Advanced Rehab Center Of Tustin

F-F755, example #1.a.

b. On 3/20/25 at 0907 hours, a treatment cart inspection was conducted with LVN 9. LVN 9 verified four Calmoseptine ointments stored inside the treatment cart did not have expiration dates or received dates on them. LVN 9 stated the ointments were to be kept for three years from the receive date. LVN 9 acknowledged the ointments should not have been kept inside the cart since the receive date was unknown.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 31 of 55 055330 Department of Health & Human Services Printed: 09/04/2025 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 055330 B. Wing 03/24/2025

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

Advanced Rehab Center of Tustin 2210 E. First Street Santa Ana, CA 92705

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 c. On 3/18/25 at 1441 hours, a medication room inspection was conducted with RN 2. Two disposal bins used for medications disposal were unlocked and contained multiple undissolved tablets, sharps containers, Level of Harm - Minimal harm or liquid medication bottles, nasal spray containers, and insulin pens. RN 2 verified the findings. potential for actual harm 48882 Residents Affected - Few 3. Review of the facility's P&P titled Medication Labeling and Storage revised 2/2023 showed the nursing staff was responsible for maintaining the medication storage and preparation areas in a clean, safe, and sanitary manner.

On 3/18/25 at 0908 hours, during the medication administration observation for Resident 113 with LVN 5, a bottle of Pro-Stat Advanced Wound Care was observed with sticky brown residue on and around the bottle cap and on the bottle. LVN 5 verified the above findings and stated the bottle of Pro-Stat should be wiped and cleaned after each use and before it was placed back inside the medication cart.

On 3/24/25 at 1033 hours, an interview was conducted with the DON. The DON stated the licensed nurses assigned to the medication carts were responsible for the cleanliness, storage, and labeling of the medications inside their assigned medication carts. The DON further stated for the dispensing of the liquid medications, the licensed nurses were expected to clean the medication bottles to ensure there were no stickiness or residue prior to placing the medication bottle back in the medication cart.

On 3/24/25 at 1321 hours, an interview was conducted with the DON and Administrator. The DON and Administrator were informed and acknowledged the above findings.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 32 of 55 055330 Department of Health & Human Services Printed: 09/04/2025 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 055330 B. Wing 03/24/2025

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

Advanced Rehab Center of Tustin 2210 E. First Street Santa Ana, CA 92705

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 0803 Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. Level of Harm - Minimal harm or potential for actual harm 47476

Residents Affected - Few Based on observation, interview, facility document review, and facility P&P review, the facility failed to ensure

the menus were followed for 20 of 93 residents who received food prepared in the kitchen as evidenced by:

* 19 residents who were on a CCHO diet were served the canned fruit instead of the diet gelatin with whip topping as shown on the posted menu.

* Resident 87 was not served the gelatin with whipped topping as per the menu.

These failures had the potential for the residents to not receive an adequate nutrition and appropriate servings to meet the residents' individual needs.

Findings:

Review of the facility's Diet Type Report dated 3/17/25, showed 93 of 96 residents residing in the facility received food prepared in the kitchen and 19 of the 96 residents had a CCHO diet.

Review of the facility's P&P titled Menus revised 10/2017 showed menus provide a variety of foods from the basic daily food groups and indicate standard portions at each meal. Copies of the menus are posted in at least two resident areas, in positions and in print large enough for residents to read them.

Review of the facility's P&P titled Substitutions revised 4/2007 showed all substitutions are noted on the menu and filed in accordance with established dietary policy.

Review of the facility's document titled Spring Cycle Menus - Week 3 Monday 3/17/25, showed the residents

on a regular, mechanical soft diet would be served the gelatin with whipped topping. The document also showed the residents on a CCHO diet would be served the diet gelatin with whipped topping.

During the lunch dining observation on 3/17/25 at 1225 hours, an observation and concurrent interview was conducted with CNA 6 for Residents 55 and 87. The following was observed:

- Resident 55's meal ticket showed the resident was to receive a regular CCHO diet. Resident 55's was not observed with the diet gelatin with whipped topping dessert. Resident 55 was instead served canned fruit.

- Resident 87's meal ticket showed the resident was to receive a regular mechanical soft diet. Resident 87 was not observed with the gelatin with whipped topping dessert.

Following the observations, CNA 6 was asked about Residents 55 and 87's missing gelatin with whipped topping dessert per the menu. CNA 6 verified Residents 55 and 87 were not served the gelatin with whipped topping dessert and would need to ask the kitchen staff.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 33 of 55 055330 Department of Health & Human Services Printed: 09/04/2025 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 055330 B. Wing 03/24/2025

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

Advanced Rehab Center of Tustin 2210 E. First Street Santa Ana, CA 92705

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 0803 On 3/17/25 at 1227 hours, a follow-up observation and concurrent interview was conducted with CNA 6. CNA 6 returned from the kitchen and stated Resident 55 could not have the gelatin because she was on a Level of Harm - Minimal harm or CCHO diet, but Resident 87 could have it and CNA 6 proceeded to provide Resident 87 with the dessert. potential for actual harm

On 3/17/25 at 1228 hours, an interview was conducted with the DSS. The DSS stated the facility gave the Residents Affected - Few residents on a CCHO diet canned fruit because the facility did not have the diet gelatin with whipped topping.

The DSS stated the facility did not change the menu. The DSS stated he would notify the residents with a note on their meal ticket, but did not get a chance to note it and did not notify the residents of the menu change.

On 3/24/25 at 1310 hours an interview was conducted with the DSS and RD. The DSS and RD acknowledged the above findings.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 34 of 55 055330 Department of Health & Human Services Printed: 09/04/2025 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 055330 B. Wing 03/24/2025

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

Advanced Rehab Center of Tustin 2210 E. First Street Santa Ana, CA 92705

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 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 47476 potential for actual harm Based on observation, interview, and facility document review, the facility failed to ensure the residents Residents Affected - Few received food with preserved nutritive content and palatibility as evidenced by:

* The pureed carrots were cooked and held in a hot oven for more than two hours prior to the meal service.

This failure had the potential to not meet the nutritional needs for the residents consuming food prepared in

the kitchen.

* The facility failed to ensure the facility food was palatable when one of 93 final sampled residents (Resident 94) and one nonsampled resident (Resident 57) who received food prepared in the facility kitchen were not satisfied with the facility food. This failure had the potential for the 4 residents to have decreased intake which could lead to unplanned weight loss and other medically related concerns.

Findings:

1. Review of the facility's Diet Type Report dated 3/17/25, showed 93 of 96 residents residing in the facility received food prepared in the kitchen and 11 of the 96 residents received pureed food.

