28 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (10 deficiencies)
13 fire-safety deficiencies
Top issue: Emergency Preparedness (10 deficiencies)
Tucson, AZ
2-star overall rating with 1-star inspections with Special Focus status with abuse icon flag with $4,194 in total fines with 28 recent health deficiencies with 13 fire-safety deficiencies in the latest cycle
2221 North Rosemont Boulevard, Tucson, AZ
(520) 881-2323
Overall
2 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Beds
94
Certified beds
Average residents
81
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Pollak Holdings
Operator or chain grouping
Approved since
1967-01-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
6 facilities
Chain averages 2 overall / 1 health / 2 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
RN hours / resident day
0.34
Registered nurse staffing · state 0.72 · national 0.68
LPN hours / resident day
1.14
Licensed practical nurse staffing · state 1.04 · national 0.87
Aide hours / resident day
2.29
Nurse aide staffing · state 2.36 · national 2.35
Total nurse hours
3.77
All reported nurse hours · state 4.12 · national 3.89
Licensed hours
1.48
RN + LPN hours · state 1.76 · national 1.54
Weekend hours
3.49
Weekend nurse staffing · state 3.62 · national 3.43
Weekend RN hours
0.24
Weekend registered nurse coverage · state 0.51 · national 0.47
Physical therapist
0.04
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.36
CMS adjusted RN staffing hours
Adjusted total hours
3.91
CMS adjusted total nurse staffing hours
Case-mix index
1.32
Higher values indicate more complex resident acuity
RN turnover
50%
Annual RN turnover · state 45% · national 45%
Total nurse turnover
61%
Annual nurse turnover · state 48% · national 46%
SNF VBP
Program rank
11,849
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
15
Composite VBP score used to determine payment impact.
Payment multiplier
0.9814
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
Readmission
1.91
Baseline 20.29% · Performance 20.55% · Measure score 1.91 · Achievement 1.91 · Improvement 0
Healthcare-associated infections
0
Baseline 6.03% · Performance 7.96% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
1.31
Baseline 69.39% · Performance 61.32% · Measure score 1.31 · Achievement 0.58 · Improvement 1.31
Adjusted total nurse staffing
2.78
Baseline 3.88 hours · Performance 3.87 hours · Measure score 2.78 · Achievement 2.78 · Improvement 0
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.08% |
10.72%
0.6 pts better
|
No Different than the National Rate · Eligible stays 114 · Observed rate 7.02% · Lower 95% interval 6.43% |
| Discharge to community | 57.84% |
50.57%
7.3 pts better
|
No Different than the National Rate · Eligible stays 95 · Observed rate 58.95% · Lower 95% interval 48.71% |
| Medicare spending per beneficiary | 1.01 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 75 · Denominator 75 |
| Falls with major injury | 1.33% |
0.77%
0.6 pts worse
|
Numerator 1 · Denominator 75 |
| Discharge self-care score | 64% |
53.69%
10.3 pts better
|
Numerator 32 · Denominator 50 |
| Discharge mobility score | 36% |
50.94%
14.9 pts worse
|
Numerator 18 · Denominator 50 |
| Pressure ulcers or injuries, new or worsened | 1.33% |
2.29%
1 pts better
|
Numerator 1 · Denominator 75 · Adjusted rate 1.2% |
| Healthcare-associated infections requiring hospitalization | 7.96% |
7.12%
0.8 pts worse
|
No Different than the National Rate · Eligible stays 71 · Observed rate 8.45% · Lower 95% interval 4.37% |
| Staff COVID-19 vaccination coverage | 1.21% |
8.2%
7 pts worse
|
Numerator 3 · Denominator 248 |
| Staff flu vaccination coverage | 6.3% |
42%
35.7 pts worse
|
Numerator 24 · Denominator 381 |
| Discharge function score | 62% |
56.45%
5.5 pts better
|
Numerator 31 · Denominator 50 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 54 · Denominator 54 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 4 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 25.58% |
25.2%
0.4 pts better
|
Numerator 11 · Denominator 43 |
Quality measures
| 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 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 94.4% |
94.6%
0.2 pts worse
|
95.5%
1.1 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 94.4% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.0% |
2.1%
0.1 pts better
|
3.3%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.2% · Q2 0.0% · Q3 1.9% · Q4 3.9% · 4Q avg 2.0% · 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 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents who lose too much weight | 5.2% |
5.3%
0.1 pts better
|
5.4%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.9% · Q2 2.6% · Q3 5.0% · Q4 5.1% · 4Q avg 5.2% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 13.8% |
20.5%
6.7 pts better
|
19.6%
5.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.5% · Q2 15.4% · Q3 11.6% · Q4 17.9% · 4Q avg 13.8% |
| Percentage of long-stay residents who received an antipsychotic medication | 12.8% |
11.8%
1 pts worse
|
16.7%
3.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.9% · Q2 6.9% · Q3 15.6% · Q4 20.0% · 4Q avg 12.8% · Used in QM five-star |
| 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 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 9.8% |
14.5%
4.7 pts better
|
16.3%
6.5 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 9.8% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 3.2% |
10.8%
7.6 pts better
|
14.9%
11.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.3% · Q2 0.0% · Q3 4.9% · Q4 2.6% · 4Q avg 3.2% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.8% |
0.9%
0.1 pts better
|
1.0%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.0% · Q3 0.0% · Q4 1.4% · 4Q avg 0.8% · 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 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 21.2% |
20.5%
0.7 pts worse
|
19.8%
1.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 15.7% · Q2 36.3% · Q3 18.9% · Q4 15.4% · 4Q avg 21.2% |
| Percentage of long-stay residents with pressure ulcers | 4.8% |
4.8%
About the same
|
5.1%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.8% · Q2 7.7% · Q3 3.3% · Q4 4.5% · 4Q avg 4.8% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.6% |
91.1%
8.5 pts better
|
81.7%
17.9 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 99.6% · Q2 99.2% · Q3 99.6% · Q4 100.0% · 4Q avg 99.6% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 8.9% |
10.7%
