Inspection Reports for
Catalina Post-Acute & Rehabilitation
2611 N Warren Ave, Tucson, AZ 85719, AZ, 85719
Back to Facility Profile39 Reports
Inspection Report — May 13, 2026
Complaint Investigation
Date: May 13, 2026
Visit Reason
On-site complaint investigation of intakes #2993133 and #2993715 at Catalina Post Acute and Rehabilitation, conducted 13 May 2026.
Complaint Details
An onsite complaint survey was conducted on May 13th, 2026 for the investigation of the intakes #2993133 and #2993715. Catalina Post Acute is in compliance with 42 CFR Part 483, Requirements for Long Term Care Facilities. There are no deficiencies cited.
Findings
This inspection found no deficiencies; the facility was in compliance with 42 CFR Part 483, Requirements for Long Term Care Facilities.
Inspection Report — Apr 21, 2026
Complaint Investigation
Date: Apr 21, 2026
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On-site complaint investigation of intakes 2970742, 00164299, and 00165612 at a Nursing Care Institution, conducted 21 April 2026.
Complaint Details
A complaint survey was conducted on April 21, 2026 for the investigation of intake(s) #: 2970742, 00164299, and 00165612. There were no findings cited.
Findings
This inspection resulted in no deficiencies or citations.
Inspection Report — Mar 17, 2026
Complaint Investigation
Date: Mar 17, 2026
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On-site complaint investigation of intake #00159994, and investigation of intakes #2787091 and #2785514 at Catalina Post Acute and Rehabilitation, conducted 17 March 2026.
Complaint Details
An onsite complaint survey was conducted on March 17, 2026 for intake #00159994. Additional investigation included intakes #2787091 and #2785514. Catalina Post Acute and Rehabilitation is in compliance with 42 CFR Part 483, Requirements for Long Term Care Facilities.
Findings
This inspection resulted in no deficiencies cited.
Report Facts
Complaints investigated: 3
Inspection Report — Jan 16, 2026
Complaint Investigation
Date: Jan 16, 2026
Visit Reason
On-site complaint investigation of complaints 2703908 and 00154629 at a Nursing Care Institution, conducted 16 January 2026.
Complaint Details
The complaint survey was conducted on January 16, 2026, of the following complaint numbers 2703908 and 00154629. There were no deficiencies cited.
Findings
One deficiency was found related to rule R9-10-401, but no evidence text was provided in the report.
Deficiencies (1)
R9-10-401 — No evidence text provided for the deficiency.
Report Facts
Deficiencies cited: 1
Inspection Report — Jan 6, 2026
Complaint Investigation
Date: Jan 6, 2026
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On-site complaint investigation of intake 00155116 and intake 2707535 at a Nursing Care Institution, conducted 6 January 2026.
Complaint Details
An onsite complaint survey was conducted on January 6, 2026 for intake 00155116. An onsite complaint survey was conducted on January 6, 2026 for intake 2707535.
Findings
This inspection resulted in no deficiencies cited.
Inspection Report — Dec 15, 2025
Complaint Investigation
Date: Dec 15, 2025
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On-site complaint investigation of intake 00152970 and intake 2691180 at a Nursing Care Institution, conducted 15 December 2025.
Complaint Details
An onsite complaint survey was conducted on December 15, 2025 for the investigation of the following intake: 00152970. An onsite complaint survey was conducted on December 15, 2025 for the investigation of the following intake: 2691180.
Findings
No deficiencies were cited during this inspection.
Inspection Report — Nov 18, 2025
Complaint Investigation
Date: Nov 18, 2025
Visit Reason
On-site complaint investigation of complaints 00150357 and 2666262 at a Nursing Care Institution, conducted 18 November 2025.
Complaint Details
The onsite complaint survey was conducted in conjunction with the investigation of complaint #00150357 and complaint #2666262. There were no deficiencies noted.
Findings
This inspection resulted in no deficiencies or citations.
Report Facts
Complaints investigated: 2
Inspection Report — Oct 29, 2025
Plan of Correction
Date: Oct 29, 2025
Visit Reason
The inspection was conducted to identify deficiencies related to the accuracy of resident assessments, specifically focusing on Resident #91's assessment and care planning.
Findings
The facility failed to ensure Resident #91's assessment was accurate and reflective of her condition, particularly regarding a chronic left humerus fracture and shoulder dislocation. This deficiency could result in the resident not receiving appropriate care necessary for her wellbeing.
Deficiencies (1)
Failure to ensure Resident #91's assessment was accurate and reflective of her status, including missing documentation of a chronic left humerus fracture and shoulder dislocation in the care plan.