Review of the facility's document titled Diet Type Report dated 3/17/25, showed 11 residents were on pureed diets.

Review of the professional reference titled How Cooking Affects the Nutrient Content of Foods dated 11/7/19, showed the following nutrients are often reduced during cooking: water-soluble vitamins: vitamin C and the B vitamins - thiamine (B1), riboflavin (B2), niacin (B3), pantothenic acid (B5), pyridoxine (B6), folic acid (B9), and cobalamin (B12), fat-soluble vitamins: vitamins A, D, E, and K, and minerals: primarily potassium, magnesium, sodium, and calcium . https://www.healthline.com/nutrition/cooking-nutrient-content.

Review of the facility's document titled Meal Times showed the following: breakfast starting at 0715 hours, lunch starting at 1155 hours, and dinner starting at 1725 hours.

On 3/18/25 at 0923 hours, an observation of the pureed food preparation and concurrent interview was conducted with [NAME] 1 with translation provided by the DSS. [NAME] 1 was assigned to puree the cooked carrots and followed the pureed vegetables recipe. [NAME] 1 placed the pureed vegetables into a metal serving container, covered with a plastic wrap, and labeled it.

On 3/18/25 at 1131 hours, an observation of the kitchen trayline was conducted. The temperature of the pureed carrots on the steam table was 172 degrees F. During the trayline, the DSS was asked where the pureed foods were kept. The DSS stated the cook put all the pureed foods in the oven for holding and the oven was at 200 degrees F.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 35 of 55 055330 Department of Health & Human Services Printed: 09/04/2025 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 055330 B. Wing 03/24/2025

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

Advanced Rehab Center of Tustin 2210 E. First Street Santa Ana, CA 92705

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 0804 On 3/18/25 at 1600 hours, an interview was conducted with the RD. The RD verified the carrots were cooked prior to the pureed preparation observation. The RD was informed the pureed food preparation was Level of Harm - Minimal harm or completed at 0945 hours and the pureed carrots had been held in the hot 200 degree F oven until the potential for actual harm trayline at 1130 hours. The RD acknowledged the findings. When asked if the pureed carrots could lose nutritive value from being prepared two hours ahead of trayline and held in the oven at 200 degrees F, the Residents Affected - Few RD stated it was not about when it was prepared, but how it was prepared and they did not lose the nutritive value.

On 3/24/25 at 1310 hours an interview was conducted with the DSS and RD. The DSS and RD acknowledged the above findings.

48882

2. Review of the facility document titled Weekly Menu Guide, showed for lunch on Monday 3/17/25, the menu was: vegetable rice, soup, corned beef, boiled dill potatoes, cabbage and carrots, wheat roll, and gelatin with whipped topping.

Medical record review for Resident 94 was initiated on 3/17/25. Resident 94 was admitted to the facility on [DATE REDACTED].

Review of Resident 94's H&P examination dated 11/27/24, showed Resident 94 had the capacity to understand and make decisions.

Review of Resident 94's Order Summary Report showed a physician's order dated 11/28/24, for a no added salt diet with regular texture, regular liquid consistency, and double portions for malnutrition and advanced age.

Review of Resident 94's MDS assessment dated [DATE REDACTED], showed Resident 94 had no impairment in functional limitation in the upper extremities and was able to eat independently.

On 3/17/25 at 1316 hours, an observation and concurrent interview was conducted with Resident 94 and LVN 1 in Resident 94's room. Resident 94 was observed attempting to cut into the corned beef on her lunch plate. Resident 94 was observed moving the knife back and forth and was unable to cut the corned beef into smaller pieces. Resident 94 stated the meat was too tough and that she could not cut into it. Resident 94 informed LVN 1 the corned beef was too tough, and she could not cut the meat. LVN 1 asked Resident 94 if

she would like another lunch tray. Resident 94 requested for LVN 1 to bring her the food brought to the facility by her visitors.

3. On 3/18/25 at 1050 hours, during the resident council meeting, Resident 57 stated the corned beef served

during the lunch meal on 3/17/25 was hard and she was unable to chew the meat; and Resident 79 stated

the corned beef was tough and she was unable to cut the meat.

On 3/18/25 at 1409 hours, an interview was conducted with the DSS. The DSS was asked if he was aware of any resident's complaints of the toughness of the corned beef served for lunch on 3/17/25. The DSS stated

on 3/17/25, Resident 425 had approached him in the hallway and had complained about the corned beef being tough. Additionally, the DSS stated he was informed by the nurse that Resident 94 had complained about her corned beef being tough. The DSS further stated both Residents 94 and 425 were offered alternatives.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 36 of 55 055330 Department of Health & Human Services Printed: 09/04/2025 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 055330 B. Wing 03/24/2025

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

Advanced Rehab Center of Tustin 2210 E. First Street Santa Ana, CA 92705

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 0804 On 3/19/25 at 1404 hours, an interview was conducted with CNA 6. CNA 6 stated on 3/17/25, she was in the dining room assisting the residents with their lunch meal. CNA 6 stated there were multiple residents who Level of Harm - Minimal harm or had reported to her that the corned beef was tough and chewy. CNA 6 stated multiple residents had potential for actual harm requested for alternative entrees. CNA 6 further stated she had assisted some of the residents to cut their corned beef into smaller pieces and agreed the corned beef was tough to cut into. Residents Affected - Few

On 3/24/25 at 1321 hours, an interview was conducted with the RD and DSS. The RD and DSS were informed and acknowledged the above findings.

On 3/24/25 at 1321 hours, an interview was conducted with the DON and Administrator. The DON and Administrator were informed and acknowledged the above findings

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 37 of 55 055330 Department of Health & Human Services Printed: 09/04/2025 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 055330 B. Wing 03/24/2025

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

Advanced Rehab Center of Tustin 2210 E. First Street Santa Ana, CA 92705

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 0805 Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. Level of Harm - Minimal harm or potential for actual harm 47476

Residents Affected - Few Based on observation, interview, facility document review and facility P&P review, the facility failed to ensure

the residents on mechanically altered diets received food in a form that met their individual needs.

* One of 11 residents (final sampled resident, Resident 3) who had physician's orders for a regular pureed diet received a regular dysphagia mechanical soft diet.

* The pureed BBQ chicken was observed with small chunks of chicken.

These failures posed the risk for complications such as choking for the 11 residents who were on pureed diets.

Findings:

Review of the facility's Diet Type Report dated 3/17/25, showed 93 of 96 residents residing in the facility received food prepared in the kitchen.

Review of the facility's document titled Diet Type Report dated 3/17/25, showed 11 residents were on pureed diets.

Review of the facility's P&P titled Therapeutic Diets revised 10/2017 showed therapeutic diets are prescribed by the attending physician to support the resident's treatment and plan of care in accordance with his or her goals and preferences.

