Healthbridge Children's Hospital - Orange D/p Snf

F-F610

32179

2. Medical Record review of Resident 17 was initiated on 2/19/25. Resident 17 was admitted to the facility on [DATE REDACTED], and readmitted on [DATE REDACTED].

Review of the Order Summary Report dated 2/20/25, showed a physician's order dated 11/15/24, for the resident to wear the bilateral AFOs two hours on and two hours off from 0800 to 2200 hours as tolerated; maintain the ankle alignment and PROM exercises and prevent further contractures; check for skin integrity prior to and after the application; and inform the rehabilitation staff, nursing staff, or MD of any redness that not disappear within 30 minutes.

On 2/20/25 at 1445 hours, a concurrent interview and medical record review was conducted with RN 1. RN 1 was asked if there was any care plan to address the use of bilateral AFOs. RN 1 was unable to provide the documentation. RN 1 acknowledged the plan of care would need to be revised. RN 1 verified the findings.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 11 of 20 555753 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555753 B. Wing 02/24/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Healthbridge Children's Hospital - Orange D/P Snf 393 S Tustin St Orange, CA 92866

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 0693 Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 51920

Residents Affected - Few Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure one of 12 final sampled residents (Resident 1) received the appropriate treatment and services to prevent

the occurrences of complications from the GT feeding.

* The facility failed to ensure Resident 1's head of bed was positioned safely at 30 to 45 degrees during the GT feeding to reduce the risk of aspiration. In addition, the facility failed to ensure Resident 1's tube feeding formula was properly labeled. These failures posed the risk for developing complications related to GT feedings, which had the potential to negatively impact the resident's well-being.

Findings:

Medical record review for Resident 1 was initiated on 2/20/25. Resident 1 was admitted to the facility on [DATE REDACTED].

Review of Resident 1's H&P examination dated 3/6/21, showed Resident 1 had no capacity to understand and make decisions.

a. Review of the facility's P&P titled Enteral Tube Feeding via Continuous Pump dated 3/2022 showed to position the head of the bed at 30 - 45 (semi-Fowler's position) for feeding unless medically contraindicated.

On 2/19/24 at 0830 hours, an initial observation was conducted for Resident 1. Resident 1 was observed to have the tracheostomy, ventilator, and a GT feeding setup.

On 2/20/25 at 0832 hours, an interview was conducted with RT 1. RT 1 verified the HOB for the residents who had a tracheostomy, on ventilators or tube feedings should be at least 30 to reduce the risk of aspiration and [NAME]. RT 1 stated it was the responsibility of all the staff to ensure the HOB was at the correct elevation.

On 2/20/25 at 0844 hours, an observation of Resident 1 and concurrent interview with RN 2 was conducted.

The HOB for Resident 1 was confirmed to be only 20 with an angle measurement tool. RN 2 stated she thought the HOB for the residents on GT feedings should be above 45 , but it was ultimately the responsibility of the resident's nurse. RN 2 verified 20 was the incorrect setting for Resident 1 as she had a tracheostomy, ventilator, and was on periodic tube feedings.

On 2/20/25 at 0956 hours, an interview was conducted with LVN 1. LVN 1 verified the HOB for Resident 1 should be at least 30 to keep the secretions away so she would not aspirate.

On 2/20/25 at 1013 hours, an interview was conducted with CNA 2. CNA 2 verified the HOB should be 30 . CNA 2 stated she knew of the need for the resident to be positioned to 30 degrees from in-service trainings at the facility.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 12 of 20 555753 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555753 B. Wing 02/24/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Healthbridge Children's Hospital - Orange D/P Snf 393 S Tustin St Orange, CA 92866

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 0693 On 2/20/25 at 1028 hours, an interview was conducted with LVN 4. LVN 4 verified the HOB for Resident 1 should be at 30 - 45 as per the facility P&P. Level of Harm - Minimal harm or potential for actual harm On 2/2025 at 1332 hours, an observation was conducted of Resident 1. Resident 1 was observed in bed.

The HOB for Resident 1 was confirmed to be only 20 with an angle measurement tool. Resident 1 was Residents Affected - Few observed with an ongoing enteral GT feeding. RN 2 entered the resident's room and verified the HOB was too low. The measurement of 20 was verified by RN 2 and she adjusted the HOB to the correct height.

b. Review of the facility's P&P titled Enteral Tube Feeding via Continuous Pump issued on 3/2022 showed for the enteral feeding formula label, to document the initials, date and time the formula was hung/administered, and initial that the label was checked against the order.

