Santa Rosa Care Center
Santa Rosa Care Center in TUCSON, AZ — inspection on February 20, 2026.
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
the Director of Nursing (DON/Staff # 82), who had interviewed Resident #1 regarding the incident. A
12:43 p.m., revealed that on January 23, 2026, resident #1 came to staff #60 during med pass,
provider, DON and Assistant Director of Nursing (ADON/Staff #2).
Staff # 60 reported that the provider came out and talked with Resident # 1 regarding the injury and ordered an x-ray of her right shoulder.
Staff # 60 reported that the results of the x-rays came in on her shift and she reported a fracture to Resident #1's right arm to her ADON. An interview with CNA (Staff # 108) on February 20, 2026, at 1:04 p.m. revealed that on the morning of January 23, 2026, Resident # 1 had informed Staff # 108 that her arm was sore, but Resident # 1 let Staff #108 and CNA (Staff # 129) transfer her via the Hoyer lift with no reported pain.
Once up, she stated that Resident # 1 went to tell LPN Staff # 60 about the pain.
Staff # 108 revealed that Resident # 1 is always a 2-person Hoyer lift.In an interview with ADON (Staff # 2) on February 20. 2026, at 1:13 p.m., revealed that she received a call from Staff #60 regarding Resident #1's pain and that Staff # 60 was going to notify the doctor.
Staff # 2 also revealed that she was notified of the fracture that same day and notified the DON, who had followed up with orders from the physician. An interview with DON (Staff # 82) on February 20, 2026, at 1:43 p.m. revealed that on January 23, 2026, Resident # 1 approached the DON and reported that her right shoulder hurt and that someone had incorrectly transferred Resident # 1. DON revealed that the physician was immediately notified, and an investigation was started.
She reported interviewing the accused staff on January 23, 2026, as well as other staff and residents.
The DON revealed not making the required notifications to the state agency, APS, Ombudsman, and Police because she thought she did not have to if the complainant was known to give false accusations, even though a major injury had occurred and the DON was investigating the cause of the injuryA policy and procedure titled Reporting Alleged Violations of Abuse, Neglect, Exploitation, Mistreatment dated July 2025, revealed that the facility will ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made if the events that cause the allegation involves abuse or results in serious bodily injury.
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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.