Health inspection·November 6, 2024

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility P&P review, the facility failed to ensure the medical records for two of eight sampled residents (Residents 3 and 7) and two nonsampled residents (Residents C and D) were complete and accurate. This failure had the potential for the resident care needs not being met as the medical information was incomplete and inaccurate. Findings: Review of the facility's P&P titled Document of Medication Administration revised 11/2022 showed a nurse or certified medication aide (where applicable) documents all medications administered to each resident on the resident's medication administration record (MAR) and is documented immediately after it is given. 1. Medical record review for Resident 3 was initiated on 10/30/24. Resident 3 was admitted to the facility on [DATE]. Review of Resident 3's MAR for October 2024 showed the following medication was scheduled to be administered daily at 0630 hours: regular insulin (diabetic medication) injection subcutaneously before meals as per the following sliding scale: if BS 60 – 150 mg/dl = 0 unit; 151 - 200 mg/dl = 4; 201 - 250 mg/dl = 6; 251 - 300 mg/dl = 8; 301 - 350 mg/dl = 12; 351 - 400 mg/dl = 14. If BS >400 mg/dl give 16 units. If BS <10 mg/dl or >400 mg/dl, notify the MD. However, this medication was not signed as administered on 10/30/24 at 0630 hours, as ordered. 2. Medical record review for Resident 7 was initiated on 10/30/24. Resident 7 was readmitted to the facility on [DATE]. Review of Resident 7's MAR for October 2024 showed the following medications were scheduled to be administered daily at 2100 hours: atorvastatin (anti-cholesterol medication) 40 mg, Melatonin (sleeping medication) 3 mg, and regular insulin injection subcutaneously before meals as per the following sliding scale: if BS 70 - 150 mg/dl = 0 unit; 151 - 200 mg/dl = 2; 201 - 250 mg/dl = 4; 251 - 300 mg/dl = 6; 301 - 350 mg/dl = 8; 351 – 400 mg/dl = 10; and 401-999 mg/dl = 12 units and call MD. However, the melatonin was not signed on 10/30/24, atorvastatin was not signed on 10/31/24, and insulin was not signed on 10/31/24 at 0630 hours, as administered as ordered. 3. Medical record review for Resident C was initiated on 10/30/24. Resident C was readmitted to the facility on [DATE]. (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 055330 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055330 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/06/2024 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)