Review of Resident 1's Medication Administration Record showed an enteral feeding physician's order dated 10/19/24, for Boost Kids Essentials with fiber 1.5 three times a day at 195 ml to run over one hour at 0900, 1300, and 1700 hours; and give 75 ml of water flush before and after the feeding.

On 2/19/25 at 0830 hours, an initial observation was conducted for Resident 1. Resident 1 was observed to have the tracheostomy, ventilator, and GT feeding setup. The feeding formula and water flush bags were observed with the label showing the date of 2/19/25, and time of 0600 hours.

On 2/20/25 at 1028 hours, an interview was conducted with LVN 4. LVN 4 stated the night shift was in charge of changing the water flush and GT feeding bags every 24 hours so the date and time on the empty bags was the date and time when the bags were changed. LVN 4 stated there was no way to know when the GT feeding formula was added to the GT feeding bag without looking in the computer. LVN 4 verified the staff did not put the date, time, or initial the GT feeding and flush bags when the feeding formula and water were added to the bags.

On 2/2025 at 1332 hours, an observation was conducted of Resident 1. Resident 1 was observed in bed with

an on going GT feeding. The date and time on the GT feeding and flush bags were noted as 2/20/25 at 0600 hours. RN 2 entered the room and stated the date and time on the bags referred to when the GT feeding and flush bags were changed. RN 2 verified the facility had no system for labeling the GT feeding bags with the date and time when the GT feeding formula was added to the bag.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 13 of 20 555753 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555753 B. Wing 02/24/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Healthbridge Children's Hospital - Orange D/P Snf 393 S Tustin St Orange, CA 92866

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 0695 Provide safe and appropriate respiratory care for a resident when needed.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 48332 potential for actual harm Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide Residents Affected - Few the necessary respiratory care and services for two of 12 final sampled residents (Residents 7 and 9).

* The facility failed to ensure Resident 7's cool aerosol therapy (treatment that uses mist of medicine to help relieve upper airway issues by loosening phlegm) plastic bag was dated as per the facility's P&P.

* The facility failed to ensure Resident 9's suction canister (bottle connected to suction machine to collect the secretions like phlegm, mucous during suctioning ) was dated when it was installed and hooked to the suction machine (medical device that removes obstructions from a patient's airway by clearing from secretions).

These failures had the potential for increased risk of infection.

Findings:

Review of the facility's P&P titled Changing Respiratory Equipment revised 1/2025 showed the purpose of

the P&P is to provide guidelines for changing respiratory therapy equipment. Continuous aerosol therapy equipment will be changed every seven days and PRN. All equipment will be dated including the tracheostomy collar. Aerosols will be issued sterile prefilled water and that is to be changed when empty or up to 48 hours of use. Suction canisters will be changed by nursing weekly and as needed. All disposable equipment will be dated when changed.

1. During the initial tour of the facility on 2/19/25 at 1605 hours, Resident 7 was observed lying in bed and connecting to a cool aerosol via T-piece (a device used for delivering oxygen through the trachea - tube like structure that connects the voice box to the lungs). The plastic bag labeled Cool Aerosol was dated 2/6/25.

On 2/20/25 at 0845 hours, a follow-up observation with concurrent interview with RT 3 for Resident 7 was conducted. The plastic bag labeled Cool Aerosol was still dated 2/6/25. RT 3 was asked when they changed

the set-up bag for the Cool Aerosol. RT 3 stated it was changed every week. RT 3 verified it was dated 2/6/25, and should have been changed last week which was on 2/13/25.

Medical record review for Resident 7 was initiated on 2/20/25. Resident 7 was initially admitted to facility on 9/19/22, and readmitted on [DATE REDACTED].

