Health inspection·May 19, 2023

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** During a review of Resident 106's admission Record (Face Sheet), the Face Sheet indicated Resident 106 was admitted to the facility on [DATE] with diagnoses that included dementia (a chronic or persistent disorder that results in progress loss of memory), unsteady gait, hypertensive disorder ([HTN] high blood pressure), coronary atherosclerosis (the buildup of fats, cholesterol and other substances in and on the artery walls), and myocardial infarction (a heart attack). During a review of Resident 106's Minimum Data Set ([MDS] a standardized assessment and care screening tool), dated 4/25/2023, the MDS indicated Resident 106's cognition (ability to think, understand, and reason) was severely impaired. The MDS indicated Resident 106 required supervision with bed mobility, dressing, eating, toilet use, personal hygiene, and transfer. During an interview and concurrent record review on 5/18/2023 at 12:27 p.m., with the MDS nurse, Resident 106's clinic record was reviewed. Resident 106's clinical record indicated there were no CP's developed to address Resident 106's diagnoses and care issues. The MDS nurse stated ideally the care plan must be generated during admission of the resident or at least forty-eight hours after the admission of the resident. The MDS nurse stated, if CPs were not created right away then the potential problem9s) were not captured and there could be a delay in care for the resident. During an interview on 5/18/2023 at 12:32 p.m., the Director of Nursing (DON) stated a CP should be initiated during admission and when there is a COC. During an interview on 5/19/2023 at 9:06 a.m., both the DON and Infection Preventionist Nurse (IPN) stated, care plans must be individualized, and person centered to attain the needs and every need must be addressed. During a review of facility's undated policy and procedure(P/P), titled Comprehensive Assessment, the P/P indicated, comprehensive assessments are conducted to assists in developing person-centered care plans. The admission assessment is a comprehensive assessment for a new resident and, under some circumstances, a returning resident that must be completed by the end of day 14, counting the date of admission to the nursing home as day 1. Significant Change in Status Assessment - The SCSA is a comprehensive assessment for a resident that must be completed when the IDT has determined that a resident meets the significant change guidelines for either major improvement or decline. It can be (MDS/CAA(s)/care plan) depend on the date that the IDT's determination was made that the resident had a significant change. A significant change is a major decline or improvement in a resident's status. Page 1 of 16 555187 555187 05/19/2023 Catalina Island Medical Center D/P Snf 100 Falls Canyon Rd Avalon, CA 90704

F 0656 Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to develop care plans for two of five sampled residents (1, 106). Resident 1, who was a high fall risk and received medications which acted as a central nervous system ([CNS] a complex of nerve tissues which controls the activities of the body) depressant (a type of medication which slows down brain activity and causes the muscles to relax) and Resident 106 who had identified care issues on admission but did not have any care plans developed to direct her care. Residents Affected - Some These deficient practices resulted in Resident 1 not being monitored for adverse side effects of prescribed medications which included hypotension (low blood pressure), dizziness, fainting, falls, impaired judgement (difficulty in forming evaluative opinions or reaching conclusions), and impaired psychomotor skills (slowing down of thought and a reduction of physical movements in an individual). These adverse side effects were associated with the use of Quetiapine (Seroquel), an antipsychotic (a class of medicines used to treat psychosis [abnormal condition of the mind]), Lexapro ([Escitalopram] a medication used to treat depression), Levetiracetam (a medication used to prevent and/or treat seizures [uncontrolled body movements]), Lamictal ([Lamotrigine] a medication used to prevent or treat seizures), Amlodipine (a medication used to treat high blood pressure), and Benazepril (a medication used to treat high blood pressure) in combination with alcohol consumption. Resident 106's care needs were not identified and had the potential for her care needs to be overlooked. Findings: During a review of Resident 1's admission Record (Face Sheet [FS]), the FS indicated Resident 1 was admitted to the facility on [DATE] with diagnosis including unspecified dementia (mental disorder in which a person loses the ability to think, remember, learn, make decisions, or solve problems), seizures, and muscle weakness (lack of strength in the muscles). During a review of Resident 1's Minimum Data Set ([MDS] a comprehensive assessment and care screening tool), dated 5/11/2023, the MDS indicated Resident 1was usually able to understand others and was sometimes understood by others. The MDS indicated Resident 1's cognitive skills for daily decision-making were moderately impaired. The MDS indicated Resident 1 required supervision and setup help only for transfers, dressing, and personal hygiene. The MDS indicated Resident 1 received antipsychotic and antidepressant medications. During a review of Resident 1's Fall Risk Assessment (FRA), dated 9/9/2021, the FRA indicated the resident had a history of falls and received a total score of 55, indicating the resident had a high fall risk. During a review of Resident 1's Order Summary Report ([OSR] physician's orders), dated 5/19/2023, the OSR orders were as follows: 1. On 9/5/2018, two beers every evening with dinner 2. On 11/20/2019, Lexapro 20 milligrams ([mg], a unit of measurement) in the morning for generalized anxiety disorder (excessive worry). 3. On 11/20/2019, Quetiapine 50 mg at bedtime for generalized anxiety disorder. 4. On 1/11/2021, Benazepril Hydrochloride 40 mg in the morning for hypertension. 555187 Page 2 of 16 555187 05/19/2023 Catalina Island Medical Center D/P Snf 100 Falls Canyon Rd Avalon, CA 90704

