Catalina Care Center in San Pedro: Inspection Record Review, Complaints and Abuse Reports (Updated October 30, 2026)

According to the citation, CDPH investigated a complaint and determined that Resident 1, a 73-year-old man with COPD (a lung disease) and heart disease, was found unresponsive on October 5, 2024 at about 9:45 a.m. and did not receive CPR. He was "full code," meaning he wanted all possible life-saving measures. His POLST form (a signed medical order stating a patient's wishes in an emergency), dated April 24, 2024, said he wanted CPR if he had no pulse and was not breathing. He signed it with his physician, and records showed he had the capacity to make that decision.

CDPH found that during a medication pass, a licensed vocational nurse (LVN 1) could not get his vital signs and called Registered Nurse 1 (RN 1). The department determined that RN 1 found him unresponsive, with warm skin and no pulse or breathing, and did not start CPR or call 911. Instead, according to the citation, RN 1 told his physician he had expired. Inspectors found this went against the facility's own CPR policy, which says to begin CPR and call 911 if cardiac arrest is likely, and its POLST policy.

The citation states Resident 1 was pronounced dead on October 5, 2024. An autopsy listed the immediate cause of death as a heart attack likely associated with low oxygen from COPD. CDPH issued a Class AA citation with a $120,000 penalty. The 2567 report states the federal survey cited F678 (cardio-pulmonary resuscitation) at severity J and found that 47 other full code residents were at risk of not receiving life-saving measures when needed.

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According to the citation, CDPH investigated a facility-reported incident and determined that the sink in Resident 1's bathroom was loose and fell from the wall, causing her to fall. Resident 1 had dementia, a past stroke affecting her left side and severely impaired decision-making, and she needed moderate to maximum help with daily care. On March 10, 2024, while a certified nursing assistant supervised her washing up, she was holding onto the hand sink when it came off the wall. The facility's own investigation said she likely hit her eye on a paper towel dispenser and her head on the wall as she slid to the floor.

CDPH found that she had bumps and discoloration near her left eye and on the back left side of her head, and later that day she complained of left hip pain. Inspectors found that the nursing notes for March 10 did not document the fall or an assessment after it. An X-ray ordered that afternoon showed a fracture at the top of her left thigh bone near the hip, and she was sent to an acute care hospital.

The department determined that maintenance or administrative staff did not check during daily rounds that sinks were securely mounted, and did not follow the facility's maintenance policy. According to the citation, after her fall the facility found at least two other loose sinks that needed repair. CDPH issued a Class A citation with a $25,000 penalty. The 2567 report states the federal survey cited F921 (safe, functional, sanitary and comfortable environment) at severity G.

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According to the citation, Resident 47 was a 76-year-old man with diabetes, kidney disease, arthritis in both knees, difficulty walking and muscle weakness. His thinking skills were not impaired. CDPH found that when physical therapy discharged him on January 3, 2024, the therapist recommended that restorative nursing aides (RNAs, aides who help residents keep their strength and mobility) walk with him. At that time he could walk 85 feet with moderate help using a platform walker, a walker with forearm supports.

The department determined that RNA 1 and RNA 2 did not walk Resident 47 as ordered and did not follow the facility's policy on resident mobility and range of motion. Inspectors found that the RNAs did not tell nursing or physical therapy staff that his walking was declining, and that his physician was not notified when he stopped walking.

CDPH found that, as a result, Resident 47 had a significant decline in mobility, going from walking 85 feet with a walker to not being able to walk. CDPH issued a Class A citation with a $25,000 penalty. The 2567 report states the federal survey cited F688 (increase or prevent decrease in range of motion and mobility) at severity G. According to the report, the same finding also covered a second resident, Resident 3, who had limited range of motion in both legs and did not receive restorative treatment to prevent further decline.

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According to the citation, Resident 1 was a 91-year-old man with dementia and severely impaired decision-making who could not stand steadily without staff help. CDPH found he had falls in April, May (three times) and November 2023. After the November 13 fall, the interdisciplinary team recommended keeping a mat alarm (a pad that sounds when a resident gets up) in his wheelchair, frequent visual checks and keeping him in front of the nursing station.

The department determined that his care plan was not updated with those recommendations. Inspectors found that on December 12, 2023, CNA 6 brought him to a nursing station without telling nursing staff to watch him. According to the citation, he wheeled himself, without staff knowing, into the dining and activity room where no staff were present, stood up from his wheelchair alone and fell. About 20 minutes after he was brought back to the nursing station, he stood up again unassisted, with a licensed vocational nurse present, and fell to the floor.

CDPH found that Resident 1 fractured his distal coccyx (the lower tailbone). The department also determined that licensed nurses and the team did not follow the facility's policies on care plans and on resident safety and supervision, which call for sharing fall interventions with all staff and making sure they are carried out. CDPH issued a Class A citation with a $25,000 penalty. The 2567 report states the federal survey cited F689 (free of accident hazards, supervision and devices) at severity G for the same failures.

