Health inspection·May 8, 2025

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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** Based 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. Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was originally admitted to the facility on [DATE] and was readmitted on [DATE] with diagnosis that included dementia (a progressive state of decline in mental abilities), anemia (a condition where the body does not have enough healthy red blood cells) chronic atrial fibrillation( irregular heartbeat where the top chambers of the heart beat too fast which can cause blood not to flow properly), and hyperlipidemia( a condition in which there are high levels of fat particles in the blood). During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool) dated 4/12/2025, the MDS indicated Resident 1 had moderately impaired cognitive (ability to think, understand, learn, and remember) skills and was independent with bed mobility, standing, transferring to and from a bed to a chair. During a review of Resident 1's Physician Order Summary Report, the Physician Order Summary Report dated 3/20/2025 indicated a physician order of Aspirin 81 milligrams (mgs- unit of measurement) by mouth in the evening for A fib. During a concurrent interview and record review on 5/7/2025, at 4:07 p.m. with Registered Nurse (RN1), reviewed Resident 1's Physician Order Summary Report and Care Plan. RN1 stated Resident 1 had no Care plan for the use of ASA and no monitoring for its side effects such as bleeding, bruising, tarry, black stool (black or tar like stool caused by blood in the upper gastrointestinal tract which is potential sign of bleeding in the esophagus, or stomach) or bleeding gums. RN 1 stated ASA could cause increase bleeding, and the resident should be monitored for any signs and symptoms of bleeding. Page 1 of 11 555187 555187 05/08/2025 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 Residents Affected - Few RN 1 stated the licensed nurses were responsible in developing a care plan to meet the needs of each resident. RN 1 stated Resident 1 could be at risk to develop adverse effects (undesirable or unintended consequences that result from a medication or treatment) from the use of ASA and could increase his risk of being hospitalized without being monitored for signs and symptoms of bleeding. During an interview on 5/8/2025, at 7:07 a.m. with the Director of Nursing (DON), the DON stated Resident 1 should have a care plan addressing the use of ASA to ensure no harm will occur from the use of ASA. The DON stated developing a care plan will ensure residents' safety and will meet Resident 1's goals and needs. The DON stated not developing a care plan and not monitoring the side effects of ASA could lead to the possibility of Resident 1 needing medical attention and could increase the risk of hospitalization. During a review of facility's policy and procedure (P&P) titled Care Plans, Comprehensive Person-Centered, dated 5/28/2024, the P&P indicated The facility will develop and implement for each resident a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs. The P&P indicated assessments of residents are ongoing and care plan reflects the currently recognized standards of practice for problem areas and conditions. 555187 Page 2 of 11 555187 05/08/2025 Catalina Island Medical Center D/P Snf 100 Falls Canyon Rd Avalon, CA 90704

F 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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. Based 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. Findings: During a concurrent interview and record review on 5/7/2025 at 1:33 p.m. with Human Resources (HR) reviewed CNA 1, CNA 2, LVN 1 and RN 3's employee files. HR stated that CNA1 was hired on 12/4/1997, CNA 2 was hired on 6/12/2017, LVN 1 was hired on 2/4/2024 and RN 3 was hired on 11/15/2022. HR stated no annual skills competency for 2024 or 2025 were found for CNA1, CNA 2, LVN 1 and RN 3. HR stated that skills competencies should be done annually to ensure staff are competent in performing their job. HR stated that there was a safety risk for the residents when staff were not competent in their jobs. During an interview on 5/8/20205 at 8:51 a.m. with the Director of Nursing (DON), the DON stated skills competencies should be completed annually and that they were used to ensure that staff members' skills were up to date. The DON stated there could be a possible safety concern for the residents when skills competencies were not assessed with the staff. During a review of facility's policy and procedure (P&P) titled, Staffing Competency and Sufficient Staffing dated 11/26/2017. The P&P indicated, facility provides sufficient numbers of nursing staff with the appropriate skills and competency necessary to provide nursing and related care and services for all residents in accordance with resident care plans and the facility assessment . All nursing staff must meet the specific competency requirements of their respective licensure and certification requirements defined by state law. 555187 Page 3 of 11 555187 05/08/2025 Catalina Island Medical Center D/P Snf 100 Falls Canyon Rd Avalon, CA 90704

