Citrus Post-acute

F-F761, the DON or designee will review data from facility rounds for medication storage compliance, and will bring the results to the monthly QAPI meeting for three months and as recommended by the committee.

- For cited

F-F842, the DON and SSD or designees will bring the results from records review and facility rounds for compliance to the monthly QAPI meeting for three months and as recommended by the committee.

- For cited

Review of the facility's Legionella Water Management Program showed Legionella testing will be performed quarterly.

Legionella testing results were dated 2/14/24 and 3/25/25.

On 5/9/25 at 1035 hours, an interview and facility document review was conducted with the Maintenance Supervisor.

The Maintenance Supervisor stated Legionella testing was conducted annually on 2/14/24 and 3/25/25.

The Maintenance Supervisor reviewed the Legionella Water Management Program binder and verified the program showed testing would be done quarterly, and had not been.

3.

Medical record review for Resident 131 was initiated on 5/7/25. Resident 131 was admitted to the facility on [DATE].

Review of Resident 131's Order Summary Report showed a physician's order dated 4/23/25, for contact enteric precaution for C. diff (Clostridium difficile-a contagious bacteria that can cause inflammation of the colon) toxin.

On 5/7/25 at 0838 hours, an observation and concurrent interview was conducted with the Optometrist at Resident 131's bedside.

The Optometrist was observed at the resident's bedside, in a mask, face shield, gown and gloves, in contact with the resident and other surfaces in the resident's room, including the edge of the bed and a bedside tray table. A sign was posted at the resident's doorway which showed for contact enteric precautions and instructed people to wash their hands with soap and water upon leaving the room.

The Optometrist stated they were informed by the facility staff that the resident had isolation precautions for a UTI, not C. diff.

The Optometrist was observed removing her isolation gown and gloves, and using ABHR for hand hygiene when leaving the room.

The Optometrist then donned a new isolation gown and gloves, and entered another resident's room, went to their bedside, and examined the resident.

The Optometrist's Assistant stated they were informed by the resident's nurse from the previous shift that Resident 131 was in isolation for a urinary tract infection, and not C. diff.

On 5/7/25 at 0855 hours, an interview and concurrent medical record review was conducted with LVN 3. LVN 3 stated Resident 131 had contact enteric precautions for C. diff, and the staff and visitors should wash their hands with soap and water when leaving the room.

4. On 5/9/25 at 1054 hour, a wound care observation for Resident 8 was conducted with LVN 2.

While LVN 2 gathered the supplies from the treatment cart, a cell phone was observed being stored in the top drawer with the treatment supplies. LVN 2 stated it was her personal cell phone and verified it should not be stored in the medication cart.

The LVN stated there was also a wound care team cell phone, which the LVN was storing in her pocket.

On 5/9/25 at 1115 hours, an interview was conducted with the DON.

The DON stated the personal cell phones should not be stored in the treatment or medication carts for infection control.

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 05/13/2025

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