Report Facts
Residents affected: 1
Date survey completed: Oct 29, 2025
Date of resident discharge: Oct 10, 2025
Date of x-ray: Aug 28, 2025
Date of admission record: Sep 10, 2025
Date of care plan initiation: Sep 11, 2025
Date of physical therapy evaluation: Sep 11, 2025
Date of occupational therapy evaluation: Sep 11, 2025
Date of physician order for x-ray: Oct 8, 2025
Date of physician order for sling use: Oct 9, 2025
Date of daily skilled note: Oct 8, 2025
Date of nursing note: Oct 9, 2025
Date of daily skilled note monitoring condition: Oct 9, 2025
Date of interviews: Oct 30, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff #84 | Registered Nurse (RN) | Observed Resident #91 moving left arm and noted shoulder was not in place |
| Staff #4 | Certified Nursing Assistant (CNA) | Reported observations about Resident #91's extremities and shoulder condition |
| Staff #77 | Certified Nursing Assistant (CNA) | Provided care observations including left arm positioning and resident responses |
| Staff #22 | Licensed Practical Nurse (LPN) | Described assessment procedures and recalled Resident #91's condition |
| Staff #1 | Licensed Practical Nurse (LPN) | Explained admission assessments and recalled care for Resident #91 |
| Staff #82 | Assistant Director of Nursing (ADON) | Discussed admission assessments and communication issues regarding therapy notes |
| Staff #28 | Director of Nursing (DON) | Reviewed assessments and care planning related to Resident #91's shoulder injury |
Inspection Report — Oct 29, 2025
Complaint Investigation
Date: Oct 29, 2025
Visit Reason
On-site complaint investigation of complaints 00147737 and 00147536 at a Nursing Care Institution, conducted 29 October 2025.
Complaint Details
An onsite complaint survey was conducted on October 28, 2025 through October 30, 2025 for the following intakes: 00147737 and 00147536. Federal comments noted intakes 2642086, 2643384, and 2642271.
Findings
The inspection found two deficiencies related to inaccurate resident assessments that could result in inappropriate care. Both deficiencies involved failure to ensure one resident’s (#91) assessment accurately reflected their status.
Deficiencies (2)
R9-10-403.C — The facility failed to ensure one resident’s (#91) assessment was accurate and reflective of the resident’s status at the time of the assessment, risking inappropriate care.
§483.20(g) — The facility failed to ensure one resident’s (#91) assessment was accurate and reflective of the resident’s status at the time of the assessment, risking inappropriate care.
Report Facts
Deficiencies cited: 2
Inspection Report — Sep 23, 2025
Date: Sep 23, 2025
Visit Reason
On-site inspection of type Other at a Nursing Care Institution conducted on 23 September 2025.
Findings
The inspection identified six deficiencies related to life safety code compliance, including means of egress obstructions, missing fire extinguisher, door maintenance, smoke barrier penetrations, incomplete fire drills, and lack of electrical equipment maintenance records.
Deficiencies (6)
Means of Egress - General — The facility failed to provide a clear means of egress to exit to a public way, which could cause harm to patients and staff in the event of a fire emergency.
Portable Fire Extinguishers — The facility failed to provide a fire extinguisher near the generator, risking harm to patients and staff during an emergency.
Corridor - Doors — The facility failed to maintain several doors, which could allow heat and/or smoke to transfer and cause harm to patients and staff.
Subdivision of Building Spaces - Smoke Barrier Construction — The facility failed to fill multiple penetrations in the smoke barriers, allowing smoke and heat to penetrate other areas and potentially harm patients during a fire.
Fire Drills — The facility failed to provide all required fire drills per NFPA 101, which can result in harm to patients and staff during an actual fire or emergency.
Electrical Equipment - Testing and Maintenance Requirements — The facility failed to provide a record of electrical equipment tests, repairs, and modifications, risking harm to residents if appliances malfunction.
Report Facts
Deficiencies cited: 6
Inspection Report — Sep 16, 2025
Routine
Date: Sep 16, 2025
Visit Reason
The inspection was conducted to assess compliance with professional standards of quality in a nursing facility, including medication administration, respiratory care, dialysis services, nursing staffing, and food safety practices.
Findings
The facility was found deficient in multiple areas including improper administration of pain medication outside physician parameters, lack of oxygen orders for a resident on oxygen therapy, incorrect dialysis assessment scheduling, failure to have an RN on duty for 8 consecutive hours on a specific day, and failure to properly label and date food items in the kitchen.
Deficiencies (5)
Failure to ensure that 1 out of 23 residents received pain medication as ordered by the physician, including administration outside prescribed parameters.
Failure to ensure an oxygen order was in place for 1 of 27 sampled residents, resulting in oxygen administration without proper orders or documentation.
Failure to ensure that one out of 12 dialysis residents was properly assessed as ordered by the physician, with pre- and post-dialysis vitals taken on incorrect days.
Failure to have a registered nurse on duty for at least 8 consecutive hours on February 8, 2025, despite census of 99 residents.
Failure to ensure that food is labeled and dated in accordance with food safety practices, including unlabeled and undated food items in the kitchen and freezer.
Report Facts
Residents affected: 23
Residents affected: 27
Residents affected: 12
RN coverage hours: 0
Food item date: 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse Staff #1 | Licensed Practical Nurse | Interviewed regarding medication administration and dialysis care |
| Director of Nursing Staff #51 | Director of Nursing | Interviewed regarding medication administration, oxygen orders, dialysis care, and RN staffing |
| Licensed Practical Nurse Staff #65 | Licensed Practical Nurse | Interviewed regarding oxygen orders for resident #45 |
| Director of Respiratory Therapy Staff #4 | Director of Respiratory Therapy | Interviewed regarding oxygen orders and respiratory therapy follow-up |
| Cook Staff #55 | Cook | Interviewed regarding food labeling and storage practices |
| Dietary Supervisor Staff #101 | Dietary Supervisor | Interviewed regarding food labeling and storage expectations |
| Administrator Staff #88 | Administrator | Interviewed regarding food labeling and storage expectations |
Inspection Report — Sep 16, 2025
Annual Inspection
Date: Sep 16, 2025
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On-site complaint investigation of intake #00144461 and recertification annual inspection at a Nursing Care Institution, conducted 14 through 16 September 2025.
