Not rated by CMS — ratings are suppressed for new or low-volume facilities.
A standard survey is most likely before around December 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Catalina Post Acute And Rehabilitation during CMS and state inspections, most recent first.
A resident with a history of a chronic left humerus fracture was admitted without a shoulder sling, and the initial nursing assessment and care plan did not reflect her upper extremity impairment. Therapy evaluations identified the fracture and recommended a sling, but this information was not communicated to nursing staff or included in the care plan. The deficiency was discovered when staff later observed the resident's shoulder appearing out of place, leading to an x-ray and delayed intervention.
A resident with cognitive impairment and on anticoagulant therapy experienced an unwitnessed fall with head injury. Although initial assessments and provider notification occurred, neurological checks were not consistently performed or documented as ordered, and there was no evidence that the provider was notified of repeated refusals. This failure to follow physician orders and facility policy resulted in a deficiency related to post-fall assessment and care.
A registry RN worked multiple shifts without the facility verifying her nursing license or competencies. The individual was later found to have impersonated a nurse using another person's license, and the required documentation and verification processes were not completed or followed by facility staff.
The facility failed to provide scheduled ADL care for two residents, leading to potential psychosocial harm. A resident with sepsis and metabolic encephalopathy did not receive scheduled showers, with refusals not documented. Another resident, dependent on staff for showering, also received inadequate care. Staff interviews revealed inconsistencies in following the shower schedule and documentation, contrary to facility policy.
The facility failed to maintain room temperatures within a safe range, leading to discomfort and potential health risks for residents. Despite temporary cooling measures, temperatures in several rooms were recorded as high as 85 degrees Fahrenheit. Residents reported difficulty sleeping and other heat-related issues, and some purchased their own fans due to inadequate cooling. The facility's emergency plan was not effectively implemented, as temperature checks were not consistently documented or performed in the hottest rooms at the hottest times of the day.
Failure to Accurately Assess and Care Plan for Resident's Chronic Shoulder Injury
Penalty
Summary
The facility failed to ensure that a resident's assessment was accurate and reflective of her status at the time of admission. The resident, who had a history of acute respiratory failure, generalized muscle weakness, tracheostomy status, and dysphagia following a cerebral infarction, was admitted without a shoulder sling despite a documented chronic left humerus fracture. The admission Minimum Data Set (MDS) did not indicate any upper extremity impairment, and the care plan lacked goals or interventions related to the resident's shoulder injury. Therapy evaluations, however, identified the chronic fracture and recommended precautions, including the use of a sling for comfort, but this information was not incorporated into the nursing assessments or care plan. Multiple staff interviews revealed that nursing staff were unaware of the resident's shoulder injury upon admission and did not observe a sling in use. Certified Nursing Assistants (CNAs) described the resident as nonverbal, with limited mobility and a left arm that hung limply or swelled, but did not recall a sling being used. Nursing staff relied on limited information from admission paperwork and did not routinely access therapy notes, which were documented in a separate system. The Assistant Director of Nursing (ADON) and Director of Nursing (DON) both acknowledged that the resident's shoulder injury was not identified in the initial assessment or care plan, and that the information was not present in the hospital facesheet or diagnoses list at the time of admission. The deficiency was further evidenced when, during routine care, staff observed the resident's left shoulder appearing out of place, prompting an x-ray and subsequent order for a sling. The lack of accurate and thorough assessment upon admission, incomplete review of hospital records, and poor communication between therapy and nursing staff led to the omission of critical information regarding the resident's chronic shoulder injury. This resulted in the resident not receiving appropriate interventions, such as the use of a sling, until the issue was later identified through observation and follow-up imaging.
Failure to Consistently Perform and Document Neurological Checks After Resident Fall
Penalty
Summary
A deficiency occurred when a resident with multiple medical conditions, including metabolic encephalopathy, unsteadiness, cognitive impairment, and on anticoagulant therapy, experienced an unwitnessed fall during the night. The resident struck her head on a counter while returning from the bathroom. Initial assessments were performed, including vital signs and application of ice to the injury site, and the provider was notified. Orders were received to document the resident's condition in progress notes every shift for three days and to conduct neurological checks. Despite these orders, neurological checks were inconsistently performed. Documentation shows that after the initial neuro checks at 3:00 am, the resident refused several subsequent checks, but the checks were resumed at 7:45 am and 8:45 am. There is no evidence that neurological checks continued after 8:45 am as ordered, and the resident was sent to the hospital at 9:45 am. The facility's policy and staff interviews confirm that neuro checks should be initiated and continued as ordered, with refusals documented and the provider notified. However, the documentation does not indicate that the provider was notified of the resident's repeated refusals or that neuro checks were consistently attempted and documented as required. The failure to follow physician orders for ongoing neurological assessment after a head injury, especially in a resident on anticoagulant therapy, represents a lapse in providing care according to professional standards. The facility's own policies require thorough assessment and documentation following a fall, particularly when the resident is at increased risk for complications. The lack of consistent neuro checks and incomplete documentation of refusals and provider notifications led to the identified deficiency.