Review of Resident 7's medical record showed the resident's diagnoses included chronic respiratory failure (condition in which lungs are unable to adequately exchange oxygen and carbon dioxide over an extended period of time leading to low oxygen level), tracheostomy status, and multiple congenial heart malformations (heart defects that are present at birth).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 14 of 20 555753 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555753 B. Wing 02/24/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Healthbridge Children's Hospital - Orange D/P Snf 393 S Tustin St Orange, CA 92866

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 0695 2. On 2/19/25 at 1615 hours, an observation and concurrent interview with LVN 5 for Resident 9 was conducted. Resident 9 was lying in her bed. Resident 9's suction canister was observed with 60 -70 ml of Level of Harm - Minimal harm or whitish secretions connected to the suction machine which was not dated. LVN 5 verified the above findings potential for actual harm stated it should be dated because all the suction canisters must be dated once it was installed and connected to the suction machine. Residents Affected - Few Medical record review for Resident 9 was initiated on 2/20/25. Resident 9 was initially admitted to facility on 2/1/23, and was readmitted on [DATE REDACTED].

Review of Resident 9's medical record showed the resident's diagnoses included acute and chronic respiratory failure with hypoxia (absence of enough oxygen in the tissues to sustain bodily functions), tracheostomy status, and dependence on ventilator (machine that moves air in and out of the lungs) status.

On 2/24/25 at 1510 hours, the CEO was made aware and acknowledged the above findings.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 15 of 20 555753 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555753 B. Wing 02/24/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Healthbridge Children's Hospital - Orange D/P Snf 393 S Tustin St Orange, CA 92866

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 0758 Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic Level of Harm - Minimal harm or medications are only used when the medication is necessary and PRN use is limited. potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 32179 Residents Affected - Few Based on observation, interview, medical record review, and facility's P&P review, the facility failed to ensure one of 12 final sampled residents (Resident 273) were free from the unnecessary psychotropic medications.

* The facility failed to monitor the episodes of OMS as one of the behavior manifestations and side effect monitoring for alprazolam (anxiety medication) and sertraline (antidepressant medication) medications for Resident 273. In addition, both medications had the same indication. This failure had the potential for inaccurate behavior and side effects monitoring, which might cause the physician for not having the necessary information to determine the effectiveness of the medications for Resident 273.

Findings:

Medical review of Resident 273 was initiated on 2/19/25. Resident 273 was admitted to the facility on [DATE REDACTED].

Review of the Order summary Report dated 2/21/25, showed a physician's order dated 2/19/25, to administer alprazolam oral tablet 0.25 mg via GT two times a day for OMS for 30 Days. The summary report also showed a physician's order dated 2/20/25, to administer sertraline hydrochloride 50 mg by mouth one time a day for OMS for five days, then give 75 mg by mouth one time a day.

On 2/24/25 at 1000 hours, an interview and concurrent medical record review for Resident 273 was conducted with RN 4. RN 4 stated there was no monitoring of the behavior for the use of sertraline medication. RN 4 acknowledged the behavior monitoring for the alprazolam medication was not accurate in

the physician's order and the order was not specific. RN 4 acknowledged both medications had the same indication for use and it would be difficult to monitor the effectiveness of the medication. RN 4 stated there was no side effect monitoring for the two medications. RN 4 verified the above findings.

On 2/24/25 at 1100 hours, an interview and concurrent medical record review with LVN 6 was conducted. LVN 6 was asked which behaviors they were monitoring for the use of alprazolam and sertraline medications. LVN 6 stated it was for OMS. LVN 6 was not sure what specific behaviors to monitor for the use of the two medications. After reviewing the TAR, LVN 6 stated they monitored for 'call out' behavior for alprazolam medication. LVN 6 acknowledged the physician's order did not specify the behaviors monitoring for the use of the alprazolam and sertraline medications. LVN 6 verified the findings.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 16 of 20 555753 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555753 B. Wing 02/24/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Healthbridge Children's Hospital - Orange D/P Snf 393 S Tustin St Orange, CA 92866

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 0761 Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately Level of Harm - Minimal harm or locked, compartments for controlled drugs. potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 32179 Residents Affected - Few Based on observation, interview, medical record review, facility document review, and facility P&P review,

the facility failed to ensure the residents' medications and biologicals were properly stored and labeled for two of 12 final sampled residents (Residents 4 and 273). In addition, the facility failed to ensure three of six medication carts had no expired supplies and medication.

* Resident 4 had a six ounce tube of Triad hydrophilic wound dressing (used to provide a moist wound healing environment) with CMC (cellulose gum) at the bedside table.