Complaint Details
An onsite recertification and re-licensure survey was conducted on September 14, 2025 through September 16, 2025 in conjunction with the investigation of intake #00144461 and intake #2612925.
Findings
The inspection found 10 deficiencies related to medication administration, respiratory care, dialysis assessments, nursing staffing, and food safety practices.
Deficiencies (10)
§483.21(b)(3) — The facility failed to ensure that 1 out of 23 residents (Resident #7) received pain medication as ordered by the physician.
§ 483.25(i) — The facility failed to ensure an oxygen order was in place for 1 of 27 sampled residents (#45), risking inappropriate oxygen administration and monitoring.
§483.25(l) — The facility failed to ensure that one out of 12 dialysis residents (Resident #96) was properly assessed as ordered by the physician.
Nursing staffing — The facility failed to use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week. The census was 99.
§483.60(i) — The facility failed to ensure that food is labeled and dated in accordance with food safety practices.
R9-10-412 — The facility failed to use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week. The census was 99.
R9-10-414 — The facility failed to ensure that 1 out of 23 residents (Resident #7) received pain medication as ordered by the physician.
R9-10-417 — The facility failed to ensure that one out of 12 dialysis residents (Resident #96) was properly assessed as ordered by the physician.
R9-10-419 — The facility failed to ensure an oxygen order was in place for one resident (#45), risking inappropriate oxygen administration and monitoring.
R9-10-423 — The facility failed to ensure that food is labeled and dated in accordance with food safety practices.
Report Facts
Deficiencies cited: 10
Complaints investigated: 2
Inspection Report — Jul 31, 2025
Complaint Investigation
Date: Jul 31, 2025
Visit Reason
On-site complaint investigation of intakes 00137805, 00134929, 2574018, and AZ00225028 at a Nursing Care Institution, conducted 31 July 2025.
Complaint Details
An onsite complaint survey was conducted on July 31, 2025 for the investigation of intake #00137805, 00134929. There were no deficiencies cited. An onsite complaint survey was conducted on July 31, 2025 for the investigation of intake #2574018, AZ00225028. There were no deficiencies cited.
Findings
This inspection found no deficiencies.
Report Facts
Complaints investigated: 4
Inspection Report — Jul 22, 2025
Complaint Investigation
Date: Jul 22, 2025
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On-site complaint investigation of complaints AZ00225160 and 00136080 at a Nursing Care Institution, conducted 21-22 July 2025.
Complaint Details
The investigation of Complaint # AZ00225160/00136080 was conducted on July 21, 2025 through July 22, 2025. No deficiencies were cited.
Findings
No deficiencies were cited during this complaint investigation.
Inspection Report — Jul 2, 2025
Complaint Investigation
Date: Jul 2, 2025
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On-site complaint investigation of intake #00135128 and intake #AZ00225050 at a Nursing Care Institution, conducted 2 July 2025.
Complaint Details
An onsite complaint survey was conducted on July 2, 2025 for the investigation of intake #00135128. An onsite complaint survey was conducted on July 2, 2025 for the investigation of intake #AZ00225050. There are no deficiencies cited.
Findings
This inspection resulted in no deficiencies or citations.
Inspection Report — Jun 23, 2025
Complaint Investigation
Date: Jun 23, 2025
Visit Reason
On-site complaint investigation of multiple complaints including AZ00214895, AZ00210194, AZ00213644, and others at a Nursing Care Institution, conducted 17 through 23 June 2025.
Complaint Details
The onsite investigation of intake AZ00214895, AZ00210194, AZ00213644, AZ00213001, AZ00213004, AZ00212980, AZ00212888, AZ00212469, AZ00212373, AZ00211287, AZ00211207, AZ00210219, AZ00205635, AZ00204234, AZ00168747, AZ00173404, 133864, AZ00172928, AZ00198858, AZ00192977, AZ00192938, AZ00191608, AZ00189601, AZ00168596, AZ00167278, AZ00166657, AZ00193747, AZ00193698, AZ00165480, AZ00188736, AZ00172507, AZ00170032, AZ00169429, 130401, 127538, 123126, 122964, AZ00208286, AZ00205782, AZ00202256, AZ00197261, AZ00186562, AZ00186488, AZ00185078, AZ00185055, AZ00184179, AZ00184767, AZ00168206, AZ00167119, AZ00194060, AZ00172260, AZ00192956, AZ00171550, AZ00224192, 127071, AZ00213599, AZ00209342, AZ00206433, AZ00204994, AZ00198163, AZ00198127, AZ00188753, AZ00166435, AZ00188586, AZ00186164, AZ00188476, AZ00187723, AZ00200087, AZ00197336, AZ00196199, AZ00196088, AZ00194032, AZ00193922, AZ00195835, AZ00195197, AZ00195438, AZ00195247, AZ00194930, AZ00194933, AZ00194578, AZ00187684, AZ00187601, AZ00185748, AZ00183597, AZ00183938, AZ00183811, and AZ00173749 was conducted on June 17, 2025 through June 20, 2025 and June 23, 2025.
Findings
The inspection found four deficiencies related primarily to failure to verify licensure and competencies of a registry registered nurse who impersonated another nurse, and failure to provide care meeting professional standards for a resident post-fall.
