Santa Rosa Care Center
1650 North Santa Rosa Avenue, Tucson, AZ 85712 · Pima County · 144 certified beds · avg 120 residents/day · certified since Apr 1, 1980
Abuse citation flag (CMS)
Part of chain: THE ENSIGN GROUP (342 facilities, chain avg rating 3.2★)
The abuse flag means inspectors cited this facility for abuse that caused harm to a resident within the past year, or potential for harm in each of the last two years. Source: CMS.
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★★☆☆☆2/5 · CMS overall rating: 3/5
The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.
Most serious findings (actual harm or immediate jeopardy)
▲ Actual harm, one-off · Aug 9, 2023 · F-0760 · triggered by a complaint
The facility did not keep residents free from significant medication errors — such as giving the wrong drug, the wrong dose, or missing a critical medication.
Why it matters: A serious medication error can cause real harm, hospitalization, or worse.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Sep 12, 2023 (Deficient, Provider has date of correction)
All citations in the current public record (28)
CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.
| Date | Severity | What the facility was cited for |
|---|---|---|
| Feb 20, 2026 | D · Potential for harm, one-off | The facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation. · from a complaint |
| Oct 31, 2025 | D · Potential for harm, one-off | The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. · from a complaint |
| Aug 29, 2025 | E · Potential for harm, repeated | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| Aug 29, 2025 | E · Potential for harm, repeated | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Aug 29, 2025 | D · Potential for harm, one-off | The facility did not properly complete the required screening (called PASARR) that identifies whether a person entering a nursing home has a mental illness or intellectual disability and needs specialized services. |
| Aug 29, 2025 | D · Potential for harm, one-off | The facility provided care that did not meet professional standards of quality — the accepted standards that nurses and other clinicians are expected to follow. |
| Aug 29, 2025 | D · Potential for harm, one-off | The facility did not provide safe, appropriate care for residents who need dialysis — the treatment that filters the blood when kidneys fail. |
| Aug 29, 2025 | D · Potential for harm, one-off | The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. |
| Jun 13, 2025 | E · Potential for harm, repeated | The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. · from a complaint |
| Feb 7, 2025 | D · Potential for harm, one-off | The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. · from a complaint |
| Dec 18, 2024 | E · Potential for harm, repeated | The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. · from a complaint |
| Nov 1, 2024 | E · Potential for harm, repeated | The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. · from a complaint |
| Nov 1, 2024 | D · Potential for harm, one-off | The facility provided care that did not meet professional standards of quality — the accepted standards that nurses and other clinicians are expected to follow. · from a complaint |
| Oct 21, 2024 | D · Potential for harm, one-off | The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. · from a complaint |
| Sep 23, 2024 | D · Potential for harm, one-off | The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. · from a complaint |
| Apr 1, 2024 | D · Potential for harm, one-off | The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. · from a complaint |
| Oct 27, 2023 | E · Potential for harm, repeated | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| Oct 27, 2023 | D · Potential for harm, one-off | The facility did not honor residents' right to form and take part in resident or family groups, such as a resident council. |
| Oct 27, 2023 | D · Potential for harm, one-off | The facility did not properly complete the required screening (called PASARR) that identifies whether a person entering a nursing home has a mental illness or intellectual disability and needs specialized services. |
| Oct 27, 2023 | D · Potential for harm, one-off | The facility's medication error rate was 5 percent or higher — meaning too many doses were given incorrectly, such as the wrong drug, dose, or time. |
| Oct 27, 2023 | D · Potential for harm, one-off | The facility did not dispose of garbage and refuse properly. |
| Oct 27, 2023 | D · Potential for harm, one-off | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Aug 9, 2023 | ▲ G · Actual harm, one-off | The facility did not keep residents free from significant medication errors — such as giving the wrong drug, the wrong dose, or missing a critical medication. · from a complaint |
| Sep 1, 2022 | E · Potential for harm, repeated | The facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs. |
| Sep 1, 2022 | E · Potential for harm, repeated | The facility did not try to gradually reduce doses of mood- and mind-altering medications or use non-drug approaches first, as required, or used 'as needed' psychiatric drugs without proper limits. |
| Sep 1, 2022 | D · Potential for harm, one-off | The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. |
| Sep 1, 2022 | D · Potential for harm, one-off | The facility used physical restraints — devices that limit a resident's movement — when they weren't needed for medical treatment. |
| Sep 1, 2022 | D · Potential for harm, one-off | The facility did not respond appropriately to alleged violations, such as reports of abuse, neglect, or mistreatment. Facilities must investigate every allegation and protect residents while they do. |
Inspection trend by year
Citations from standard inspections stayed about the same across the last two inspection cycles (6 → 6).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2022 | 5 | 0 | E |
| 2023 | 7 | 1 | G ▲ |
| 2024 | 6 | 0 | E |
| 2025 | 9 | 0 | E |
| 2026 | 1 | 0 | D |
Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.
Fines and enforcement (last 3 years)
No fines or payment denials in the published 3-year window.