F 0730 Observe each nurse aide's job performance and give regular training. Level of Harm - Minimal harm or potential for actual harm Based 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). Residents Affected - Few This failure had the potential to negatively affect the care of the residents. Findings: During a concurrent interview and record review on 5/7/2025 at 1:33 p.m. with Human Resources (HR) we reviewed CNA1 and CNA 2's employee files. HR stated that CNA1 was hired on 12/4/1997 and CNA 2 was hired on 6/12/2017 and both CNA 1 and CNA 2 did not have an annual performance evaluation for 2024. HR stated that performance evaluations should be done annually to create a baseline for their performance. HR stated the performance evaluation was used to help determine the strengths and weaknesses of the employee. During an interview on 5/8/25 at 8:51am with the Director of Nursing (DON), the DON stated performance evaluations should be conducted annually and that they were used to acknowledge the staff's strengths and to help improve any weaknesses. The DON stated there could be a possible safety concern for the residents when performance evaluation was not done. During a review of facility's policy and procedure(P&P) titled, Performance Evaluation (undated). The P&P indicated the facility endeavors to review each employee's performance on an annual basis. The performance evaluations are intended to make you aware of your progress, areas for improvement and objectives or goals for future work performance. 555187 Page 4 of 11 555187 05/08/2025 Catalina Island Medical Center D/P Snf 100 Falls Canyon Rd Avalon, CA 90704

F 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs. 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 two of two sampled residents (Resident 1 and Resident 2) were free of unnecessary medicines by failing to: Residents Affected - Some 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. Findings: 1. During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was originally admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses including dementia (a progressive state of decline in mental abilities), anemia (a condition where the body does not have enough healthy red blood cells) chronic atrial fibrillation( irregular heartbeat where the top chambers of the heart beat too fast which can cause blood not to flow properly), and hyperlipidemia( a condition in which there are high levels of fat particles in the blood). During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool) dated 4/12/2025, the MDS indicated Resident 1 had moderately impaired cognitive skills ( signifies a noticeable decline including memory loss, language difficulties, decision making that affects daily life). The MDS indicated Resident 1 was independent with bed mobility, standing, transferring to and from a bed to a chair. During a review of Resident 1's Physician Order Summary Report, the Physician Order Summary Report dated 3/20/2025 indicated an order of Aspirin 81 milligrams (mgs- unit of measurement) by mouth in the evening for Afib. During a concurrent interview and record review on 5/7/2025, at 4:07 p.m. with Registered Nurse (RN1), reviewed Resident 1's Physician Order Summary Report and Medication Administration Record. RN 1 stated there was no physician order to monitor for side effects ( any effect of a medicine that is in addition to its intended effect which can be harmful or unpleasant) of ASA. RN 1 stated aspirin can increase the risk for bleeding and could lead to gastrointestinal bleeding ( bleeding anywhere in the upper or lower digestive system ). RN1 stated Resident could develop an adverse effect like bleeding and could lead to increased risk for hospitalization if the resident was not being monitored for side effects of ASA. During an interview on 5/8/2025, at 7:57 a.m. with the Director of Nursing (DON), the DON stated Resident 1 should be monitored for any signs and symptoms of bleeding because of the ASA. The DON stated Resident 1 could be at risk of increased hospitalization or getting sick because ASA could cause bleeding. The DON stated the facility should ensure Resident 1 would not have any harm from using the ASA by adequate monitoring of resident's response to the medicine and its possible side effects. 555187 Page 5 of 11 555187 05/08/2025 Catalina Island Medical Center D/P Snf 100 Falls Canyon Rd Avalon, CA 90704