Deficiencies (4)
R9-10-403 — The facility failed to ensure a registry registered nurse had the necessary competencies and skill sets to care for residents, and the nurse impersonated another individual's RN license. The facility lacked documentation verifying the nurse's licensure and competency prior to working.
R9-10-406 — The facility failed to ensure the registry registered nurse possessed the specific qualifications, skills, and knowledge required to provide expected physical and behavioral health services. The nurse's licensure could not be verified and the facility lacked proper screening documentation.
§ 483.25 — The facility failed to ensure one resident was provided care meeting professional standards following a fall, including incomplete neurological checks as ordered by the physician. This could lead to missed injury and delayed care.
§483.35 — The facility failed to ensure the registry registered nurse had the competencies and skill sets necessary to care for residents' needs. The nurse's licensure was not verified and required screening documentation was missing.
Report Facts
Deficiencies cited: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff #467 | Registered Nurse | Registry RN who impersonated another nurse and lacked verified licensure and competencies. |
| Staff #56 | Dietary Supervisor | Alerted the Director of Nursing about the alleged perpetrator registry RN. |
| Staff #147 | Director of Nursing | Attempted to verify the Arizona license for the agency RN and was unable to find licensure. |
| Staff #118 | Human Resources Manager | Interviewed regarding hiring process and verification of registry staff licensure. |
Inspection Report — Jun 4, 2025
Complaint Investigation
Date: Jun 4, 2025
Visit Reason
On-site complaint investigation of complaints AZ00224720 and SF00132201 at a Nursing Care Institution, conducted 4 June 2025.
Complaint Details
The complaint survey was conducted on June 4, 2025 through June 4, 2025 of the following complaint numbers: AZ00224720 and SF00132201. There were no deficiencies cited.
Findings
This inspection resulted in no deficiencies or citations.
Report Facts
Complaints investigated: 2
Inspection Report — May 27, 2025
Complaint Investigation
Date: May 27, 2025
Visit Reason
On-site complaint investigation of complaints AZ00224605, SF00130966, SF00131075, SF00131257, AZ00224562, and AZ00224587 at a Nursing Care Institution, conducted 27 May 2025.
Complaint Details
An onsite complaint survey was conducted on May 30, 2025 for the investigation of complaints: #AZ00224605, #SF00130966, #SF00131075, and #SF00131257. Federal comments also note investigation of complaints: #AZ00224562, #AZ00224605, and #AZ00224587.
Findings
This inspection resulted in no citations or deficiency findings.
Inspection Report — May 1, 2025
Complaint Investigation
Date: May 1, 2025
Visit Reason
On-site complaint investigation of intakes 00128004 and AZ00224341 at a Nursing Care Institution, conducted 1 May 2025.
Complaint Details
The onsite investigation of intakes 00128004 and AZ00224341 was conducted on May 1, 2025. No deficiencies were cited.
Findings
No deficiencies were cited during this complaint investigation.
Inspection Report — Mar 27, 2025
Complaint Investigation
Date: Mar 27, 2025
Visit Reason
On-site complaint investigation of intakes SF00123145, SF00124038, SF00123894, SF00123771, AZ00223856, AZ00223944, AZ00223920 and AZ00223910 at a Nursing Care Institution, conducted 27 March 2025.
Complaint Details
The onsite investigation of intakea SF00123145, SF00124038, SF00123894, and SF00123771 was conducted on March 27, 2025. The onsite investigation of intakes AZ00223856, AZ00223944, AZ00223920 and AZ00223910 was conducted on March 27, 2025. No deficiencies were cited.
Findings
No deficiencies were cited during this complaint investigation.
Inspection Report — Mar 18, 2025
Complaint Investigation
Date: Mar 18, 2025
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On-site complaint investigation of intake numbers 00122802 and AZ00223803 at a Nursing Care Institution, conducted 18 March 2025.
Complaint Details
An onsite complaint survey was conducted on March 18, 2025 for the investigation of intake # 00122802 and intake # AZ00223803. There were no deficiencies cited.
Findings
This inspection resulted in no deficiencies cited.
Inspection Report — Oct 25, 2024
Complaint Investigation
Date: Oct 25, 2024
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On-site complaint investigation of intakes AZ00214821, AZ00217436, and AZ00217586 at a Nursing Care Institution, conducted 22-23 October 2024.
Complaint Details
A complaint survey was conducted on October 22, 2024 through October 23, 2024 for the investigation of intakes #AZ00214821, #AZ00217436, and #AZ00217586. Federal comments note investigation of intakes #AZ00214819, #AZ00217436, and #AZ00217585 with no deficiencies cited.
Findings
This inspection found no deficiencies.
Report Facts
Complaints investigated: 3
Inspection Report — Sep 23, 2024
Complaint Investigation
Date: Sep 23, 2024
Visit Reason
On-site complaint investigation of intake numbers AZ00215967 and AZ00215919 at a Nursing Care Institution, conducted 23 September 2024.
Complaint Details
A complaint survey was conducted on September 23, 2024 for the investigation of intake # AZ00215967 and intake # AZ00215919. There were no deficiencies cited.
Findings
This inspection resulted in no deficiencies cited.
Inspection Report — Aug 8, 2024
Complaint Investigation
Date: Aug 8, 2024
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On-site complaint investigation of complaint AZ00214261 at a Nursing Care Institution, conducted 8 August 2024.
