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 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 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.

Investigation of complaint AZ00214261. One deficiency cited related to care plan and nursing care provision.

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 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.

Investigation of complaint AZ00212786. Two deficiencies cited related to safe environment and heating/cooling systems.

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.

Investigation of complaints AZ0020436, AZ00204154, AZ00198862, and AZ00168335. Two deficiencies cited related to policies/procedures and basic life support.

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 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.

State compliance survey with investigation of intake #AZ00196810. Thirteen deficiencies cited related to policies, medication administration, skin integrity, enteral nutrition, respiratory care, drug labeling, food safety, refuse disposal, and care plans.

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 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.