Review of the facility's document titled Regular Pureed Diet dated 2023 showed the pureed diet is a regular diet that has been designed for residents who have difficulty chewing and/or swallowing. The texture of the food should be of a smooth and moist consistency and able to hold its shape. All foods are prepared in a food processor or blender.

1. During the lunch dining observation on 3/17/25 at 1204 hours, LVN 7 and CNA 5 were observed checking

the trays on the meal cart. LVN 7 checked the facility document titled Diet Type Report, then checked the meal on the tray. Resident 3 was served a regular dysphagia mechanical soft meal. Resident 3's meal ticket stated her diet was for regular dysphagia mechanical soft.

On 3/17/25 at 1218 hours, an observation of Resident 3 and concurrent interview was conducted with LVN 7, Resident 3 no longer had a regular dysphagia mechanical soft meal and was served a pureed diet instead. LVN 7 stated she changed Resident 3's meal tray because the Diet Type Report showed she should have a regular pureed diet. LVN 7 was unable to state why Resident 3's meal ticket showed a different diet than the Diet Type Report. LVN 7 stated she would have to ask her charge nurse about the correct diet.

On 3/17/25 at 1226 hours, an observation and concurrent interview was conducted with Resident 3. Resident 3 stated she did not know why her meal was changed, but the pureed diet did not taste good.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 38 of 55 055330 Department of Health & Human Services Printed: 09/04/2025 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 055330 B. Wing 03/24/2025

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

Advanced Rehab Center of Tustin 2210 E. First Street Santa Ana, CA 92705

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 0805 On 3/17/25 at 1228 hours, an interview and concurrent facility document review was conducted with the DSS. The DSS stated they would go by the Diet Type Report for the resident's diet. The DSS verified Level of Harm - Minimal harm or Resident 3 should have not been served the regular mechanical soft diet as per her meal ticket. potential for actual harm

On 3/18/25 at 1000 hours, am interview was conducted with the ST. The ST stated she had updated Residents Affected - Few Resident 3's diet to a mechanical soft diet on Friday, but something happened on the EHR and the physician's order was not updated.

2. Review of the facility document titled Spring Cycle Menus - Week 3 Tuesday 3/18/25, showed the residents on pureed diets were to receive pureed BBQ chicken.

On 3/18/25 at 0923 hours, an observation of the pureed preparation was conducted with [NAME] 1 with translation provided by the DSS. [NAME] 1 had pre-prepared 15 portions of regular BBQ chicken in a pan. [NAME] 1 was observed to use a Robot Coupe blender to blend the whole pieces of BBQ chicken in two separate batches. Once each batch was blended, she placed the pureed chicken into a pan. The pan with

the completed BBQ chicken puree was observed with small chunks of chicken throughout the puree. [NAME] 1 then covered and labeled the pureed BBQ chicken.

After the pureed food preparation was completed with [NAME] 1 on 3/18/25 at 0945 hours, the pureed BBQ was observed with the DSS. The DSS acknowledged there were small chunks of chicken still in the pureed BBQ chicken and stated they would blend it more.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 39 of 55 055330 Department of Health & Human Services Printed: 09/04/2025 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 055330 B. Wing 03/24/2025

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

Advanced Rehab Center of Tustin 2210 E. First Street Santa Ana, CA 92705

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 0812 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food

in accordance with professional standards. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 47476

Residents Affected - Some Based on observation, interview, facility document review, and facility P&P review, the facility failed to ensure

the sanitary requirements were met in the kitchen.

* The facility failed to ensure proper labeling and dating of foods in the kitchen and failed to ensure the expired food items in the kitchen were discarded.

* The facility failed to ensure the kitchen equipment were in good condition.

* The facility failed to ensure proper labeling and dating of foods in the refrigerator used for the residents' food brought in by visitors and failed to ensure the expired foods were discarded.

* The facility failed to ensure the microwave used to warm up the residents' food brought in from the outside was maintained in sanitary condition and free of food residue.

* The facility failed to ensure the kitchen staff correctly tested the chemical concentration measured in parts per million for the quaternary sanitizing solution used to sanitize food contact surfaces.

These failures had the potential to cause foodborne illnesses in a medically vulnerable resident population who consumed food prepared in the kitchen.

Findings:

Review of the facility's Diet Type Report dated [DATE REDACTED], showed 93 of 96 residents residing in the facility received food prepared in the kitchen.

1. Review of the facility's P&P titled Food Receiving and Storage revised ,d+[DATE REDACTED] showed the section titled Refrigerated/Frozen storage, all the foods stored in the refrigerator or freezer are covered, labeled and dated (use by date). Refrigerated foods are labeled, dated and monitored so they are used by their use-by date, frozen, or discarded.

Review of the facility's P&P titled Foods Brought by Family/Visitors revised ,d+[DATE REDACTED] showed the foods, beverages, or perishable food that requires refrigeration can be stored for the resident in the facility designated residents' refrigerator.

On [DATE REDACTED] at 755 hours, an initial tour of the kitchen was conducted with the RD.

a. In the walk-in refrigerator, the following was observed:

- a pack of unpasteurized Lucerne cage free eggs labeled with the name and room number of Resident 423. There were eight eggs left in the container;

- one container of sour cream without a use-by date;

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 40 of 55 055330 Department of Health & Human Services Printed: 09/04/2025 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 055330 B. Wing 03/24/2025

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

Advanced Rehab Center of Tustin 2210 E. First Street Santa Ana, CA 92705

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 0812 - two pans of jello without a use-by date;

Level of Harm - Minimal harm or - a container of buttermilk ranch dressing with an open date of [DATE REDACTED]. There was dried whitish sticky potential for actual harm residue observed on the container and no use-by date;

Residents Affected - Some - a container filled with seven pre-prepared sandwiches with a prepared date of [DATE REDACTED] and unreadable use-by date;

- a bag of sliced ham without a use-by date;

- a container filled with six ground beef packets with a pulled date of [DATE REDACTED] and a use-by date of [DATE REDACTED]; and

- a container filled with three ground beef packs and one ground turkey pack with a pulled date of [DATE REDACTED], and a use-by date of [DATE REDACTED].

The RD verified the findings and stated he would throw out the sandwiches and ground meats. The RD verified the items should be labeled with the date and use-by date.

b. In Freezer 1, the following was observed with the DSS:

- five packs of frozen waffles, without a label.

The DSS verified the findings.

c. On the counter directly adjacent to Freezer 1, a container with two peanut butter jelly sandwiches was observed with a prepared date of [DATE REDACTED] and use-by date of [DATE REDACTED].