Complaint Details
The investigation of complaint AZ00214261 was conducted on August 8, 2024. The investigation of complaint AZ00214260 was conducted on August 8, 2024. The following deficiency was cited:
Findings
The inspection found one deficiency related to failure to ensure residents received activities of daily living care per facility policy.
Deficiencies (1)
R9-10-414 — The facility failed to ensure two residents did not consistently receive scheduled showers twice weekly as required by their care plans and facility policy, with missed showers not properly documented or made up.
Report Facts
Deficiencies cited: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff #130 | Certified Nursing Assistant | Interview regarding shower schedules and resident refusals |
| Staff #120 | Licensed Practical Nurse | Interview regarding shower assignments and documentation |
| Staff #59 | Director of Nursing | Interview regarding expectations for shower schedules and documentation |
Inspection Report — Aug 8, 2024
Routine
Date: Aug 8, 2024
Visit Reason
The inspection was conducted to assess compliance with facility policies regarding activities of daily living (ADL) care, specifically focusing on whether residents received scheduled bathing and showering services as required.
Findings
The facility failed to ensure that two residents (#21 and #52) consistently received the required two showers per week as per facility policy, with documentation showing missed showers and incomplete records. Staff interviews confirmed expectations for shower schedules and documentation, but noted refusals and lack of documentation for some missed care.
Deficiencies (1)
Failure to ensure residents received activities of daily living (ADL) care per facility policy, specifically missed showers for residents #21 and #52.
Report Facts
Showers provided: 1
Showers provided: 1
Shower frequency policy: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant | Interviewed regarding shower schedules and resident refusals. | |
| Licensed Practical Nurse | Interviewed about shower assignments, skin checks, and documentation. | |
| Director of Nursing | Interviewed about expectations for shower schedules and documentation. |
Inspection Report — Jul 26, 2024
Complaint Investigation
Date: Jul 26, 2024
Visit Reason
On-site complaint investigation of intakes AZ00213661 and AZ00213654 at a Nursing Care Institution, conducted 25-26 July 2024.
Complaint Details
An onsite complaint survey was conducted on July 25, 2024 through July 26, 2024 for the investigation of intake # AZ00213661. An onsite complaint survey was conducted on July 25, 2024 through July 26, 2024 for the investigation of intake # AZ00213654. There were no deficiencies cited.
Findings
No deficiencies were cited during this complaint investigation.
Report Facts
Complaints investigated: 2
Inspection Report — Jul 9, 2024
Complaint Investigation
Date: Jul 9, 2024
Visit Reason
On-site complaint investigation of complaint AZ00212786 and AZ00212782 at a Nursing Care Institution, conducted 8-9 July 2024.
Complaint Details
The investigation of complaint AZ00212786 and complaint AZ00212782 was conducted on July 8, 2024 through July 9, 2024. The facility failed to maintain safe room temperatures as reported by residents and confirmed by observations and documentation review.
Findings
The inspection found two deficiencies related to the facility's failure to maintain safe room temperatures within the required range, placing residents at increased risk of harm such as heat-related illness and sleep disruption.
Deficiencies (2)
§483.10(i) — The facility failed to ensure room temperatures were within the safe temperature range, resulting in residents experiencing heat discomfort and potential harm. Temperature logs were incomplete and residents reported inability to sleep due to heat.
R9-10-425 — The administrator failed to ensure heating and cooling systems maintained the nursing care institution at a temperature between 70° F and 84° F. Maintenance records showed no timely action and residents reported ongoing heat issues despite use of portable cooling devices.
Report Facts
Deficiencies cited: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff #158 | Maintenance staff who took temperature observations on 7/8/2023 at 4:10 P.M. |
Inspection Report — Jul 9, 2024
Routine
Date: Jul 9, 2024
Visit Reason
The inspection was conducted due to concerns about the facility's failure to maintain safe room temperatures, which put residents at risk of harm such as lack of sleep and heat stroke.
Findings
The facility failed to ensure room temperatures were within the safe range, with temperatures reaching as high as 85 degrees Fahrenheit. Multiple residents reported discomfort and difficulty sleeping due to the heat. Temporary cooling units were placed, and a new HVAC unit was ordered but not yet installed. Documentation of temperature checks was incomplete, and staff interviews revealed inconsistent monitoring.
Deficiencies (1)
Failure to maintain room temperatures within safe range, risking resident harm such as lack of sleep and heat stroke.
Report Facts
Temperature readings: 85
Number of residents interviewed: 8
Number of portable cooling units placed: 11
Temperature check frequency: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Interviewed about emergency plan and measures taken to combat heat | |
| Certified Nursing Assistant | Reported residents' complaints about heat and air conditioning failure | |
| Maintenance Supervisor | Reported on air conditioning repairs and temperature monitoring practices | |
| Administrator | Provided information on temperature thresholds and emergency plan | |
| Maintenance Staff #158 | Conducted temperature observations and reported on air conditioning failure |
Inspection Report — Mar 20, 2024
Complaint Investigation
Date: Mar 20, 2024
Visit Reason
On-site complaint investigation of intakes AZ00207450, AZ00206436, AZ00207448, and AZ00206434 at a Nursing Care Institution, conducted 20 March 2024.
Complaint Details
An onsite complaint survey was conducted on March 20, 2024 for the investigation of the intakes#AZ00207450, and AZ00206436. Federal comments note investigation of intakes#AZ00207448, and AZ00206434. There were no deficiencies cited.
Findings
This inspection resulted in no deficiencies cited.
