Inspection visit

InspectionAugust 22, 2023

FOOTHILL REGIONAL MEDICAL CENTER D/P SNFCMS #5557306 citations on this visit

6 citations recorded

Inspector’s narrative

What the inspector wrote

This survey cited 6 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.

F 0563 Honor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility document review, the facility failed to allow visitation from a family member for one of 17 sampled residents (Resident 3). This failure had the potential to negatively affect the resident's psychosocial well-being. Residents Affected - Few Findings: Review of the Centers for Medicare & Medicaid Services (CMS), QSO-20-39-NH (Quality, Safety, and Oversite), memorandum, revised 05/08/2023, showed facilities must allow visitation at all times and for all residents as permitted under the regulations. Facilities cannot limit the frequency and length of visits for residents, the number of visitors, or require advance scheduling of visits. Review of the facility's Notice titled Your Information, Your Rights, Our Responsibilities, revised 3/2019 showed the residents have the right to designate a support person as well as visitors of their choosing. However, the facility may establish reasonable restrictions upon visitation and must inform the resident or their support person of any limitations. Medical record review for Resident 3 was initiated on 8/14/23. Resident 3 was originally admitted to the facility on [DATE], and transferred to Hospital 1 on 3/5/23. Resident 3 was readmitted to the facility on [DATE]. Review of Resident 3's History & Physical Examination from Hospital 1 dated 3/5/23, showed Resident 3 was developmentally delayed and had an extensive medical history. Resident 3 was transferred from the facility to Hospital 1 on 3/5/23, due to increased oxygen requirements. On 8/10/23 at 1019 hours, an interview was conducted with Family Member C. Family Member C stated Resident 3 was nonverbal, able to smile, liked to be hugged, and knew when someone was at his bedside. Family Member C stated Family Member D treated Resident 3 as if Resident 3 was her own child. Resident 3 felt comfort when Family Member D was around and had a special bond with Resident 3. Family Member C stated Resident 3 would smile when Family Member D would visit. Family Member C stated Hospital 1 informed her the facility was not taking Resident 3 back due to Family Member D's behavior toward facility staff. Family Member C stated on 3/21/23, while Resident 3 was still in Hospital 1, Family Member C had a meeting with the facility's CNO and another staff member at the facility. The CNO told her the facility would only allow Resident 3 to be readmitted from Hospital 1 under the condition that Family Member D would not be allowed to visit Resident 3. Family Member C stated she had no other choice but to agree to this condition because the only other (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 14 Event ID: 555730 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 555730 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/22/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Foothill Regional Medical Center D/P Snf 14662 Newport Avenue Tustin, CA 92780 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 0563 Level of Harm - Minimal harm or potential for actual harm facility with a bed available was very far away. The CNO stated the facility was concerned for the staff because Family Member D was mean and did a background check on one of their staff. Family Member C stated prior to this, the facility had not brought up any of these allegations, never warned her, nor had a meeting with her about their concerns. Family Member C asked if the facility could have a meeting with Family Member D to discuss the issues, but the CNO said no. Residents Affected - Few On 8/14/23 at 1546 hours, an interview was conducted with the Nurse Manager. The Nurse Manager stated there was an incident where Family Member D yelled at a CNA, and the CNA was unable to complete the care for Resident 3 that day. The Nurse Manager stated she informed Family Member D that she could not yell at the facility staff. On 8/14/23 at 1546 hours, a telephone interview was conducted with the CNO. The CNO stated Resident 3 had been living at the facility for a while and all the staff adored Resident 3. The CNO stated she had several conversations with Family Member C about Family Member D's behavior. The CNO verified the facility was not going to accept Resident 3 back from Hospital 1 because of Family Member D's behavior. The CNO stated she spoke with Family Member C, and Family Member C agreed restricting the visitation rights of Family Member D as a condition for Resident 3 to come back to the facility. Cross reference to F626. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555730 If continuation sheet Page 2 of 14 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 555730 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/22/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Foothill Regional Medical Center D/P Snf 14662 Newport Avenue Tustin, CA 92780 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 0583 Keep residents' personal and medical records private and confidential. Level of Harm - Potential for minimal harm Based on observation and interview, the facility failed to ensure the residents' medical records were safeguarded to protect their confidential health information. This failure had the potential for the residents' personal and health information to be accessed by the unauthorized users. Residents Affected - Some Findings: On 8/4/23 at 1032 hours, an observation of medication administration was conducted with LVN 6. A Medication Administration Record binder was observed