Catalina Island Health

Inspectors wroteBased on observation, interview, and record review, the facility failed to store food in a safe and sanitary manner. The facility had four residents receiving an oral diet. The facility failed to:1. Ensure open bags of frozen french fries and frozen ravioli were labeled with open dates.2. Ensure open containers of hot sauce, ground white pepper, dash original seasoning, chili powder, cayenne pepper, corn tortillas, white bread, dry pasta, cheese and garlic croutons, vanilla wafers, and shortbread cookies were labeled with open dates.3. Ensure an open container of liquid whole eggs and a clear plastic tub of peaches stored in the refrigerator were labeled with open dates. These failures had the potential to place residents at risk for developing foodborne illnesses (illnesses resulting from eating contaminated or spoiled foods) and could reduce the quality of food served in the facility.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure the Ombudsman (an advocate for residents of nursing homes, board and care centers, and assisted living facilities) was notified for one of four sampled residents (Resident 4) who was hospitalized on [DATE]. This failure violated the rights of Resident 4 by not notifying the Ombudsman to ensure Resident 4's discharge was safe and appropriate.

Inspectors wroteBased on interview and record review, the facility failed to ensure annual performance evaluations were conducted for three sampled staff members Certified Nursing Assistant (CNA 1, CNA 2, CNA 3) and one Licensed Vocational Nurse (LVN 2). This deficient practice had the potential to affect the facility's ability to assess staff performance, identify training needs, and ensure staff competency in providing quality care to residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications and biologicals (group of medications) were properly labeled and stored in the medication storage rooms. The facility failed to:1. Ensure three open packages of house supply albuterol sulfate inhalation solution (breathing treatment), not assigned to a specific resident, were labeled with an open date while stored in a cupboard.2. Ensure the medication room refrigerator functioned properly, as ice buildup was observed on the back wall of the refrigerator and multiple boxes of insulin (used to control blood sugar) and tetanus vaccines (used to protect against bacterial infections) were stored in a pool of standing water inside the refrigerator. [...]

Inspectors wroteBased on interviews and record review, the facility's Quality Assessment and Assurance (QAA-ongoing, facility-wide management process used to monitor clinical and administrative services, to ensure resident care meets established standards) Committee failed to provide effective oversight and monitoring to ensure sustained compliance with the facility's Plan of Correction (POC) for deficiencies cited during the previous recertification survey. Specifically, the QAA Committee failed to identify, monitor, and implement corrective actions to prevent the recurrence of deficiencies related to Payroll-Based Journal (PBJ- a mandatory, auditable data system used by the Centers for Medicare & Medicaid Services [CMS]) reporting, nurse aide performance reviews, and food labeling and storage practices. [...]

Inspectors wroteBased on interviews and record review, the facility failed to ensure Certified Nurse Assistants (CNAs) completed a minimum of 12 hours of annual in-service education for CNA 1, CNA 2, and CNA 3. This failure to provide the required annual in-service training has the potential to affect the CNAs' knowledge, skills, and competence in providing safe and effective care to residents.

Inspectors wroteBased on interview and record review the facility failed to submit Payroll Based Journal (PBJ- auditable and verifiable staffing data from nursing facilities) staffing data to the Centers for Medicare & Medicaid Services (CMS). This failure had the potential to affect the care and services of the residents.

Inspectors wroteBased on interview and record review the facility failed to ensure annual skills competencies (a measurable pattern of knowledge, skills, abilities, behaviors, and other characteristics in performing that an individual need to perform work roles or occupational functions successfully) were completed for four facility staff (Certified Nursing Assists (CNA) CNA 1, CNA 2, Licensed Vocational Nurse (LVN), LVN 1 and Registered Nurse (RN), RN 3). This deficient practice had the potential for the facility not to be able to assess the skills necessary to provide nursing services to assure resident safety and to ensure facility staff will be performed within the acceptable standards of practice.