Report Facts
Complaints investigated: 4
Inspection Report — Jan 26, 2024
Complaint Investigation
Date: Jan 26, 2024
Visit Reason
On-site complaint investigation of complaints AZ00205113, AZ00205623, AZ00205110, and AZ00205461 at a Nursing Care Institution, conducted 25 January 2024.
Complaint Details
The investigation of complaints (AZ00205113, and AZ00205623) was conducted on January 25, 2023, via closed record review, staff interviews, review of facility documentation and facility policy and procedures, and through the observation of current practice. The investigation of complaints (AZ00205110, and AZ00205461) was conducted on January 25, 2023, via closed record review, staff interviews, review of facility documentation and facility policy and procedures, and through the observation of current practice. There were no deficiencies cited.
Findings
This inspection resulted in no deficiencies cited.
Inspection Report — Dec 27, 2023
Complaint Investigation
Date: Dec 27, 2023
Visit Reason
On-site complaint investigation of complaints AZ0020436, AZ00204154, AZ00198862, and AZ00168335 at a Nursing Care Institution, conducted 26-27 December 2023.
Complaint Details
The investigation of complaint AZ0020436, AZ00204154, AZ00198862, and AZ00168335 was conducted on December 26, 2023 through December 27, 2023. The investigation of complaint AZ0020435, AZ00204153, AZ00198862, and AZ00168336 was also conducted during this period.
Findings
The inspection found two deficiencies related to the facility's failure to honor a resident's Do Not Resuscitate (DNR) order, resulting in inappropriate initiation of CPR contrary to the resident's advance directives.
Deficiencies (2)
R9-10-403 — The facility failed to ensure a resident's code status was honored, as CPR was initiated despite a Do Not Attempt Resuscitation order and documented advance directive refusing resuscitation measures.
§483.24(a)(3) — The facility failed to provide basic life support in accordance with the resident's advance directives, as CPR was performed contrary to the resident's Do Not Resuscitate status.
Report Facts
Deficiencies cited: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff #27 | Certified Nursing Assistant | Interviewed regarding checking code status and CPR initiation. |
| Staff #85 | Registered Nurse | Interviewed regarding knowledge of resident code status and CPR procedures. |
| Staff #65 | Director of Nursing | Interviewed regarding facility policy and expectations about honoring DNR orders. |
Inspection Report — Nov 9, 2023
Complaint Investigation
Date: Nov 9, 2023
Visit Reason
On-site complaint investigation of intakes AZ00202931, AZ00202929, AZ00202930, and AZ00202928 at a Nursing Care Institution, conducted 9 November 2023.
Complaint Details
The complaint survey was conducted on November 9, 2023 for the investigation of intake #s: AZ00202931, AZ00202929, AZ00202930, and AZ00202928. No deficiencies were cited.
Findings
No deficiencies were cited during this complaint investigation.
Inspection Report — Sep 5, 2023
Complaint Investigation
Date: Sep 5, 2023
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On-site complaint investigation of intake AZ00199678 and AZ00199677 at a Nursing Care Institution, conducted 5 September 2023.
Complaint Details
The complaint survey was conducted on September 5, 2023 for the investigation of intake #AZ00199678 and intake #AZ00199677. There were no deficiencies cited.
Findings
This inspection resulted in no citations or deficiency findings.
Inspection Report — Jul 7, 2023
Complaint Investigation
Date: Jul 7, 2023
Visit Reason
The inspection was conducted to investigate complaints regarding medication administration and pressure ulcer care for resident #140 at Catalina Post Acute and Rehabilitation.
Complaint Details
The complaint investigation found that medication administration errors occurred with missed doses and lack of physician notification. The facility also failed to provide ordered wound care treatments. Interviews with nursing staff and the Director of Nursing confirmed these issues and non-compliance with facility policies.
Findings
The facility failed to ensure medication was administered as ordered and that the physician was notified of missed doses for resident #140. Additionally, the facility failed to provide appropriate pressure ulcer care and prevent new ulcers from developing for the same resident. Documentation and staff interviews revealed missed medication doses and treatments, lack of physician notification, and incomplete signing of medication and treatment administration records.
Deficiencies (2)
Medication was not administered as ordered for resident #140, including missed doses of Vancomycin, Meropenem, and Levofloxacin, and the physician was not notified.
Failure to provide appropriate pressure ulcer care and prevent new ulcers for resident #140, including missed wound treatments as ordered.
Report Facts
Missed medication administrations: 8
Pressure ulcer measurements: 2.5
Pressure ulcer measurements: 4
Pressure ulcer measurements: 3
Pressure ulcer measurements: 19
Pressure ulcer measurements: 17
Pressure ulcer measurements: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN/staff #67) | Interviewed regarding medication administration and emergency medication supply | |
| Director of Nursing (DON/staff #20) | Interviewed regarding medication administration practices, physician notification, and documentation expectations | |
| Wound Registered Nurse (RN/staff #133) | Interviewed regarding wound care assessments and treatment administration |
Inspection Report — Jul 7, 2023
Routine
Date: Jul 7, 2023
Visit Reason
The inspection was conducted to assess compliance with healthcare regulations related to medication administration, pressure ulcer care, feeding tube management, respiratory care, medication storage, food safety, and waste disposal at Catalina Post Acute and Rehabilitation.
