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C+
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VILLA MARIA POST ACUTE AND REHABILITATION Inspection Report, Violations & Safety Grade (TUCSON, Arizona)

4310 EAST GRANT ROAD, TUCSON, Arizona 85712

Phone: 5203239351

CMS Overall:3/5

Overview & Bed Count

Certified Beds
83
Avg Residents/Day
51.6
Ownership
For profit - Limited Liability company
Provider Type
Medicare and Medicaid
County
Pima
Sprinkler Systems
Yes
Special Focus
None
Abuse Icon
No

CMS Star Ratings

Overall3/5
Health2/5
Staffing3/5
Quality5/5

Nurse Staffing Check

MetricThis FacilityArizona AvgDifference
RN Hours per Resident per Day0.220.74-0.52
Total Nurse Hours per Resident per Day3.544.08-0.54
CMS Staffing Rating3/53/5-
Nursing Staff Turnover35.7%44.8%-

Health Citation History

26 health citations on record

DateCategoryDescriptionSeverity
2026-06-19Quality of Life and Care DeficienciesEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.D – Moderate Harm Potential
2026-01-23Resident Assessment and Care Planning DeficienciesPASARR screening for Mental disorders or Intellectual DisabilitiesE – Moderate Harm Potential
2026-01-23Quality of Life and Care DeficienciesProvide appropriate treatment and care according to orders, resident’s preferences and goals.E – Moderate Harm Potential
2026-01-23Pharmacy Service DeficienciesProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.E – Moderate Harm Potential
2026-01-23Resident Assessment and Care Planning DeficienciesSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.E – Moderate Harm Potential
2026-01-23Pharmacy Service DeficienciesEnsure each resident’s drug regimen must be free from unnecessary drugs.D – Moderate Harm Potential
2024-10-03Freedom from Abuse, Neglect, and Exploitation DeficienciesProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.G – Actual Harm
2024-07-24Quality of Life and Care DeficienciesProvide appropriate treatment and care according to orders, resident’s preferences and goals.D – Moderate Harm Potential
2024-04-12Quality of Life and Care DeficienciesProvide for the safe, appropriate administration of IV fluids for a resident when needed.G – Actual Harm
2024-02-16Quality of Life and Care DeficienciesProvide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.E – Moderate Harm Potential
2023-09-15Resident Rights DeficienciesHonor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.D – Moderate Harm Potential
2023-09-15Resident Rights DeficienciesNot transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.D – Moderate Harm Potential
2023-09-15Resident Assessment and Care Planning DeficienciesAssess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.D – Moderate Harm Potential
2023-09-15Resident Assessment and Care Planning DeficienciesPASARR screening for Mental disorders or Intellectual DisabilitiesD – Moderate Harm Potential
2023-09-15Quality of Life and Care DeficienciesEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.D – Moderate Harm Potential
2023-09-15Quality of Life and Care DeficienciesProvide safe and appropriate respiratory care for a resident when needed.D – Moderate Harm Potential
2023-09-15Quality of Life and Care DeficienciesProvide safe, appropriate pain management for a resident who requires such services.D – Moderate Harm Potential
2023-09-15Nursing and Physician Services DeficienciesHave a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.D – Moderate Harm Potential
2023-09-15Infection Control DeficienciesProvide and implement an infection prevention and control program.D – Moderate Harm Potential
2022-08-11Quality of Life and Care DeficienciesProvide appropriate pressure ulcer care and prevent new ulcers from developing.E – Moderate Harm Potential
2022-08-11Nursing and Physician Services DeficienciesProvide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.E – Moderate Harm Potential
2022-08-11Resident Assessment and Care Planning DeficienciesPASARR screening for Mental disorders or Intellectual DisabilitiesD – Moderate Harm Potential
2022-08-11Resident Assessment and Care Planning DeficienciesEnsure services provided by the nursing facility meet professional standards of quality.D – Moderate Harm Potential
2022-08-11Quality of Life and Care DeficienciesProvide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.D – Moderate Harm Potential
2022-08-11Pharmacy Service DeficienciesEnsure each resident’s drug regimen must be free from unnecessary drugs.D – Moderate Harm Potential
2022-08-11Administration DeficienciesProvide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.D – Moderate Harm Potential

Fire Safety Citation History

9 fire safety citations on record

DateCategoryDescriptionSeverity
2023-09-15Smoke DeficienciesProvide properly protected cooking facilities.E – Moderate Harm Potential
2023-09-15Egress DeficienciesInstall resident room doors of proper design and width.D – Moderate Harm Potential
2023-09-15Smoke DeficienciesInstall corridor and hallway doors that block smoke.D – Moderate Harm Potential
2023-09-15Gas, Vacuum, and Electrical Systems DeficienciesEnsure that testing and maintenance of electrical equipment is performed.D – Moderate Harm Potential
2022-08-11Egress DeficienciesAdd 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.D – Moderate Harm Potential
2022-08-11Egress DeficienciesProvide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.D – Moderate Harm Potential
2022-08-11Gas, Vacuum, and Electrical Systems DeficienciesEnsure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.D – Moderate Harm Potential
2020-10-30Emergency Preparedness DeficienciesEstablish staff and initial training requirements.E – Moderate Harm Potential
2020-10-30Gas, Vacuum, and Electrical Systems DeficienciesEnsure that personnel concerned with handling of medical gases and cylinders are trained on the risk.E – Moderate Harm Potential

Total Penalties & Fines

$8,018
Total Fine Amount (CMS)
1
Number of Fines
1
Total Penalties
DateTypeFine AmountPayment Denial
2024-04-12Fine$8,018-

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