left open and unattended on top of Medication Cart A in a hallway, showing the residents' personal and health information. The documents showed the list of medications that the residents were being administered. On 8/4/23 at 1055 hours, an interview was conducted with LVN 6. LVN 6 verified the above finding and further stated he should have closed the Medication Administration Record binder on top of Medication Cart A before going into a resident's room. On 8/4/23 at 1107 hours, an interview was conducted with RN 3. RN 3 stated the Medication Administration Record binder should be closed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555730 If continuation sheet Page 3 of 14 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 555730 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/22/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Foothill Regional Medical Center D/P Snf 14662 Newport Avenue Tustin, CA 92780 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 0626 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy. **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 allow one of 17 sampled residents (Resident 3) to return and resume residence in the facility after the acute care hospital determined Resident 3 was ready for discharge. This failure caused Resident 3 to remain in the acute care hospital for an additional three days, which had the potential to negatively impact the resident's well-being. Findings: Review of the facility's P&P titled Transfer/Discharge of Resident-Pediatric revised on 9/2021 showed discharge planning meetings will begin 3 months before discharge for planned transfers or as soon as possible for unplanned transfers. Meetings will be coordinated by the social worker and will be attended by members of the resident's family and interdisciplinary team. Medical record review for Resident 3 was initiated on 8/14/23. Resident 3 was originally admitted to the facility on [DATE], and transferred to the acute care hospital on 3/5/23. Resident 3 was readmitted to the facility on [DATE]. Review of Resident 3's History & Physical Examination from Hospital 1, dated 3/5/20, showed Resident 3 was developmentally delayed and had an extensive medical history. Resident 3 was transferred from the facility to Hospital 1 on 3/5/23, due to increased oxygen requirements. Review of Hospital 1's case management notes for Resident 3 showed the following entries by multiple Case Managers (CM): - On 3/20/23 (no time), showed the CM rounded with the Charge RN at Hospital 1. Resident 3 ready for transfer to the facility. Called the facility and spoke with the facility's RN. The facility's RN provided the room and bed assignment for Resident 3. - On 3/20/23 at 1115 hours, showed per the facility's RN, the facility's CNO declined accepting Resident 3 back to the facility. - On 3/20/23 at 1330 hours, showed per the facility, Resident 3's Family Member D was verbally abusive to staff, and the facility would not accept Resident 3 back unless Resident 3's primary responsible family member (Family Member C) verbally agreed to restrict Family Member D from visiting Resident 3. - On 3/20/23 at 1400 hours, showed the CM contacted the facility and spoke with the RN care coordinator who stated she would confirm whether or not they would accept Resident 3 back after the CNO spoke with Family Member C. - On 3/20/23 at 1500 hours, showed the CM spoke with the CNO who stated the facility would not accept Resident 3 back because of repeated issues with Family Member D. - On 3/22/23 at 1500 hours, showed the CM called the facility, an agreement was not formalized with Family Member C, therefore, Resident 3 would not be transferred to the facility. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555730 If continuation sheet Page 4 of 14 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 555730 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/22/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Foothill Regional Medical Center D/P Snf 14662 Newport Avenue Tustin, CA 92780 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 0626 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few - On 3/23/23 at 0725 hours, showed the CM received a call from Hospital 1's MD confirming the facility would accept Resident 3. On 8/16/23 at 1150 hours, an interview was conducted with the Director of Quality and Risk. The Director of Quality and Risk stated an administrative discharge would be done if a resident needed a higher level of care or a resident was aging out. The Director of Quality and Risk stated the family would be involved in the discharge process. On 8/14/23 at 1546 hours, a telephone interview was conducted with the CNO. The CNO stated Resident 3 had been living at the facility for a while and all the staff adored Resident 3. The CNO verified the facility was not going to accept Resident 3 back from Hospital 1 because of Family Member D's behavior. The CNO stated she spoke with Family Member C, and Family Member C agreed restricting the visitation rights of Family Member D as a condition for Resident 3 to come back to the facility. Cross reference to F563. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555730 If continuation sheet Page 5 of 14 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 555730 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/22/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Foothill Regional Medical Center D/P Snf 14662 Newport Avenue Tustin, CA 92780 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the proper GT care for two of 17 sampled residents (Residents 4 and 16) as evidenced by: * Residents 4 and 16's GTs were not flushed with water before being administered their first medications and in between each of their medications per the facility's P&P. This failure posed the risk for Residents 4 and 16 to develop complications related to their GT. Findings: According to the Journal of Parenteral and Enteral Nutrition, Volume 41, Issue 1 dated 01/17, showed feeding tubes are prone to clogging for a variety of reasons that include insufficient water flushes and incorrect medication preparation and administration. The document further showed to flush feeding tubes before and after each medication administration. Review of the facility's P&P titled Enteral Nutrition and Medication Administration revised 2/2020 showed when medications are administered via enteral routs, the tubes should be flushed with a minimum of 10ml water, medication given and then another fluid flush to follow before feeding is resumed. Review of the facility's Skills Feeding Tube: Medication Administration-CE (undated), showed the enteral tube should be flushed with purified water before and after administering a liquid or crushed medication to prevent the medication from adhering to the inside of the tube and causing blockage. 1. Medical record review was initiated for Resident 4 on 8/4/23. Resident 4 was admitted to the facility on [DATE]. Review of Resident 4's Medication Administration Record for August 2023 showed Resident 4 was being administered most of her medications through her GT. On 8/4/23 at 0940 hours, a medication administration observation for Resident 4 was conducted with LVN 5. LVN 5 was observed administering medication to Resident 4 via her GT. LVN 5 did not flush Resident 4's GT with water before administering the first medication and in between each medication. On 8/4/23 at 1102 hours, an interview was conducted with LVN 5. LVN 5 verified the above finding and stated she should have flushed Resident 4's GT with water before administering the first medication and in between each medication. 2. Medical record review was initiated for Resident 16 on 8/4/23. Resident 16 was admitted to the facility on [DATE]. Review of Resident 16's Medication Administration Record for August 2023 showed Resident 16 was getting most of her medications through her GT. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555730 If continuation sheet Page 6 of 14 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 555730 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/22/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Foothill Regional Medical Center D/P Snf 14662 Newport Avenue Tustin, CA 92780 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0693 Level of Harm - Minimal harm or potential for actual harm On 8/4/23 at 1032 hours, a medication administration observation for Resident 16 was conducted with LVN 6. LVN 6 was observed administering medications to Resident 16; however, LVN 6 did not flush Resident 16's GT with water before administering the first medication. LVN 6 was also observed to combine Resident 16's crushed medications together and administered Resident 16's multiple medications together, not separately. Cross reference F755, example #1. Residents Affected - Few On 8/4/23 at 1055 hours, an interview was conducted with LVN 6. LVN 6 verified the above finding. LVN 6 stated he should have flushed Resident 16's GT with water before administering the first medication. On 8/4/23 at 1107 hours, an interview was conducted with RN 3. RN 3 stated the licensed staff was expected to flush the residents' GT with 5 to 10 ml water before administering the first medication and to flush the GT with 5 to 10 ml water in between each medication including after giving the last medication to prevent GT clogs. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555730 If continuation sheet Page 7 of 14 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 555730 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/22/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Foothill Regional Medical Center D/P Snf 14662 Newport Avenue Tustin, CA 92780 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and medical record review, the facility failed to provide the pharmaceutical services to ensure the accurate medication dispensing and administration as evidenced by: * The facility failed to ensure the crushed medications administered via GT were administered separately and not combined as per the facility's policy and standards of nursing practice. This failure had the potential to alter the composition of the medications. * The facility failed to ensure Resident 4's supply of Vitamin D was available. LVN 5 took another resident's medication supply of Vitamin D due to the lack of Resident 4's medication supply. This failure posed the risk of residents not receiving their ordered dose of medication and has the potential for medication errors. * The facility failed to ensure Medication Administration Records for seven of 17 sampled residents (Residents 1, 5, 6, 7, 9, 13, and 14) were immediately signed as administered after the medications were administered to the residents. This failure posed the risk for double-dosing and missed does of prescribed medications which may compromise resident safety. * The facility failed to establish a system to keep an accurate count when the scheduled routine medications were dispensed from the facility pharmacy once a week on Wednesdays and administered to the residents by the licensed nurses during the week. There were medication leftovers for Residents 1, 5, 6, 7, 8, 9, 10, and 14 after the licensed nurses had administered the last doses before the refills. In addition, there was no last doses of medications available for Residents 4, 11, 12, and 13 before the licensed nurses administered the medications before the refills. This failure posted the potential risk for medication