Cycle 1
Health 2023-10-27 · Fire 2023-10-27
8 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (2 deficiencies)
7 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Tucson, AZ
Santa Rosa Care Center
3-star overall rating with 2-star inspections with abuse icon flag with 8 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
1650 North Santa Rosa Avenue, Tucson, AZ
(520) 795-1610
Overall
3 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
144
Certified beds
Average residents
116
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1980-04-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
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
0.33
Registered nurse staffing · state 0.72 · national 0.68
LPN hours / resident day
0.92
Licensed practical nurse staffing · state 1.04 · national 0.87
Aide hours / resident day
3.16
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
1.25
RN + LPN hours · state 1.76 · national 1.54
Weekend hours
4.10
Weekend nurse staffing · state 3.62 · national 3.43
Weekend RN hours
0.25
Weekend registered nurse coverage · state 0.51 · national 0.47
Physical therapist
0.01
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.40
CMS adjusted RN staffing hours
Adjusted total hours
5.39
CMS adjusted total nurse staffing hours
Case-mix index
1.12
Higher values indicate more complex resident acuity
RN turnover
30%
Annual RN turnover · state 45% · national 45%
Total nurse turnover
49%
Annual nurse turnover · state 48% · national 46%
SNF VBP
Value-based purchasing
Program rank
3,317
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
44.91
Composite VBP score used to determine payment impact.
Payment multiplier
0.9981
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Healthcare-associated infections
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Total nurse turnover
2.57
Baseline 36.89% · Performance 53.17% · Measure score 2.57 · Achievement 2.57 · Improvement 0
Adjusted total nurse staffing
6.41
Baseline 4.04 hours · Performance 4.90 hours · Measure score 6.41 · Achievement 6.41 · Improvement 4.46
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | Not Available |
10.72%
|
Not Available · Eligible stays Not Available · Observed rate Not Available · Lower 95% interval Not Available · No data were submitted for this measure. |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays Not Available · Observed rate Not Available · Lower 95% interval Not Available · No data were submitted for this measure. |
| Medicare spending per beneficiary | Not Available |
1.02
|
No data were submitted for this measure. |
| Drug regimen review with follow-up | Not Available |
95.27%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Falls with major injury | Not Available |
0.77%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Pressure ulcers or injuries, new or worsened | Not Available |
2.29%
|
Numerator Not Available · Denominator Not Available · Adjusted rate Not Available · No data were submitted for this measure. |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays Not Available · Observed rate Not Available · Lower 95% interval Not Available · No data were submitted for this measure. |
| Staff COVID-19 vaccination coverage | 7.09% |
8.2%
1.1 pts worse
|
Numerator 10 · Denominator 141 |
| Staff flu vaccination coverage | 31.79% |
42%
10.2 pts worse
|
Numerator 62 · Denominator 195 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 96.2% |
97.1%
0.9 pts worse
|
93.4%
2.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 95.6% · Q2 99.1% · Q3 98.1% · Q4 92.2% · 4Q avg 96.2% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 98.3% |
94.6%
3.7 pts better
|
95.5%
2.8 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 98.3% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.8% |
2.1%
0.3 pts better
|
3.3%
1.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.6% · Q2 1.8% · Q3 1.9% · Q4 0.9% · 4Q avg 1.8% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.2% |
4.2%
4 pts better
|
11.4%
11.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.9% · 4Q avg 0.2% |
| Percentage of long-stay residents who lose too much weight | 3.2% |
5.3%
2.1 pts better
|
5.4%
2.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.6% · Q2 2.8% · Q3 2.9% · Q4 3.6% · 4Q avg 3.2% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 29.1% |
20.5%
8.6 pts worse
|
19.6%
9.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 27.3% · Q2 29.6% · Q3 28.2% · Q4 31.2% · 4Q avg 29.1% |
| Percentage of long-stay residents who received an antipsychotic medication | 45.3% |
11.8%
33.5 pts worse
|
16.7%
28.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 42.6% · Q2 46.0% · Q3 45.1% · Q4 47.3% · 4Q avg 45.3% · 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 | 8.9% |
14.5%
5.6 pts better
|
16.3%
7.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.6% · Q2 12.2% · Q3 9.6% · Q4 2.2% · 4Q avg 8.9% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 11.0% |
10.8%
0.2 pts worse
|
14.9%
3.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.0% · Q2 12.2% · Q3 9.3% · Q4 9.5% · 4Q avg 11.0% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.5% |
0.9%
0.4 pts better
|
1.0%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.9% · Q2 0.9% · Q3 0.0% · Q4 0.0% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.4% |
1.2%
1.2 pts worse
|
1.7%
0.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.6% · Q2 2.6% · Q3 1.9% · Q4 2.6% · 4Q avg 2.4% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 18.5% |
20.5%
2 pts better
|
19.8%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 14.2% · Q2 20.6% · Q3 18.1% · Q4 21.1% · 4Q avg 18.5% |
| Percentage of long-stay residents with pressure ulcers | 4.1% |
4.8%
0.7 pts better
|
5.1%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.1% · Q2 3.1% · Q3 4.1% · Q4 3.9% · 4Q avg 4.1% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 56.6% |
91.1%
34.5 pts worse
|
81.7%
25.1 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q3 47.8% · Q4 59.1% · 4Q avg 56.6% |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-09-01 · Fire 2022-09-01
12 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (9 deficiencies)
9 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (4 deficiencies)
Cycle 3
Health 2021-03-26 · Fire 2021-03-26
17 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
2 fire-safety deficiencies
Top issue: Services (1 deficiency)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2023-10-27
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2023-12-18
E · Potential for more than minimal harm
2023-10-27
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2023-12-18
E · Potential for more than minimal harm
2023-10-27
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2023-12-18
E · Potential for more than minimal harm
2023-10-27
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-12-18
E · Potential for more than minimal harm
2023-10-27
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2023-12-18
D · Potential for more than minimal harm
2023-10-27
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-12-18
D · Potential for more than minimal harm
2023-10-27
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-12-18
D · Potential for more than minimal harm
2022-09-01
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2022-11-14
D · Potential for more than minimal harm
2022-09-01
K223 · Egress Deficiencies
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2022-11-14
D · Potential for more than minimal harm
2022-09-01
K342 · Smoke Deficiencies
Fire Safety
Have a complete alarm system manually initiated and initiated by fire sprinkler system connection.