F 0656 5. On 8/27/2022, Levetiracetam 1500 mg two times a day for seizure preventions. Level of Harm - Minimal harm or potential for actual harm 6. On 1/26/2023, Amlodipine Besylate 5 mg in the morning for hypertension. 7. On 2/28/2023, Lamictal 200 mg in the morning for seizure prevention. Residents Affected - Some 8. On 3/17/2023, Lamictal 100 mg at bedtime for seizure disorder. During an interview on 5/18/2023 at 12:54 p.m. with the Nurse Practitioner (NP), the NP stated there was no CP for Resident 1 for monitoring the side effects of drinking two beers every night in combination with Resident 1's medications. The NP stated an updated care plan was important to make sure the resident can receive the correct care, monitoring and services. During an interview on 5/19/2023 at 11:45 a.m., with the facility's Pharmacy Consultant (PC), the PC stated Resident 1 should be monitored by the nursing staff for side effects of the medications Resident 1 was taking in combination with his prescribed alcohol consumption. The PC stated Resident 1had a potential risk for hypotension (low blood pressure), dizziness, fainting, falls, impaired judgement (difficulty in forming evaluative opinions or reaching conclusions), and impaired psychomotor skills (slowing down of thought and a reduction of physical movements in an individual) including coordination (the ability to use different parts of the body together smoothly and efficiently). During a review of the facility's undated policy and procedure (P/P) titled, Comprehensive Care Plan, the P/P indicated the comprehensive, person-centered care plan is developed within seven days of completion of the required MDS assessment (admission, annual, or significant change in status). 555187 Page 3 of 16 555187 05/19/2023 Catalina Island Medical Center D/P Snf 100 Falls Canyon Rd Avalon, CA 90704