F 0757 Level of Harm - Minimal harm or potential for actual harm 2. During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was admitted to the facility on [DATE] with a diagnosis including post-traumatic stress disorder (PTSD-mental health condition that's caused by an extremely stressful or terrifying event), anxiety ( persistent and excessive worry that interferes with daily activities) disorder and dementia (a progressive state of decline in mental abilities). Residents Affected - Some During a review of Resident 2's MDS dated [DATE], the MDS indicated Resident 2 had mild cognitive impairment. The MDS indicated Resident 2 was independent (resident completes activity by themselves) with activities of daily Living (ADLs- activities such as bathing, dressing and toileting a person performs daily). The MDS also indicated Resident 2 had an active diagnosis of PTSD, and anxiety. The MDS also indicated Resident 2 was taking an antipsychotic (medication used to treat psychotic disorders) and an antidepressant (medication used to treat depression). During a concurrent interview and record review on 5/7/25 at 2:37 pm with Registered Nurse 1 (RN), reviewed Resident 2's Physician Order Summary dated 5/7/25. The Physician Order Summary indicated Resident 2 was taking Lexapro 20 mg give one tablet by mouth one time a day to decrease angry outbursts related to generalized anxiety, monitor for angry outbursts. RN 1 stated she used to monitor Resident 2 for angry outbursts and was not sure why it was not being monitored any more. RN 1 stated they should have been monitoring Resident 2's behaviors to ensure that Resident 2 was not receiving any unnecessary medications. During an interview on 5/8/25 at 7:08 a.m. with the Director of Nursing (DON), the DON stated when Resident 2's physician wrote the order for Lexapro, Resident 2's physician did not add monitoring for angry outburst in the supplemental documentation section . The DON stated that Resident 2 was at risk for unnecessary medications when not monitoring the behavior that the medication was prescribed for. During a review of facility's policy and procedure(P&P) titled, Prevention of Unnecessary and Duplicate Medications, reviewed 1/17/2024, the P&P indicated a medication is considered unnecessary if the resident experiences inadequate monitoring for adverse consequences or effectiveness. The P&P indicated the nursing staff will monitor and document in the resident's chart for medications 'therapeutic response and potential adverse consequences such as side effects, interactions or signs of toxicity( the degree to which a substance can harm or cause damage to humans). 555187 Page 6 of 11 555187 05/08/2025 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 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview and record review, the facility failed to store food in a safe and sanitary manner by failing to: Residents Affected - Some 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. Findings: During a concurrent observation and interview on 5/6/2025, at 9:05 a.m. with [NAME] (CK1), observed an open bags of frozen tater tots, frozen mixed vegetables with ice crystals inside the original plastic bag , and frozen dumplings not labeled with an open date and by use by date. CK 1 stated the kitchen staff should label open food items with an open date and use by date. During an observation and interview on 5/6/2025, at 8:55 a.m. with CK 1 and Food Service Worker (FSW 1), three rolls of bacon wrapped in foil and wax paper were not labeled with open date and by use date in the refrigerator. CK 1 and FSW 1 confirmed the rolls of wrapped bacon were not dated when it was open and by use date. During a telephone interview on 5/7/2025, at 10:48 a.m. with Certified Dietary Manager (CDM), CDM stated open bags of leftovers from the freezer and refrigerator should be stored in a sealed bag with an open date and use by date so the kitchen staff would know how long they could use the open bags of frozen and refrigerated food items. CDM stated this practice will ensure food safety and prevention of food borne illnesses among residents and staff. During an interview on 5/8/2025, at 6:58 a.m. with the Director of Nursing (DON), the DON stated labeling open bags of food items in the freezer or refrigerator with open date and use by date could ensure freshness of the food being served and prevent spoilage of food which could lead to sickness among the residents when consumed. During a review of facility's policy and procedure (P&P) titled, Food Receiving and Storage, dated 5/31/2022, the P&P indicated All foods stored in the refrigerator or freezer are covered, labeled dated with use by date. The P&P indicated refrigerated foods are labeled, dated and monitored so they are used by their use-by date, frozen or discarded. 555187 Page 7 of 11 555187 05/08/2025 Catalina Island Medical Center D/P Snf 100 Falls Canyon Rd Avalon, CA 90704

