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Complaint Investigation

Brookdale Santa Catalina

May 29, 2026 · Tucson, AZ · 7500 North Calle Sin Envidia
Citations 3
CMS Rating 4/5
Beds 42
Provider ID 035253
Healthcare Facility
Brookdale Santa Catalina
Tucson, AZ  ·  View full profile →
Source Document
Official CMS Inspection Report (Medicare.gov)
Downloaded from CMS/Medicare.gov. Reflects what state inspectors documented and does not include the facility's plan of correction, which is submitted separately. Facilities may have taken corrective actions since this report was released.
Inspection Summary

BROOKDALE SANTA CATALINA in TUCSON, AZ — inspection on May 29, 2026.

Found 3 citations. Severity: Standard violations.

Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.

Inspection Findings

FF0607
Freedom from Abuse, Neglect, and Exploitation Deficiencies

035253 05/29/2026

Brookdale Santa Catalina 7500 North Calle Sin Envidia Tucson, AZ 85718

patients went their whole shift without being changed and properly cared for - Staff #9 stated that it did sound like an allegation of neglect and it would need to be reported to the SA. A telephonic interview was conducted on May 29, 2026 at 12:15 P.M. with the Senior Director of Clinical Services for Skilled Nursing (Staff # 44).

Staff #44 stated that on April 16, 2026 the facility received an anonymous complaint via the company's Integrity Phone Line, alleging that facility management staff did not take action regarding allegations of neglect.

Staff #44 indicated that management staff were placed on suspension while an investigation was conducted.

Staff #44 explained that during an interview with Staff #9, he shared a complaint/grievance made by a Nursing Student alleging that a CNA was not providing cares and services to residents.

Staff #44 stated that Staff #9 indicated he had investigated the incident by speaking with residents and staff members, who raised no concerns regarding the cares provided by Staff #13, and therefore concluded that the alleged neglect had not occurred.

Staff #44 stated that Staff #9 shared that he did not report the alleged abuse to the SA because he felt that it did not take place.

However, Staff #9 did not provide documentation of his investigation.

Staff #44 stated that the standard process requires the investigation to be documented.

Staff #44 explained that once she became aware of the allegation of neglect, it was reported to the SA on April 17, 2026.

Staff #44 also shared that the facility's policy on neglect requires that allegations of suspected neglect must be reported to the SA, and it that this requirement not followed.

Review of the facility's policy and procedures titled, Abuse, Neglect, & Exploitation Policy, last revised in October 2022, revealed the policy defines neglect as the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress.

The policy further identifies the alleged neglect is to be made to the SA within 24 hours and the follow-up investigation report is submitted within 5 working days of the initial report.

035253 05/29/2026

Brookdale Santa Catalina 7500 North Calle Sin Envidia Tucson, AZ 85718

at 12:01 P.M. with the facility's former Administrator (ADM/Staff #9).

Staff #9 stated that he was not notified of an allegation of neglect in March of 2026 and denied receiving a text message with a picture of the complaint/grievance form.

Staff #9 stated that he was traveling at the time the incident allegedly took place; however, he did acknowledge that he was the abuse coordinator even while traveling and was expected to be available if neglect or abuse situations arose.

Staff #9 stated there was no alternate abuse coordinator in place at that time.

When surveyor read aloud the following statement written on the complaint/grievance form - multiple patients went their whole shift without being changed and properly cared for - Staff #9 stated that it did sound like an allegation of neglect.A telephonic interview was conducted on May 29, 2026 at 12:15 P.M. with the Senior Director of Clinical Services for Skilled Nursing (Staff # 44).

Staff #44 stated that on April 16, 2026 the facility received an anonymous complaint via the company's Integrity Phone Line, alleging that facility management staff did not take action regarding allegations of neglect.

Staff #44 indicated that management staff were placed on suspension while an investigation was conducted.

Staff #44 explained that during an interview with Staff #9, he shared a complaint/grievance made by a Nursing Student alleging that a CNA was not providing cares and services to residents.

Staff #44 stated that Staff #9 indicated he had investigated the incident by speaking with residents and staff members, who raised no concerns regarding the cares provided by Staff #13, and therefore concluded that the alleged neglect had not occurred.

However, Staff #9 did not provide documentation of his investigation.

Staff #44 also shared that the facility's policy on neglect requires that allegations of suspected neglect be thoroughly investigated and documented, and that this requirement was not followed.

Review of the facility's policy and procedures titled, Abuse, Neglect, & Exploitation Policy, last revised in October 2022, revealed the policy defines neglect as the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress.

The policy further identifies the alleged neglect is to be investigated as soon as practicable by interviewing residents and staff members, and maintain a written record of the investigation.

Frequently Asked Questions

What is an F-tag violation?
F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
Were these violations corrected?
Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
How often do nursing home inspections happen?
CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
What should families do about these violations?
Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in TUCSON, AZ, (5) Report new concerns to state authorities.
Where can I see the full inspection report?
Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from BROOKDALE SANTA CATALINA or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.


More Reports

About This Inspection Report

Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.

Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.

Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.