misuses. Findings: 1. According to the Journal of Parenteral and Enteral Nutrition, Volume 41, Issue 1 dated 01/17, showed medications should be administered separately via GT. The document also showed to avoid mixing different medications intended for administration through the feeding tube given the risks for physical and chemical incompatibilities, tube obstruction and altered therapeutic drug responses. Review of the facility's Skills Feeding Tube: Medication Administration-CE (undated), showed when administering more than one tablet via GT, crush or dissolve and dilute each medication individually. Medical record review was initiated for Resident 16 on 8/4/23. Resident 16 was admitted to the facility on [DATE]. On 8/4/23 at 1032 hours, an observation of medication preparation and administration for Resident 16 was conducted with LVN 6. LVN 6 was observed preparing Resident 16's following medications: - topiramate (medication for seizures) 50 mg; - cholecalciferol (a nutritional supplement) 800 IU; (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555730 If continuation sheet Page 8 of 14 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 555730 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/22/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Foothill Regional Medical Center D/P Snf 14662 Newport Avenue Tustin, CA 92780 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 0755 - clonazepam (used for seizures) 1 mg; Level of Harm - Minimal harm or potential for actual harm - baclofen (medication for spasms) 20 mg; - calcium carbonate (a nutritional supplement) 750 mg; Residents Affected - Some - Calcitrol (a nutritional supplement) 0.25 mcg; - Thera-M multivitamin (a nutritional supplement); and - Keppra (medication for seizures)100 mg. LVN 6 was observed combining Resident 16's medications and crushed together. LVN 6 then diluted the combined crushed medications with water. LVN 6 was then observed to administer the combined crushed medications via GT to Resident 16. On 8/4/23 at 1055 hours, a follow-up interview was conducted with LVN 6. LVN 6 verified the above finding. LVN 6 stated he should have crushed the medications separately and administered the medications via GT one at a time. On 8/4/23 at 1107 hours, an interview was conducted with RN 3. RN 3 stated the licensed staff was expected to crushed the medications separately and administer the crushed medications via GT one at a time. Cross reference to F693, example #2. 2. Review of the facility's P&P titled Medication Orders and Management revised 9/2021 showed no medication shall be used for any resident other than the resident for whom it is prescribed. Medical record review was initiated for Resident 4 on 8/4/23. Resident 4 was admitted to the facility on [DATE]. Review of Resident 4's Patient Orders showed a physician's order dated 10/6/22, to administer 2000 IU of cholecalciferol solution via GT daily as a supplement. The order further showed this medication was dispensed as vitamin D3 liquid 400 IU/ml. Review of Resident 4's Medication Administration Record for August 2023 showed cholecalciferol solution 2000 IU was administered to Resident 4 as ordered by the physician. On 8/4/23 at 0910 hours, an observation of medication preparation for Resident 4 was conducted with LVN 5. LVN 5 stated she could not find Resident 4's bottle of liquid Vitamin D3 and took another resident's botte of liquid Vitamin D. LVN 5 administered another residents' liquid Vitamin D to Resident 4. On 8/4/23 at 1102 hours, a follow-up interview was conducted with LVN 5. LVN 5 stated she should not have borrowed the Vitamin D from another resident. On 8/4/23 at 1107 hours, an interview was conducted with RN 3. RN 3 stated the licensed staff should not borrow medications or supplements from other resident's medication supply. The licensed nurses (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555730 If continuation sheet Page 9 of 14 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 555730 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/22/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Foothill Regional Medical Center D/P Snf 14662 Newport Avenue Tustin, CA 92780 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 0755 should call pharmacy to refill any missing medications. Level of Harm - Minimal harm or potential for actual harm 3.a. Medical record review was initiated for Resident 1 on 8/4/23. Resident 1 was admitted to the facility on [DATE]. Residents Affected - Some Review of Resident 1's Medication Administration Record dated 8/9/23, showed 9 of 15 morning scheduled medications were not signed as administered, at approximately two and a half hours after the medications were administered to Resident 1. b. Medical record review was initiated for Resident 5 on 8/4/23. Resident 5 was admitted to the facility on [DATE]. Review of Resident 5's Medication Administration Record dated 8/9/23, showed 15 of 15 morning scheduled medications were not signed as administered, at approximately one and a half hours after the medications were administered to Resident 5. c. Medical record review was initiated for Resident 6 on 8/4/23. Resident 6 was admitted to the facility on [DATE]. Review of Resident 6's Medication Administration Record dated 8/9/23, showed 17 of 17 morning scheduled medications were not signed as administered, at approximately one and a half hours after the medications were administered to Resident 6. d. Medical record review was initiated for Resident 7 on 8/4/23. Resident 7 was admitted to the facility on [DATE]. Review of Resident 7's Medication Administration Record dated 8/9/23, showed 23 of 25 morning scheduled medications were not signed as administered, at approximately one and a half hours after