Above average — CMS composite of the measures below.
A standard survey is most likely before around December 2026
Estimate from public CMS data, current as of October 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.
Delayed Access to Personal Belongings: A resident with multiple chronic conditions and mobility limitations was readmitted after a hospital stay, but her personal items were left in bags behind her door and she could not access them for an extended period. She reported missing items, including her phone and charger, and said she had asked multiple CNAs for help unpacking without success. Staff said belongings were usually bagged by housekeeping and should be returned and unpacked within a day or a few days, but the record review showed no inventory reconciliation when the resident left or returned.
Neglect Related to Hydration and Access to Fluids: A resident with severe cognitive impairment and multiple chronic conditions, including ESRD on dialysis, had no fluid restriction but was found with dry, chapped lips, no water pitcher or glass in the room, and a bedside table positioned out of reach. The resident stated she was thirsty and had to use the call light to request water, while the CNA POC showed several "not applicable" fluid entries on days the resident was not out of the facility and several days with low documented intake. Staff and the DON confirmed that water should be available in the room and that neglect includes failure to provide water and basic needs.
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 opioid pain management orders had oxycodone administered outside the physician’s parameters, including doses given when pain was documented as 0/10. The MAR and MAR notes showed repeated administrations and effectiveness charting that did not align with the resident’s recorded pain levels. An LPN described checking pain and BP before giving PRN meds, and the DON acknowledged that giving oxycodone at 0/10 was outside the ordered parameters and had been an ongoing issue.
Missing Oxygen Order for Resident Receiving Oxygen: A resident with COPD, chronic respiratory failure with hypoxia, heart failure, and other chronic conditions was observed using oxygen at 2 L/min, but no oxygen order was found in the chart. The MDS noted oxygen therapy, the resident reported being on oxygen since admission and sometimes feeling out of breath, and staff confirmed the resident was not followed by RT and that no oxygen order was present in the physician orders section.
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.
Delayed Access to Personal Belongings
Penalty
Summary
The facility failed to ensure that one resident had access to personal belongings within a reasonable timeframe to support a homelike environment. Resident #201 was readmitted with multiple diagnoses including toxic encephalopathy, COPD, chronic respiratory failure with hypoxia, depression, anxiety, Parkinson's disease with dyskinesia, insomnia, heart and kidney disease, chronic pain, obesity, dependence on supplemental oxygen, osteoarthritis, and age-related osteoporosis. The resident's MDS reflected preferences for caring for personal belongings, using a phone in private, and having a place to lock personal belongings, but the inventory of personal effects dated July 4, 2026 showed no personal belongings upon readmission. The resident stated that when she went to the hospital from the facility, personal items such as her phone, charger, cold cream, pens, clothes, and other belongings went missing or were broken. She reported that after returning to the facility, her belongings were in plastic bags behind the room door, but because of mobility limitations she could not access them. She said she had asked multiple CNAs for help unpacking the bags since readmission, but no one had assisted her, and she felt sad and uneasy because she did not know what belongings she still had or whether items were missing. She also stated that she had not been able to call her daughter or receive calls from friends and family because she did not have access to her phone. Observation showed plastic wrapped around the room door handle and secured to the closet door to hold the door open, with several plastic bags stacked behind the door and no personal items displayed in the resident's designated area. Staff interviews showed that belongings were typically bagged by housekeeping when a resident went to the hospital and were supposed to be returned and unpacked after readmission, usually within a day or a few days. Staff also stated that inventory reconciliation should occur, but the facility records reviewed showed no evidence of documentation of items when the resident left for the hospital or reconciliation when she returned. The resident later stated that housekeeping finally assisted her with unpacking and that her phone and charger were found in one of the bags.