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to revise a Care Plan (CP) for one of two sampled residents (Resident 1) who was assessed to need monitoring while smoking. This deficient practice resulted in Resident 1 having a lighting device while standing and unattended while smoking on the facility's patio and had the potential for Resident 1 to be at risk of accidents, harm, and/or injuries while smoking. Findings: During a review of Resident 1's admission Record (Face Sheet [FS]), the FS indicated Resident 1 was admitted to the facility on [DATE] with diagnosis including unspecified dementia (mental disorder in which a person loses the ability to think, remember, learn, make decisions, or solve problems), seizures (uncontrolled body movements and changes in behavior which occur because of abnormal electrical activity in the brain), aphasia (difficulty with language and speech), and muscle weakness (lack of strength in the muscles). During a review of Resident 1's Minimum Data Set ([MDS] a comprehensive assessment and care screening tool), dated 5/11/2023, the MDS indicated Resident 1 was usually able to understand others and was sometimes understood by others. The MDS indicated Resident 1's cognitive skills for daily decision-making were moderately impaired. The MDS indicated Resident 1 required supervision for transfer, dressing, and personal hygiene. The MDS indicated Resident 1 had functional limitations in range of motion ([ROM] full movement potential of a joint) on two lower extremities (legs) and used a cane for mobility. During a review of Resident 1's Fall Risk Assessment (FRA), dated 9/9/2021, the FRA indicated Resident 1 had a history of falls and received a total score of 55, indicating the resident was a high fall risk. During a review of Resident 1's Smoking Evaluation Tool (SET), dated 2/9/2023, the SET indicated Resident 1 was not able to verbalize safe smoking principles, was not able to safely utilize a lighter, and smoking directions were for staff to light Resident 1' cigarette. During a review of Resident 1's Care Plan (CP) initiated 3/28/2019 and titled, The Resident is a Smoker, the CP goal included the resident will not suffer injury from unsafe smoking practices through the review date. The CPs interventions included notify charge nurse immediately if it is suspected resident has violated the facility smoking policy and the resident is able to keep lighter at bedside only if resident does not break policy and try to light up in the room. The CP has not been revised since 10/4/2022. During a review of Resident 1's Order Summary Report ([OSR] physician's orders), dated 5/19/2023, the OSR indicated on 1/8/2023, Resident 1 should sit down when outside smoking a cigarette. During an observation on 5/17/2023 at 12:36 p.m., on the smoking patio, Resident 1 was observed standing on the smoking patio alone, pulling out a blue lighter from his right pants pocket, lighting and smoking his cigarette. Continued observation of the smoking patio indicated there was no staff 555187 Page 4 of 16 555187 05/19/2023 Catalina Island Medical Center D/P Snf 100 Falls Canyon Rd Avalon, CA 90704

F 0657 present supervising Resident 1. Level of Harm - Minimal harm or potential for actual harm During an interview on 5/17/2023 at 12:40 p.m., with Licensed Vocational Nurse 2 (LVN 2), LVN 2 stated Resident 1 was not allowed to light his own cigarettes or smoke unsupervised. LVN 2 stated, Resident 1 should not have access to a lighter because it could lead to accidents, such as burning himself and/or other residents. LVN 2 stated, the lighter should not be kept in a place where residents have direct access to it. LVN 2 stated, it was hard to monitor Resident 1 because he was allowed to smoke whenever he wanted to, and the nurses were sometimes busy caring for other residents. LVN 2 stated Resident 1 does not want to wait for a staff member to light his cigarette for him. Residents Affected - Few During an interview on 5/18/2023 at 12:54 p.m., with a Nurse Practitioner (NP), the NP stated she thought she had reviewed and revised Resident 1's CP to reflect the updated smoking policy indicating; any resident with smoking privileges requiring monitoring while smoking shall have the direct supervision of a staff member, family member, visitor or volunteer worker at all times while smoking. During a review of the facility's undated policy and procedure (P/P) titled, Comprehensive Care Plan, the P/P indicated assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change. The interdisciplinary team reviews and updates the care plan when there has been a significant change in the resident's condition. During a review of the facility's undated P/P titled, Smoking - Residents, the P/P indicated any smoking-related privileges, restrictions, and concerns (for example, need for close monitoring) are noted on the care plan, and all personnel caring for the resident shall be alerted to these issues. Any resident with smoking privileges requiring monitoring while smoking shall always have direct supervision. 555187 Page 5 of 16 555187 05/19/2023 Catalina Island Medical Center D/P Snf 100 Falls Canyon Rd Avalon, CA 90704

