Catalina Post Acute and Rehabilitation

In the surveyor’s words

From the most serious findings on record at Catalina Post Acute and Rehabilitation, in the surveyor’s own words.

• Actual harm, isolatedF689Mar 10, 2022

  Based on clinical record review, review of facility records, staff interviews, and review of policies and procedures, the facility failed to ensure one resident (#1) was provided adequate supervision to prevent an unwitnessed fall with significant injuries that required hospitalization . The deficient practice could result in additional residents sustaining significant injuries from falls. Findings include: Resident #1 was admitted on [DATE] with diagnoses that included acute [CONDITION(S)], [CONDITION(S)], dependence on respirator, dependence on supplemental oxygen, anxiety disorder, and acute embolism and [CONDITION(S)] in right lower extremity. An Initial Admission Record dated [DATE] at 8:51 p.m. […]

• No harm, potential for more than minimal, widespreadF727Sep 16, 2025

  Based on review of facility documentation, staff interviews and facility policy, the facility failed to use the services of a registered nurse (RN) for at least 8 consecutive hours a day, 7 days a week. The census was 99. The deficient practice has the potential to negatively affect resident care.Findings include:Review of the facility staff posting for February 8, 2025, revealed 12 hours for an RN on February 8, 2025. However, review of the facility labor punch details revealed that on February 8, 2025 there was no RN on duty for 8 consecutive hours.An interview was conducted on September 16, 2025 at 8:30 a.m. with the Director of Nursing (DON/staff #51). She stated that she was aware of the regulation requiring RN nursing coverage being 8 consecutive hours daily. […]

• No harm, potential for more than minimal, patternF812Sep 16, 2025

  Facility The facility failed to ensure that food is labeled and dated in accordance with food safety practices.Based on observations, staff interviews and policy review, the facility failed to ensure that food is labeled and dated in accordance with professional food safety standards.Findings include:An initial kitchen walk-through was conducted on September 14, 2025 at 9:00 AM. The cook, staff #55, was present during the walk-through, as the dietary manager was not on premises at the time. A bag of jalapenos, dated August 27, 2025, was observed in the cooling refrigerator. Staff #55 stated that the jalapenos should not be in the refrigerator more than 2 weeks. […]

• No harm, potential for more than minimal, patternF584Jul 9, 2024

  Based on observations, clinical record reviews, resident and staff interviews, and facility documentation, policy and procedures, the facility failed to ensure room temperatures were within the safe temperature range. The deficient practice put the residents at increased risks for harm such as lack of sleep and heat stroke. Findings include: A TELS (Facility maintenance reporting) report for 6/1/2024 through 7/8/2024 did not include any requests for action regarding temperature. However, interviews with 8 residents included that they had been informing staff of the problems with temperatures. […]

• No harm, potential for more than minimal, patternF812Jul 7, 2023

  Based on observations, staff interview, and policy review, the facility failed to ensure food items were labeled and dated when opened. The deficient practice could result in a potential for food borne illness. Findings include: A freezer observation on [DATE] at 7:15 a.m. revealed vegetable patties and raw chicken not covered, labeled or dated. A refrigerator observation on [DATE] at 7:20 a.m. revealed potatoes, lemons and oranges not labeled or dated. Additionally, 2 oranges were observed to exhibit a fuzzy, grayish substance on the outside of the orange. The discolored oranges were present in a box of oranges. The kitchen manager removed the two oranges and stated that she generally reviews refrigerator contents once a week after deliveries. […]