St Edna Subacute And Rehabilitation Center
Inspection Findings
F-Tag F695
F-F695
, the DON or designer will review physicians' oxygen orders for compliance, and will bring the results to the monthly QAPI meeting for three months and as recommended by the committee.
- For cited
F-Tag F761
F-F761
, the DON or designee will review data from facility rounds for medication storage compliance, and will bring the results to the monthly QAPI meeting for three months and as recommended by the committee.
- For cited
F-Tag F842
F-F842
, the DON and SSD or designees will bring the results from records review and facility rounds for compliance to the monthly QAPI meeting for three months and as recommended by the committee.
- For cited
F-Tag F880
F-F880
.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 60 of 68 555093 Department of Health & Human Services Printed: 08/27/2025 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 555093 B. Wing 05/13/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
St Edna Subacute and Rehabilitation Center 1929 N. Fairview Street Santa Ana, CA 92706
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** 39683 potential for actual harm Based on observation, interview, medical record review, facility document review and facility P&P review, the Residents Affected - Some facility failed to maintain the infection prevention control program and practices designed to provide a safe and sanitary environment to help prevent the transmission of communicable diseases and infections.
* The facility failed to implement the infection control monitoring and surveillance for April 2025.
* The facility failed to perform legionella testing per the facility's Legionella Water Management Program frequency.
* The facility failed ton ensure Resident 131's contact enteric precautions were followed.
* Staff''s personal cell phone was stored in the treatment cart with the residents' treatment supplies.
* Staff placed their face-shield on top of an upside-down dirty linen cart lid.
* CNA 1 failed to don the gown when providing high-contact care to Resident 38 who was on EBP.
* The facility failed to ensure residents' clean clothes were transported in a way that maintained infection control.
* Two of four LVNs (LVNs 4 and 6) observed for medication administration did not follow proper hand hygiene procedure.
* The tip of the eye medication dropper touch Resident 40's eyelashes during the medication administration.
* The back side of the glucometer (medical device for determining the approximate concentration of glucose
in the blood) for Medication Cart 2 was observed with red-brown smudges.
These failures posed the risk for transmission of disease-causing microorganisms and infections.
Findings:
1. On 5/13/25 at 0800 hours, a concurrent interview and review of the facility's IPCP was conducted with the IP. The IP stated the process was to review the residents' antibiotic orders as soon as possible to determine if their suspected infection met Loeb's Criteria (a set of minimum symptoms and signs used to guide the decision-making process for initiating antibiotic therapy in long-term care settings) or McGeer's Criteria (a set of specific definitions to identify true infections in long term nursing facilities). Infections are monitored for trends to determine if an outbreak occurs, or needed education on infection control practices.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 61 of 68 555093 Department of Health & Human Services Printed: 08/27/2025 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 555093 B. Wing 05/13/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
St Edna Subacute and Rehabilitation Center 1929 N. Fairview Street Santa Ana, CA 92706
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 Review of the facility's antibiotic report for April 2025 showed 25 antibiotics were ordered for suspected infections. The IP stated she did not review the residents' suspected infections for April, to determine if they Level of Harm - Minimal harm or met criteria. The list showed Resident 123 started piperacillin sodium tazobactam (antibiotic) on 4/30/25. The potential for actual harm IP reviewed Resident 123's records and verified the resident did not meet either Loeb's or McGeer's Criteria for infection. The IP verified since she did not review any residents with antibiotic orders for suspected Residents Affected - Some infections in April previously, other residents with suspected infections might not have met criteria.
2. Review of the facility's Legionella Water Management Program showed Legionella testing will be performed quarterly. Legionella testing results were dated 2/14/24 and 3/25/25.
On 5/9/25 at 1035 hours, an interview and facility document review was conducted with the Maintenance Supervisor. The Maintenance Supervisor stated Legionella testing was conducted annually on 2/14/24 and 3/25/25. The Maintenance Supervisor reviewed the Legionella Water Management Program binder and verified the program showed testing would be done quarterly, and had not been.
3. Medical record review for Resident 131 was initiated on 5/7/25. Resident 131 was admitted to the facility
on [DATE REDACTED].
