Santa Rosa Care Center
Santa Rosa Care Center in TUCSON, AZ — inspection on October 31, 2025.
Found 1 citation. 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
abuse as when someone is not receiving proper care, medical attention, or is harmed by staff or other residents.
She also explained the incident as where one resident was wanting the bathroom light on while the other resident wanting the bathroom light off. Resident #16 then pushed Resident #87 out of the way and he then fell and hit the back of his head on the floor.
Staff #3 described Resident #87 as someone who is very clean and likes to sleep in the dark.
Staff then separated the two residents and moved Resident #16 to a different room before eventually moving him to a different unit.
She also indicated that Resident #87 sustained a laceration to the back of her head and that she believed it was 4-centimeters.
Staff #3 explained that Resident #16 had never exhibited physical aggression towards others and he was new to the current facility.
There was no indication that he had physical aggression towards others prior to be admitted to the current facility.
When asked to read the October 11, 2025 progress note, she indicated the note mentioned Resident #16 had physical aggression behaviors at his previous facility.
Staff #3 explained that when new residents are admitted , they are put in the locked unit to observe their behaviors and to determine if the unit is a good fir for them or if they can be put in a less restrictive unit.
When asked what the risk to the residents are if they are abused by other residents, Staff #3 shared that residents could fall, have physical injuries, can be affected mentally, become depressed, or self-isolate.
She also indicated that this situation she would consider this abuse due to the fact that Resident #16 willfully harmed Resident #87.
Review of the policy titled Identifying Types of Abuse, dated 2001 indicated that Abuse was the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. It also identified resident-to-resident abuse as a type of abuse.
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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.