the medications were administered to Resident 7. e. Medical record review was initiated for Resident 9 on 8/4/23. Resident 9 was admitted to the facility on [DATE]. Review of Resident 9's Medication Administration Record dated 8/9/23, showed two of 13 morning scheduled medications were not signed as administered, at approximately one hour after the medications were administered to Resident 9. f. Medical record review was initiated for Resident 13 on 8/4/23. Resident 13 was admitted to the facility on [DATE]. Review of Resident 13's Medication Administration Record dated 8/9/23, showed 11 of 11 morning scheduled medications were not signed as administered, at approximately two and half hours after the medications were administered to Resident 13. g. Medical record review was initiated for Resident 14 on 8/4/23. Resident 14 was admitted to the facility on [DATE]. Review of Resident 14's Medication Administration Record dated 8/9/23, showed 22 of 26 morning scheduled medications were not signed as administered, at approximately one and half hours after the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555730 If continuation sheet Page 10 of 14 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 555730 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/22/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Foothill Regional Medical Center D/P Snf 14662 Newport Avenue Tustin, CA 92780 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 0755 medications were administered to Resident 14. Level of Harm - Minimal harm or potential for actual harm On 8/9/23 at 1045 hours, an interview and concurrent medical record review of Residents 9 and 14's Medication Administration Records was conducted with LVN 8. LVN 8 verified the Medication Administration Records for Residents 9 and 14 were not signed immediately after Residents 9 and 14's medications were administered. LVN 8 stated she should have signed the Medication Administration Record after giving the medications. Residents Affected - Some On 8/9/23 at 1120 hours, an interview and concurrent medical record review of Residents 5, 6, and 7 was conducted with RN 4. RN 4 verified the Medication Administration Records for Residents 5, 6, and 7 were not signed immediately after the medications were administered. RN 4 stated she finished giving the medications to the residents but did not sign their Medication Administration Record. RN 4 stated she should have signed the Medication Administration Record after giving the medications for each resident. On 8/9/23 at 1505 hours, an interview was conducted with the Nurse Manager. The Nurse manager stated licensed nurses need to sign the resident's' Medication Administration Record right after giving each resident's medication. 4. On 8/4/23 at 1020 hours, an interview was conducted with the Pharmacist. The Pharmacist stated the hospital pharmacy refilled medications for all the residents of the SNF. The medications were refilled once a week, on Wednesdays. The Pharmacist stated the hospital pharmacy dispensed the exact number of doses needed by a resident for the 7-day cycle in accordance with the physicians' orders. On 8/9/23 at 0820 hours, an inspection of Medication Carts A, B, C, and D were conducted. a. On 8/9/23 at 0820 hours, an inspection of Medication Cart A was conducted with LVN 6. Medication Cart A was observed to have doses of medications leftover. i. Medication Cart A was observed to have the following leftover doses for Resident 1: - Docusate Sodium (for bowel management) 50 mg one table every eight hours. There was one tablet left over from the previous week's cycle. - Sodium chloride (for supplement) solution in syringe one syringe daily. There was one syringe left over from the previous week's cycle. - Calcium Carbonate (for supplement) solution in a syringe one syringe twice a day. There was one syringe left over from the previous week's cycle. ii. Medication Cart A was observed to have the following leftover doses for Resident 8: - Fish oil (for supplement) 1000 mg one capsule daily. There was one capsule left over from the previous week's cycle. b. On 8/9/23 at 0834 hours, an inspection of Medication Cart B was conducted with LVN 1. Medication Cart B was observed to have missing doses of medication to complete the 7-day refill cycle. i. Medication Cart B was observed to have the following missing dose for Resident 11: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555730 If continuation sheet Page 11 of 14 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 555730 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/22/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Foothill Regional Medical Center D/P Snf 14662 Newport Avenue Tustin, CA 92780 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some - Levetiracetam (for seizure disorder) 440 mg twice a day. There was one dose missing from the bubble pack to complete the 7-day refill cycle. ii. Medication Cart B was observed to have the following missing dose for Resident 12: - Famotidine (for gastric reflex) 10 mg twice a day. There was one dose missing from the bubble pack to complete the 7-day refill cycle. iii. Medication Cart B was observed to have the following missing dose for Resident 13: - Tapazole (for overproduction of hormone from thyroid) 5 mg daily. There was one dose missing from the bubble pack to complete the 7-day refill cycle. c. On 8/9/23 at 0855 hours, an inspection of Medication Cart C was conducted with LVN 7. Medication Cart C was observed to have doses of medications leftover. i. Medication Cart C was observed to have the following leftover doses for Resident 5: - Calcium Carbonate (for supplement) solution in a syringe one syringe twice a day. There was one syringe left over from