Review of Resident 131's Order Summary Report showed a physician's order dated 4/23/25, for contact enteric precaution for C. diff (Clostridium difficile-a contagious bacteria that can cause inflammation of the colon) toxin.
On 5/7/25 at 0838 hours, an observation and concurrent interview was conducted with the Optometrist at Resident 131's bedside. The Optometrist was observed at the resident's bedside, in a mask, face shield, gown and gloves, in contact with the resident and other surfaces in the resident's room, including the edge of
the bed and a bedside tray table. A sign was posted at the resident's doorway which showed for contact enteric precautions and instructed people to wash their hands with soap and water upon leaving the room.
The Optometrist stated they were informed by the facility staff that the resident had isolation precautions for
a UTI, not C. diff. The Optometrist was observed removing her isolation gown and gloves, and using ABHR for hand hygiene when leaving the room. The Optometrist then donned a new isolation gown and gloves, and entered another resident's room, went to their bedside, and examined the resident. The Optometrist's Assistant stated they were informed by the resident's nurse from the previous shift that Resident 131 was in isolation for a urinary tract infection, and not C. diff.
On 5/7/25 at 0855 hours, an interview and concurrent medical record review was conducted with LVN 3. LVN 3 stated Resident 131 had contact enteric precautions for C. diff, and the staff and visitors should wash their hands with soap and water when leaving the room.
4. On 5/9/25 at 1054 hour, a wound care observation for Resident 8 was conducted with LVN 2. While LVN 2 gathered the supplies from the treatment cart, a cell phone was observed being stored in the top drawer with
the treatment supplies. LVN 2 stated it was her personal cell phone and verified it should not be stored in the medication cart. The LVN stated there was also a wound care team cell phone, which the LVN was storing in her pocket.
On 5/9/25 at 1115 hours, an interview was conducted with the DON. The DON stated the personal cell phones should not be stored in the treatment or medication carts for infection control.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 62 of 68 555093 Department of Health & Human Services Printed: 08/27/2025 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 555093 B. Wing 05/13/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
St Edna Subacute and Rehabilitation Center 1929 N. Fairview Street Santa Ana, CA 92706
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 5. On 5/9/25 at 0859 hours, a laundry area inspection was conducted with the Maintenance Supervisor and Janitor. Upon entering the dirty linen area, the Janitor was observed wearing a gown and face-shield, putting Level of Harm - Minimal harm or a clean liner in the dirty linen cart. The Janitor removed his face-shield, placed it on the upside-down dirty potential for actual harm linen cart lid, and washed his hands. The Janitor then picked up the mask and placed it on a hook. The Janitor and Maintenance Supervisor verified the face-shield should not be placed on the contaminated Residents Affected - Some surface of the dirty linen cart lid.
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6. Review of the facility's P&P titled Infection Prevention Manual for Long Term Care, revised 5/2024 showed
it is the policy of the facility to implement enhanced barrier precautions when indicated for the prevention of transmission of multi drug- resistant organisms. The EBP refer to an infection control intervention designed to reduce the transmission of multidrug- resistant organisms that employ targeted gown and gloves use
during high contact resident care activities. PPE for EBP is only necessary when performing high-contact care activities. High-contact Resident care activities may include:
a. Dressing
b. Bathing
c. Transferring
d. Providing hygiene
e. Changing linens.
On 5/7/25 at 0803 hours, during the initial tour of the facility, an EBP sign was observed posted outside of Resident 38's room alerting the providers and staff to wear gloves and gown for the following high-contact resident care activities: dressing, bathing/showering, transferring, changing linens, providing hygiene, changing briefs or assisting with toileting, device care or use, and wound care. A E sticker was observed placed next to Resident 38's name.
On 5/7/25 at 0908 hours, CNA 1 was observed turning Resident 38 on his left side to reposition the sheet under Resident 38. CNA 1 was then observed putting on a new gown for Resident 38. CNA 1 was not observed wearing a gown. On the ground, next to Resident 38's bed were two clear bags containing soiled linen inside.
