Inspection Reports for Catalina Post-Acute & Rehabilitation
2611 N Warren Ave, Tucson, AZ 85719, AZ, 85719
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Inspection Report
Complaint Investigation
Capacity: 102
Deficiencies: 18
Jul 31, 2025
Visit Reason
State-compiled facility profile showing multiple complaint inspections from 2023 to 2025 with deficiency history and investigation summaries.
Findings
Across multiple complaint inspections, Catalina Post Acute And Rehabilitation had several deficiencies related to resident care, medication administration, environmental safety, and staff compliance. Many inspections found no deficiencies, but some cited issues with care plans, medication errors, temperature control, and staff fingerprint clearance.
Complaint Details
Multiple complaint investigations conducted from 2023 through 2025 with intake numbers including #00137805, 00134929, AZ00225160, 00136080, 00135128, AZ00224720, AZ00224605, SF00130966, SF00131075, SF00131257, AZ00214821, AZ00217436, AZ00217586, AZ00215967, AZ00214261, AZ00212786, AZ0020436, AZ00202931, AZ00199678, AZ00193546, AZ00192645, and others. Some investigations resulted in deficiencies cited, others found no deficiencies.
Deficiencies (18)
| Description |
|---|
| R9-10-414.B. An administrator shall ensure that a care plan for a resident: R9-10-414.B.3.b. Assist the resident in maintaining the resident's highest practicable well-being according to the resident's comprehensive assessment. Failed to ensure two residents received activities of daily living care per facility policy. |
| §483.10(i) Safe Environment. The facility failed to ensure room temperatures were within the safe temperature range, putting residents at risk of harm such as lack of sleep and heat stroke. |
| R9-10-425.A. Heating and cooling systems maintain the nursing care institution at a temperature between 70° F and 84° F; Failed to maintain safe temperature range in the facility. |
| R9-10-403.C.1.j. Policies and procedures are established, documented, and implemented to protect the health and safety of a resident that cover health care directives; Failed to ensure a resident's code status was honored, resulting in inappropriate CPR. |
| §483.24(a)(3) Personnel provide basic life support, including CPR, to a resident requiring such emergency care prior to the arrival of emergency medical personnel and subject to related physician orders and the resident's advance directives. Failed to honor resident's DNR order. |
| R9-10-403.C.2.d. Policies and procedures for physical health services and behavioral health services cover storing, dispensing, administering, and disposing of medication; Failed to ensure multi-dose insulin vials were dated and discarded properly. |
| §483.10(g)(14) Notification of Changes. Failed to ensure medication was administered as ordered for one resident and that physician was notified of missed doses. |
| R9-10-406.F.3.c. Documentation of individual's compliance with fingerprint clearance requirements; Failed to ensure an employee denied fingerprint clearance did not continue to provide services. |
| §483.25(b) Skin Integrity. Failed to ensure one resident received care and services to prevent and treat pressure ulcers as ordered. |
| §483.25(g)(4)-(5) Enteral Nutrition. Failed to ensure one resident with enteral feeding tube received appropriate treatment and services to prevent complications. |
| § 483.25(i) Respiratory care, including tracheostomy care and tracheal suctioning. Failed to ensure one resident did not receive unnecessary oxygen therapy and physician was notified appropriately. |
| §483.45(g) Labeling of Drugs and Biologicals and §483.45(h) Storage of Drugs and Biologicals. Failed to ensure multi-dose vials were dated and discarded within required time frame. |
| §483.60(i) Food safety requirements. Failed to ensure food items were labeled and dated when opened, risking food borne illness. |
| §483.60(i)(4) Dispose of garbage and refuse properly. Failed to ensure area around dumpsters was free of refuse and garbage, risking unsanitary conditions. |
| R9-10-412.B.6.b. Nurse notification to physician after incidents. Failed to ensure physician was notified of missed medication administrations for one resident. |
| R9-10-414.B.3.b. Failed to assist residents in maintaining highest practicable well-being by failing to provide care related to pressure ulcers and enteral feeding tube treatment as ordered. |
| R9-10-423.A.3.b. Failed to ensure nursing care institution can store, refrigerate, and reheat food to meet dietary needs; food items not labeled or dated. |
| R9-10-425.A.5.b.i. Garbage and refuse stored according to requirements; failed to keep area around dumpsters free of refuse. |
Report Facts
Inspections on page: 23
Total deficiencies: 18
Complaint inspections: 22
Total capacity: 102
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| ETHAN BRAMSCHREIBER | Administrator | Named as facility administrator in facility information |
| Director of Nursing (DON/staff #59) | Director of Nursing | Interviewed regarding shower care deficiency and medication administration |
| Certified Nursing Assistant (CNA/staff #130) | Certified Nursing Assistant | Interviewed regarding shower care deficiency |
| Licensed Practical Nurse (LPN/staff #120) | Licensed Practical Nurse | Interviewed regarding shower care documentation |
| Certified Nursing Assistant (CNA/staff #27) | Certified Nursing Assistant | Interviewed regarding code status and CPR deficiency |
| Registered Nurse (RN/staff #85) | Registered Nurse | Interviewed regarding code status and CPR deficiency |
| Director of Nursing (DON/staff #65) | Director of Nursing | Interviewed regarding code status and CPR deficiency |
| Registered Nurse (RN/staff #6) | Registered Nurse | Interviewed regarding medication storage and administration deficiencies |
| Licensed Practical Nurse (LPN/staff #34) | Licensed Practical Nurse | Interviewed regarding medication storage and administration deficiencies |
| Director of Nursing (DON/staff #20) | Director of Nursing | Interviewed regarding multiple deficiencies including medication administration, oxygen therapy, and fingerprint clearance |
| Human Resources Director (staff #74) | Human Resources Director | Interviewed regarding fingerprint clearance deficiency |
| Wound Registered Nurse (RN/staff #133) | Wound Registered Nurse | Interviewed regarding pressure ulcer care deficiency |
| Licensed Vocational Nurse (LVN/staff #29) | Licensed Vocational Nurse | Interviewed regarding oxygen therapy deficiency |
| Dietary Supervisor (staff #65) | Dietary Supervisor | Interviewed regarding food safety and refuse deficiencies |
| Administrator (staff #115) | Administrator | Interviewed regarding food safety and refuse deficiencies |
| Pharmacy Consultant (staff #34) | Pharmacy Consultant | Interviewed regarding enteral feeding medication administration deficiency |
| Licensed Practical Nurse (LPN/staff #67) | Licensed Practical Nurse | Interviewed regarding missed medication administration deficiency |
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