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According to the citation, Resident 1 was a 54-year-old woman with paralysis on one side of her body, difficulty walking and a high fall risk score. CDPH found that after an earlier assisted fall in March 2023, her care plan required two staff members for all transfers and bed movement, and assessments in October 2023 again showed she needed extensive two-person help.

The department determined that on November 15, 2023, a certified nursing assistant (CNA 1) moved Resident 1 from her wheelchair to her bed alone, against her care plan and the facility's fall policy, and she fell. Inspectors found that a licensed vocational nurse (LVN 1) did not assess where her pain was or how bad it was, did not tell her physician she was in severe pain in her right leg, and did not get orders for pain medication. According to the citation, her physician was not notified until about 9 a.m. the next day.

CDPH found that Resident 1 went 17 and a half hours after the fall without pain medication while in what the citation calls excruciating pain. She had a fracture of the right femur (thigh bone) and was transferred to an acute care hospital for right hip repair surgery. CDPH issued a Class A citation with a $25,000 penalty. The 2567 report states the federal survey cited F697 (pain management) at severity G, and the same survey also lists F689 (free of accident hazards, supervision and devices) at severity G.

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According to the citation, Resident 1 was an 85-year-old man with COVID-19, diabetes and kidney failure who had severely impaired decision-making. He tested positive for COVID-19 on March 18, 2023 and was moved to an isolation room. CDPH found that on March 26, 2023 at about 8 a.m., a certified nursing assistant (CNA 1) found him weak, with slow, shallow breathing and an oxygen level of 88% on room air, and reported it right away to a licensed vocational nurse (LVN 1).

The department determined that LVN 1 did not go to his room to assess him, did not call his physician about the change in condition, and did not keep checking on him. Inspectors found that at 10:45 a.m., two and a half hours later, CNA 1 found him unresponsive, with no pulse and not breathing. According to the citation, the registered nurse supervisor began CPR but put a non-rebreather oxygen mask on him at 15 liters per minute instead of giving rescue breaths with an AMBU bag (a hand-held breathing device) or by mouth. CDPH found he was not adequately ventilated because CPR was done incorrectly.

The citation states Resident 1 was pronounced dead by paramedics at the facility at 11:21 a.m. CDPH issued a Class AA citation with a $120,000 penalty. The 2567 report states the federal survey cited F726 (competent nursing staff) at severity J for nurses lacking the skills to perform effective CPR. The same survey also lists F580 (notifying the physician of changes) and F684 (quality of care), each at severity J.

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The 2567 report states that inspectors investigating a complaint in March 2023 found the facility did not ensure a certified nursing assistant (CNA 1) did not physically and verbally abuse Resident 1. Resident 1 had heart failure and diabetes, was alert and oriented, and depended on two staff members for transfers and bed movement. According to the report, her care plan said she preferred to be changed at certain times by certain CNAs and that staff should let her choose when to be changed.

Inspectors found that on the night shift of March 10, 2023, Resident 1 refused to let CNA 1, who worked through a staffing registry, change her wet brief. Resident 1 told inspectors that when she asked her roommate to turn on the call light, CNA 1 said in a loud, aggressive voice, "you better not turn on the call light." She said CNA 1 told her, "that is why you are blind, you cannot walk, and you are going to be in that bed for the rest of your life." According to the report, Resident 1 said CNA 1 grabbed her wrist tightly, pulled and pushed her from side to side, and hit her face on the bed rail, and that she screamed for help until a nurse came in.

The 2567 report states that Resident 1 felt helpless, useless and afraid that CNA 1 was going to kill her. A report of abuse was filed the same day, and the social services director, administrator and director of nursing interviewed her. The federal survey cited F600 (freedom from abuse and neglect) at severity G and also lists F609 (reporting of alleged violations) at severity D.

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According to the citation, Resident 1 was a 69-year-old woman with end stage kidney disease and a heart muscle disease who was admitted on November 1, 2022. Her physician ordered hemodialysis (a treatment that filters waste and extra fluid from the blood) every Monday, Wednesday and Friday at an outside center, and her care plan included transportation. CDPH found that her last dialysis treatment was on November 7, 2022, and she missed her treatments on November 9 and November 10.

The department determined that the facility did not carry out the dialysis order, did not notify her physician of the missed treatment on November 9, did not make sure she had transportation as its policy required, and did not oversee her dialysis or stay in contact with the dialysis center. Inspectors found that a family member had been driving her to dialysis. The director of nursing told inspectors she could not find any dialysis record, nurses' notes or change of condition notes for the missed treatment, and that the physician should have been notified. A dialysis center nurse said she did not know Resident 1 lived in a nursing home, and that missed dialysis can cause fluid overload and high potassium.

According to the citation, on November 11, 2022 at 9:47 a.m., Resident 1 became unresponsive while a family member was driving her to dialysis. Paramedics found her heart had stopped and started CPR. She was taken to an acute care hospital, and the citation states she expired about six hours later. CDPH issued a Class AA citation with a $100,000 penalty.

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