The DSS verified the findings.

d. The juice machine was observed with four juice containers hooked up. The four juice containers were observed without labels.

The DSS verified the findings and stated the kitchen staff would change out all the juices.

e. In Freezer 2, the following was observed:

- one bag of corn on the cob without a label.

The DSS verified the findings.

2. According to the USDA Food Code 2022 Section ,d+[DATE REDACTED].11, Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils, the food-contact surfaces of cooking equipment and pans shall be kept free of encrusted grease deposits and other soil accumulations. Nonfood-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 41 of 55 055330 Department of Health & Human Services Printed: 09/04/2025 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 055330 B. Wing 03/24/2025

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

Advanced Rehab Center of Tustin 2210 E. First Street Santa Ana, CA 92705

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 0812 Review of the facility's P&P titled Sanitization revised ,d+[DATE REDACTED] showed all utensils, counters, shelves and equipment are kept clean, maintained in good repair and are free from breaks, corrosions, open seams, Level of Harm - Minimal harm or cracks and shipped areas that may affect their use or proper cleaning. Seals, hinges and fasteners are kept potential for actual harm in good repair.

Residents Affected - Some a. On [DATE REDACTED] at 0820 hours, during the initial tour in the kitchen conducted with the DSS, the plate lowerator was observed to have two loose handles. Additionally, there was dried food debris observed on the bottom panels of the plate lowerator.

The DSS verified the findings.

b. On [DATE REDACTED] at 0904 hours, the can opener was observed with a chipped stainless-steel coating, exposing

the blade.

The DSS verified the findings and stated the kitchen staff would replace the blade.

c. On [DATE REDACTED] at 0904 hours, two upper plate domes were observed with warped and corroded areas.

On [DATE REDACTED] at 1310 hours, the DSS and RD were informed and acknowledged the findings.

3. Review of the facility's P&P titled Food Receiving and Storage revised ,d+[DATE REDACTED] showed under the section titled Foods and Snacks Kept on Nursing Units, all foods belonging to residents are labeled with the resident's name, the item and the use-by date. Other opened containers are dated and sealed or covered

during storage.

Review of the facility's P&P titled Foods Brought by Family/Visitors revised ,d+[DATE REDACTED] showed perishable foods must be stored in re-sealable containers with tightly fitting lids in the refrigerator. Containers will be labeled with the resident's name and the received date. The leftover foods may be kept in the refrigerator per

the resident's request, the staff will wrap the leftover container/or food in a plastic bag, then label with name, date and disposed of within 72 hours. Prepared or perishable food if stored in the refrigerator must be disposed of within three days.

On [DATE REDACTED] at 0828 hours, an observation of the residents' refrigerator was conducted with the DSS. The following was observed:

- a plastic wrapped box labeled for Resident 94 with a date of [DATE REDACTED], without a use-by date;

- a plastic bag labeled with Resident 89's name, containing an opened container of sour cream undated;

- orange containers with food inside wrapped in plastic labeled with Resident 94's name and undated;

- an opened package of sliced pepper jack cheese for Resident 51, labeled with his name and undated;

- a plastic bag labeled with Resident 95's name and dated [DATE REDACTED], without a use-by date. The plastic bag contained two containers of partially eaten leftovers.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 42 of 55 055330 Department of Health & Human Services Printed: 09/04/2025 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 055330 B. Wing 03/24/2025

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

Advanced Rehab Center of Tustin 2210 E. First Street Santa Ana, CA 92705

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 0812 The DSS verified the above findings.

Level of Harm - Minimal harm or 4. According to the USDA Food Code 2022 Section ,d+[DATE REDACTED].11, Equipment, Food-Contact Surfaces, potential for actual harm Nonfood-Contact Surfaces, and Utensils, the food-contact surfaces of cooking equipment and pans shall be kept free of encrusted grease deposits and other soil accumulations. Nonfood-contact surfaces of equipment Residents Affected - Some shall be kept free of an accumulation of dust, dirt, food residue, and other debris.

On [DATE REDACTED] at 0830 hours, an observation of the residents' microwave was conducted with the DSS. The residents' microwave was observed with spots of dried and crusted brown residues on the walls of the microwave. The DSS verified the findings and stated it was not clean. The DSS stated the housekeeping staff would clean it.

5. Review of the facility's P&P titled Sanitation revised ,d+[DATE REDACTED] showed the manual washing and sanitizing is a three-step process for washing, rinsing and sanitizing. The chemical sanitizing solutions are used according to manufacturer's instructions.

Review of the manufacturer's guidelines for the quaternary sanitizer testing showed testing instructions to withdraw and tear off approximately two inches of paper from dispenser. Dip the paper for 10 seconds and don't shake. In addition, the testing solution should be between 200 - 400 parts per million (ppm).

On [DATE REDACTED] at 0854 hours, an observation and concurrent interview was conducted with the Dietary Aide regarding the facility's manual ware washing. The Dietary Aide was asked to demonstrate how he tested the chemical sanitizing solution. The Dietary Aide was observed filling up a red bucket with the sanitizing solution and obtaining a strip of test paper. The Dietary Aide dipped the strip into the red bucket for one second, read

the strip, then stated it was at 200 ppm. The Dietary Aide verified he dipped the test strip in the sanitizing solution for one second. The Dietary Aide verified the strip should be dipped for 10 seconds.

On [DATE REDACTED] at 1310 hours, an interview was conducted with the DSS and RD. The DSS and RD acknowledged all of the above findings.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 43 of 55 055330 Department of Health & Human Services Printed: 09/04/2025 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 055330 B. Wing 03/24/2025

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

Advanced Rehab Center of Tustin 2210 E. First Street Santa Ana, CA 92705

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 0813 Have a policy regarding use and storage of foods brought to residents by family and other visitors.

Level of Harm - Minimal harm or 47476 potential for actual harm Based on interview, facility document review, and facility P&P review, the facility failed to ensure the Residents Affected - Few education on safe food handling of outside food was provided to the staff, residents, and visitors. This failure had the potential to cause foodborne illnesses to the medically vulnerable resident population who consumed food brought from the outside sources.

Findings:

Review of the facility's P&P titled Foods Brought by Family/Visitors revised 12/2023 showed the residents, residents' representatives, families, and visitors will be educated on the facility's food policy including safe food handling of foods brought from outside. The educational material on food handling and safety will be available at the reception desk. The Admission Coordinator or designee will review the food policy with emphasis on safe food handling to the resident, and/or representative during initial admission agreement packet review.