the previous week's cycle. ii. Medication Cart C was observed to have the following leftover doses for Resident 7: - Calcium Carbonate (for supplement) solution in a syringe one syringe twice a day. There was one syringe left over from the previous week's cycle. - Sodium chloride (for supplement) solution in syringe one syringe daily. There was one syringe left over from the previous week's cycle. - Gabapentin (for spasticity) 100 mg each capsule at bedtime. There were 16 capsules left over from the previous week's cycle. d. On 8/9/23 at 0950 hours, an inspection of Medication Cart D was conducted with LVN 8. Medication Cart D was observed to have doses of medications leftover. i. Medication Cart D was observed to have the following leftover doses for Resident 9: - Calcium Carbonate (for supplement) solution in a syringe one syringe twice a day. There was one syringe left over from the previous week's cycle. ii. Medication Cart D was observed to have the following leftover doses for Resident 10: - Cyproheptadine (for gastrointestinal motility) 2 mg one tablet at bedtime. There was one tablet left over from the previous week's cycle. - Calcium Carbonate (for supplement) solution in a syringe one syringe twice a day. There were two syringes left over from the previous week's cycle. - Gabapentin (for spasticity) 200 mg every eight hours. There were two capsules left over from the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555730 If continuation sheet Page 12 of 14 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 555730 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/22/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Foothill Regional Medical Center D/P Snf 14662 Newport Avenue Tustin, CA 92780 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 0755 previous week's cycle. Level of Harm - Minimal harm or potential for actual harm iii. Medication Cart D was observed to have the following leftover doses for Resident 14: Residents Affected - Some - Calcium Carbonate (for supplement) solution in a syringe one syringe twice a day. There were three syringes left over from the previous week's cycle. On 8/9/23 at 0840 hours, a concurrent interview and Medication Cart B check with LVN 1. LVN 1 verified the above findings and stated he did not know why one of the medications was not available for last dose administration before Residents 11, 12, and 13's medications were refilled. LVN 1 stated he had to call the hospital pharmacy to provide the doses of medications for Residents 11, 12, and 13 to administer at 1000 hours. On 8/9/23 at 1055 hours, an interview was conducted with the Pharmacist. The Pharmacist stated the reason for the leftover medications after the last dose administration could be the licensed nurses missed to administer doses of the medications or the medications were held because the residents were sick. The Pharmacist was not able to state why there were no medication left for the last dose administration. The Pharmacist stated the facility pharmacy refilled the correct numbers of medications in each medication cart each week. A review of nurses notes and Medication Administration Records for Residents 1, 4. 5, 7, 8, 9, 10, 11, 12, 13, and 14 dated from 8/3/23 to 8/8/23, showed the residents did not have any medication withheld due to change of conditions. The nurse' notes indicated all medications were administered to the residents and the residents tolerated well. On 8/9/23 at 1505 hours, the Nurse Manager was informed and acknowledged the findings. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555730 If continuation sheet Page 13 of 14 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 555730 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/22/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Foothill Regional Medical Center D/P Snf 14662 Newport Avenue Tustin, CA 92780 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation and interview, the facility failed to ensure the safe storage and labeling of medications as evidenced by: * A medication cart (Medication Cart A) was left unlocked and unattended when LVN 6 walked away from the medication cart and into a resident's room to administer medications. Medication Cart A was accessible to unlicensed staff and visitors. This failure had the potential to allow unauthorized access to medications and residents' medication records. * Two opened bottles of medications were not labeled with open and expiration dates. This failure posed the risk for the residents receiving expired medications. Findings: 1. On 8/4/23 at 1032 hours, an observation of medication preparation and administration was conducted with LVN 6. LVN 6 was observed to leave Medication Cart A unlocked and unattended in the hallway when LVN 6 went into a resident's room to administer medications. On 8/4/23 at 1055 hours, an interview was conducted with LVN 6. LVN 6 stated he should have locked the medication cart before going into the resident's room to administer medications. On 8/4/23 at 1107 hours, an interview was conducted with RN 3. RN 3 stated the medication carts need to be locked when the licensed nurses go into residents' rooms to administer medications. 2. On 8/9/23 at 0950 hours, a concurrent observation of medication preparation and interview was conducted with LVN 8. A bottle of acetaminophen 160 mg/ml (medication for pain) and a bottle of D-Vite (a vitamin D supplement) were observed open with no open and expiration dates on the bottles. LVN 8 verified the above findings. LVN 8 stated when a licensed nurse opened a bottle of liquid medication, he or she should write the open and expiration dates on the bottle. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555730 If continuation sheet Page 14 of 14

