)
1 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Tucson, AZ
Brookdale Santa Catalina
2-star overall rating with 2-star inspections with 7 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
7500 North Calle Sin Envidia, Tucson, AZ
(520) 742-6242
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
42
Certified beds
Average residents
35
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Brookdale Senior Living
Operator or chain grouping
Approved since
1999-03-11
CMS approved date
Coverage
Medicare
Participation flags
Chain footprint
14 facilities
Chain averages 3 overall / 3 health / 3 staffing / 4 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.78
Registered nurse staffing · state 0.72 · national 0.68
LPN hours / resident day
1.59
Licensed practical nurse staffing · state 1.04 · national 0.87
Aide hours / resident day
2.04
Nurse aide staffing · state 2.36 · national 2.35
Total nurse hours
4.41
All reported nurse hours · state 4.12 · national 3.89
Licensed hours
2.37
RN + LPN hours · state 1.76 · national 1.54
Weekend hours
4.09
Weekend nurse staffing · state 3.62 · national 3.43
Weekend RN hours
0.39
Weekend registered nurse coverage · state 0.51 · national 0.47
Physical therapist
0.17
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.79
CMS adjusted RN staffing hours
Adjusted total hours
4.47
CMS adjusted total nurse staffing hours
Case-mix index
1.35
Higher values indicate more complex resident acuity
RN turnover
17%
Annual RN turnover · state 45% · national 45%
Total nurse turnover
42%
Annual nurse turnover · state 48% · national 46%
SNF VBP
Value-based purchasing
Program rank
1,951
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
52.77
Composite VBP score used to determine payment impact.
Payment multiplier
1.0074
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
5.17
Baseline 17.49% · Performance 19.04% · Measure score 5.17 · Achievement 5.17 · Improvement 0
Healthcare-associated infections
5.36
Baseline 6.99% · Performance 6.23% · Measure score 5.36 · Achievement 5.36 · Improvement 3.31
Total nurse turnover
7.07
Baseline 62.50% · Performance 34.78% · Measure score 7.07 · Achievement 7.07 · Improvement 6.86
Adjusted total nurse staffing
3.50
Baseline 4.50 hours · Performance 4.07 hours · Measure score 3.50 · Achievement 3.50 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.55% |
10.72%
0.8 pts worse
|
No Different than the National Rate · Eligible stays 267 · Observed rate 11.24% · Lower 95% interval 9.18% |
| Discharge to community | 60.64% |
50.57%
10.1 pts better
|
Better than the National Rate · Eligible stays 250 · Observed rate 57.6% · Lower 95% interval 53.79% |
| Medicare spending per beneficiary | 0.83 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 98.81% |
95.27%
3.5 pts better
|
Numerator 166 · Denominator 168 |
| Falls with major injury | 0.6% |
0.77%
0.2 pts better
|
Numerator 1 · Denominator 168 |
| Discharge self-care score | 54.03% |
53.69%
0.3 pts better
|
Numerator 67 · Denominator 124 |
| Discharge mobility score | 60.48% |
50.94%
9.5 pts better
|
Numerator 75 · Denominator 124 |
| Pressure ulcers or injuries, new or worsened | 3.57% |
2.29%
1.3 pts worse
|
Numerator 6 · Denominator 168 · Adjusted rate 3.96% |
| Healthcare-associated infections requiring hospitalization | 6.23% |
7.12%
0.9 pts better
|
No Different than the National Rate · Eligible stays 146 · Observed rate 4.79% · Lower 95% interval 3.57% |
| Staff COVID-19 vaccination coverage | 2.08% |
8.2%
6.1 pts worse
|
Numerator 1 · Denominator 48 |
| Staff flu vaccination coverage | 26.32% |
42%
15.7 pts worse
|
Numerator 15 · Denominator 57 |
| Discharge function score | 62.1% |
56.45%
5.6 pts better
|
Numerator 77 · Denominator 124 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 32 · Denominator 32 |
| Transfer of health information to patient | 98.26% |
96.28%
2 pts better
|
Numerator 113 · Denominator 115 |
| Resident COVID-19 vaccinations up to date | 20.99% |
25.2%
4.2 pts worse
|
Numerator 17 · Denominator 81 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
97.1%
2.9 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 7.1% |
2.1%
5 pts worse
|
3.3%
3.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 7.1% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
4.2%
4.2 pts better
|
11.4%
11.4 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% |
| Percentage of long-stay residents who lose too much weight | 52.4% |
5.3%
47.1 pts worse
|
5.4%
47 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 52.4% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 18.2% |
20.5%
2.3 pts better
|
19.6%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 18.2% |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.3%
0.3 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% |
| Percentage of long-stay residents whose need for help with daily activities has increased | 50.0% |
10.8%
39.2 pts worse
|
14.9%
35.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 50.0% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
0.9%
0.9 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
1.2%
1.2 pts better
|
1.7%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 31.4% |
20.5%
10.9 pts worse
|
19.8%
11.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 31.4% |
| Percentage of long-stay residents with pressure ulcers | 10.5% |
4.8%
5.7 pts worse
|
5.1%
5.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 10.5% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 93.8% |
91.1%
2.7 pts better
|
81.7%
12.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 93.8% · Q2 94.6% · Q3 94.8% · Q4 92.1% · 4Q avg 93.8% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 9.4% |
10.7%
1.3 pts better
|
12.0%
2.6 pts better
|
Short Stay · 20240701-20250630 · Adjusted 9.4% · Observed 9.3% · Expected 11.1% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.1%
1.1 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 92.1% |
87.3%
4.8 pts better
|
79.7%
12.4 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 92.1% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 26.3% |
24.6%
1.7 pts worse
|
23.9%
2.4 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 26.3% · Observed 25.4% · Expected 23.0% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-01-05 · Fire 2023-01-05
17 health deficiencies
Top issue: Infection Control (5 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2022-01-14 · Fire 2022-01-14
6 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2024-05-01
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-06-20
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-06-27
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2025-08-01
D · Potential for more than minimal harm
2025-06-27
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-08-01
D · Potential for more than minimal harm
2025-02-12
F726 · Nursing and Physician Services Deficiencies
Health
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Corrected 2025-02-27
D · Potential for more than minimal harm
2024-06-24
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2024-07-03
D · Potential for more than minimal harm
2024-06-24
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-07-26
E · Potential for more than minimal harm
2024-05-01
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2024-05-17
E · Potential for more than minimal harm
2024-05-01
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-05-17
E · Potential for more than minimal harm
2024-05-01
F908 · Environmental Deficiencies
Health
Keep all essential equipment working safely.