On 3/19/25 at 1336 hours, an interview was conducted with CNA 2. CNA 2 stated she had the residents who brought in food from the outside. CNA 2 stated she would microwave the food, if the resident requested, in

the resident microwave. When asked if she heated it to a specific temperature, CNA 2 stated she would microwave the food for 30 seconds to a minute and would not make it too hot so the resident would not burn themselves. CNA 2 stated the DSD provided in-service about safe food handling.

On 3/20/25 at 0814 hours, an interview was conducted with CNA 3. CNA 3 stated she had the residents who brought in food from the outside. CNA 3 stated she did not know any information about safe food handling but would let the resident ate the food at one time and would throw the leftovers away. When asked if she heated the foods in the microwave to a specific temperature, CNA 3 stated she would microwave the food for one half to one minute and no more than that because it would be too hot for the resident. CNA 3 stated she did not know how to check the temperatures of the food. CNA 3 stated the DSD provided in-service about safe food handling.

On 3/20/25 at 0824 hours, an interview was conducted with CNA 4. CNA 4 stated he had the residents who brought in food from the outside. When asked how he reheated foods, CNA 4 stated he would ask how hot

the resident wanted it and the resident would tell him how long to microwave for. CNA 4 stated he would check the temperature by putting the back of his hand on it. CNA 4 was asked what he knew regarding safe food handling. CNA 4 stated he did not know much and has not had education from the facility for safe food handling.

On 3/20/25 at 0829 hours, an interview was conducted with LVN 6. LVN 6 stated for safe food handling, they would make sure the food was clean and not contaminated. When asked what she taught to the residents or visitors who brought food from the outside, LVN 6 stated she would make sure the resident was not allergic to the food and would store the food for only 24 hours. When asked about food temperatures, LVN 6 stated

she could not put the food in the refrigerator right away because it was warm and would wait 30 min or an hour.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 44 of 55 055330 Department of Health & Human Services Printed: 09/04/2025 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 055330 B. Wing 03/24/2025

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

Advanced Rehab Center of Tustin 2210 E. First Street Santa Ana, CA 92705

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 0813 On 3/20/25 at 0838 hours, an interview and concurrent facility P&P review was conducted with the DSD. The DSD stated he provided in-services to the CNAs and charge nurses for food brought in from the outside by Level of Harm - Minimal harm or going over the facility policy titled Foods Brought by Family/Visitors. The DSD stated he would teach the staff potential for actual harm that the food needs to be labeled with the date, after 72 hours they would discard the food, and would tell them if the food was opened, they could not put it back into the refrigerator to prevent infection. When asked Residents Affected - Few what education was provided regarding the safe food handling, the DSD verified he did not provide education specific to safe food handling.

On 3/20/25 at 0846 hours, an interview was conducted with RN 2. RN 2 was asked about the safe food handling of the foods brought in from the outside. RN 2 stated she would teach the resident/visitors to wash their hands and when they wanted to microwave the food, to give it to the staff and a CNA would help to microwave the food. RN 2 stated she would make sure the food was labeled with the name, room number, and time and after three days, it would be thrown away. RN 2 stated safe food handling education was provided by the kitchen and DSD.

On 3/20/25 at 0853 hours, an interview, concurrent facility document and facility P&P review was conducted with the RD. The RD stated he had not yet given any in-services to the staff outside of the kitchen. When asked about the safe food handling education provided, the RD verified he did not provide safe food handling education to the visitors/family but would do it upon request. The facility educational material on food handling and safety located at the reception desk was reviewed with the RD. The RD verified the educational material did not have any information on safe food handling.

On 3/20/25 at 0900 hours, an interview and concurrent facility P&P review was conducted with the Admissions Director. The Admissions Director stated upon admission, she would provide the policy titled Foods Brought by Family/Visitors and the policy titled Reheating Food Brought in for a Resident (which did not show any information regarding safe food handling). The Admissions Director stated she would let the family know if the resident was on a specific diet, they would need to check with the dietician so they would not bring anything that would harm the resident and if there was food that could be stored, would only hold it for 72 hours and would dispose of the food if not consumed. When asked about teaching regarding safe food handling, the Admissions Director verified she only provided the two policies, and she did not provide information specific to safe food handling.

On 3/24/25 at 1330 hours, an interview was conducted with the Administrator and DON. The Administrator and DON acknowledged the findings.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 45 of 55 055330 Department of Health & Human Services Printed: 09/04/2025 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 055330 B. Wing 03/24/2025

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

Advanced Rehab Center of Tustin 2210 E. First Street Santa Ana, CA 92705

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 0838 Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 39670

Residents Affected - Few Based on interview and facility document review, the facility failed to ensure the Facility Assessment addressed or included the following:

1. Active involvement of required individuals in developing the Facility Assessment;

2. Resources necessary to care for residents including weekends;

3. A plan to maximize recruitment and retention of direct care staff; and

4. A contingency plan for staffing needs.

This failure had the potential to not meet the residents' care needs if the assessed population's needs and resources were not comprehensively identified and addressed.

Findings:

According to the CMS QSO-24-13-NH dated 6/18/24, with an implementation date of 8/8/24, CMS had issued a revised guidance for long-term care facility assessment requirement. The Facility Assessment should address and included the active involvement of the direct care staff in developing the Facility Assessment. Also included the staffing resources necessary to care for the residents, including the weekends; a plan to maximize recruitment and retention of direct care staff member, and a contingency plan for staffing needs for the events not to activate the facility's emergency plan.

Review of the Facility's assessment dated [DATE REDACTED], did not show the direct care staff member, direct care representatives, residents, residents' representatives, and residents' family members were actively involved

in developing the Facility Assessment; the resources necessary to care for the residents including weekends; and a plan to maximize recruitment and retention of the direct care staff, or include a contingency plan for the staffing needs.

On 3/24/25 at 0826 hours, an interview and concurrent facility document review of the Facility Assessment was conducted with the Administrator. The Administrator verified the Facility Assessment was dated 1/16/25, and acknowledged he was not aware of the new update of the Facility Assessment from the CMS. The Administrator verified there were no direct care staff, direct care representatives, residents, residents' representatives, and family members actively involved in developing the Facility Assessment. The Administrator further verified there were no resources necessary to care for the residents including weekends, and a plan to maximize recruitment and retention of the direct care staff, or include a contingency plan for the staffing needs. The Administrator verified and acknowledged the Facility Assessment was not updated based on the latest guidance from the CMS.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 46 of 55 055330 Department of Health & Human Services Printed: 09/04/2025 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 055330 B. Wing 03/24/2025

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

Advanced Rehab Center of Tustin 2210 E. First Street Santa Ana, CA 92705

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 0842 Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Level of Harm - Potential for minimal harm 35346

Residents Affected - Some Based on interview and facility document review, the facility failed to ensure the documentation on the Quality Control Log was accurate for one of four medication carts. This failure had the potential for not knowing if the documented blood sugars for the residents were accurate.