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents were supervised while smoking and/or did not cigarette lighters accessible and used by them for two of two sampled residents (Residents 1 and 4). These deficient practices resulted in Residents 1 and/or 4 being left alone while smoking cigarettes and having cigarette lighters on their person and/or at their bedside and using it to light their cigarettes unattended. These deficient practices had the potential for burn injuries to occur. Findings: a. During a review of Resident 1's admission Record (Face Sheet [FS]), the FS indicated Resident 1 was admitted to the facility on [DATE] with diagnosis including unspecified dementia (mental disorder in which a person loses the ability to think, remember, learn, make decisions, or solve problems), seizures (uncontrolled body movements and changes in behavior which occur because of abnormal electrical activity in the brain) and muscle weakness (lack of strength in the muscles). During a review of Resident 1's Minimum Data Set ([MDS] a comprehensive assessment and care screening tool), dated 5/11/2023, the MDS indicated Resident 1 was usually able to understand other and was sometimes understood by others. The MDS indicated Resident 1's cognitive skills for daily decision-making were moderately impaired. The MDS indicated Resident 1 required supervision and setup help only for transfers, dressing, and personal hygiene. The MDS indicated Resident 1 had functional limitations in range of motion ([ROM] full movement potential of a joint) to both of his lower extremities (legs) and used a cane for mobility. During a review of Resident 1's Smoking Evaluation Tool (SET), dated 2/9/2023, the SET indicated Resident 1 was not able to verbalize safe smoking principles, was not able to safely utilize a lighter, and staff should light Resident 1's cigarette. The SET indicated, Resident 1 care plan was reviewed and revised for appropriate supervision and smoking directions for staff to light Resident 1's cigarette. During a review of Resident 1's Care Plan (CP), dated 3/28/2019, the CP indicated Resident 1 smoked. The CP's goal indicated Resident 1 will not suffer injury from unsafe smoking practices through the review date (6/26/2023). The CPs interventions indicated to notify the charge nurse immediately if Resident 1 was suspected of violating the facility smoking policy. The CP indicated the last revision date was 10/4/2022. During a review of Resident 1's Order Summary Report ([OSR] physician's orders), dated 1/8/2023, the OSR indicated Resident 1 was to sit down when outside smoking a cigarette. During an observation on 5/17/2023 at 12:36 p.m., Resident 1 was observed standing on the smoking patio, he pulled a blue cigarette lighter from his right pants pocket, lit a cigarette, and smoked it without staff present to supervise him. After Resident 1 was finished smoking, Resident 1 was observed placing the blue cigarette lighter in a white cup located inside the dining room. During an interview on 5/17/2023 at 12:40 p.m., with Resident 1, Resident 1 stated he was allowed 555187 Page 6 of 16 555187 05/19/2023 Catalina Island Medical Center D/P Snf 100 Falls Canyon Rd Avalon, CA 90704

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some to light his own cigarettes and to smoke anytime he wanted to. Resident 1 stated when he wants to smoke, he goes to the dining room, grabs the blue lighter out of the white cup, smokes his cigarette, then puts the blue lighter in the white cup when he is finished smoking. Resident 1 stated he does not have to ask staff for the lighter because the staff told him where the lighter was located and asked him to make sure he puts the lighter back where he found it when he was done smoking his cigarette. Resident 1 stated he smokes by himself all the time. During an interview on 5/17/2023 at 12:40 p.m., with Licensed Vocational Nurse 2 (LVN 2), the LVN 2 stated Resident 1 was not allowed to light his own cigarettes or smoke unsupervised and should not have access to a lighter because it could lead to accidents such as burning himself or other residents. LVN 2 stated, the lighter should not be kept in a place where residents have direct access to it, and residents were not allowed to keep the lighters in their room. LVN 2 stated, it was all the staff's responsibility to monitor the residents who smoke; however staff allows Residents to smoke wherever they want for fear the residents will become angry. LVN 2 stated Resident 1 does not abide by the smoking schedule, and it was hard to monitor him because he was allowed to smoke cigarettes whenever he wants to and the nurses are sometimes busy with other residents and Resident 1 does not want to wait for staff to light his cigarette for him. During an interview on 5/18/2023 at 12:54 p.m., with a Nurse Practitioner (NP), the NP stated she thought she had reviewed and revised Resident 1's CP to reflect the updated smoking policy indicating; any resident with smoking privileges requiring monitoring while smoking shall have the direct supervision of a staff member, family member, visitor or volunteer worker at all times while smoking b. During a review of Resident 4's FS, the FS indicated Resident 4 was admitted to the facility on [DATE], with diagnosis including chronic obstructive pulmonary disease ([COPD], a group of diseases which cause airflow blockage and breathing-related problems), unspecified asthma (a condition which the airways narrow, swell and may produce extra mucous), and malignant (term used to describe cancer) carcinoid (a slow growing cancerous tumor) tumor (abnormal growth of body tissue) of bronchus (a large airway which leads from the windpipe to the lung) and lung (a pair of spongy, air-filled organs located on either side of the chest). During a review of Resident 4's MDS, dated [DATE], the MDS indicated Resident 4 had the ability to understand and be understood by others. The MDS indicated Resident 4's cognitive skills for daily decision-making were moderately impaired. The MDS indicated Resident 4 required supervision and setup help only by staff for transfers, dressing, and personal hygiene. During a review of Resident 4's SET, dated 2/9/2023, the SET indicated Resident 4 had short term memory loss and poor short-term memory. During a review of Resident 4's CP dated 3/13/2023, the CP indicated Resident 2 smoked. The goal indicated Resident 4 would not suffer injury from unsafe smoking practices through the review date (5/24/2023). The CPs interventions indicated to notify the charge nurse immediately if Resident 4 was suspected of violating the facility's smoking policy, staff were to monitor the cigarette lighter and keep it in the Oak Room, and lighting of cigarettes was monitored by staff. During a review of Resident 4's SET, dated 4/24/2023, the SET indicated Resident 4 was not able to safely utilize a lighter. During a concurrent observation and interview on 5/17/2023 at 12:53 p.m., Resident 4 was observed 555187 Page 7 of 16 555187 05/19/2023 Catalina Island Medical Center D/P Snf 100 Falls Canyon Rd Avalon, CA 90704