Neglect Related to Hydration and Access to Fluids
Penalty
Summary
The facility failed to ensure that one sampled resident was free from neglect related to adequate hydration and access to fluids. The resident was admitted with multiple diagnoses including urinary tract infection, altered mental status, epilepsy, metabolic encephalopathy, anemia in chronic kidney disease, end stage renal disease with dependence on renal dialysis, atrial fibrillation, chronic diastolic heart failure, atherosclerotic heart disease, hypertensive heart and chronic kidney disease with stage 5 chronic kidney disease, cirrhosis of the liver, type 2 diabetes mellitus, orthostatic hypotension, depression, and anxiety disorder. The 5-day MDS showed a BIMS score of 00, indicating severe cognitive impairment. The physician orders did not show a fluid restriction. The care plan identified the resident as at risk for malnutrition/hydration and included interventions to offer and encourage snacks and fluids between meals, and to keep needed items such as water within reach. However, the fluid intake documentation in the POC Response History showed multiple entries marked as "not applicable" on days when the resident was not documented as being out of the facility, and several days reflected total fluid intake amounts of 740 cc, 720 cc, 700 cc, and 960 cc. The progress notes did not show that the resident was out of the facility on the dates associated with the "not applicable" entries. During observations on July 30, 2026, no water pitcher or glass was seen in the resident's room, and the bedside tray table was positioned out of the resident's reach. The resident was observed with dry, chapped lips and stated that she was thirsty and had to use the call light to ask for water, but the call light had been tucked into the side of the bed and was not readily accessible. Staff interviews confirmed that water pitchers should be in resident rooms and refreshed at least twice per shift, that the resident had no fluid restriction, and that the bedside table should be within reach. The DON stated that neglect includes not providing food, water, and basic needs, and that the resident should have been receiving water during the day, with the fluid intake record intended to reflect intake from trays and bedside pitchers.
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.
Pain Medication Given Outside Physician Parameters
Penalty
Summary
The facility failed to ensure that one resident received pain medication as ordered by the physician. The resident was admitted with morbid obesity, muscle weakness, cognitive communication deficit, bipolar disorder, and major depressive disorder, and the care plan identified that the resident was on opioids for pain management with interventions to administer opioids as prescribed. The resident’s MDS showed a BIMS score of 14, indicating cognitive intactness, and also reflected opioid use. The physician order dated August 16, 2025 directed oxycodone 10 mg by mouth every 4 hours as needed for pain rated 6 to 10. The MAR showed oxycodone was administered multiple times on August 26 and 27, 2025, including administrations documented for pain levels of 0 out of 10 and 9 out of 10. MAR administration notes documented that doses given for pain levels of 0 were later marked effective, even though another oxycodone dose was then given again when the resident’s pain was documented as 0. During interview, the LPN stated staff would assess pain and blood pressure before giving the medication and would document effectiveness after 30 minutes to an hour. The DON stated medications were expected to be administered within physician parameters and acknowledged that giving oxycodone when the pain level was 0/10 was outside those parameters; she also stated this had been an ongoing issue. The facility policy stated that medication orders are to be accurately implemented only upon the order of a licensed and authorized person in accordance with the resident’s plan of care.
Missing Oxygen Order for Resident Receiving Oxygen
Penalty
Summary
The facility failed to ensure an oxygen order was in place for one resident who had diagnoses including COPD, chronic respiratory failure with hypoxia, heart failure, and other chronic conditions. The quarterly MDS indicated the resident was cognitively intact and noted that the resident was on oxygen therapy while in the facility. However, a review of the physician orders found no oxygen order in the record, and the care plan referenced oxygen use only as ordered. Facility documentation also did not show an oxygen order for the resident. During observation, the resident was seen reclining in bed with a nasal cannula in place and the oxygen concentrator set at 2 liters per minute. No documentation was noted on the tubing showing when it had last been changed. The resident stated that she had been on 2 liters of oxygen since arriving at the facility and sometimes felt out of breath. Staff interviews confirmed that the resident was not followed by respiratory therapy, that no oxygen order was found in the physician orders section of the record, and that the resident was being followed by nursing. The DON stated that oxygen orders are expected to be in place and properly documented for residents not followed by respiratory therapy, and that she did not see an oxygen order for this resident.
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 | ★★★★★ | 0 | 0 |
| Villa Maria Post Acute And Rehabilitation | 2.9 mi | ★★★★★ | 6 | 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 | ★★★★★ | 6 | 0 |
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