Findings:

On 3/20/25 at 0815 hours, an interview and concurrent facility document review was conducted with LVN 10.

Review of the Quality Control Log showed the serial number labeled on the glucometer device did not match

the serial number documented on the Quality Control Record. LVN 10 verified the findings.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 47 of 55 055330 Department of Health & Human Services Printed: 09/04/2025 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 055330 B. Wing 03/24/2025

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

Advanced Rehab Center of Tustin 2210 E. First Street Santa Ana, CA 92705

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 0880 Provide and implement an infection prevention and control program.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 49644 potential for actual harm Based on observation, interview, medical record review, facility document review, and facility P&P review, Residents Affected - Some the facility failed to implement the infection control practices designed to provide a safe and sanitary environment and help prevent the development and transmission of diseases and infections.

* The facility failed to ensure the facility's monthly Infection Prevention and Control Surveillance Log was accurate.

* The facility failed to ensure the laundry staff did not reuse the dirty gowns.

* The facility failed to ensure there were no facility staff's personal belongings in the extra clean linen cart.

* The facility failed to ensure Resident 36 was placed on contact isolation precautions while the clostridum difficile (bacteria that causes diarrhea and inflammation of the colon) test was pending. In addition, Resident 36's shared toilet was observed with brown stains.

* The facility failed to implement the EBP per the facility's P&P for Residents 421 and 423 with central lines (thin, flexible tube inserted into a large vein near the heart).

* The facility failed to ensure CNA 3 doffed the gown after transferring Resident 52 from the bed to the chair and before coming in contact with Resident 1.

* The facility failed to ensure LVN 6 followed the infection control protocols when LVN 6 was observed removing a box of tissue from Resident 78's bedside table and placing the box of tissue on Resident 1's bedside table. Resident 78 was on EBP.

These failures posed the risk for not identifying infections and controlling the transmission of communicable diseases to the other residents throughout the facility.

Findings:

1. Review of the facility's P&P titled Surveillance for Infections revised 9/2023 showed the facility employs an infection control surveillance program to help prevent to the extent possible the development and transmission of disease and infection. The IP (or designee), under the guidance of the Infection Control Committee and Medical Director shall be responsible to implement the surveillance program.

Review of the facility's monthly Infection Prevention and Control Surveillance Log showed inaccurate documentation for the months of January and February 2025. The Meet McGeer Criteria (a set of specific definitions to identify true infections in long term nursing facilities) column on the Infection Prevention and Control Surveillance Log had nine N/A answers for January 2025 and four N/A answers for February 2025.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 48 of 55 055330 Department of Health & Human Services Printed: 09/04/2025 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 055330 B. Wing 03/24/2025

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

Advanced Rehab Center of Tustin 2210 E. First Street Santa Ana, CA 92705

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 0880 On 3/19/25 at 0906 hours, an interview and concurrent medical record review was conducted with the IP.

The IP verified the Meet McGeer Criteria column on the Infection Prevention and Control Surveillance Log Level of Harm - Minimal harm or had nine N/A answers for January 2025 and four N/A answers for February 2025. The IP stated the answer potential for actual harm for the Meet McGeer Criteria column should be Yes or No. The IP further stated there was an error in generating the Excel (a spreadsheet software program) sheet. The IP stated if she had seen the N/A under Residents Affected - Some the Meet McGeer Criteria column, she would have changed her answer from N/A to Yes. The IP stated the Infection Prevention and Control Surveillance Log should be accurate, so if another facility staff would look at

the log, the facility staff would know if it was a true infection.

On 3/20/25 at 0844 hours, an interview and concurrent medical record review was conducted with the DON.

The DON acknowledged the above findings. The DON stated there was an error in answering the Meet McGeer Criteria on the surveillance log. The DON stated the IP should have corrected it immediately upon identification so it would not confuse the facility staff who would need to read and interpret the report.

2. Review of the facility's P&P titled Personal Protective Equipment revised 8/2024 showed the personal protective equipment appropriate to specific task requirements is available at all times. Section e showed gown use:

iii. Re-use (over multiple days) and extended use (over multiple residents) of gowns are not allowed.

On 3/19/25 at 1410 hours, an observation of the facility's laundry room and concurrent interview was conducted with the Housekeeping Manager. A laundry staff was observed removing her dirty gown and hanging the dirty gown in the middle of the two gowns and touching each other. Each hook for the dirty gown was labeled with the name of the facility's staff. The Housekeeping Manager verified the laundry staff's dirty gown was touching other used gowns of the laundry staff. The Housekeeping Manager stated the laundry staff used the gown about four times a day. The Housekeeping Manager further stated the laundry room did not have more space for the gown. The Housekeeping Manager stated the laundry staff washed the gown at

the end of the shift for usage on the next day.

On 3/19/25 at 1447 hours, an interview was conducted with Laundry Staff 1. Laundry Staff 1 verified she sorted the dirty linen, removed her gown and gloves, and hung the dirty gown in between two dirty gowns. Laundry Staff 1 stated she used the same gown four to five times a day. Laundry Staff 1 further stated she washed all the dirty gowns at the end of her shift. Laundry Staff 1 stated it would be better if the gowns were separated and not touching each other. Laundry Staff 1 stated the facility staff could use the disposable gown so the gown could used one time and thrown away.

On 3/19/25 at 1546 hours, an interview was conducted with the IP. The IP acknowledged the above findings.

The IP stated the dirty gowns should have been separated. The IP further stated the used gown should have been discarded and not reused. The IP stated if the gown was contaminated and it was touching the other gowns, the contamination could spread.

3. Review of the facility's P&P titled Departmental (Environmental Services)- Laundry and Linen revised 1/2014 showed the purpose of this procedure is to provide a process for the safe and aseptic handling, washing, and storage of linen. Further review of the P&P showed the clean linen will remain hygienically clean (free of pathogens in sufficient numbers to cause human illness) through measures designed to protect

it from environmental contamination, such as covering clean linen carts.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 49 of 55 055330 Department of Health & Human Services Printed: 09/04/2025 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 055330 B. Wing 03/24/2025

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

Advanced Rehab Center of Tustin 2210 E. First Street Santa Ana, CA 92705

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 0880 On 3/19/25 at 1410 hours, an observation of the facility's laundry room and concurrent interview was conducted with the Housekeeping Manager. A personal lunch bag, jacket, and sweater were observed inside Level of Harm - Minimal harm or the extra clean linen cart in the laundry room. The Housekeeping Manager verified the laundry staff's potential for actual harm personal lunch bag, jacket, and sweater were inside the extra clean linen cart. The Housekeeping Manager stated the laundry staff should store their personal belongings outside of the laundry room. The Residents Affected - Some Housekeeping Manager stated the laundry staff stored their personal belongings in the extra clean linen cart because the locker was too far for the laundry staff.