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some standing on the smoking patio, he pulled a grey lighter from his right pants pocket, lit a cigarette, and smoked it without staff present to supervise him. Resident 4 stated the grey lighter was his and he keeps it in his room. Resident 4 stated he independently goes to the smoking patio and smokes whenever he wants to smoke. During an interview on 5/17/2023 at 1:35 p.m., with the Quality Assurance Nurse (QA), the QA stated, the purpose of having and implementing their smoking policy, was to prevent accidents, injury and potential harm to the residents who smoke. During a review of the facility's undated Policy and Procedure (P/P), titled, Smoking - Residents, the P/P indicated any smoking related privileges, restrictions, and concerns (for example, need for close monitoring) are noted on the care plan, and all personnel caring for the resident shall be alerted to these issues. Any resident with smoking privileges requiring monitoring while smoking shall always have direct supervision. Lighters, including matches are held in a designated area. 555187 Page 8 of 16 555187 05/19/2023 Catalina Island Medical Center D/P Snf 100 Falls Canyon Rd Avalon, CA 90704

F 0732 Post nurse staffing information every day. Level of Harm - Potential for minimal harm Based on observation, interview, and record review, the facility failed to ensure nurse staffing information, including the name of the facility, the date, the hours worked by direct care licensed and unlicensed nurses each shift and the resident census, was posted and visible to residents and visitors. Residents Affected - Many This deficient practice resulted in the number of direct care nursing staff unavailable to residents and visitors and had the potential for residents and visitors to be unaware of nursing staff providing care daily. Findings: During an observation on 5/17/2023 at 9:15 a.m., 5/18/2023 at 7:35 a.m., and 5/19/2023 at 8 a.m., no nurse staffing information was posted in the facility's entrance or other area visible to residents and/or visitors. During an interview on 5/19/2023 at 12:32 p.m., with the Chief Nursing Officer (CNO), the CNO stated the facility does not post daily nurse staffing hours. The CNO stated staffing information should be posted to let visitors and residents know the nurse staffing information for the day. During a concurrent interview and record review, on 5/19/2023, at 1:18 p.m., with the CNO, the facility's policies and procedures (P/P) were reviewed. The CNO stated the facility does not have a policy for posting nurse staffing information. 555187 Page 9 of 16 555187 05/19/2023 Catalina Island Medical Center D/P Snf 100 Falls Canyon Rd Avalon, CA 90704

