Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record

Santa Rosa Care Center

TUCSON, AZ · 144 certified beds · Last Life Safety survey August 29, 2025

CMS Certification Number 035004 · first certified April 1980

Ownership

Operated by THE ENSIGN GROUP · For profit - Limited Liability company

  • New ownershipOwnership changed December 1, 2025 (change of ownership)from SRCV-ROSA LLC
22
Citations on file
Rolling three-year window
3
Life Safety surveys
In the same window
4
Tags cited more than once
Across separate surveys
10
Inspection & testing records
Of the citations on file

Position within AZ

22 citations — more than 92% of the 140 certified nursing homes in AZ. Compared within AZ rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated

Improvingfewer citations at the latest survey than at its earlier surveys in the window.

The latest survey found 6 citations; the earlier surveys in the window averaged 8. With 3 surveys on file this is a direction of travel, not a conclusion.

When is the next survey likely?

The window opens October 2026 — about 1 month from now. This facility’s last Life Safety survey was August 2025. Facilities in AZ are typically surveyed 14–22 months after the last one (median 18), measured over 143 consecutive surveys in the last two years of CMS records.

A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to three years in Maryland. How the window is measured

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Which alerts

3 inspection-and-testing tags have been cited here at more than one survey. Nationally, that pattern is common: about three quarters of cited facilities have at least one repeated tag, and half of the facilities ever cited for sprinkler inspection and testing are cited for it again. A repeat is usually a recordkeeping gap rather than a new hazard.

Emergency preparedness

4 of the 22 citations on file are Emergency Preparedness E-tags. E-tags are cited under 42 CFR §483.73 and concern the emergency plan, training, drills, communications and supplies. Nationally about half of certified facilities have at least one. The Emergency Preparedness Index

Physical environment (health survey)

3 physical-environment citations on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 22 Life Safety citations above. The Physical Environment Index

  • F-0880 Provide and implement an infection prevention and control program.
  • F-0584 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.

How that compares

Citations on file over three years

Compared with the median facility in AZ, and nationally. Surveyors differ markedly between states, so the AZ figure is the meaningful one.

This facility22AZ median8National median11
Citations on file over three years, compared
MeasureCitations
This facility22
Median facility in AZ8
Median facility nationally11

Survey history

Citations at each Life Safety survey
92022-0972023-1062025-08
Citations at each Life Safety survey
Survey dateCitations
September 1, 20229
October 27, 20237
August 29, 20256

Most-cited tags

Most-cited tags at this facility
K-03633K-09183E-00392K-09232K-03421K-03411K-02111E-00301
Most-cited tags at this facility
TagWhat the surveyor checksTimes citedLast cited
K-0363Install corridor and hallway doors that block smoke.32025-08-29
K-0918Have generator or other power source capable of supplying service within 10 seconds.32025-08-29
E-0039Conduct testing and exercise requirements.22025-08-29
K-0923Have proper medical gas storage and administration areas.22025-08-29
K-0342Have a complete alarm system manually initiated and initiated by fire sprinkler system connection.12022-09-01
K-0341Install a fire alarm system that can be heard throughout the facility.12023-10-27
K-0211Keep aisles, corridors, and exits free of obstruction in case of emergency.12025-08-29
E-0030List the names and contact information of those in the facility.12025-08-29

What the citations cover

Citations by CMS category
  • Gas, Vacuum, and Electrical Systems Deficiencies 8
  • Smoke Deficiencies 6
  • Emergency Preparedness Deficiencies 4
  • Egress Deficiencies 3
  • Other 1
Citations by CMS category
CategoryCitations
Gas, Vacuum, and Electrical Systems Deficiencies8
Smoke Deficiencies6
Emergency Preparedness Deficiencies4
Egress Deficiencies3
Miscellaneous Deficiencies1

Every citation on file

As published by CMS, newest survey first. Descriptions are CMS’s own wording.

August 29, 2025 — 6 citations

Citations issued on August 29, 2025
TagWhat the surveyor checksStatus
E-0030List the names and contact information of those in the facility.Deficient, Provider has date of correction (September 19, 2025)
E-0039Conduct testing and exercise requirements.Deficient, Provider has date of correction (September 24, 2025)
K-0211Keep aisles, corridors, and exits free of obstruction in case of emergency.Deficient, Provider has date of correction (August 27, 2025)
K-0363Install corridor and hallway doors that block smoke.Deficient, Provider has date of correction (September 30, 2025)
K-0918Have generator or other power source capable of supplying service within 10 seconds.Deficient, Provider has date of correction (September 1, 2025)
K-0923Have proper medical gas storage and administration areas.Deficient, Provider has date of correction (October 1, 2025)

October 27, 2023 — 7 citations

Citations issued on October 27, 2023
TagWhat the surveyor checksStatus
E-0004Develop and maintain an Emergency Preparedness Program (EP).Deficient, Provider has date of correction (December 18, 2023)
K-0222Add 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.Deficient, Provider has date of correction (December 18, 2023)
K-0341Install a fire alarm system that can be heard throughout the facility.Deficient, Provider has date of correction (December 18, 2023)
K-0363Install corridor and hallway doors that block smoke.Deficient, Provider has date of correction (December 18, 2023)
K-0372Ensure smoke barriers are constructed to a 1 hour fire resistance rating.Deficient, Provider has date of correction (December 18, 2023)
K-0918Have generator or other power source capable of supplying service within 10 seconds.Deficient, Provider has date of correction (December 18, 2023)
K-0923Have proper medical gas storage and administration areas.Deficient, Provider has date of correction (December 18, 2023)

September 1, 2022 — 9 citations

Citations issued on September 1, 2022
TagWhat the surveyor checksStatus
E-0039Conduct testing and exercise requirements.Deficient, Provider has date of correction (November 14, 2022)
K-0223Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.Deficient, Provider has date of correction (November 14, 2022)
K-0342Have a complete alarm system manually initiated and initiated by fire sprinkler system connection.Deficient, Provider has date of correction (November 14, 2022)
K-0363Install corridor and hallway doors that block smoke.Deficient, Provider has date of correction (November 14, 2022)
K-0761To conduct inspection, testing and maintenance of fire doors by qualified individuals.Deficient, Provider has date of correction (November 14, 2022)
K-0914Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.Deficient, Provider has date of correction (November 14, 2022)
K-0918Have generator or other power source capable of supplying service within 10 seconds.Deficient, Provider has date of correction (November 14, 2022)
K-0920Ensure proper usage of power strips and extension cords.Deficient, Provider has date of correction (November 14, 2022)
K-0921Ensure that testing and maintenance of electrical equipment is performed.Deficient, Provider has date of correction (November 14, 2022)

Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.