Citrus Post-acute
Citrus Post-Acute in SANTA ANA, CA — inspection on June 21, 2024.
Found 6 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
Review of Resident 30's plan of care showed a care plan problem dated [DATE], addressing Resident 30's coccyx pressure injury.
The interventions/tasks included the following:
- Daily wound care as ordered: collagenase powder and Silvadene external cream 1%, to apply to sacrum topically every day for pressure injury for 30 days after cleansing with Dakin's solution, irrigate with normal saline.
Dry well.
Apply Silvadene, then apply collagen powder and calcium alginate, and seal with a bordered gauze daily for 30 days; and;
- Use one vial via irrigation every day shift for wound care for 30 days.
Soak wound with gauze saturated with acetic acid for five minutes, pat dry, apply Bactroban (antibiotic) ointment, and cover with a dry dressing daily for 30 days.
On [DATE] at 1020 hours, an interview and concurrent medical record review was conducted with LVN 3. LVN 3 verified Resident 30's plan of care showed two wound care interventions. LVN 3 verified Resident 30's plan of care was not revised to only show the current wound care treatment for Resident 30.
555093
Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 555093 B.
Wing 06/21/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
St Edna Subacute and Rehabilitation Center 1929 N.
Fairview Street Santa Ana, CA 92706
Review of Resident 32's POLST dated [DATE], showed to attempt CPR, and to provide full treatment, and long-term artificial nutrition, including feeding tubes for Resident 32.
Review of Resident 32's Order Review Report showed the following physician's orders dated:
- [DATE], for full cardiopulmonary resuscitation (CPR).
This order was discontinued on [DATE]; and
- [DATE], for full cardiopulmonary resuscitation (CPR).
Review of Resident 32's plan of care showed a care plan problem initiated by the SSD dated [DATE], addressing Resident 32 desired no life-prolonging measures in the event of a cardiac or respiratory arrest as evidenced by advance directives.
The interventions/tasks included no CPR, ensure the resident had a signed DNR order in the medical records and skilled nursing facility would not initiate CPR in the event if cardiac or respiratory arrest.
On [DATE] at 1620 hours, an interview and concurrent medical record review for Resident 32 was conducted with the SSD.
The SSD verified the above findings.
When asked about the plan of care showing a care plan problem initiated by the SSD on [DATE], addressing Resident 32 desired no life-prolonging measures in the event of a cardiac or respiratory arrest as evidenced by an advance directives, the SSD verified she initiated the care plan problem and interventions but did not know why Resident 32 was DNR when her code status was a full code.
The SSD verified Resident 32's plan of care did not reflect the resident's correct code status which was full code.
Cross reference to
Review of Resident 95's MDS dated [DATE], showed Resident 95 had a moderate cognitive impairment.
555093
Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 555093 B.
Wing 06/21/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
St Edna Subacute and Rehabilitation Center 1929 N.
Fairview Street Santa Ana, CA 92706
Review of the facility's P&P titled dish machine usage dated 2/2009 showed in part, Check the temperature of the wash and rinse cycles, verifying that both meet the temperature posted on the dish machine.
Review of the dish machine operational requirements located on the dish machine showed minimum wash temperature 120 degrees Fahrenheit (F) and minimum rinse temperature 120 degrees F.
Review of the facility's document titled Dish machine temperature and Sanitizing Agent Log for the month of June, showed on 6/18/24 for lunch time the dish washing, the wash temperature was 120 degrees F and the rinse was 130 degrees F.
Review of the facility's job description titled Dietary Aide signed by [NAME] 1 on 4/18/11, showed to prepare food, etc., in accordance with sanitary regulations as well as with our established policies and procedures.
Review of the facility's document titled Inservice Lesson Plan and Attendance Record titled Dishwasher Machine Proper Temperature dated 6/19/24, showed a video was given by the Maintenance Director. DA 1 was not in attendance.
555093
Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 555093 B.
Wing 06/21/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
St Edna Subacute and Rehabilitation Center 1929 N.
Fairview Street Santa Ana, CA 92706
Review of the facility's P&P titled Dish Machine Usage dated 2/2009 showed in part, if using a low temperature machine, check the sanitizer level using a litmus test strip.
Record data on the dish machine temperature log.
Review of the facility's document titled Dish machine temperature and Sanitizing Agent Log showed the minimum ppm (parts per million) for the sanitizing agent should be 50 ppm.
Review of the employee file for DA 1 did not include a job description.
Review of the facility's document titled General Orientation showed DA 1 was hired on 1/8/24.
The CDM was not able to provide documentation of an in-service education training on the dish machine sanitizing agent was provided for the kitchen employees for the past year.
On 6/18/24 at 1448 hours, an observation of the dish machine and concurrent interview was conducted with DA 1 using the CDM as a translator.
The DA 1 was asked to test the sanitizing solution of the dish machine. DA 1 dipped the sanitizing solution test strip into the dish machine rinse water.
The sanitizing solution test strip was a dark purple color.
The DA was asked to compare the sanitizing solution test strip to the ppm indicator on the bottle of the test strip.
The DA did not know what the required ppm of the sanitizing test strip should be for the dish machine rinse water.
The CDM stated DA 1 had only been working at the facility for two months.
On 6/20/24 at 1430 hours, an interview was conducted with the RD.
The RD confirmed all employees should be competent in dish machine procedures.
c.
Review of the facility's P&P titled Manual Cleaning and Sanitizing dated 2/2009 showed in part, Sanitizing Method: Immersion for a least 30 seconds in a sanitizing solution of 220 ppm of quaternary ammonia .
Review of the employee file for DA 1 did not include a job description.
Review of the facility's document titled General Orientation showed DA 1 was hired on 1/8/24.
The CDM was not able to provide documentation of an in-service education training on the manual ware washing sink was provided for the kitchen employees for the past year.
555093
Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 555093 B.
Wing 06/21/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
St Edna Subacute and Rehabilitation Center 1929 N.
Fairview Street Santa Ana, CA 92706
Review of the facility's P&P titled Hand washing techniques effective 2/2009 showed hand washing is to be done after removal of medical, surgical or utility gloves, and after scraping or racking dishes on the soiled end of the dish machine.
a.
Review of the facility's job description titled Dietary Aide signed by [NAME] 1 on 4/18/11, showed Safety and Sanitation: Follow established Infection Control and Universal Precautions policies and procedures when performing daily tasks.
Review of the facility's document titled Inservice Lesson Plan and Attendance Record Hand washing dated 4/18/23 and 11/14/23, showed [NAME] 1 was in attendance on 11/14/23.
On 6/19/24 at 1051 hours, during the puree food preparation, after she touched multiple surfaces with ungloved hands, [NAME] 1 donned a pair of gloves without washing her hands on two separate occasions.
555093
Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 555093 B.
Wing 06/21/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
St Edna Subacute and Rehabilitation Center 1929 N.
Fairview Street Santa Ana, CA 92706