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation and interview, the facility failed to ensure a bottle of medication that had no expiration date had a date documented on it to indicate when the bottle was opened. This deficient practice resulted in the inability to determine when medication was no longer acceptable for administration and had the potential for ineffective medication management and/or harm to the residents. Findings: During an observation on 5/17/2023 at 11:49 a.m., of the facility's medication storage room a bottle of Vancomycin Hydrochloride 125 milligrams ([mg] a unit of measurement) was opened. The bottle of medication had no expiration date and there was no date written on the bottle to indicate when it was opened. During an interview on 5/17/23 at 12:07 p.m., both Registered Nurse (RN) 1 and RN 2 stated when medications are opened there must be an open date written on the bottle. RN 1 and RN 2 stated medications whose expiration date could not be determined should not be stored in the medication room for safety purposes. During the review of facility's undated policy and procedure (P/P) titled Medication Labeling and Storage the P/P indicated, labeling of medications and biologicals dispensed by the pharmacy is consistent with applicable federal and state requirements and currently accepted pharmaceutical practices. The medication label includes, at a minimum: expiration date, when applicable. For over the counter (OTC) medications in bulk containers (if permitted by state law) the label contains: expiration date (if applicable). 555187 Page 10 of 16 555187 05/19/2023 Catalina Island Medical Center D/P Snf 100 Falls Canyon Rd Avalon, CA 90704

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure an opened container of juice and a cup of milk were discarded 24 hours after the date documented on the container and cup and they failed to ensure the automatic ice dispensing and water machine was cleaned regularly. This deficient practice resulted in exposure of residents to contaminated food products and had the potential for food borne illnesses (also called food poisoning caused by eating contaminated food, spoiled or toxic food) to occur in five of five sampled residents (Residents 1, 2, 3, 4, and 106) who resided in the facility, received drinks from multi use containers and ice/water from the ice and water dispensing machine. Findings: a. During a dining room observation on 5/17/2023 at 12:48 p.m., a refrigerator containing food served to residents was noted with a carton containing Cranberry Juice Cocktail, with a white label dated 1/27/2023 and a cup covered with a clear lid that contained a white liquid, with a handwritten date of 5/4/2023. During an interview on 5/17/2023 at 12:49 p.m., with Licensed Vocational Nurse (LVN 1), LVN 1 stated the cranberry juice cocktail should have been thrown away a long time ago or at least a month after being opened. LVN 1 stated she thought the white liquid in the clear cup was milk from a resident's meal tray and should not have been in the resident refrigerator. During an interview on 5/18/2023 at 7:45 a.m., with the Dietary Supervisor (DS), the DS stated, all prepped food and beverages are dated upon preparation and expire five days after the preparation date. The DS indicated all food which was opened needed to have an opened date. The DS stated the date on the cranberry juice cocktail (1/27/2023) indicated the date the juice was received and it should have been labeled by staff when it was opened. During a review of the facility's undated policy and procedure (P/P) titled, Food Receiving and Storage, the P/P indicated beverages are dated when opened and discarded after twenty-four hours. b. During an observation on 5/18/2023 at 9:25 a.m., in the ice machine and water dispenser room, the automatic ice dispensing and water machine contained a white substance on the plastic area where the ice is dispensed from, and the silver faucet water dispenser had a black substance on the end of the dispenser. During a concurrent interview and record on 5/18/2023 at 9:26 a.m., with the Maintenance Supervisor (MS), the Ice Machine's Sanitizer Record Log (SL), dated January to December (no indication of the year) was reviewed, the SL indicated for day's 1 and 2, there were signatures noted under the p.m. column. The SL indicated for day's 3 thru 12 the sections were blank. The MS stated for days 1 and 2 on the SL, 1 is for the month of January and 2 is for the month of February. The MS stated for the months of March thru December, (numbered 3-12 on the SL) there were no signature's indicating sanitizing was completed. The MS stated the facility cleans the ice and water machine daily but could not provide documentation indicating the daily cleaning was completed. 555187 Page 11 of 16 555187 05/19/2023 Catalina Island Medical Center D/P Snf 100 Falls Canyon Rd Avalon, CA 90704