On 3/19/25 at 1546 hours, an interview was conducted with the IP. The IP acknowledged the above findings.

The IP stated the personal belongings of the laundry staff might be dirty and it should have been kept in the laundry staff's locker room. The IP stated the personal belongings could cause cross contamination with the clean linen.

On 3/21/25 at 1555 hours, the Administrator and DON were informed and acknowledged the above findings.

35346

4. Review of the facility's P&P titled Clostridium Difficile revised 10/2018 showed the residents with diarrhea and suspected clostridium difficile infections were placed on contact precautions while awaiting laboratory results.

On 3/18/25 at 0853 hours, an interview was conducted with Resident 36. Resident 36 stated there were brown stains on the shared toilet inside her room. There was no posted signage on the resident's doorway for isolation precautions.

Medical record review for Resident 36 was initiated on 3/18/25. Resident 36 was readmitted to the facility on [DATE REDACTED].

Review of Resident 36's H&P examination dated 12/8/24, showed Resident 36's diagnoses included dementia and schizoaffective disorder (mental health condition that is marked by a mix of schizophrenia symptoms, such as hallucinations and delusions, and mood disorder symptoms, such as depression, mania).

Review of Resident 36's physician's orders showed an order dated 3/15/25, to obtain laboratory test (collect stool) for the clostridum difficile.

Further review of Resident 36's medical record showed Resident 36 had a history of clostridum difficile.

On 3/18/25 at 1006 hours, an observation, interview, and concurrent medical record review was conducted with the IP. The IP verified Resident 36's shared toilet had brown stains on it. The IP reviewed Resident 36's medical record and verified Resident 36's laboratory result for the clostridum difficile was not in the resident's medical record. The IP verified Resident 36 had a loose bowel movement on 3/15/25. The IP verified there should have been posted signage outside of Resident 36's room to indicate the contact isolation precautions for Resident 36, while the clostridum difficile laboratory result was pending due to the resident's history of clostridum difficile.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 50 of 55 055330 Department of Health & Human Services Printed: 09/04/2025 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 055330 B. Wing 03/24/2025

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

Advanced Rehab Center of Tustin 2210 E. First Street Santa Ana, CA 92705

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 0880 39670

Level of Harm - Minimal harm or 5.a. Review of the facility's P&P titled Standard Precautions, Enhanced Barrier Precautions and potential for actual harm Transmission Based Precautions revised 8/7/24, showed the residents with a medical device such as central/vascular catheters was considered a high risk of infection and would be placed on Enhanced Barrier Residents Affected - Some Precaution to reduce the transmission of pathogens.

During the initial tour of the facility on 3/17/25 at 1021 hours, Resident 421 was observed in bed. Resident 421 stated he had a surgery on both of his feet due to an infection. Resident 421 stated he had a PICC line

on the right upper arm and showed his PICC line with the transparent dressing. The PICC line dressing was observed with a label dated 3/13/25. However, Resident 421 was not on EBP. There was no posted signage of the EBP and no PPE supply was observed.

Medical record review for Resident 421 was initiated on 3/18/25. Resident 421 was admitted to the facility on [DATE REDACTED].

Review of Resident 421's Order Summary Report dated 3/19/25, showed no documented evidence a physician's order was obtained for Resident 421's EBP related to his central line.

b. During the initial tour of the facility on 3/17/25 at 1042 hours, Resident 423 was observed in bed. Resident 423 had a PICC line on the left upper arm with a transparent dressing. The transparent dressing was observed with a date label dated 3/13/25. However, Resident 421 was not on EBP. There were no posted signage of the EBP and PPE supplies.

Medical record review for Resident 423 was initiated on 3/17/25. Resident 423 was admitted to the facility on [DATE REDACTED].

Review of Resident 423's Order Summary Report dated 3/19/25, showed no documented evidence a physician's order was obtained for Resident 423's EBP related to the resident's central line.

On 3/17/25 at 1324 hours, an observation and concurrent interview for Residents 421 and 423 was conducted with RN 1. RN 1 was asked about the facility's P&P for the residents who have a PICC lines. RN 1 stated the residents with a central line should be on EBP. RN 1 verified and acknowledged Residents 421 and 423 had PICC lines and were not placed on EBP.

On 3/24/25 at 1347 hours, an interview and concurrent medical record review for Residents 421 and 423 was conducted with the DON. The DON was informed and verified the above findings.

48882

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 51 of 55 055330 Department of Health & Human Services Printed: 09/04/2025 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 055330 B. Wing 03/24/2025

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

Advanced Rehab Center of Tustin 2210 E. First Street Santa Ana, CA 92705

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 0880 6. On 3/19/25 at 0827 hours, an observation and concurrent interview with CNA 3 was conducted in Room D. CNA 3 was observed wearing a gown and transferring Resident 52 (Resident 1's roommate) from the bed Level of Harm - Minimal harm or to the chair. After the transfer, CNA 3 was observed brushing Resident 52's hair. LVN 6 was observed in potential for actual harm Room D attempting to remove Resident 1's layers of clothes, to obtain a blood pressure reading. LVN 6 was observed asking CNA 3 to assist her to remove Resident 1's sweater. CNA 3 was then observed removing Residents Affected - Some her gloves, performing hand hygiene, and entering Resident 1's environment. CNA 3 was not observed doffing the gown. CNA 3 was then observed removing Resident 1's hat from her head and assisting Resident 1 to remove her right arm from her shirt sleeve. CNA 3 was asked about the protocol for the use of the gown

in between residents and CNA 3 stated Residents 1 and 52 were not on isolation so the same gown could be used between the residents. LVN 6 was observed instructing CNA 3 to remove her gown and to don a new gown.

On 3/19/25 at 1414 hours, an interview was conducted with the IP. The IP stated the facility staff were expected to adhere to the standard precautions when caring for the residents who were not on EBP. The IP stated the gowns were for single use for one resident only and the same gown should not be used between

the residents. The IP stated the facility staff were expected to doff the gown, perform hand hygiene, and don

a new gown before assisting another resident with care.

On 3/24/25 at 1033 hours, an interview was conducted with the DON. The DON stated the gowns were used for each individual resident. The DON stated regardless of the isolation or precautions, when the facility staff donned a gown, the gown should be used when providing care for one resident only and the same gown should not be used between the residents.

On 3/24/25 at 1321 hours, an interview was conducted with the Administrator and DON. The Administrator and DON were informed and acknowledged the above findings.