Findings
The facility was found deficient in multiple areas including failure to administer medications as ordered and notify physicians, incomplete pressure ulcer treatments, improper feeding tube medication administration, unnecessary oxygen therapy without physician notification, improper labeling and storage of insulin vials, unlabeled and expired food items, and unsanitary conditions around outside dumpsters.
Deficiencies (7)
Failure to ensure medication was administered as ordered for one resident (#140) and that a physician was notified.
Failure to provide appropriate pressure ulcer care and prevent new ulcers from developing for resident (#140).
Failure to ensure one resident (#19) with an enteral feeding tube received appropriate treatment and services to prevent complications.
Failure to ensure one resident (#11) did not receive unnecessary oxygen therapy, risking respiratory acidosis and death.
Failure to ensure multi-dose insulin vials were dated and discarded within required time frames and properly labeled.
Failure to ensure food items were labeled and dated when opened, including presence of expired and discolored food.
Failure to ensure the area around outside dumpsters was free of refuse/garbage, creating unsanitary conditions.
Report Facts
Missed medication administrations: 8
Pressure ulcer measurements: 2.5
Pressure ulcer measurements: 4
Pressure ulcer measurements: 3
Pressure ulcer measurements: 19
Pressure ulcer measurements: 17
Pressure ulcer measurements: 3
Tube feeding rate: 85
Tube feeding volume: 1360
Medication flush volume: 100
Insulin vial volume: 5
Insulin vial volume: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN) | Interviewed regarding medication administration and emergency medication supply | |
| Director of Nursing (DON) | Interviewed regarding medication administration expectations and oxygen therapy | |
| Wound Registered Nurse (RN) | Interviewed regarding wound care and treatment administration | |
| Registered Nurse (RN) | Observed medication administration for feeding tube resident | |
| Pharmacy Consultant | Interviewed regarding feeding tube medication administration and flushing | |
| Licensed Vocational Nurse (LVN) | Interviewed regarding oxygen therapy and physician notification | |
| Licensed Practical Nurse (LPN) | Interviewed regarding insulin vial labeling and storage | |
| Dietary Supervisor | Interviewed regarding food labeling, storage, and refuse conditions | |
| Administrator | Interviewed regarding expectations for food safety and refuse management |
Inspection Report — Jul 7, 2023
Annual Inspection
Date: Jul 7, 2023
Visit Reason
On-site complaint investigation of intake #AZ00196810 and recertification survey conducted June 28, 2023 through July 7, 2023 at Catalina Post Acute and Rehabilitation, a Nursing Care Institution.
Complaint Details
The State compliance survey was conducted June 28, 2023 through July 7, 2023 in conjunction with investigation of intake #AZ00196810. The recertification survey was conducted June 28, 2023 through July 7, 2023 in conjunction with investigation of intake #AZ00196809.
Findings
The inspection found 13 deficiencies including failures in medication storage and labeling, medication administration and physician notification, personnel fingerprint clearance compliance, pressure ulcer care, enteral feeding treatment, oxygen therapy management, food safety labeling and storage, and refuse disposal.
Deficiencies (13)
R9-10-403 — The facility failed to ensure multi-dose insulin vials were dated and discarded within the required time frame, with unlabeled and undated vials found, risking incorrect medication administration.
§483.10(g)(14) — The facility failed to administer antibiotics as ordered for resident #140 and did not notify the physician of missed doses or attempt to access emergency medication supply.
R9-10-406 — The facility allowed an employee denied fingerprint clearance to continue providing nursing services, violating background check requirements.
§483.25(b) — The facility failed to provide ordered treatments for pressure ulcers for resident #140, with multiple treatments not administered as required.
§483.25(g)(4)-(5) — The facility failed to ensure resident #19 received appropriate enteral feeding treatment, including failure to flush the feeding tube before and after medication administration.
§ 483.25(i) — The facility failed to wean resident #11 from oxygen therapy appropriately and did not notify the physician of oxygen saturation results, risking respiratory complications.
§483.45(g)-(h) — The facility failed to ensure multi-dose insulin vials were dated and discarded timely, with unlabeled and undated vials found, risking resident health.
§483.60(i) — The facility failed to label and date food items when opened, and stored discolored and expired food, risking foodborne illness.
§483.60(i)(4) — The facility failed to keep the area around dumpsters free of refuse and garbage, creating unsanitary conditions and potential pest harborage.
R9-10-412 — The facility failed to notify a physician when medication was not administered as ordered for resident #140 and staff did not sign the medication administration record.
R9-10-414 — The facility failed to assist residents #140 and #19 in maintaining their highest practicable well-being by not providing ordered pressure ulcer and enteral feeding treatments.
R9-10-423 — The facility failed to ensure food items were labeled and dated when opened, including discolored and expired items found in storage.
R9-10-425 — The facility failed to maintain the area around dumpsters free of refuse and garbage, risking adverse effects on residents and staff.
Report Facts
Deficiencies cited: 13
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff #6 | Registered Nurse | Insulin vial inspection and medication administration |
| Staff #34 | Licensed Practical Nurse | Insulin vial inspection and medication storage interview |
| Staff #20 | Director of Nursing | Interviews regarding insulin vial labeling, medication administration, oxygen therapy, and treatment administration |
| Staff #67 | Licensed Practical Nurse | Interview regarding missed medication administration and emergency medication supply |
| Staff #74 | Human Resources Director | Personnel file review and fingerprint clearance interview |
| Staff #123 | Registered Nurse | Employee denied fingerprint clearance |
| Staff #133 | Registered Nurse (Wound) | Interview regarding pressure ulcer treatment |
| Staff #29 | Licensed Vocational Nurse | Interview regarding oxygen therapy and physician notification |
| Staff #65 | Dietary Supervisor | Interviews regarding food labeling, storage, and refuse conditions |
| Staff #115 | Administrator | Interviews regarding food safety and refuse expectations |
Inspection Report — Jul 7, 2023
Date: Jul 7, 2023
Visit Reason
On-site inspection of a Nursing Care Institution classified as 'Other' type, conducted 7 July 2023. This was a recertification survey for Medicare under the Life Safety Code 2012 Edition.
