Health inspection·February 2, 2024

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **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 necessary care and services were provided to meet the care needs related to the tracheostomy care for one of the three sampled residents (Resident 2). Residents Affected - Few * The facility failed to ensure the tracheostomy care was provided to Resident 2 as per the facility's P&P. This failure posed the risk for not keeping the stoma area clean and being susceptible to infection. Findings: Review of the facility's P&P titled Trach Care dated 5/2014 showed the respiratory care staff along with nursing staff will provide proper and correct tracheostomy/stoma care in order to keep stoma area clean, free of secretions, and less susceptible to infection. The procedure showed the following: - to dampen the applicators and gauze with hydrogen peroxide (mild antiseptic) and swab the secretions from stoma/trach area until clean. Rinse with sterile water. On 2/1/24 at 1200 hours, a tracheostomy care observation of Resident 2 with RT 2 was conducted. RT 2 prepared a sterile table with the trach care kit. RT 2 then washed his hands and donned sterile gloves, with RT 3 assisting in repositioning and loosening Resident 2's tracheostomy tie. RT 2 removed Resident 2's old sponge covering the stoma, then removed the trach tube, and placed a new trach tube. RT 2 then covered the stoma with a clean dry gauze, then applied a dated new tie to secure the tracheostomy. RT 2 stated he forgot to bring the hydrogen peroxide to mix with sterile water to clean the skin around the stoma before inserting the new tracheostomy tube and covering with a dry gauze. Medical record review was initiated on 2/2/24. Resident 2 was admitted to the facility on [DATE]. Review of the physician's orders showed the following orders dated 2/2/23: - to change trach tube tie after bath in AM and PRN - to change trach 5.5 Peds [NAME] uncuffed monthly and as needed for airway patency On 2/1/24 at 1505 hours, an interview with the lead RT was conducted. The lead RT stated skin around the tracheostomy stoma should be cleansed with 3% hydrogen peroxide mixed with ½ strength sterile water before covering the tracheostomy stoma with a gauze and securing with new dated tie. (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 3 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 02/02/2024 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)