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Citations

6 citations recorded^*CMS

What do CMS severity letters mean?

Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.

General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.

Each letter combines severity with scope: how many residents the deficiency affected.

0563GeneralS&S Dpotential for harm
F563 - The resident has a right to receive visitors of his or her choosing at the time o
Honor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing.
0583GeneralS&S Bno actual harm
F583 - Privacy and Confidentiality
Keep residents' personal and medical records private and confidential.
0626GeneralS&S Dpotential for harm
F626 - Transfer and discharge-
Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy.
0693GeneralS&S Dpotential for harm
F693 - Assisted nutrition and hydration
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
0755GeneralS&S Epotential for harm
F755 - Pharmacy Services
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
0761GeneralS&S Dpotential for harm
F761 - Labeling of Drugs and Biologicals
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

FAQ · About this visit

Common questions about this visit

What happened during the August 22, 2023 survey of FOOTHILL REGIONAL MEDICAL CENTER D/P SNF?

This was a inspection survey of FOOTHILL REGIONAL MEDICAL CENTER D/P SNF on August 22, 2023. The surveyor cited 6 deficiencies, recorded on the federal Form 2567 statement of deficiencies.

Were any deficiencies cited at FOOTHILL REGIONAL MEDICAL CENTER D/P SNF on August 22, 2023?

Yes, 6 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Honor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing."

What type of survey was this?

This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.

SourceView on CMS Care Compare

Next steps

Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.

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Data from CMS Care Compare public records. Dataset last refreshed June 15, 2026. If you believe any information is inaccurate, report it here.

Inspection·August 22, 2023