Corrected 2024-05-17
D · Potential for more than minimal harm
2024-05-01
F625 · Resident Rights Deficiencies
Health
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Corrected 2024-05-17
D · Potential for more than minimal harm
2024-05-01
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2024-05-17
E · Potential for more than minimal harm
2023-01-05
F726 · Nursing and Physician Services Deficiencies
Health
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Corrected 2023-04-05
E · Potential for more than minimal harm
2023-01-05
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-04-05
E · Potential for more than minimal harm
2023-01-05
F881 · Infection Control Deficiencies
Health
Implement a program that monitors antibiotic use.
Corrected 2023-04-05
D · Potential for more than minimal harm
2023-01-05
F578 · Resident Rights Deficiencies
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2023-04-05
D · Potential for more than minimal harm
2023-01-05
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2023-04-05
D · Potential for more than minimal harm
2023-01-05
F661 · Resident Assessment and Care Planning Deficiencies
Health
Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
Corrected 2023-04-05
D · Potential for more than minimal harm
2023-01-05
F730 · Nursing and Physician Services Deficiencies
Health
Observe each nurse aide's job performance and give regular training.
Corrected 2023-04-05
D · Potential for more than minimal harm
2023-01-05
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2023-04-05
D · Potential for more than minimal harm
2023-01-05
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2023-04-05
D · Potential for more than minimal harm
2023-01-05
F882 · Infection Control Deficiencies
Health
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
Corrected 2023-04-05
D · Potential for more than minimal harm
2023-01-05
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2023-04-05
D · Potential for more than minimal harm
2023-01-05
F888 · Infection Control Deficiencies
Health
Ensure staff are vaccinated for COVID-19
Corrected 2023-04-05
D · Potential for more than minimal harm
2023-01-05
F943 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.
Corrected 2023-04-05
D · Potential for more than minimal harm
2023-01-05
F947 · Nursing and Physician Services Deficiencies
Health
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Corrected 2023-04-05
E · Potential for more than minimal harm
2022-01-14
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2022-02-18
E · Potential for more than minimal harm
2022-01-14
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2022-02-18
E · Potential for more than minimal harm
2022-01-14
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2022-02-18
D · Potential for more than minimal harm
2022-01-14
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2022-02-18
D · Potential for more than minimal harm
2022-01-14
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2022-02-18
D · Potential for more than minimal harm
2022-01-14
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2022-02-18
Penalties and ownership
What sits behind the stars
Ownership
Arcpi Holdings Inc
5% Or Greater Direct Ownership Interest · Organization
American Retirement Corporation
5% Or Greater Indirect Ownership Interest · Organization
Brookdale Senior Living Inc
5% Or Greater Indirect Ownership Interest · Organization
Curtis, Rebecca
Operational/Managerial Control · Individual
Kussow, Dawn
Operational/Managerial Control · Individual
Kussow, Dawn
Corporate Officer · Individual
La Marre, Kevin
Corporate Officer · Individual
Munoz, Anna
Operational/Managerial Control · Individual
Munoz, Anna
Corporate Officer · Individual
Radeka, Nicholas
Operational/Managerial Control · Individual
Schiltz, Julie
Operational/Managerial Control · Individual
Stengle, Nikolas
Operational/Managerial Control · Individual
Stengle, Nikolas
Corporate Officer · Individual
Wadleigh, John
Operational/Managerial Control · Individual
White, Chadwick
Operational/Managerial Control · Individual
White, Chadwick
Corporate Director · Individual
White, Chadwick
Corporate Officer · Individual
Nearby options
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4-star overall rating with 3-star inspections with 4 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#2
La Canada Care Center
Tucson, AZ
4-star overall rating with 3-star inspections with 4 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#3
Casas Adobes Post Acute Rehab Center
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3-star overall rating with 2-star inspections with abuse icon flag with 6 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
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