Corrected 2022-11-14
D · Potential for more than minimal harm
2022-09-01
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2022-11-14
D · Potential for more than minimal harm
2022-09-01
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2022-11-14
D · Potential for more than minimal harm
2022-09-01
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2022-11-14
D · Potential for more than minimal harm
2022-09-01
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-11-14
D · Potential for more than minimal harm
2022-09-01
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2022-11-14
D · Potential for more than minimal harm
2022-09-01
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2022-11-14
E · Potential for more than minimal harm
2021-03-26
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2021-04-23
E · Potential for more than minimal harm
2021-03-26
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2021-04-23
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-10-31
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2025-11-13
E · Potential for more than minimal harm
2025-06-13
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2025-07-14
D · Potential for more than minimal harm
2025-02-07
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2025-02-08
E · Potential for more than minimal harm
2024-12-18
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2024-12-19
E · Potential for more than minimal harm
2024-11-01
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2024-11-02
D · Potential for more than minimal harm
2024-11-01
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-11-02
D · Potential for more than minimal harm
2024-10-21
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2024-10-22
D · Potential for more than minimal harm
2024-09-23
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2024-10-25
D · Potential for more than minimal harm
2024-04-01
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2024-04-25
E · Potential for more than minimal harm
2023-10-27
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 2023-12-06
D · Potential for more than minimal harm
2023-10-27
F565 · Resident Rights Deficiencies
Health
Honor the resident's right to organize and participate in resident/family groups in the facility.
Corrected 2023-11-08
D · Potential for more than minimal harm
2023-10-27
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2023-12-13
D · Potential for more than minimal harm
2023-10-27
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2023-12-08
D · Potential for more than minimal harm
2023-10-27
F814 · Nutrition and Dietary Deficiencies
Health
Dispose of garbage and refuse properly.
Corrected 2023-12-06
D · Potential for more than minimal harm
2023-10-27
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-12-08
G · Actual harm
2023-08-09
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2023-09-12
E · Potential for more than minimal harm
2023-05-22
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 2023-05-31
E · Potential for more than minimal harm
2022-09-01
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2022-11-23
E · Potential for more than minimal harm
2022-09-01
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 2022-11-23
D · Potential for more than minimal harm
2022-09-01
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2022-11-23
D · Potential for more than minimal harm
2022-09-01
F604 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Corrected 2022-11-23
D · Potential for more than minimal harm
2022-09-01
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2022-11-23
G · Actual harm
2021-03-26
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2021-04-29
E · Potential for more than minimal harm
2021-03-26
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 2021-04-29
E · Potential for more than minimal harm
2021-03-26
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2021-04-29
E · Potential for more than minimal harm
2021-03-26
F761 · Pharmacy Service Deficiencies
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 2021-04-29
E · Potential for more than minimal harm
2021-03-26
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2021-04-29
D · Potential for more than minimal harm
2021-03-26
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2021-04-29
D · Potential for more than minimal harm
2021-03-26
F622 · Resident Rights Deficiencies
Health
Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
Corrected 2021-04-29
D · Potential for more than minimal harm
2021-03-26
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 2021-04-29
D · Potential for more than minimal harm
2021-03-26
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2021-04-29
D · Potential for more than minimal harm
2021-03-26
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 2021-04-29
D · Potential for more than minimal harm
2021-03-26
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 2021-04-29
D · Potential for more than minimal harm
2021-03-26
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 2021-04-29
D · Potential for more than minimal harm
2021-03-26
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2021-04-29
D · Potential for more than minimal harm
2021-03-26
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2021-04-29
D · Potential for more than minimal harm
2021-03-26
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2021-04-29
Penalties and ownership
What sits behind the stars
Ownership
Nearby options
Other facilities in reach
#1
Handmaker Home For The Aging
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
#2
Foothills Rehabilitation Center
Tucson, AZ
3-star overall rating with 3-star inspections with 5 recent health deficiencies with 21 fire-safety deficiencies in the latest cycle
#3
Villa Maria Post Acute And Rehabilitation
Tucson, AZ
3-star overall rating with 2-star inspections with $8,018 in total fines with 9 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
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