* Resident 273 had a 22-gram tube of mupirocin (used to treat skin infections) 2% ointment and a 60-gram tube of Venelex wound dressing (used to cover wounds) on the bedside table.

* Medication Cart 2 had eight packets of SurePrep protective wipe (skin protectant) with an expiration date of [DATE REDACTED].

* Medication Cart 4 had an AG Cuffill pressure manometer (used for measuring and regulating intra-cuff pressure) with an expiration date of [DATE REDACTED].

* Medication Cart 6 had a GT feeding tube extension sets with Enfit (enteral feeding connection) connectors with an expiration date of [DATE REDACTED], and 42 packets of SurePrep protective wipe with an expiration date of [DATE REDACTED].

These failures had the potential for the unsecured medications be accessible to other residents and visitors, and the residents receiving expired or contaminated biologicals or medications.

Findings:

Review of the facility's P&P titled Medication Storage in the Facility dated ,d+[DATE REDACTED] showed the medications and biologicals are stored safely, securely and properly, following manufactures' recommendations or those of the supplier. Medications will not be kept on hand after the expiration date on the label (and no contaminated or deteriorated medications shall be available).

1. Medical review for Resident 273 was initiated on [DATE REDACTED]. Resident 273 was admitted to the facility on [DATE REDACTED].

On [DATE REDACTED] at 0830 hours, Resident 273 was observed with a 22-gram tube of mupirocin 2% ointment and a 60-gram tube of Venelex wound dressing on the bedside table.

On [DATE REDACTED] at 1440 hours, an observation and concurrent interview was conducted with RN 4. RN 4 was asked about the two tubes of medications on the resident's bedside table. RN 4 stated the medications were brought in with Resident 273 since the resident was admitted to the facility. RN 4 stated the medications should be locked or stored in the medication treatment cart. RN 4 verified the above findings.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 17 of 20 555753 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555753 B. Wing 02/24/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Healthbridge Children's Hospital - Orange D/P Snf 393 S Tustin St Orange, CA 92866

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 0761 2. Medical Record review of Resident 4 was initiated on [DATE REDACTED]. Resident 4 was admitted to the facility on [DATE REDACTED], and readmitted on [DATE REDACTED]. Level of Harm - Minimal harm or potential for actual harm On [DATE REDACTED] at 0815 hours, Resident 4 was observed with a six ounce tube of Triad hydrophilic wound dressing with CMC at the bedside table. Residents Affected - Few

On [DATE REDACTED] at 1430 hours, an observation and concurrent interview was conducted with LVN 1. LVN 1 stated

the wound dressing medication was brought in with Resident 4 since the resident was admitted to the facility. LVN 1 stated the wound dressing medication should be stored in medication treatment cart. LVN 1 verified

the above findings.

45064

3. On [DATE REDACTED] at 0813 hours, an inspection of Medication Cart 2 was conducted with RN 1. Medication Cart 2 was observed with eight packets of SurePrep protective wipe with an expiration date of [DATE REDACTED]. RN 1 stated

the expired supplies should be removed from the treatment cart immediately. RN 1 stated the SurePrep wipe was used to clean the skin to ensure the wound dressing would adhere better. RN 1 stated the expired supplies could be less effective. RN 1 verified the findings.

4. On [DATE REDACTED] at 0845 hours, an inspection of Medication Cart 4 was conducted with RT 1. Medication Cart 4 was observed with an AG Cuffill pressure manometer with an expiration date of [DATE REDACTED]. RT 1 stated the expired supplies needed to be remove from medication cart immediately. RT 1 verified the findings.

5. On [DATE REDACTED] at 0824 hours, an inspection of Medication Cart 6 was conducted with LVN 3. Medication Cart 6 was observed with a GT feeding tube extension sets with Enfit connectors with an expiration date of [DATE REDACTED], and 42 packets of SurePrep protective wipe with an expiration date of [DATE REDACTED]. LVN 3 stated the expired supplies should be removed from the medication immediately. LVN 3 stated the expired supplies could be less effective when used. LVN 3 verified the findings.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 18 of 20 555753 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555753 B. Wing 02/24/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Healthbridge Children's Hospital - Orange D/P Snf 393 S Tustin St Orange, CA 92866

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 0851 Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data. Level of Harm - Minimal harm or potential for actual harm 45064

Residents Affected - Few Based on interview and facility document review, the facility failed to submit the complete and accurate direct care staffing information to CMS. This failure posed the risk of inaccurate auditable data reporting.

