SANTA ANA, CA - Advanced Rehab Center of Tustin faced multiple federal citations during a March 2025 inspection, with violations spanning medication safety, food service operations, and infection control protocols.
Medication Storage and Safety Failures
Federal inspectors documented serious medication management issues throughout the facility. During a March 20 inspection, surveyors discovered two unlocked disposal bins in the medication room containing undissolved tablets, liquid medication bottles, nasal spray containers, and insulin pens. Licensed nurses confirmed these bins should have been secured at all times.
Additional medication cart inspections revealed four Calmoseptine ointments without expiration or received dates. The licensed vocational nurse acknowledged these medications should not have remained in the cart without proper dating, as facility policy requires medications to be kept for three years from the received date.
Inspectors also found a bottle of Pro-Stat Advanced Wound Care with sticky brown residue on the cap and bottle during medication administration. The facility's policy requires all liquid medications to be cleaned after each use before returning them to medication carts.
These medication storage violations create significant risks for residents, as improperly stored or contaminated medications can lead to adverse drug reactions, infections, or ineffective treatment. Unlocked disposal bins pose particular dangers, as they could allow access to controlled substances or sharp objects that could harm residents or visitors.
Kitchen Safety and Food Service Violations
The facility's kitchen operations faced extensive scrutiny, with inspectors documenting multiple food safety failures that could expose residents to foodborne illnesses.
Food Storage and Labeling Issues
In the walk-in refrigerator, surveyors found numerous unlabeled or improperly dated items, including containers of sour cream without use-by dates, ground beef packages with expired dates from February, and pre-prepared sandwiches with unreadable expiration information. Federal food safety guidelines require all perishable items to be properly labeled with preparation and expiration dates to prevent consumption of spoiled food.
The facility also stored unlabeled frozen items, including waffles and corn on the cob, violating basic food storage protocols. Juice containers connected to the beverage system lacked proper labeling, making it impossible to track freshness or rotation schedules.
Equipment Maintenance Problems
Kitchen equipment showed signs of deterioration that could compromise food safety. Inspectors documented a can opener with chipped stainless steel coating exposing the blade, warped and corroded plate domes, and a plate service device with loose handles and dried food debris.
According to USDA Food Code standards, food-contact surfaces must remain free of grease deposits, corrosion, and accumulated debris. Damaged equipment creates opportunities for bacterial growth and contamination that can cause serious illness in elderly residents with compromised immune systems.
Nutritional Compliance Issues
The facility failed to follow posted menus, serving incorrect items to residents with special dietary needs. Nineteen residents on controlled carbohydrate diets received regular canned fruit instead of the prescribed diet gelatin with whipped topping. The dietary services supervisor acknowledged the facility lacked the proper diet items but failed to notify residents of the substitution.
Proper menu adherence ensures residents receive appropriate nutrition for their medical conditions. Diabetic residents, in particular, require consistent carbohydrate control to manage blood sugar levels effectively.
Food Quality and Preparation Concerns
Multiple residents complained about food quality during the inspection period. Several residents reported that corned beef served on March 17 was too tough to cut or chew. One resident was observed struggling to cut the meat and requested alternative food brought by visitors.
Additionally, inspectors observed pureed barbecue chicken containing visible chunks, creating choking hazards for residents requiring smooth-textured foods. The dietary services supervisor acknowledged the food needed additional processing to meet pureed diet requirements.
Pureed diets are prescribed for residents with swallowing difficulties or dysphagia. Improperly prepared foods can cause choking, aspiration pneumonia, or other serious complications in vulnerable residents.
Infection Control Protocol Failures
The facility demonstrated multiple lapses in infection prevention practices that could facilitate disease transmission among residents.
Personal Protective Equipment Misuse
Staff members repeatedly violated proper gown usage protocols. Inspectors observed a certified nursing assistant using the same gown while caring for two different residents without changing between patients. Laundry staff were found reusing dirty gowns multiple times per day and hanging contaminated gowns in contact with each other.
Licensed staff also made critical errors, including a nurse who moved a tissue box from one resident's area to another resident's space, despite the first resident being on enhanced barrier precautions due to a pressure ulcer.
Central Line Management
Two residents with PICC lines (peripheral intravenous central catheters) were not placed on enhanced barrier precautions despite facility policy requiring such measures for residents with central venous access. These medical devices carry high infection risks and require specialized handling protocols to prevent bloodstream infections.
Central line-associated infections can be life-threatening in elderly residents and may lead to sepsis, prolonged hospitalization, or death. Proper infection control protocols are essential for preventing these serious complications.
Isolation Procedure Failures
A resident with a history of C. difficile infection and pending laboratory results was not placed on contact isolation precautions while awaiting test results. Inspectors also noted brown stains on the shared toilet in this resident's room, indicating inadequate sanitation.
C. difficile causes severe diarrhea and colitis, particularly dangerous for elderly residents. The bacteria spreads through contact with contaminated surfaces, making proper isolation and cleaning essential for preventing outbreaks.
Administrative and Documentation Issues
The facility's infection surveillance logs contained inaccurate entries, with multiple "N/A" responses in columns requiring "Yes" or "No" answers about whether infections met standardized criteria. The infection preventionist acknowledged these errors could confuse staff attempting to identify true infections.
Additionally, the facility's assessment required by federal regulations failed to include input from direct care staff, residents, or family members in its development. The administrator acknowledged the assessment did not meet current federal guidance requirements.
Food Safety Education Gaps
Staff interviews revealed inconsistent knowledge about safe food handling practices for items brought by families and visitors. While the facility had policies requiring education on food safety, multiple staff members demonstrated inadequate understanding of proper food storage temperatures, reheating procedures, and contamination prevention.
Regulatory Response
The violations documented during this inspection represent systemic issues requiring comprehensive corrective action. Each citation area poses distinct risks to resident health and safety, from medication errors to foodborne illness to healthcare-associated infections.
Federal nursing home regulations exist to ensure residents receive safe, appropriate care in a sanitary environment. These violations indicate multiple breakdowns in the facility's quality assurance systems that require immediate attention and ongoing monitoring.
The facility must submit detailed correction plans addressing each violation and demonstrate sustained compliance during future inspections to ensure resident safety and regulatory compliance.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Advanced Rehab Center of Tustin from 2025-03-24 including all violations, facility responses, and corrective action plans.
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