7. Medical record review for Resident 78 was initiated on 3/19/25. Resident 78 was admitted to the facility on [DATE REDACTED].

Review of Resident 78's Order Summary Report for March 2025 showed a physician's order dated 1/7/25, for the enhanced barrier precautions related to the resident's sacral pressure ulcer.

On 3/19/25 at 0842 hours, a medication administration observation for Resident 1 was conducted with LVN 6. During the medication administration observation, LVN 6 was observed removing the box of tissues from Resident 78 (Resident 1's roommate)'s bedside table and placing the box of tissues on Resident 1's bedside table. LVN 6 was then observed grabbing a tissue and attempted to hand the tissue to Resident 1. LVN 6 was stopped and asked if Resident 78 was on any isolation precautions. LVN 6 stated Resident 78 was on EBP. LVN 6 was then observed asking the a facility staff to retrieve a new box of tissues for Resident 1.

On 3/19/25 at 0921 hours, an interview was conducted with LVN 6. LVN 6 verified she removed the box of tissues from Resident 78's bedside table and placed the box of tissues on Resident 1's bedside table. LVN 6 stated Resident 78 was on EBP and everything in Resident 78's surroundings, including her bedside table were considered contaminated. LVN 6 stated there was a potential risk of transmission of organisms between the residents.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 52 of 55 055330 Department of Health & Human Services Printed: 09/04/2025 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 055330 B. Wing 03/24/2025

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

Advanced Rehab Center of Tustin 2210 E. First Street Santa Ana, CA 92705

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 0880 On 3/19/25 at 1414 hours, an interview was conducted with the IP. The IP stated for the residents on standard precautions and cohorted in the same room as the residents on EBP, the facility staff were Level of Harm - Minimal harm or expected to adhere to the standard precautions when caring for non-EBP residents. The IP stated for the potential for actual harm residents on EBP, their belongings or items in their environment should not be shared with the other residents in the room due to the risk of the potential transmission of organisms to the other residents in the Residents Affected - Some room.

On 3/24/25 at 1321 hours, an interview was conducted with the Administrator and DON. The Administrator and DON were informed and acknowledged the above findings.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 53 of 55 055330 Department of Health & Human Services Printed: 09/04/2025 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 055330 B. Wing 03/24/2025

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

Advanced Rehab Center of Tustin 2210 E. First Street Santa Ana, CA 92705

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 0881 Implement a program that monitors antibiotic use.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 49644 potential for actual harm Based on interview, medical record review, and facility P&P review, the facility failed to implement the Residents Affected - Few antibiotic stewardship program.

* The facility failed to ensure if the McGeer's criteria for true infection was completed and accurate for one of 20 final sampled residents (Resident 61) . This failure had the potential for inaccurately identifying true infections and potentially inhibiting residents from receiving the appropriate treatment and care.

Findings:

According to the CDC, antibiotics are some of the most commonly prescribed medications in nursing homes. Over the course of a year, up to 70% of nursing home residents get an antibiotic. Roughly 40% to 75% of antibiotics are prescribed incorrectly. In nursing homes, high rates of antibiotics are prescribed to prevent UTI and RTI. Prescribing antibiotics before there is an infection often contributes to misuse. Often residents are given antibiotics just because they are colonized with (carrying) bacteria that are not making the person sick. Prescribing antibiotics for colonization contributes to antibiotic overuse. When patients are transferred between facilities, for example from a nursing home to a hospital, poor communication between facilities about prescribed antibiotics (e.g., rationale, number of days) plus insufficient infection control practices can result in antibiotic misuse and the spread of antibiotic resistance. Antibiotic-related harms, such as diarrhea from C. difficile can be severe, difficult to treat, and lead to hospitalization s and deaths, especially among people over age 65.

Review of the facility's P&P titled Antibiotic Stewardship revised 11/2019 showed to optimize the use of the antibiotics by improving prescribing practices and to reduce inappropriate antibiotic use. Section D showed

the following Policy and Practice Change:

- The facility has chosen to use guidelines developed by McGeer/Loeb and Stone and include newer surveillance information by McGeer/Loeb and Stone Criteria for initiation of antibiotics. The nurse will inform

the physician of this prescribing protocol.

- The SBAR will be utilized in conjunction with McGeer/Loeb and Stone guidelines to communicate with the physician when there is change of condition.

Medical record review for Resident 61 was initiated on 3/19/25. Resident 61 was admitted to the facility on [DATE REDACTED], and readmitted on [DATE REDACTED].

Review of Resident 61's H&P examination dated 2/27/25, showed the resident had no capacity to understand and make decisions.

Review of Resident 61's View Radiology Report reviewed 2/3/25, showed Resident 61 had infiltrate in the left lung base and COPD.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 54 of 55 055330 Department of Health & Human Services Printed: 09/04/2025 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 055330 B. Wing 03/24/2025

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

Advanced Rehab Center of Tustin 2210 E. First Street Santa Ana, CA 92705

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 0881 Review of Resident 61's Order Summary Report showed a physician's order dated 2/3/25, to administer levofloxacin (antibiotic) oral tablet 500 mg medication one tablet by mouth one time a day for COPD/cough Level of Harm - Minimal harm or for seven days. potential for actual harm

Review of Resident 61's Infection SBAR - Respiratory Tract - Pneumonia dated 2/3/25, failed to show if the Residents Affected - Few McGeer's criteria was met for true infection. Additionally, only two instead of three criteria were marked for

the McGeer's criteria for Respiratory Tract- Pneumonia.

On 3/19/25 at 0906 hours, an interview and concurrent medical record review was conducted with the IP.

The IP verified Resident 61's Infection SBAR - Respiratory Tract- Pneumonia form did not show if the McGeer's criteria was met or not met for true infection. The IP acknowledged three criteria must be present to be considered as met the McGeer's criteria for respiratory tract-pneumonia. The IP verified the licensed nurse documented only two out of the three criteria on Resident 61's Infection SBAR - Respiratory Tract- Pneumonia form. The IP stated the third criteria of acute function decline should have been marked as Resident 61 was noted with decline in function. The IP further stated the licensed nurse should have made a note in the SBAR whether the McGreer's criteria was met or not met. The IP stated she would confirm if it was met or not met after the licensed nurse completed the infection SBAR.

On 3/20/25 at 0844 hours, an interview and concurrent medical record review was conducted with the DON.

The DON acknowledged the above findings. The DON stated the licensed nurse should have completed Resident 61's sign and symptoms to meet the McGeer's criteria. The DON stated the licensed nurse should have documented Resident 61 had met the criteria for signs and symptoms of pneumonia.

On 3/21/25 at 1555 hours, the Administrator and DON were informed and acknowledged the above findings.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 55 of 55 055330