Findings:

Review of the CMS CASPER reports showed the facility triggered a One-Star Staffing Rating due to the failure to submit data for the quarter from 7/1/24 to 9/20/24.

Review the Pediatric Monthly Subacute Staffing Report showed the following:

- For September 2024, the RN and LVN hours were within the requirement. However, there were 17 days that the CNA hours were below the minimum, for a total of 167.66 hours below the minimum.

- For October 2024, the RN and LVN hours were within the requirement. However, there were nine days that

the CNA hours were below the minimum, for a total of 76.68 hours below the minimum.

- For November 2024, the RN and LVN hours were within the requirement. However, there were five days that the CNA hours were below the minimum, for a total of 30.10 hours below the minimum.

- For December 2024, the RN and LVN hours were within the requirement. However, there were five days that the CNA hours were below the minimum, for a total of 37.99 hours below the minimum.

- For January 2025, the RN and LVN hours were within the requirement. However, there were 16 days that

the CNA hours were below the minimum, for the a total of 100.31 hours below the minimum.

There were negative variances of the CNA hours for the months mentioned above; however, there were excess nursing hours; therefore, the nursing staff assisted the residents with resident care.

On 2/21/25 at 1109 hours, an interview and concurrent facility document review was conducted with the CEO. When asked about the data submitted to CMS related to the payroll and reports generated triggering extremely low staffing on weekends, the CEO stated she submitted the PBJ electronically in October 2024 but did not submit it in the required XML format. The CEO stated the submitted PBJ was rejected, but she did not notice the rejection initially. The CEO stated when she found out it was rejected, she tried to resubmit

the PBJ but was not able to. The CEO stated the October 2024 PBJ was submitted on 10/25/24 (Friday), and

the facility tried resubmitting on 10/28/24 (Monday); however, there was no option to resubmit the PBJ. The CEO stated the facility was unable to contact CMS to obtain the information on how to resubmit the PBJ because there was no contact information available. When asked to provide the documentation of the October 2024 PBJ rejection notice, the CEO was unable to show or provide the copy. The CEO stated when

she went back to the CMS PBJ website, she was unable to print the notice.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 19 of 20 555753 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555753 B. Wing 02/24/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Healthbridge Children's Hospital - Orange D/P Snf 393 S Tustin St Orange, CA 92866

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 0908 Keep all essential equipment working safely.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 35346 potential for actual harm Based on observation, interview, and facility P&P review, the facility failed to ensure the resident care Residents Affected - Few equipment was kept in safe operating condition as evidenced by:

* The facility's mechanical lift stopped working during the transfer for one nonsampled resident (Resident 12).

* The ice buildup was observed in the enteral feeding refrigerator.

These failures posed the risk for equipment hazards or unsafe practices which could affect the residents' well-being in the facility.

Findings:

1. Review of the facility's P&P titled Hydro-Lift Instructions for Use dated [DATE REDACTED], showed the lift was to be charged daily, with minimum charging time of eight hours.

On [DATE REDACTED] at 1600 hours, an observation was conducted with CNA 1. CNA 1 was observed transferring Resident 12 from the resident's bed to a wheelchair using a mechanical lift. When lifting Resident 12 approximately one and a half feet above her wheelchair, the mechanical lift stopped working. CNA 1 stated

the mechanical lift's battery had died . CNA 1 was then observed manually pushing the mechanical lift and placing Resident 12 back to her bed. CNA 1 then stated she would get a charged battery for the mechanical lift.

On [DATE REDACTED] at 1645 hours, an interview was conducted with the Maintenance Director/Plants Operations. The Maintenance Director/Plants Operations was informed of the mechanical lift stopped working during a resident transfer. The Maintenance Director/Plants Operations stated the facility staff were expected to replace the mechanical lift's battery with a charged battery after each use.

2. On [DATE REDACTED] at 0955 hours, an observation and concurrent interview was conducted with RN 4. When RN 4 asked where the food items brought from outside of the facility could be stored, RN 4 showed a refrigerator labeled hospital nutrition only. The prepared enteral feedings used for the residents were observed stored inside the refrigerator with ice build up along the back side of the refrigerator. RN 4 verified the above findings.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 20 of 20 555753