SANTA ANA, CA - A June 2024 state inspection of St Edna Subacute and Rehabilitation Center identified widespread deficiencies affecting resident safety, nutrition, infection control, and basic care standards across multiple operational areas.
Critical Food Safety Failures Exposed
Federal and state inspectors documented serious breakdowns in the facility's food service operations that potentially exposed 122 residents to foodborne illness risks. The violations revealed systemic problems with staff training, food handling procedures, and equipment maintenance.
Kitchen staff demonstrated a fundamental lack of knowledge about basic food safety protocols. During the inspection, a dietary aide who had been employed for two months was unable to explain proper sanitizer concentrations for dish machines or manual washing procedures, despite these being essential daily tasks. The facility could not provide documentation that kitchen employees had received any food safety training within the past year.
Temperature control failures presented immediate health risks. Inspectors found partially cooked chicken cooling improperly in the walk-in refrigerator, with temperatures dropping from 91.4°F to 75°F over two hours without any monitoring. Food safety standards require cooked foods to cool from 135°F to 70°F within two hours, then to 41°F or below within four additional hours. The facility was not documenting this critical cooling process, which is essential for preventing bacterial growth that can cause serious illness in elderly populations.
The facility's meat thawing procedures violated established safety protocols. Ground beef labeled as having been removed from the freezer on June 17 was found completely thawed by June 18—far faster than the facility's stated three-day thawing period should allow. When questioned, kitchen staff provided contradictory information about who was responsible for dating thawed meats and how long items should remain in the thawing process.
Proper thawing is critical because improper procedures can allow the outer layers of meat to reach temperatures where dangerous bacteria multiply rapidly while inner portions remain frozen. The facility's policy required thawing under refrigeration or running water below 70°F, but inconsistent labeling and monitoring made it impossible to verify compliance.
Hand hygiene violations were observed repeatedly throughout the inspection period. Kitchen staff changed gloves without washing hands after touching contaminated surfaces, directly violating infection control principles. One dietary aide touched a trash can while removing gloves, then immediately donned new gloves without hand washing. On multiple occasions over several days, different kitchen employees failed to wash hands between glove changes during food preparation.
This represents a fundamental failure in basic food safety training. Hand washing before and after glove use is one of the most critical infection prevention measures in food service, as gloves can develop microscopic tears and do not eliminate the need for proper hand hygiene.
Nutritional Quality and Menu Deficiencies
The facility failed to meet basic nutritional standards for residents receiving Vietnamese menus and pureed diets, potentially compromising the health of vulnerable residents who depend on the facility for complete nutritional support.
Vietnamese menu offerings, which had been in use for over five years, lacked essential documentation. The facility had no nutritional analysis to confirm these menus met recommended dietary intake levels, no recipes for pureed foods, and no updates to reflect current dietary standards. The menus used outdated texture categories that did not align with the International Dysphagia Diet Standardization Initiative (IDDSI) framework—the accepted standard for ensuring safe food textures for residents with swallowing difficulties.
The IDDSI framework provides standardized terminology and testing methods to describe food textures from Level 3 (liquidized) through Level 7 (regular). The Vietnamese menus used terms like "mechanical" that do not correspond to these standardized levels, making it impossible to ensure residents received appropriately textured foods to prevent choking or aspiration.
For American menu pureed diets served to 23 residents, staff did not follow established recipes, creating inconsistencies in food texture and nutritional content. During meal preparation observations, a cook used a different type of ham for pureed diets than specified in the recipe, resulting in significantly higher sodium content—831 mg versus 642 mg per serving. For a population that often has hypertension and other cardiovascular conditions, this 29% increase in sodium represents a meaningful health risk.
Pureed vegetables were prepared incorrectly and held at high temperatures for extended periods, degrading their nutritional value. Green peas were cooked, pureed, then placed in a 450°F oven for nearly two hours before meal service. Water-soluble vitamins like vitamin C and B-complex vitamins are particularly sensitive to prolonged heat exposure, meaning residents likely received vegetables with significantly diminished nutritional content.