On 5/7/25 at 0918 hours, an interview was conducted with CNA 1. CNA 1 stated she was changing Resident 38's linen and sheets and was proving care to him. When asked about the facility's EBP protocol, CNA 1 stated for the residents who were on EBP, a sign would be placed outside of the resident's door and an E sticker would be placed next to the resident's name to notify staff when EBP should be followed. CNA 1 further stated for the residents on EBP, the staff should don a gown and gloves when providing care, changing, providing showers, and repositioning the resident. When asked if Resident 38 was on EBP, CNA 1 stated Resident 38 was on EBP due to the wound on his heel. CNA 1 verified she did not don a gown when providing care to Resident 38 and stated she should have worn a gown.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 63 of 68 555093 Department of Health & Human Services Printed: 08/27/2025 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 555093 B. Wing 05/13/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
St Edna Subacute and Rehabilitation Center 1929 N. Fairview Street Santa Ana, CA 92706
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 Medical record review for Resident 38 was initiated on 5/7/25. Resident 38 was admitted to the facility on [DATE REDACTED], and readmitted on [DATE REDACTED]. Level of Harm - Minimal harm or potential for actual harm Review of Resident 38's H&P examination dated 10/22/24, showed Resident 38 had no capacity to make medical decisions. Residents Affected - Some
Review of Resident 38's Order Summary Report showed a physician's order dated 4/1/25, for EBP every shift for the left hallucial diabetic wound.
On 5/12/25 at 1410 hours, an interview was conducted with the DON. The DON stated the facility staff were expected to wear a gown and gloves when entering the room, to provide direct care to the residents who were on the EBP.
On 5/13/25 at 1207 hours, an interview was conducted with the Administrator and DON. The Administrator and DON were informed and acknowledged the above findings.
47474
7. Review of the facility's P&P titled Laundry Manual - General Policy (undated) showed the clean linen shall be stored, handled, and transported in a way that precludes cross-contamination.
On 5/9/25 at 1023 hours, during an observation, Laundry Assistant 1 transported an uncovered laundry cart containing the residents' clean clothes down the hallway near rooms [ROOM NUMBERS]. The laundry cart was stationed across from room [ROOM NUMBER] and exposed with residents' clean clothes touching the handrails.
On 5/9/25 at 1026 hours, an observation and concurrent interview with Laundry Assistant 1 was conducted next to the laundry cart. Laundry Assistant 1 requested for CNA 7 be present during the interview to interpret. Laundry Assistant 1 verified the findings. Laundry Assistant 1 verified she had the laundry cart opened while transporting it down the hallway and verified the residents' clothes were touching the handrails. Laundry Assistant 1 further stated the laundry cart should have been closed to prevent contamination of the clean clothes.
On 5/13/25 at 1208 hours, an interview was conducted with the Administrator and the DON. The Administrator and DON were informed and acknowledged the above findings.
51352
8. Review of the facility's P&P titled Review of the facility's P&P titled Preparation and General Guidelines IIA2: Medication Administration - General Guidelines revised 11/2021 showed the person administering the medications adheres to good hand hygiene, which includes washing hands thoroughly before beginning a medication pass, prior to handling any medication, after coming into direct contact with a resident, and before and after administration of ophthalmic preparations, and medications given via enteral tubes.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 64 of 68 555093 Department of Health & Human Services Printed: 08/27/2025 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 555093 B. Wing 05/13/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
St Edna Subacute and Rehabilitation Center 1929 N. Fairview Street Santa Ana, CA 92706
