Catalina Post Acute: Assessment Accuracy Failures - AZ
Resident 91 arrived at Catalina Post Acute and Rehabilitation on September 10, 2025, but staff didn't discover her shoulder dislocation until the wound care team examined her weeks later. The team noticed an indent where the shoulder appeared separated and out of place.
The facility's initial nursing assessment documented only that the resident had a contracture to her left arm and range of motion limitations. It made no mention of the shoulder injury that would later require an x-ray and sling.
Director of Nursing Staff 28 explained that the wound care team had never examined the resident before and noticed the shoulder separation when they moved her arm. After speaking with the family, they learned it was an old fracture. The doctor ordered an x-ray, and the resident's daughter brought in a sling.
The resident didn't have a sling when she was admitted.
Staff 28 acknowledged the information about the fracture wasn't on the hospital facesheet provided at admission and wasn't listed in the resident's diagnoses. However, after the resident was sent to the hospital on October 10, 2025, staff found information about the fracture on the hospital discharge list.
This was the resident's second stay at the facility. Staff were also unaware of her shoulder issue during her first admission the previous year.
When asked about the discrepancy between therapy notes that identified the shoulder injury history and the nursing assessment that missed it entirely, Staff 28 couldn't explain the gap. She acknowledged it was something that needed to be addressed.
The Director of Nursing said initial assessments must be as accurate as possible because they help nurses understand residents' conditions and provide adequate treatment. She explained that inaccurate assessments create risks depending on what gets missed.
Staff 28 described the resident as not alert and oriented, unresponsive to staff, and requiring two-person assistance for care.
The nursing director emphasized that the resident's shoulder dislocation history was important information. Had it been known earlier, she would have expected to see it documented in the care plan and assessments.
Without accurate assessment information, nurses wouldn't know what to look for and couldn't protect the dislocated shoulder, Staff 28 explained. The resident should have had a sling when she was admitted, but the facility should have reviewed the admission paperwork more thoroughly.
Staff 28 said her expectation was for staff to read residents' hospital history paperwork more thoroughly. The information was missed in multiple places, and the facility was using float help at the time of admission, so she wasn't sure where the breakdown occurred.
The facility's admission policy, last reviewed in May 2025, states that licensed nurses must initiate admission assessments. The policy establishes guidelines for processing residents' entry into the nursing facility while protecting their federal and state rights.
A registered nurse interviewed about the case said she would expect information about a shoulder dislocation history to appear under the resident's medical diagnoses and in the care plan after reviewing the documentation.
The inspection found that therapy notes contained the shoulder injury information that nursing staff had missed during their initial assessment process.
Staff 28 acknowledged that when she spoke with another staff member about the case, she got the impression that person didn't know about the shoulder fracture until speaking with the provider.
The resident required a two-person assist for all care, making proper documentation of her shoulder injury crucial for staff safety protocols and resident protection during transfers and daily activities.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Catalina Post Acute and Rehabilitation from 2025-10-29 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: July 22, 2026 · Our methodology
CATALINA POST ACUTE AND REHABILITATION in TUCSON, AZ was cited for violations during a health inspection on October 29, 2025.
The team noticed an indent where the shoulder appeared separated and out of place.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.