Catalina Post Acute And Rehabilitation
Inspection Findings
F-Tag F0641
F 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
should be care planned. After reviewing the care plan, she indicated that the shoulder injury was not in the resident's care plan. She added that she would expect to see information related to the history of the resident's shoulder dislocation under the resident's medical diagnosis and in the care plan.An interview was conducted on October 30, 2025 at 10:52 A.M. with the Director of Nursing (DON/Staff #28). Staff #28 explained that new admissions are given an initial assessment which includes the full body assessment, skin, neurological, and cardiopulmonary. Also, these initial assessments might trigger additional assessments such as pain management and psychotropics. The initial assessments are completed by the nurse working the floor. Staff #28 shared that it was important for these initial assessments to be as accurate as possible because they help the nurses know about the residents so they can treat the residents adequately. If the assessments were not accurate as possible then the risk to the residents would be dependent on what was missed. Staff #28 indicated that she was somewhat familiar with Resident #91 but knew she was not alert and oriented, did not respond well to staff, and was a two-person assist for cares.
When asked to review the initial nursing assessment (Initial admission Record), written on September 10, 2025, Staff #28 shared that the assessment noted Resident #91 had a contracture to the left arm and had
a ROM limitation on all sides. When asked why an x-ray was ordered, she explained that the wound care team and never seen her and moved her arm and they noticed the shoulder was separated as there was an indent so it looked like it was not in place. The nurse had spoken with the family and the provider and the family said it was an old fracture. The doctor wanted an x-ray to follow up and then the daughter brought in
a sling for the resident to use. Staff #28 explained that Resident #91 did not have a sling with her when she was admitted . She also shared that when she spoke with the Staff #84, she was given the impression the
she did not know about the shoulder fracture until she spoke with the provider. Staff #28 also shared that when the resident was admitted , the information about the fracture was not on the facesheet provided by
the hospital and was not on the resident's diagnoses list. She added that after the resident was sent to the hospital, on October 10, 2025, they found information on the hospital discharge list about the fracture. She shared that this recent admission was the 2nd time Resident #91 was at the facility and they were unaware of her shoulder issue during the 1st admission period last year. Staff #28 explained that the resident's history of shoulder dislocation is important and if it was known earlier, she'd expect to see it on the care plan and assessments. She added that the risk to the resident for not having an accurate assessment is that nurses would not know what to look for and they did not protect the dislocated shoulder. She added that the resident should have had a sling on when she was admitted to the facility but the facility should have reviewed the admission paperwork more thoroughly. She stated that her expectation was for staff to read residents' history paperwork from the hospital more thoroughly. It was missed in multiple places and
the facility was using float help at the time of the admission so she was not sure where the ball was dropped. When asked why the Therapy notes identified Resident #91's shoulder injury history and the facility's initial nursing assessment did not, Staff #28 was not able to identify the discrepancy and acknowledged that was something that needed to be addressed.Review of the facility's policy titled, Admission, indicates it was last reviewed in May 2025. The policy states that it was the policy of this facility to have well defined guidelines for processing the Resident's entry into the nursing facility and the resident's right guaranteed under federal and state law are protected. The procedure explained that the Licensed Nurse was to initiate the admission assessments.
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CATALINA POST ACUTE AND REHABILITATION in TUCSON, AZ inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in TUCSON, AZ, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from CATALINA POST ACUTE AND REHABILITATION or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.