F 0812 Level of Harm - Minimal harm or potential for actual harm During a concurrent interview and record review, on 5/19/2023, at 1:18 p.m., with the Chief Nursing Officer (CNO), the facility's policies and procedures (P/P) were reviewed. The CNO stated the facility does not have a cleaning and disinfecting policy for the ice and water machine. During a review of the facility's P/P, the facility did not have an infection control policy. Residents Affected - Some During a review of the facility's Installation, Operation, and Service Manual for their ice and water dispensing machine, the service manual indicated the recommended cleaning procedures should be performed for the exterior water station tube as needed, [NAME]-annually for the ice machine transport tube and ice storage area/bin. The service manual indicated; cleaning of all equipment should be performed more often if environmental conditions dictate. 555187 Page 12 of 16 555187 05/19/2023 Catalina Island Medical Center D/P Snf 100 Falls Canyon Rd Avalon, CA 90704

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** During an interview on 5/18/2023 at 2:47 p.m., the Infection Preventionist Nurse (IPN) and Director of Nursing (DON) stated the facility does not have a system in place to assess where Legionella and other opportunistic waterborne pathogens can grow and spread or a system to prevent the pathogens growth in the facility's water system. The IPN and the DON stated the facility does not have a policy and procedure (P/P) regarding Legionella and other opportunistic waterborne pathogens. Residents Affected - Some Based on observation, interview and record review, the facility failed to ensure infection control practices were implemented for one sampled resident (Resident 4) by failing to: 1. Ensure tubing for a nebulizer (changes liquid medicine into fine droplets in an aerosol or mist form which are inhaled though a mouthpiece or mask) mouthpiece did not touch the floor. 2. Establish a water management program for the prevention of water borne pathogens (illnesses caused by microorganisms in untreated or contaminated water). There were 5 residents in the facility at the time of recertification survey. This deficient practice placed Resident 4 at risk for acquiring infections which could cause a potential decline in the resident's health and quality of life and had the potential to expose residents and staff to Legionella (bacteria that can cause serious lung infections) and water borne infections. Findings: During a review of Resident 4's admission Record (Face Sheet), the Face Sheet indicated Resident 4 was admitted to the facility on [DATE], with diagnosis of chronic obstructive pulmonary disease ([COPD] a group of diseases which cause airflow blockage and breathing related problems), unspecified asthma (a condition which the airways narrow, swell and may produce extra mucous), and malignant (term used to describe cancer) carcinoid (a slow growing cancerous tumor) tumor (abnormal growth of body tissue) of bronchus (a large airway which leads from the windpipe to the lung) and lungs. During a review of Resident 4's Minimum Data Set ([MDS] a standardized assessment and care screening tool), dated 3/23/2023, the MDS indicated Resident 4 had the ability to understand and be understood by others. During a review of Resident 4's Order Summary Report ([OSR] physician's orders), dated 5/19/2023, the OSR indicated Resident 4 received Albuterol Sulfate Nebulization Solution (medication used to help relax and open air passages to the lungs to make breathing easier) 2.5 milligrams ([mg] a unit of measurement)/0.5 milliliters ([mL] ) a unit of measurement) every four hours and DuoNeb Inhalation Solution (medication used to prevent wheezing [high-pitched whistling sound made while breathing], difficulty breathing, chest tightness, and coughing in people with COPD) 0.5-2.5 mg/3 mL four times a day. During a concurrent observation and interview on 5/17/2023 at 10:28 a.m., with Registered Nurse 1 (RN 1), in Resident 4's room, the tubing from Resident 4's nebulizer was uncovered and touching the floor. RN 1 stated, the tubing should not be touching the floor. RN 1 stated, if any part the nebulizer tubing is touching the floor, it places the resident at risk for infection. 555187 Page 13 of 16 555187 05/19/2023 Catalina Island Medical Center D/P Snf 100 Falls Canyon Rd Avalon, CA 90704

