Kindred Hospital Brea D/p Snf

F 0658 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

was asked regarding the expected appropriate and immediate action would be when a resident was observed to be lethargic and had an alarming pulse oximeter. The RT Supervisor stated the expectation would be to provide hyperoxygenation at 100%, call for help immediately, which should take less than a minute for other licensed staff to respond. The RT Supervisor stated she did not expect the RTs to wait five minutes or more to do an assessment and provide interventions when the RT observed the resident to be lethargic and pulse oximeter was alarming or if the RT was not certain about a resident's condition. In addition, the RT Supervisor stated the RTs must call for help from the licensed nurses and staff immediately. The RT Supervisor reviewed Resident 1's progress notes and verified the progress notes failed to show documentation regarding the incident from RT 1. The RT Supervisor verified the above findings. The RT Supervisor stated RT 1 did not need to document since the assigned RT responded to the code blue (a hospital code for a medical emergency, typically a patient in cardiac or respiratory arrest, requiring immediate medical intervention from a specialized team) and documented in Resident 1's progress notes. On [DATE REDACTED] at 1520 hours, a follow up interview was conducted with the DON. The DON stated all the licensed staff must check the residents first and assess for the level of consciousness, breathing, and pulse, which should take less than 30 seconds then call for rapid response or code blue immediately. On [DATE REDACTED] at 1545 hours, an interview was conducted with the Administrator and DON. The Administrator stated the nursing and respiratory therapy staff worked collaboratively as a part of the Interdisciplinary Collaborative Care Team. Together they develop the care plan(s) of the residents which were documented by the nursing staff. The Administrator stated all the facility's P&Ps must be followed by

the Interdisciplinary Collaborative Care Team. The Administrator and DON were informed and acknowledged the above findings.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/17/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Kindred Hospital Brea D/P Snf

875 N Brea Blvd Brea, CA 92821

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684

was conducted with the Administrator and DON. The Administrator and DON were informed and acknowledged the above findings.

Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/17/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Kindred Hospital Brea D/P Snf

875 N Brea Blvd Brea, CA 92821

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

earlier today. 3. Review of the Operator's Manual titled Med Air Pus 8 Alternating Pressure ad Low Air Loss Mattress Replacement System revised 3/15/16, showed the weight setting buttons (+) and (-) can be used to adjust the pressure of the inflated cells based on the patient's weight. The pressure of the mattress can be adjusted by choosing the patient's corresponding weight setting using the weight setting buttons.

Medical record review for Resident 3 was initiated on 9/2/25. Resident 3 was admitted to the facility on [DATE REDACTED], with the diagnosis of Stage 4 pressure ulcer of the sacral region. Review of Resident 3's MDS assessment dated [DATE REDACTED], showed Resident 3 had severe cognitive impairment. The MDS further showed Resident 3 was at risk for developing pressure injuries, and was totally dependent on the facility staff for rolling from left to right. Review of Resident 3's Physician Order Sheet for August 2025 showed a physician's order dated 3/20/25, to place Resident 3 on a pressure relieving mattress due to her Stage 4 pressure injury. Review of Resident 3's plan of care showed an active care plan problem (undated) addressing Resident 3's potential for further pressure injury development, skin breakdown, and skin discoloration. The interventions included to provide the pressure reducing mattress for skin management.

Review of Resident 3's Weight Worksheet showed on 8/4 and on 9/2/25, Resident 3 weighed 119 pounds.

On 9/2/25 at 0915, 1020, and 1110 hours, Resident 3 was observed lying on a LAL mattress. The LAL mattress unit was observed on and set at 300 pounds. On 9/2/25 at 1124 hours, an interview and concurrent medical record review for Resident 3 was conducted with LVN 2. LVN 2 stated for the residents

on a LAL mattress, the settings on the LAL mattress unit should correlate with the resident's current weight.

LVN 2 reviewed Resident 3's medical record and stated on 9/2/25, Resident 3 weight 119 pounds. On 9/2/25 at 1240 hours, an interview and concurrent observation was conducted with LVN 2. Resident 3 was observed lying on the LAL mattress and the LAL unit was observed set at 300 pounds. LVN 2 verified the above findings and stated the weight setting should not be set at 300 pounds. LVN 2 stated if the setting was set too firm, or not appropriate to the resident's weight, then it might affect the healing of the resident's wounds. On 9/4/25 at 1400 hours, an interview was conducted with the DON. The DON stated the treatment nurses were responsible for checking to ensure the settings on the LAL mattress unit were appropriate for the resident when they went in the room to provide the wound treatment. The DON stated

the licensed nurses entering the resident's room should also be looking at the settings. The DON stated if

the residents were on the incorrect setting for a long period of time, it might affect the healing of the wound.

On 9/7/25 at 1545 hours, an interview was conducted with the Administrator and DON. The Administrator and DON were informed and acknowledged the above findings.

Event ID:

Facility ID:

If continuation sheet