Inspection Reports for
Catalina Post-Acute & Rehabilitation

The facility failed to ensure that Resident #91's assessment was accurate and reflective of her condition at admission, missing critical information about a chronic left humerus fracture and shoulder dislocation, which led to inadequate care planning and risk of harm.

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.

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.

The facility was found deficient in multiple areas including improper administration of pain medication, lack of oxygen orders for a resident on oxygen therapy, incorrect dialysis assessment and documentation, failure to have an RN on duty for 8 consecutive hours on a specific day, and improper food labeling and dating practices.

The complaint investigation substantiated that registry RN (Staff #467) impersonated a licensed nurse and worked without a verified license, posing potential harm to residents.

The facility substantiated that a registry nurse (Staff #467) worked without a verified nursing license by impersonating another individual's RN license. The facility lacked proper cross-check verification processes at the time, posing potential harm to residents.

The complaint investigation substantiated that registry RN Staff #467 impersonated a licensed nurse and worked without a verified license, confirmed by facility investigation and interviews with Human Resources and Director of Nursing.

The facility substantiated that a registry RN (Staff #467) had impersonated a licensed nurse using another individual's RN license and worked without a verified license, posing potential harm to residents. The facility lacked proper cross-checks for license verification at the time.

The facility failed to ensure that two residents (#21 and #52) received the required number of showers per week according to facility policy, with documented missed showers over multiple weeks. Staff interviews revealed inconsistent documentation and that resident #52 frequently refused care without proper documentation.

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.

The facility failed to ensure room temperatures were within a safe range, with temperatures observed as high as 85 degrees Fahrenheit. Residents reported difficulty sleeping and discomfort due to the heat. Temporary cooling units were placed, but temperature monitoring was inconsistent and incomplete. Staff interviews revealed delays and inadequate responses to the air conditioning failure.

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.

The complaint investigation found that CPR was initiated on a resident with a Do Not Attempt Resuscitation (DNR) order, contrary to the resident's advance directives and physician orders. The facility acknowledged the failure to respect the resident's wishes.

The facility failed to ensure that a resident's Do Not Attempt Resuscitation (DNR) order was followed, as CPR was initiated despite the resident's documented refusal of resuscitation measures. Interviews with staff confirmed that CPR should not have been performed given the resident's code status.

The complaint investigation found that CPR was initiated on a resident with a documented DNR order and advance directive refusing resuscitation, which was not in accordance with the resident's wishes. The deficiency was substantiated with staff interviews and clinical record review.

The facility failed to ensure that a resident's code status was honored, as CPR was initiated despite a physician's DNR order and a Prehospital Medical Care Directive refusing resuscitation. Interviews with staff confirmed that CPR should not have been performed on this resident.

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.

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.

The complaint investigation found that medication administration errors occurred with missed doses and lack of physician notification. The facility also failed to provide ordered pressure ulcer treatments and proper documentation. The deficiencies affected a few residents and were substantiated by clinical record reviews and staff interviews.

The facility failed to ensure that medication was administered as ordered for resident #140, with multiple missed doses and no physician notification. Additionally, the facility failed to provide appropriate pressure ulcer care and treatments as ordered, with incomplete documentation and unsigned medication and treatment administration records.

The facility was found deficient in multiple areas including missed medication administrations without physician notification, incomplete pressure ulcer treatments, improper feeding tube medication administration, unnecessary oxygen therapy without physician notification, unlabeled and undated insulin vials, unlabeled and expired food items, and unsanitary conditions around outside dumpsters.

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.

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.

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.

The complaint investigation was substantiated with findings that the facility did not properly document or fully assess an incident of alleged physical abuse involving a resident during a shower. The investigation included interviews with staff and review of the facility's abuse prevention policy.

The facility failed to implement its abuse policy after a report of resident abuse was received. Interviews and record reviews revealed that a resident was allegedly subjected to rough handling by staff during a shower, causing pain and distress, and the facility did not fully document or assess the incident as required by policy.

The facility was found deficient in multiple areas including failure to provide appropriate treatment and care for residents, inconsistent pressure ulcer treatment, inadequate restorative 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.

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.