The facility also failed to serve complete meals as planned. Multiple residents did not receive coleslaw that was listed on the menu for their meal. One resident ordered a cheeseburger but received only the patty and bun without the lettuce, tomato, and onions that should have accompanied it. These omissions may seem minor but represent a pattern of inattention to resident preferences and complete nutritional delivery.
Infection Control Breakdowns Throughout Facility
Widespread infection control failures created conditions that could facilitate disease transmission among the facility's 133 residents, many of whom had compromised immune systems or other vulnerabilities.
The facility's infection surveillance program, which should track and analyze infections to identify patterns and prevent outbreaks, was fundamentally flawed. For the first three months of 2024, the facility had no infection control data whatsoever. The infection preventionist, who started in April 2024, only tracked residents who exhibited symptoms and received antibiotic prescriptions, missing asymptomatic infections and failing to conduct comprehensive surveillance.
More concerning, the infection preventionist incorrectly classified multiple infections, making the surveillance data unreliable for identifying trends or implementing prevention measures. In one example, she classified a urinary tract infection as healthcare-acquired when it should have been categorized as community-acquired based on the admission timeline. In another case, she documented yeast in urine from a hospital specimen as a facility-acquired infection. These misclassifications distort the facility's infection rates and prevent accurate assessment of care quality.
Catheter care violations observed during the inspection directly contradicted evidence-based practices for preventing urinary tract infections, which are among the most common healthcare-associated infections in nursing homes. Inspectors observed catheter drainage bags touching the floor for two different residents on multiple days. The floor represents one of the most contaminated surfaces in healthcare settings, and contact between drainage bags and the floor can introduce bacteria that travel up the catheter into the bladder.
One resident had a physician order requiring enhanced barrier precautions during catheter care, meaning staff should wear gowns and gloves during any care involving the catheter or gastrostomy tube. However, a licensed vocational nurse entered the resident's room and provided care without wearing the required isolation gown, despite a sign posted outside the room clearly indicating the precaution requirements.
Clean linen storage in the laundry area violated basic sanitation principles. Freshly washed linens were observed touching used isolation gowns, contaminated clothing, and a dusty fan. An uncovered linen cart sat in the hallway by the laundry door. These conditions create opportunities for cross-contamination, where pathogens from soiled items transfer to clean linens that will be used for resident care.
Equipment sanitation failures compounded infection risks. The ice machine, which should provide clean ice for resident consumption, had black residue inside the chute when wiped with a paper towel. The maintenance director's cleaning procedure did not follow manufacturer specifications for dilution ratios of cleaning and sanitizing solutions, meaning the equipment was not being effectively disinfected.
Medication Administration and Record-Keeping Errors
Documentation failures and medication administration errors identified during the inspection raised concerns about the accuracy of resident medical records and the safety of medication practices.
For one resident prescribed blood pressure medication with specific holding parameters, the medication administration record showed the drug was given when the resident's systolic blood pressure was 100 mmHg—below the 110 mmHg threshold at which the medication should be held. When questioned, the nurse stated she had actually held the medication but documented it incorrectly as given. She showed the surveyor the intact medication bubble pack as evidence.
This type of documentation error, while not resulting in actual medication administration in this case, represents a serious safety concern. Accurate medication records are essential for tracking therapeutic responses, identifying adverse effects, and ensuring continuity of care. Incorrect documentation could lead to confusion during shift changes, medication errors by other staff, or inappropriate medical decisions based on false information.
Another resident's medication administration record was missing documentation for seven different medications that should have been given on a specific date, including insulin with blood sugar monitoring, blood pressure medications, a laxative, and psychiatric medication. The assistant director of nursing verified these omissions but could not explain why the medications were not documented.
