Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
VILLA MARIA POST ACUTE AND REHABILITATION
TUCSON, AZ · 83 certified beds · Last Life Safety survey September 15, 2023
CMS Certification Number 035147 · first certified August 1987
Ownership
Operated by THE ENSIGN GROUP · For profit - Limited Liability company
- Ownership changed July 1, 2022 (change of ownership)from VILLA MARIA CARE CENTER, LLC
Position within AZ
9 citations — more than 55% 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
The latest survey found 4 citations; the earlier surveys in the window averaged 2.5. With 3 surveys on file this is a direction of travel, not a conclusion.
When is the next survey likely?
Well past the typical window (November 2024 to July 2025), and past the point by which nine in ten AZ facilities have been surveyed. This facility’s last Life Safety survey was September 2023. 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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Emergency preparedness
1 of the 9 citations on file is 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 9 Life Safety citations above. The Physical Environment Index
How that compares
Compared with the median facility in AZ, and nationally. Surveyors differ markedly between states, so the AZ figure is the meaningful one.
| Measure | Citations |
|---|---|
| This facility | 9 |
| Median facility in AZ | 8 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| October 30, 2020 | 2 |
| August 11, 2022 | 3 |
| September 15, 2023 | 4 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| K-0926 | Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk. | 1 | 2020-10-30 |
| K-0324 | Provide properly protected cooking facilities. | 1 | 2023-09-15 |
| K-0363 | Install corridor and hallway doors that block smoke. | 1 | 2023-09-15 |
| K-0222 | Add 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. | 1 | 2022-08-11 |
| K-0223 | Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | 1 | 2022-08-11 |
| K-0233 | Install resident room doors of proper design and width. | 1 | 2023-09-15 |
| K-0914 | Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | 1 | 2022-08-11 |
| K-0921 | Ensure that testing and maintenance of electrical equipment is performed. | 1 | 2023-09-15 |
What the citations cover
- Gas, Vacuum, and Electrical Systems Deficiencies 3
- Egress Deficiencies 3
- Smoke Deficiencies 2
- Emergency Preparedness Deficiencies 1
| Category | Citations |
|---|---|
| Gas, Vacuum, and Electrical Systems Deficiencies | 3 |
| Egress Deficiencies | 3 |
| Smoke Deficiencies | 2 |
| Emergency Preparedness Deficiencies | 1 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
September 15, 2023 — 4 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0233 | Install resident room doors of proper design and width. | Deficient, Provider has date of correction (November 16, 2023) |
| K-0324 | Provide properly protected cooking facilities. | Deficient, Provider has date of correction (November 16, 2023) |
| K-0363 | Install corridor and hallway doors that block smoke. | Deficient, Provider has date of correction (November 16, 2023) |
| K-0921 | Ensure that testing and maintenance of electrical equipment is performed. | Deficient, Provider has date of correction (November 16, 2023) |
August 11, 2022 — 3 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0222 | Add 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 (September 26, 2022) |
| K-0223 | Provide 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 (September 26, 2022) |
| K-0914 | Ensure 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 (September 26, 2022) |
October 30, 2020 — 2 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0037 | Establish staff and initial training requirements. | Deficient, Provider has date of correction (December 8, 2020) |
| K-0926 | Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk. | Deficient, Provider has date of correction (December 8, 2020) |
Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.