F 0851 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data. Based on interview and record review the facility failed to submit Payroll Based Journal (PBJ- auditable and (CMS). This failure had the potential to affect the care and services of the residents. Findings: During a review of the facility's PBJ staffing data report dated 5/2/2025, the PBJ indicated that no data had been reported for the month October 1 through December 31. During an interview on 5/8/25 at 8:51 a.m., with the Director of Nursing (DON), the DON stated the facility updated their firewall ( a physical structure or network security system designed to prevent the spread of unauthorized access) year 2024. The DON stated that it might be the reason why staffing data was not transmitted to CMS. The DON stated she will work on finding the data. During a review of the facility's policy and procedure (P&P) titled Reporting Direct Care Staffing Information (Payroll-Based Journal) dated 11/26/2022 indicated Direct care staffing information is reported system (PBJ). Staffing information is collected daily and reported for each fiscal quarter no later than 45 days after the end of the reporting quarter. 555187 Page 8 of 11 555187 05/08/2025 Catalina Island Medical Center D/P Snf 100 Falls Canyon Rd Avalon, CA 90704

F 0867 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. Based 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. Findings: recertification survey indicated the following repeat deficiencies in comprehensive resident's centered care plans, pharmacy services and food labeling and storage. During a concurrent interview and record review on 5/8/25 at 8:51a.m., with the Director of Nursing (DON), the DON stated that the facility did have deficiencies in comprehensive resident centered care plans, pharmacy services and food labeling and storage from the previous recertification survey in 2024. The DON stated she tried to keep up and more monitoring needs to be done. During a review of the facility's policy and procedure (P&P) titled Quality Assurance and Performance improvement (QAPI) dated 5/31/2024, the P&P indicated The QAPI is implemented and maintained to address identified priorities, and is based on data, resident and staff input and other information that measures performance and focuses on problems and opportunities that reflect processes, functions and services provided to the residents. 555187 Page 9 of 11 555187 05/08/2025 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** Based 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: Residents Affected - Few 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. Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was originally admitted to the facility on [DATE] and was readmitted on [DATE] with diagnosis including dementia (a progressive state of decline in mental abilities), anemia (a condition where the body does not have enough healthy red blood cells) chronic atrial fibrillation( irregular heartbeat where the top chambers of the heart beat too fast which can cause blood not to flow properly), and hyperlipidemia( a condition in which there are high levels of fat particles in the blood). During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool) dated 4/12/2025, the MDS indicated Resident 1 had moderately impaired cognitive skills ( signifies a noticeable decline including memory loss, language difficulties, decision making that affects daily life) and was independent with bed mobility, standing, transferring to and from a bed to a chair. During a medication administration observation on 5/7/2025, at 7:33 a.m. with Registered Nurse (RN 1), RN 1 picked up her cell phone to answer a call with her hand wearing a glove. Observed RN 1 removed her gloves after the phone call and proceeded to put on a pair of gloves without performing hand hygiene and finished her medication administration to Resident 1 with gloves on. During an interview on 5/7/2025, at 8:12 a.m. with RN 1, RN 1 stated she should have practiced hand hygiene before putting on a new pair of gloves during medication administration to prevent spread of infection among residents and staff. During an interview on 5/7/2025, at 1:17 p.m. with Infection Preventionist Nurse (IPN), IPN stated the licensed nurses should not be wearing gloves and was not necessary to don a pair of gloves when they are administering oral medications to the residents to maintain resident's dignity. IPN stated hand hygiene should be performed before donning a pair of gloves, after removal of gloves and the use of gloves was not a replacement for hand hygiene or handwashing. IPN stated RN 1 should have practiced hand hygiene in between the tasks during medication administration or before donning a new pair of gloves to prevent spread of infection. During an interview on 5/8/2025, at 7:01 a.m. with the Director of Nursing (DON), the DON stated RN 1 should have washed her hands after removing her gloves and before putting on a new pair of gloves to prevent cross contamination and the spread of germs among the staff and residents. During a review of facility's policy and procedure (P&P) titled, Hand Hygiene Policy, dated 555187 Page 10 of 11 555187 05/08/2025 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 10/3/2024, the P&P indicated Hand hygiene was the primary means to prevent spread of infection. The P&P indicated to use an alcohol- based hand rub (ABHR- refers to a liquid or gel hand hygiene product containing alcohol that is used to kill microorganisms on the hands) or soap and water for the following situations including before preparing or handling medications and after removing gloves. Residents Affected - Few 555187 Page 11 of 11