1.8 pts better
|
12.0%
3.1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 8.9% · Observed 8.9% · Expected 11.2% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.4% |
1.1%
0.3 pts worse
|
1.6%
0.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 1.2% · Q2 1.7% · Q3 1.8% · Q4 0.7% · 4Q avg 1.4% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 93.4% |
87.3%
6.1 pts better
|
79.7%
13.7 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 93.4% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 20.0% |
24.6%
4.6 pts better
|
23.9%
3.9 pts better
|
Short Stay · 20240701-20250630 · Adjusted 20.0% · Observed 17.8% · Expected 21.2% · Used in QM five-star |
Survey summary
Top issue: Freedom from Abuse and Neglect and Exploitation (10 deficiencies)
13 fire-safety deficiencies
Top issue: Emergency Preparedness (10 deficiencies)
Top issue: Freedom from Abuse and Neglect and Exploitation (3 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Top issue: Quality of Life and Care (3 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Fire safety
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-12-03
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-11-05
Fire Safety
Develop Emergency Preparedness policies and procedures.
Corrected 2024-12-06
Fire Safety
Establish policies and procedures including evacuation.
Corrected 2024-12-06
Fire Safety
Establish policies and procedures for sheltering.
Corrected 2024-12-06
Fire Safety
Establish policies and procedures for volunteers.
Corrected 2024-12-06
Fire Safety
Establish roles under a Waiver declared by secretary.
Corrected 2024-12-06
Fire Safety
List the names and contact information of those in the facility.
Corrected 2024-12-06
Fire Safety
Provide family notifications of emergency plan.
Corrected 2024-12-06
Fire Safety
Conduct testing and exercise requirements.
Corrected 2024-12-06
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2024-12-06
Fire Safety
Conduct risk assessment and an All-Hazards approach.
Corrected 2024-12-06
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-12-05
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2023-12-08
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-12-08
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-12-08
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-12-08
Fire Safety
Have a complete alarm system manually initiated and initiated by fire sprinkler system connection.
Corrected 2022-10-21
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-10-21
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2022-10-21
Inspection history
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Not marked corrected
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Not marked corrected
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Not marked corrected
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2025-12-27
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2025-10-30
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2025-10-30
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2025-09-26
Health
Respond appropriately to all alleged violations.
Corrected 2025-09-26
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 2025-09-13
Health
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Corrected 2025-09-13
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2025-05-02
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2025-03-18
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2025-03-18
Health
Respond appropriately to all alleged violations.
Corrected 2025-03-18
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2024-12-06
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2024-12-06
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2024-12-06
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-12-06
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2024-12-06
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2024-12-06
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2024-12-06
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-12-06
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2024-12-06
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2024-12-06
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 2024-12-06
Health
Ensure that a resident does not develop patterns of decreased social interaction and/or increased withdrawn, angry, or depressive behaviors, unless unavoidable.
Corrected 2024-12-06
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2024-12-06
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2024-12-06
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2024-12-06
Health
Ensure that residents are free from significant medication errors.
Corrected 2024-12-06
Health
Provide timely, quality laboratory services/tests to meet the needs of residents.
Corrected 2024-12-06
Health
Provide and implement an infection prevention and control program.
Corrected 2024-12-06
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-10-18
Health
Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy.
Corrected 2024-06-21
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-10-19
Health
Honor the resident's right to organize and participate in resident/family groups in the facility.
Corrected 2023-10-26
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-10-19
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 2023-10-19
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2023-10-19
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2022-10-15
Health
Provide and implement an infection prevention and control program.
Corrected 2022-10-15
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2022-10-15
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2022-10-15
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 2022-10-15
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2022-10-15
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2022-10-15
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2022-10-15
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2022-10-15
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 2022-10-15
Penalties and ownership
Fine · fine $4,194
Fine
Corporate Director · Individual
Corporate Officer · Individual
W-2 Managing Employee · Individual
Operational/Managerial Control · Organization
Corporate Officer · Individual
Corporate Director · Individual
Corporate Officer · Individual
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