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 5/7/25 at 0802 hours, the GT medication administration observation was conducted for Resident 102 with LVN 6. LVN 6 donned gloves and used Super Sani-Cloth sanitizing wipes to disinfect the BP cuff, tubing, and Level of Harm - Minimal harm or machine. LVN 6 doffed the gloves. LVN 6 did not perform hand hygiene after doffing the gloves. LVN 6 potential for actual harm unlocked Medication Cart 2 and removed the glucometer, lancet (small, sharp, single-use device typically used to prick a finger to obtain a small blood sample for testing), and glucometer test trips and put the items Residents Affected - Some on a tray. LVN 6 picked up the tray and entered Resident 102's room without performing hand hygiene. LVN 6 donned gloves and adjusted the prongs of Resident 102's nasal cannula (flexible tube to deliver oxygen into the nose). LVN 6 did not change her gloves or perform hand hygiene. LVN 6 wiped Resident 102's left ring finger with an alcohol swab for a few seconds. LVN 6 used the lancet on Resident 102's finger and obtained a blood sugar reading from Resident 102. LVN 6 doffed the gloves. LVN 6 left the room without performing hand hygiene. LVN 6 walked to the medication cart at Resident 102's doorway. LVN 6 entered Resident 102's room without performing hand hygiene, picked up Resident 102's remote from the floor, and placed the remote on Resident 102's bed. LVN 6 left the room without performing hand hygiene and walked to Medication Cart 2. LVN 6 donned clean gloves and used Super Sani-Cloth sanitizing wipes to disinfect the BP cuff, tubing, and machine. LVN 6 washed her hands in Resident 102's bathroom. LNV 6 prepared Resident 102's medications. LVN 6 used alcohol-based hand rub, donned a gown, and entered Resident 102's room with the medications. LVN 6 placed the medications on the bedside table and walked out of Resident 102's room without performing hand hygiene. LVN 6 walked to Medication Cart 2, took a pair of clean gloves, and entered Resident 102's room. LVN 6 did not perform hand hygiene before entering Resident 102's room. LVN 6 donned gloves and pulled the privacy curtain in preparation for the medication administration for Resident 102. LVN 6 left the room to walk to Medication Cart 2. LVN 6 did not perform hand hygiene when she left the room. LVN 6 doffed her gloves, picked up the stethoscope from Medication Cart 2 and entered Resident 102's room. LVN 6 did not perform hand hygiene prior to entering Resident 102' room. LVN 6 used Super Sani-Cloth sanitizing wipes to disinfect the stethoscope. LVN 6 donned gloves and began the medication administration for Resident 102. LVN 6 did not perform hand hygiene after using ungloved hands to sanitize the stethoscope or before she began the medication administration for Resident 102.
On 5/7/25 at 1236 hours, a follow-up interview was conducted with LVN 6. LVN verified the staff should wash their hands or used alcohol-based hand rub prior to any medication administration. LVN 6 verified the staff should have washed her hands before donning gloves, after doffing gloves, and between tasks.
9. Review of the facility's P&P titled Specific Medication Administration Procedures IIB5: Eye Drop Administration revised 6/2021 showed the staff wash hands before and after the procedure. The tip of the dropper must not touch the eye or any other surface.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 65 of 68 555093 Department of Health & Human Services Printed: 08/27/2025 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 555093 B. Wing 05/13/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
St Edna Subacute and Rehabilitation Center 1929 N. Fairview Street Santa Ana, CA 92706
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 5/7/25 0858 hours, a medication administration observation for Resident 40 was conducted with LVN 4. LVN 4 donned gloves and used Super Sani-Cloth sanitizing wipes to disinfect the BP cuff and stethoscope. Level of Harm - Minimal harm or LVN 6 doffed the gloves and did not perform hand hygiene. LVN 4 began medication preparation for potential for actual harm administration to Resident 40. LVN 4 finished preparing the medications for Resident 40, performed hand hygiene with alcohol-based hand rub, and entered Resident 40's room. LVN 4 administered Resident 40's Residents Affected - Some oral medications. LVN 4 then donned gloves to administer the GeriCare artificial tears to Resident 40. LVN 6 did not wash her hands prior to donning the gloves. LVN 4 administered one drop of GeriCare artificial tears to Resident 40's left eye. The tip of the dropper of the GeriCare medication touched the eyelashes on Resident 40's left eye. LVN 4 pressed a tissue to the inner corner of Resident 40's left eye. LVN 4 then administered one drop of the GeriCare medication to Resident 40's right eye.
On 5/7/25 at 1303 hours, a follow-up interview was conducted with LVN 4. LVN 4 stated staff must wash their hands or use alcohol-based hand rub prior to the administration of ophthalmic (medications to treat conditions of the eye) medications. LVN 4 stated she did not see if the tip of the dropper for the GeriCare medication touched Resident 40's eyelashes during the medication administration. LVN 4 verified the dropper was no longer safe to use if the tip of the dropper touches the resident's eye or any other surface.