Inspectors wroteBased on interview and record review, the facility failed to ensure two of two sampled residents (Resident 1 and Resident 2) were free of unnecessary medicines by failing to: 1. Monitor adverse effects of Aspirin( medicine used to reduce pain, fever and help prevent blood clots by thinning out the blood) for Resident 1. 2. Ensure behavior monitoring was done for the use of Lexapro ( medication used to treat depression) for Resident 2. These failures had the potential to result in Resident 1 and Resident 2 developing an adverse reaction ( unwanted and undesirable effects ) to the medications unrecognized and not identified by staff.

Inspectors wroteBased on observation, interview and record review, the facility failed to store food in a safe and sanitary manner by failing to: 1. Ensure an open bags of frozen tater tots, frozen dumplings and frozen mixed vegetables were labeled with an open date, use by date and were stored in sealed plastic bags or containers in the freezer. 2. Ensure three rolls of bacon wrapped in a foil and wax paper were labeled by use date and open date in the refrigerator. This failure had the potential to put residents at risk for developing food borne illnesses (illness cause by food contaminated with bacteria, viruses, parasites, or toxins ) and to decrease the quality of food served in the facility.

Inspectors wroteBased on interview and record review, the facility failed to initiate and implement a comprehensive care plan for one of two sampled residents (Resident 1) by failing to: 1. Develop an individualized and person-centered plan of care to address the use of aspirin (ASA- medicine used to reduce pain, fever and help prevent blood clots by thinning out the blood). 2. Implement interventions to monitor signs and symptoms of bleeding related to the use of ASA. This failure had the potential to put Resident 1 at risk of side effects (an often harmful and unwanted effect of a drug that occurs along with the basic desired effect) of ASA not being identified and can cause a delay of care or treatment.

Inspectors wroteBased on interview and record review the facility failed to ensure annual performance evaluations were conducted for two sampled facility staff (Certified Nursing Assistants (CNA), CNA 1 and CNA 2). This failure had the potential to negatively affect the care of the residents.

Inspectors wroteBased on interview and record review, the facility's Quality Assessment and Assurance Committee (QAA) failed to ensure effective oversight of the facility and implementation of the facility's plan of correction (POC) of the deficient practices identified during the previous recertification survey. This deficient practice resulted in the facility, to have repeat deficiencies in the area of comprehensive resident centered care plans, pharmacy services and food labeling and storage.

Inspectors wroteBased on observation, interview and record review, the facility failed to observe infection control practices for one of two sampled residents (Resident 1) by failing to: 1. To practice hand hygiene( practice of cleaning your hands to prevent the spread of germs, viruses, and bacteria) after removal of used gloves during medication administration for Resident 1. This failure had the potential to cause cross contamination( physical movement or transfer of harmful bacteria from one person, object or place to another) and could put residents and staff at risk for the spread of infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the storage, preparation and distribution of food was done under sanitary conditions by failing to: 1. Label open perishable food items on the kitchen shelves with the open-date. 2. Label open foods in the refrigerator with an open date. 3. Label open foods in Residents' refrigerator. This deficient practice placed the facility residents at risk for foodborne illness.

Inspectors wroteBased on interview, and record review, the facility failed to implement a baseline care plan for two of three sampled residents (Residents 1 and 2) who were taking Melatonin (a non-pharmaceutical sleep aid) for sleep difficulty. This deficient practice had the potential to place the residents at risk for prolonged sleep. A. During a review of Resident 2's admission record, the admission Record indicated Resident 2 was admitted on [DATE] with diagnoses that included dementia (impaired ability to remember, think, or make decisions that interferes with everyday activities) with agitation, insomnia (difficulty falling asleep, staying asleep, or getting good quality sleep), unsteady gait (walking), and hypertension (high blood pressure). [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident was free from unnecessary drugs for one of three sampled residents (Residents 2) by not monitoring the specific behavior manifestation according to the prescribed antipsychotic (medication used to treat severe mental illness) medication dose ordered. This deficient practice had the potential to result in over use of an antipsychotic medication, without monitoring for the effectiveness and/or ineffective of the medication and can lead to adverse drug reactions. [...]