Findings
The inspection found two deficiencies related to fire door maintenance and exposed electrical wiring. Plans of correction were provided and accepted.
Deficiencies (2)
Doors with Self-Closing Devices — The facility failed to maintain two sets of rated corridor fire doors that did not close properly when released from the magnet, posing a fire safety hazard.
Utilities - Gas and Electric — The facility failed to ensure a protected covering completely covered exposed wires, including a broken outlet cover with an exposed gap in the kitchen, risking harm to patients and staff.
Report Facts
Deficiencies cited: 2
Inspection Report — Mar 24, 2023
Complaint Investigation
Date: Mar 24, 2023
Visit Reason
The inspection was conducted following a complaint of resident abuse involving Resident #13, triggered by an incident reported on 01/15/23 where the resident alleged rough treatment by staff during a shower.
Complaint Details
The complaint investigation was substantiated based on interviews with staff and the resident's daughter, and review of the 5-day Investigative Report. The facility did not fully document the incident or complete a full skin assessment as required. The resident reported being squeezed and roughly handled by a CNA during a shower on 01/15/23.
Findings
The facility failed to implement its abuse policy after the report of abuse was received. Interviews and record reviews revealed that the resident was allegedly squeezed and roughly handled by a Certified Nursing Assistant during a shower, causing pain and distress. The facility did not fully document or assess the resident's condition following the incident as required by policy.
Deficiencies (1)
Failure to implement abuse policy after a report of resident abuse was received for one resident.
Report Facts
Residents Affected: 1
Sample Size: 2
Inspection Report — Jul 21, 2022
Routine
Date: Jul 21, 2022
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements related to resident care, medication administration, pressure ulcer treatment, mobility services, fall management, and infection control practices at Catalina Post Acute and Rehabilitation.
Findings
The facility was found deficient in multiple areas including failure to provide appropriate treatment and care according to orders, inconsistent pressure ulcer care, inadequate restorative and mobility services, failure to assess residents after falls, administration of unnecessary medications, and lapses in infection prevention and control practices such as improper glucometer disinfection and hand hygiene.
Deficiencies (6)
Failure to ensure one resident received treatment and care according to professional standards, including delayed treatment for abnormal blood sugar and lack of vital sign monitoring during condition changes.
Failure to provide appropriate pressure ulcer care and prevent new ulcers from developing for two residents, including missed treatments on multiple dates.
Failure to provide appropriate care to maintain or improve range of motion and mobility, including lack of monitoring of orthopedic boot use and missed restorative nursing services.
Failure to ensure consistent assessment and monitoring of a resident after repeated falls.
Failure to ensure residents were not administered unnecessary medications, including administration of antihypertensives outside ordered parameters.
Failure to implement infection prevention and control program adequately, including improper glucometer cleaning between residents, inadequate hand hygiene during wound care, and lack of infection control signage at facility entrances.
Report Facts
Residents affected: 1
Residents affected: 2
Residents affected: 5
Residents affected: 3
Residents affected: 4
Medication administrations outside parameters: 9
Medication administrations outside parameters: 3
Medication administrations outside parameters: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff #49 | Licensed Practical Nurse | Interviewed regarding fall assessments and medication administration |
| Staff #68 | Director of Nursing | Provided multiple interviews regarding nursing expectations, medication administration, wound care, and infection control |
| Staff #74 | Registered Nurse / Infection Control Preventionist | Interviewed regarding glucometer cleaning and infection control signage |
| Staff #79 | Certified Nursing Assistant | Interviewed regarding orthopedic boot application |
| Staff #94 | Licensed Practical Nurse / Wound Nurse | Observed and interviewed regarding wound care practices |
| Staff #99 | Licensed Practical Nurse | Observed and interviewed regarding glucometer use and cleaning |
| Staff #54 | Registered Nurse | Interviewed regarding medication administration and parameters |
| Staff #136 | Director of Nursing | Interviewed regarding wound care and fall management |
| Staff #96 | Physical Therapist | Interviewed regarding restorative nursing orders and coordination |
| Staff #118 | Administrator | Provided infection control signage documentation |
10 CMS Surveys
CMS Survey — Mar 24, 2023
Mar 24, 2023
CMS Survey — Jul 7, 2023
Jul 7, 2023
CMS Survey — Dec 27, 2023
Dec 27, 2023
CMS Survey — Jul 9, 2024
Jul 9, 2024
CMS Survey — Aug 8, 2024
Aug 8, 2024
CMS Survey — Jun 23, 2025
Jun 23, 2025
CMS Survey — Oct 29, 2025
Oct 29, 2025
CMS Survey — Jul 21, 2022
Jul 21, 2022
CMS Survey — Jul 7, 2023
Jul 7, 2023
CMS Survey — Sep 16, 2025
Sep 16, 2025
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