Catalina Post Acute and Rehabilitation

Inspectors wroteBased on observations, resident interviews, staff interviews, and a review of policies and procedures, the facility failed to ensure that one resident, out of three sampled residents (#201), had access to personal belongings within the facility, in reasonable timeframe, to ensure a homelike environment. The deficient practice could impact the resident's psychosocial well-being, and adjustment to the facility.

Inspectors wroteBased on clinical record review, staff interviews, facility documentation, and policy review, the facility failed to ensure 1 of 3 sampled residents (Resident #301) was free from neglect related to adequate hydration and access to fluids to meet the resident's needs. The deficient practice could result in dehydration and associated complications, including physical discomfort and decline in the resident's health status.

Inspectors wroteBased on interviews, review of clinical record, and review of facility policy and procedure, the facility failed to ensure one resident's (#91) assessment was accurate and reflective of the resident's status at the time of the assessment. The deficient practice could result in the resident not receiving appropriate care that is necessary for their wellbeing.

Inspectors wroteFacility 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.

Inspectors wroteBased on a review of the clinical record, staff interviews, and the facility's policies and procedures, the facility failed to ensure that 1 out of 23 residents (Resident # 7) received pain medication as ordered by the physician.

Inspectors wroteBased on clinical record review, interviews, facility documentation and policy review, the facility failed to ensure an oxygen order was in place for 1 of 27 sampled residents (#45) in accordance with professional standards of practice. The deficient practice could result in being oxygen administered when not needed, oxygen concentration levels not aligned with the resident's needs, as well as appropriate monitoring, changing of oxygen tubing and documentation. Based on clinical record review, interviews, facility documentation and policy review, the facility failed to ensure an oxygen order was in place for one resident (#45) out of 21 The deficient practice could result in being oxygen administered when not needed, oxygen concentration levels not aligned with the resident's needs, as well as appropriate monitoring, changing of oxygen tubing and documentation.

Inspectors wroteBased on resident interview, policy review, and staff interview, the facility failed to ensure a Registered Nurse (RN/Registry Staff # 467), who was from a staffing agency and not employed by the facility directly, had the specific competencies and skill sets necessary to care for residents' needs. This failure had the potential to affect all residents assigned to the RN's care during her shift.

Inspectors wroteBased on clinical record, resident and staff interviews and facility documents, the facility failed to ensure that two residents (#21, #52) received activities of daily living (ADL) care per facility policy. Failure to do so could result in psychosocial harm.

Inspectors wroteBased 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.

Inspectors wroteBased on clinical records, staff interviews, and facility policy, the facility failed to ensure a resident's code status was honored.

Inspectors wroteBased 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.

Inspectors wroteBased on observations, staff interviews, and policy review, the facility failed to ensure the area around the dumpsters was free of refuse/garbage. The deficient practice could result in an unsanitary condition and the harborage of pests and insects.

Inspectors wroteBased on clinical record review, staff interviews and facility policy review, the facility failed to ensure that medication was administered as ordered for one resident ( #140) and that a physician was notified.

Inspectors wroteBased on clinical record review, staff interviews and facility policy, the facility failed to ensure one resident (#140) receive care and services to prevent/heal pressure ulcers.

Inspectors wroteBased on clinical record review, observation, staff interviews, and policies, the facility failed to ensure one sampled resident (#19) who had an enteral feeding tube received the appropriate treatment and services to prevent complications. The deficient practice could result in potential enteral feeding tube complications.

Inspectors wroteBased on clinical record reviews, staff interviews and policy and procedures, the facility failed to ensure one resident (#11) did not receive unnecessary oxygen therapy. The deficient practice could result in high carbon dioxide content in the resident 's blood that can lead to respiratory acidosis and death.

Inspectors wroteBased on observations, staff interviews, review of Centers for Disease Control and Prevention guidelines, the facility failed to ensure multi-dose vials that had been opened and accessed were dated and discarded within the required time frame.

Inspectors wroteBased on clinical record reviews, staff interviews, and policy review, the facility failed to ensure 3 residents (#87, #36, #33, and #34) were not administered unnecessary medications. The sample size was 5. The deficient practice could result in residents receiving medications that may not be necessary.

Inspectors wroteBased on observations, staff interviews, and policy reviews, the facility failed to ensure infection control practices were followed. The deficient practice could result in the spread of infection.

Inspectors wroteBased on clinical record review, staff interviews, and facility policy and procedure, the facility failed to ensure one sampled resident (#87) received treatment and care in accordance with professional standards of practice. The deficient practice could result in delayed treatment for abnormal blood sugar levels and vital signs not being monitored during a change in condition.

Inspectors wroteBased on clinical record reviews, staff interviews, and policy reviews, the facility failed to ensure two residents (#33 and #45) consistently received the necessary treatment and services to promote the healing of pressure ulcers. The sample size was 4. The deficient practice could delay healing of pressure ulcers.

Inspectors wroteBased on observations, clinical record review, staff interviews, and policy review, the facility failed to provide evidence that one resident (#238) with limited mobility consistently received appropriate services regarding an orthopedic boot, and that one resident (#33) with limited mobility was provided restorative services as ordered. The sample size was 5 residents. The deficient practice could result in orthopedic boots not being applied for residents, and residents not being provided with restorative services as ordered.

Inspectors wroteBased on clinical record review, staff interview, and policy review, the facility failed to ensure one resident (#4) known to have repeated falls was consistently assessed after falls. The sample size was 3 residents. The deficient practice could result in residents not being assessed after a fall.