10. On 5/8/25 at 1228 hours, an inspection of Medication Cart 2 and a concurrent interview was conducted with the Unit Manager. The back side of glucometer was observed with red-brown smudges. The Unit Manager verified the presence of the red-brown smudges. When asked what the red-brown smudges on the back side of the glucometer were, the Unit Manager stated she did not know.
On 5/13/25 at 1116 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 66 of 68 555093 Department of Health & Human Services Printed: 08/27/2025 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 555093 B. Wing 05/13/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
St Edna Subacute and Rehabilitation Center 1929 N. Fairview Street Santa Ana, CA 92706
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 39683 potential for actual harm Based on interview, medical record review, facility record review, and facility P&P review, the facility failed to Residents Affected - Some implement their antibiotic stewardship program including timely monitoring of antibiotic use.
* The IP did not review antibiotics for appropriateness for April 2025 which showed 25 antibiotics were ordered.
* The IP failed to notify Residents 14 and 26's physicians to re-evaluate the appropriateness of the residents' antibiotics when it was determined their suspected infections did not meet criteria.
These failures had the potential of not accurately identifying true infections and exposing the residents to unnecessary antibiotic use.
Findings:
According to the CDC, repeated and/or improper use of antibiotics was the primary cause of the proliferation of drug-resistant bacteria. Each time a person uses antibiotics, the sensitive bacteria are killed; however, resistant bacteria may result. These resistant bacteria may then grow and multiply. When the antibiotics fail to work, the consequences include longer lasting illnesses, extended hospital stays, and the need for more expensive and toxic medications. Some resistant infections can even cause death.
On 5/13/25 at 0800 hours, a concurrent interview and review of the facility's IPCP, antibiotic stewardship, and Residents 14, 26, and 123's medical records was conducted with the IP. The IP stated the process was to review the residents' antibiotic orders as soon as possible to ensure the appropriateness of the antibiotics ordered. The IP stated she would review the residents' medical records, determine if the antibiotic ordered was appropriate and notify the physician to reevaluate.
a. Review of facility's antibiotic report for April 2025 showed 25 antibiotics were ordered for suspected infections. The IP stated she did not review the residents' antibiotic orders for April 2025. The list showed Resident 123 was started on the piperacillin sodium tazobactam (antibiotic) medication on 4/30/25. The IP reviewed Resident 123's medical record and verified the resident did not meet the criteria for appropriate antibiotic usage. The IP verified since she did not review any residents' antibiotic orders for April previously and other residents could have received inappropriate antibiotics.
The IP reviewed Resident 123's MARs for April and May 2025 and verified the antibiotics were administered to the resident for the full seven days of the ordered therapy.
b. Review of the line listing report for March 2025 showed Resident 14 started doxycycline monohydrate (antibiotic) 100 mg medication on 3/5/25, for an infection that did not meet criteria. The IP verified there were no records to show the physician was notified that Resident 14's suspected infection did not meet the criteria and re-evaluated the antibiotics for appropriateness.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 67 of 68 555093 Department of Health & Human Services Printed: 08/27/2025 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 555093 B. Wing 05/13/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
St Edna Subacute and Rehabilitation Center 1929 N. Fairview Street Santa Ana, CA 92706
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 The IP reviewed Resident 14's MAR for March 2025 and verified the doxycycline monohydrate 100 mg medication was administered to the resident for the full 10 days of the ordered therapy. Level of Harm - Minimal harm or potential for actual harm c. Review of the line listing report for March 2025 showed Resident 26 started Levaquin 750 mg (antibiotic)
on 3/18/25, for a suspected infection that did not meet criteria. The IP verified there were no records to show Residents Affected - Some the physician was notified that Resident 26's suspected infection did not meet criteria and re-evaluated the antibiotics for appropriateness.
The IP reviewed Resident 26's MAR for March 2025 and verified the Levaquin 750 mg medication was administered to the resident for the full seven days of the ordered therapy.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 68 of 68 555093