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During a review of an online article titled, How to Use a Nebulizer, National Heart, Lung, and Blood Institute https://www.nhlbi.nih.gov/resources/how-use-nebulizer, the article indicated to store nebulizer parts (medicine cup, mouthpiece or mask, and tubing) in a dry, clean plastic storage bag to prevent the spread of germs (microscopic bacteria, viruses, fungi. During a review of an online article titled, Oxygen Tubing in Nursing Homes and FDD, Wisconsin Healthcare-Associated Infections in LTC Coalition https://www.dhs.wisconsin.gov/regulations/nh/hai-ltc-oxygen-tubing.pdf, the article indicated to change tubing when know contamination occurs. During a concurrent interview and record review, on 5/19/2023, at 1:18 p.m., with the Chief Nursing Officer ([CNO], an experienced nurse who helps manage finances, enforce policies, and connects patients with the care they need) the facility's policies and procedures (P/P) were reviewed. The CNO stated the facility does not have a policy for nebulizer mouthpiece care, oxygen tubing, or breathing treatment. 555187 Page 14 of 16 555187 05/19/2023 Catalina Island Medical Center D/P Snf 100 Falls Canyon Rd Avalon, CA 90704

F 0881 Implement a program that monitors antibiotic use. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the Antibiotic Stewardship protocol (the effort to measure and improve how antibiotics are prescribed by clinicians and used by patients) was implemented for two of two sampled residents (Resident 1 and Resident 2). Both Residents 1 and Resident 2 were given antibiotics without properly screening for appropriate indications for use. Residents Affected - Some This deficient practice resulted in Residents 1 and 2 receiving antibiotics that had the potential to be ineffective because of a developed resistance to the antibiotic. Findings: a. During a review of Resident 1's admission Record (Face Sheet [FS]), the FS indicated Resident 1 was admitted to the facility on [DATE] with diagnosis including unspecified dementia (mental disorder in which a person loses the ability to think, remember, learn, make decisions, or solve problems). During a review of Resident 1's Minimum Data Set ([MDS] a comprehensive assessment and care screening tool), dated 5/11/2023, the MDS indicated Resident 1 was usually able to understand others and was sometimes understood by others. The MDS indicated Resident 1's cognitive skills for daily decision-making were moderately impaired. During a review of Resident 1's Order Summary Report ([OSR] physician's order) the OSR indicated an order for Amoxicillin (an antibiotic) capsule 500 milligrams ([mg] a unit of measurement) three times daily for seven days for a tooth infection. b. During a review of Resident 2's FS, the FS indicated Resident 2 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included anemia (a condition in which the bodies does not have enough healthy red blood cells), essential hypertension ([HTN] high blood pressure), unspecified atrial fibrillation (a heart condition that causes an irregular and often abnormally fast heart rate), muscle weakness and suicidal ideations (thinking about suicide or wanting to take your own life). During a review of Resident 2's MDS, dated [DATE], the MDS indicated Resident 2's cognition (ability to think, understand, and reason) was intact. During a review of Resident 2's OSR dated 2/20/2023, the OSR indicated Cefdinir (an antibiotic) capsule 300 mg by mouth two times a day for seven days. During an interview on 5/18/2023 at 2:47 p.m., with the Infection Preventionist Nurse (IPN), the IPN nurse stated, the facility does not have an antibiotic stewardship binder and there was no system or protocol to review clinical signs and symptoms and laboratory reports to determine if the antibiotic was indicated for the specific bacteria. The IPN stated, there was no system in place to periodically review antibiotic use by the prescribing doctors and there was no monitoring system in place to determine if the antibiotic use was effective During a review of facility's undated policy and procedure (P/P), titled Antibiotic Stewardship, 555187 Page 15 of 16 555187 05/19/2023 Catalina Island Medical Center D/P Snf 100 Falls Canyon Rd Avalon, CA 90704

F 0881 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some the P/P indicated, antibiotic usage and outcome data will be collected and documented using a facility-approved antibiotic surveillance tracking form. The data will be used to guide decisions for improvement of individual resident antibiotic prescribing practices and facility-wide antibiotic stewardship. As part of the facility antibiotic stewardship program, all clinical infections treated with antibiotics will undergo review by the infection preventionist, or designee. The IP, or designee, will review antibiotic utilization as part of the antibiotic stewardship program and identify specific situations that are not consistent with the appropriate use of antibiotics. All resident antibiotic regimens will be documented on the facility-approved antibiotic surveillance tracking form. 555187 Page 16 of 16