Catalina Post Acute and Rehabilitation

Resident Assessment and Care Planning Deficiencies

Ensure each resident receives an accurate assessment.

Egress Deficiencies

Keep aisles, corridors, and exits free of obstruction in case of emergency.

Smoke Deficiencies

Properly select, install, inspect, or maintain portable fire extinguishes.

Smoke Deficiencies

Install corridor and hallway doors that block smoke.

Smoke Deficiencies

Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

Miscellaneous Deficiencies

Have simulated fire drills held at unexpected times.

Gas, Vacuum, and Electrical Systems Deficiencies

Ensure that testing and maintenance of electrical equipment is performed.

Nutrition and Dietary Deficiencies

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Resident Assessment and Care Planning Deficiencies

Ensure services provided by the nursing facility meet professional standards of quality.

Quality of Life and Care Deficiencies

Provide safe and appropriate respiratory care for a resident when needed.

Nursing and Physician Services Deficiencies

Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.

Quality of Life and Care Deficiencies

Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.

Resident Rights Deficiencies

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

Quality of Life and Care Deficiencies

Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.

Violation cited

Based 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.

Based 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.

Based on observation, it was determined that the facility failed to provide a clear means of egress to exit to a public way. Failure to provide a clear and unobstructed means of egress could cause harm to patients and staff in the event of a fire emergency.

Based on observation, the facility failed to provide a fire extinguisher near the generator. Failing to have an available fire extinguisher during an emergency could result in harm to the patients and/or staff.

Based on observation, the facility failed to maintain several doors in the building. Failing to maintain doors in the facility could allow heat and/or smoke to transfer, which will cause harm to the patients and/or staff.

Based on observation, it was determined that the facility failed to fill multiple penetrations in the smoke barriers. Failing to seal the penetrations, holes, and openings in the smoke barriers will allow smoke and heat to penetrate other wings or possibly the whole facility, which could cause harm to the patients in the event of a fire.

Based on observation and staff interviews, the facility failed to provide a record of electrical equipment tests, repairs, and modifications. Failing to conduct maintenance on patient care appliances could cause harm to the residents if the appliance malfunctions.Â

Based on a record review and interviews, the facility failed to provide all required fire drills per NFPA 101. Failing to conduct fire drills in accordance with the life safety code, one per shift per quarter, to familiarize staff with conditions under an actual fire, can result in harm to patients and/or staff during an actual fire or emergency situation.

Based 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.

Based 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 a review of clinical records, staff interviews, and review of the facility's policies and procedures, the facility failed to ensure that one out of 12 dialysis residents (Resident # 96) was properly assessed as ordered by the physician.

Based on a review of clinical records, staff interviews, and review of the facility's policies and procedures, the facility failed to ensure that one out of 12 dialysis residents (Resident # 96) was properly assessed as ordered by the physician.

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). 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.

The facility failed to ensure that food is labeled and dated in accordance with food safety practices.

Based on review of facility documentation, staff interviews and facility policy, the facility failed to use the services of a registered nurse (RN) for at least 8 consecutive hours a day, 7 days a week. The census was 99. The deficient practice has the potential to negatively affect resident care.

Facility The facility failed to ensure that food is labeled and dated in accordance with food safety practices.

Based on review of facility documentation, staff interviews and facility policy, the facility failed to use the services of a registered nurse (RN) for at least 8 consecutive hours a day, 7 days a week. The census was 99.Â

Based 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.