Unlicensed Agency RN Provided Care Without Verification
Penalty
Summary
The facility failed to ensure that a registry RN had the appropriate competencies and valid licensure to care for residents. The RN, contracted through a staffing agency, worked multiple shifts without the facility verifying her nursing license. The issue came to light when a dietary supervisor recognized the RN as a potential candidate for a non-nursing position, prompting the DON to attempt license verification. The facility was unable to verify the RN's license through the state board, and the staffing agency could not provide verification or contact the RN. It was determined that the individual had impersonated a registered nurse using another person's license, and the facility substantiated that an unlicensed nurse had provided care. Review of facility policies and interviews with the HR Manager and DON revealed that the process for verifying licensure and competencies for registry staff was not consistently followed. The HR Manager could not locate documentation that the required checklist for verifying licensure and background checks was completed for the registry RN. The DON confirmed that there was no cross-check in place for license verification of agency staff at the time, and the facility relied on the agency to provide documentation. The facility's policy required sufficient nursing staff with appropriate competencies, but this was not ensured in the case of the registry RN.
Failure to Provide Scheduled ADL Care
Penalty
Summary
The facility failed to ensure that two residents received activities of daily living (ADL) care according to the facility's policy, which could result in psychosocial harm. Resident #52, who was admitted with diagnoses of sepsis and metabolic encephalopathy, had a care plan that included encouraging participation in self-care activities. However, documentation revealed that the resident did not receive the scheduled showers, with only one shower provided during certain weeks and none during others. Interviews with staff indicated that the resident frequently refused care, but these refusals were not documented as required by the facility's policy. Resident #21, admitted with diagnoses including morbid obesity and bipolar disorder, was also found to have received inadequate ADL care. The resident was dependent on staff for showering, yet documentation showed that the resident received only one shower during certain weeks and none during others. Interviews with staff, including a CNA and an LPN, revealed that showers were scheduled but not consistently provided or documented, especially when residents refused care. The Director of Nursing confirmed that the expectation was for staff to follow the shower schedule and document all care, including refusals, which was not done in these cases.
Facility Fails to Maintain Safe Room Temperatures
Penalty
Summary
The facility failed to maintain room temperatures within a safe range, leading to discomfort and potential health risks for residents. Despite the absence of temperature-related requests in the facility maintenance reporting system, multiple residents reported issues with high temperatures to the staff. The facility's documentation showed that an order for a new HVAC unit was placed, and temporary cooling measures such as rental air conditioning units, swamp coolers, and portable fans were implemented. However, these measures were insufficient, as temperatures in several rooms were recorded as high as 85 degrees Fahrenheit. Interviews with residents revealed widespread dissatisfaction and discomfort due to the heat. Residents reported difficulty sleeping and other heat-related issues, such as headaches and excessive sweating. Some residents resorted to purchasing their own fans due to inadequate cooling provided by the facility. The maintenance staff confirmed that the air conditioning system failed, and temporary fixes were attempted but were unsuccessful. The facility's emergency plan, which required temperature checks every two hours, was not effectively implemented, as temperature checks were not consistently documented or performed in the hottest rooms at the hottest times of the day. The facility's staff, including the Director of Nursing and the administrator, acknowledged the temperature issues but did not provide clear evidence of an enacted emergency plan. The administrator stated that room temperatures should be under 80 degrees Fahrenheit, yet the facility failed to maintain this standard. The deficiency in maintaining a safe and comfortable environment for residents was evident, as the facility did not adequately address the temperature issues despite being aware of the problem.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Tucson
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Park Avenue Health And Rehabilitation Center | 0.8 mi | — | 1 | 0 |
| Villa Maria Post Acute And Rehabilitation | 2.9 mi | — | 5 | 0 |
| The Center At Tucson | 3.5 mi | — | 0 | 0 |
| Santa Rosa Care Center | 3.6 mi | — | 2 | 0 |
| Haven Of Tucson | 3.7 mi | — | 2 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.