Nurse staffing (from payroll records, adjusted for how much care residents need)
| Measure | This facility | Arizona avg | U.S. avg | Where it stands |
|---|---|---|---|---|
| Total nurse staffing (hours per resident per day) | 4.25 | 3.97 | 3.95 | top 26% in Arizona; top 30% in the U.S. |
| Registered Nurse hours | 0.39 | 0.69 | 0.69 | bottom 12% in Arizona; bottom 21% in the U.S. |
| Weekend total nurse staffing | 3.68 | 3.50 | 3.50 | top 29% in Arizona; top 34% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.23 | 0.49 | 0.48 | bottom 13% in Arizona; bottom 17% in the U.S. |
| Total nursing staff turnover (%) | 58.2 | 45.2 | 45.8 | bottom 17% in Arizona; bottom 19% in the U.S. |
| RN turnover (%) | 84.6 | 43.6 | 42.9 | bottom 2% in Arizona; bottom 3% in the U.S. |
Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 3.35, RN 0.31, weekend 2.90. Staffing rating: 2/5.
Self-reported quality measures
Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.
Quality measures rating: 5/5 · long-stay residents: 5/5 · short-stay residents: —/5
Who owns this facility
For profit - Limited Liability company · changed ownership in the last 12 months
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Burnam, Soon | Individual | Corporate Officer | NOT APPLICABLE | 05/09/2025 |
| Ensign Services INC | Organization | ADP of the SNF | NOT APPLICABLE | 05/09/2025 |
| Jones, Christine | Individual | Corporate Officer | NOT APPLICABLE | 05/09/2025 |
| Keetch, Chad | Individual | Individual Is an Owner, Partner or Trustee of Any ADP of the SNF | NOT APPLICABLE | 02/03/2026 |
| Peterson, Forrest | Individual | Corporate Director | NOT APPLICABLE | 05/09/2025 |
| Port, Barry | Individual | Individual Is an Owner, Partner or Trustee of Any ADP of the SNF | NOT APPLICABLE | 11/26/2025 |
| Rowe, Christopher | Individual | Operational/Managerial Control | NOT APPLICABLE | 12/01/2025 |
| Rowe, Christopher | Individual | ADP of the SNF | NOT APPLICABLE | 12/01/2025 |
| Santa Rosa Propco, LLC | Organization | ADP of the SNF | NOT APPLICABLE | 12/01/2025 |
| Sato, Ami | Individual | Corporate Officer | NOT APPLICABLE | 05/09/2025 |
| Singh, Harbir | Individual | Operational/Managerial Control | NOT APPLICABLE | 12/01/2025 |
| Singh, Harbir | Individual | ADP of the SNF | NOT APPLICABLE | 12/01/2025 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "What systems do you use to prevent medication errors, and what happens when one occurs?"
- "When abuse or theft is suspected, who do you notify, how fast, and how do you inform the family?"
- "Tell me about this abuse or neglect citation — what happened, and what specific changes did you make afterward?"
- "What did your most recent kitchen inspection find, and can I see how food is stored and prepared?"
- "Who leads your infection prevention program, and how do you make sure staff follow practices like hand hygiene every day?"
- "How do you screen new residents for mental health and disability-related needs, and how do you provide the specialized services they require?"
- "Can you tell me what this citation involved and what steps you took to bring care back up to standard?"
- "How do you coordinate and monitor care for residents who receive dialysis?"
- "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
- "Can I see the results and plan of correction from your most recent state inspection?"
Nearby facilities (within 20 miles)
| Facility | Distance | City | Overall | Inspection | Flags |
|---|---|---|---|---|---|
| Handmaker Home for the Aging | 0.7 mi | Tucson, AZ | ★★★☆☆ | 2/5 | abuse |
| Foothills Rehabilitation Center | 0.7 mi | Tucson, AZ | ★★☆☆☆ | 1/5 | |
| Villa Maria Post Acute and Rehabilitation | 0.8 mi | Tucson, AZ | ★★★☆☆ | 2/5 | |
| The Center at Tucson | 1.1 mi | Tucson, AZ | ★★★★★ | 5/5 | |
| Sabino Canyon Rehabilitation & Care Center | 1.2 mi | Tucson, AZ | ★★★★☆ | 3/5 | |
| Pueblo Springs Rehabilitation Center | 1.2 mi | Tucson, AZ | ★★☆☆☆ | 3/5 | |
| Sandstone Estates Rehab Centre | 1.8 mi | Tucson, AZ | ★☆☆☆☆ | 1/5 | |
| Devon Gables Rehabilitation Center | 1.8 mi | Tucson, AZ | ★★☆☆☆ | 2/5 | abuse |
| Haven of Tucson | 2.1 mi | Tucson, AZ | ★★☆☆☆ | 2/5 | |
| Haven of Saguaro Valley | 2.6 mi | Tucson, AZ | ★★★★★ | 4/5 |
Compare this facility with the 3 closest →
Facility data as of CMS processing date 2026-08-01. CCN 035004.