In skilled nursing facilities, missing documentation creates the presumption that care was not provided, as records serve as the legal proof of medication administration. For time-sensitive medications like insulin and blood pressure drugs, missed doses can have immediate clinical consequences.
Equipment Maintenance and Safety Hazards
Multiple equipment failures and maintenance deficiencies created potential safety hazards and compromised the facility's ability to provide sanitary care.
The commercial dish machine, essential for properly sanitizing dishes and utensils used by 122 residents, was operating below manufacturer specifications. The machine's wash temperature measured 100-106°F and rinse temperature 108-114°F, well below the required minimum of 120°F for both cycles. These temperatures are insufficient to effectively kill pathogens, meaning residents may have been served meals on inadequately sanitized dishes.
When initially observed, the maintenance director suggested the water simply needed to run longer to reach proper temperature. However, on subsequent inspection the next day, temperatures remained below specifications, indicating a mechanical problem rather than a temporary issue.
Kitchen structural deficiencies facilitated pest entry. The metal screen door on the kitchen's back entrance had been improperly installed, creating a gap that did not seal flush with the door jamb. A window screen above a food preparation counter was bent and torn. These openings provided entry points for flies, which were observed throughout the kitchen and dining room during multiple inspection days, including landing on resident food plates during meal service.
The kitchen floor itself presented a sanitation and safety concern. The linoleum flooring was damaged and not intact, exposing concrete underneath. Floors in food preparation areas must be smooth, nonabsorbent, and easily cleanable to prevent bacterial harboring in cracks and crevices. The administrator stated the corporate office was working on replacement but could not provide documentation of when repairs would occur.
Bed Safety Assessment Failures
The facility failed to properly assess entrapment risks for residents using bed rails, despite documented cases of serious injury and death from bed rail entrapment in nursing home populations.
Federal guidance identifies seven zones around hospital beds where entrapment can occur: within the rail, under the rail between supports, between the rail and mattress, under the rail at the ends, between split rails, between the rail end and head or footboard, and between the head or footboard and mattress. Proper assessment requires measuring gaps in each zone to ensure they do not allow body parts to become trapped.
For three residents reviewed who used bed rails, the facility's entrapment assessment documentation was incomplete or inaccurate. Measurement worksheets were missing documentation for multiple entrapment zones applicable to the type of rails in use. The maintenance director, responsible for conducting these assessments, could not explain what the assessment codes meant and could not correctly identify which zones needed evaluation for different rail configurations.
This represents a critical knowledge gap in safety assessment. Elderly residents with confusion, restlessness, or uncontrolled body movement are at highest risk for entrapment events. Without proper assessment of all potential entrapment zones, the facility cannot ensure the rails intended to assist with mobility do not pose an entrapment hazard.
Additional Issues Identified
Beyond the major violations detailed above, inspectors documented problems across multiple operational areas. Clean linen carts in the hallway contained water bottles and personal items mixed with linens intended for resident use. Trash containers in shower rooms overflowed with soiled incontinence products and isolation gowns, preventing lids from closing properly. The facility had no standardized training program for new kitchen employees and did not document competency verification after training periods.
Fire safety equipment in the walk-in refrigerator showed a sprinkler head with rust-colored residue that was not flush with the ceiling. Plumbing in the kitchen lacked proper air gaps to prevent backflow contamination of the ice machine and a food preparation sink. Multiple pieces of kitchen cookware had baked-on black residue that was not removed during cleaning.
The facility's infection control program lacked documentation that staff received education on safe food handling practices when family members brought food for residents. The policy restricted storage of perishable foods brought by visitors but provided no written guidance to families about safe food handling or time limits for consuming brought items.
These cumulative deficiencies reflect systemic problems with staff training, supervision, quality assurance monitoring, and leadership oversight affecting virtually every aspect of facility operations and resident care.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for St Edna Subacute and Rehabilitation Center from 2024-06-21 including all violations, facility responses, and corrective action plans.
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