Laguna Hills Health: Contaminated Diaper Reuse - CA
The incident occurred during routine urinary catheter care for Resident 37 at Laguna Hills Health and Rehabilitation Center. After cleaning the catheter with soap and water, LVN 5 tried to reapply the same diaper the resident had been wearing.
The nurse verified the diaper contained pinkish-colored drainage before attempting to put it back on the patient. Only then did LVN 5 request assistance from a certified nursing assistant to change the diaper.
State inspectors interviewed LVN 5 on August 21st. The nurse claimed she "did not notice the pinkish-colored drainage on the diaper" and acknowledged she "should have checked prior to attempting to reapply the used diaper."
LVN 5 admitted she "should have used a new diaper to prevent any contamination."
The facility's infection preventionist confirmed the basic protocol during an August 25th interview. For residents wearing diapers, licensed staff cleaning urinary catheters should examine the diaper before reapplying it to check whether it was clean or contained any drainage.
If drainage is observed, a new diaper should be used to prevent contamination, the infection preventionist stated.
The administrator and director of nursing acknowledged the findings when informed by inspectors on August 25th.
The violation occurred at a 120-bed facility on Health Center Drive that provides skilled nursing and rehabilitation services. Federal inspectors classified the incident as causing minimal harm or potential for actual harm, affecting few residents.
Urinary catheter care requires strict infection control protocols. Catheters create a direct pathway for bacteria to enter the urinary tract, making proper hygiene essential to prevent potentially serious infections.
Reusing contaminated materials during catheter care violates basic infection prevention standards. The pinkish drainage LVN 5 observed could indicate blood, infection, or other medical concerns requiring immediate attention rather than reapplication to the patient.
The nurse's admission that she should have inspected the diaper first suggests awareness of proper procedures but failure to follow them during patient care.
Federal regulations require nursing homes to maintain infection prevention and control programs to prevent the development and transmission of communicable diseases and infections. Staff must follow established procedures for infection control during all patient care activities.
The facility must now develop a plan of correction addressing how it will prevent similar incidents and ensure staff compliance with infection control protocols during catheter care.
LVN 5's request for assistance changing the diaper came only after attempting to reuse the contaminated material, raising questions about whether proper protocols would have been followed without the visible drainage serving as a warning.
The timing suggests the nurse recognized the contamination risk but only after potentially exposing the catheter patient to harmful bacteria or other pathogens present in the used diaper.
Resident 37's specific medical condition and any consequences from the incident were not detailed in the inspection report. The minimal harm classification indicates no serious injury resulted, but the potential for infection remained significant.
The violation represents a fundamental breakdown in infection control during one of the most infection-prone procedures in nursing home care. Catheter-associated urinary tract infections rank among the most common healthcare-associated infections in long-term care facilities.
Proper catheter care protocols exist specifically to prevent such contamination events. The nurse's acknowledgment of the error confirms knowledge of correct procedures but failure to implement them consistently during patient care.
The facility's infection preventionist clearly articulated the standard protocol, indicating policies were in place but not followed by LVN 5 during the August incident.
State inspectors completed their review on August 25th following the complaint-based investigation that uncovered the contaminated diaper incident.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Laguna Hills Health and Rehabilitation Center from 2025-08-25 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 19, 2026 · Our methodology
LAGUNA HILLS HEALTH AND REHABILITATION CENTER in LAGUNA HILLS, CA was cited for violations during a health inspection on August 25, 2025.
The incident occurred during routine urinary catheter care for Resident 37 at Laguna Hills Health and Rehabilitation Center.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.