Inspection visit
Health inspection
2 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 2 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0656
Level of Harm - Potential for
minimal harm
Residents Affected - Some
Develop and implement a complete care plan that meets all the resident's needs, with timetables and
actions that can be measured.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interview and medical record review, the facility failed to develop the comprehensive plans of care to reflect
the individual care needs for one of six sampled residents (Resident 1).
* The facility failed to develop a care plan problem to address Resident 1's neck redness under the
tracheostomy [a procedure to help air and oxygen reach the lungs by creating an opening into the trachea
(windpipe) from outside the neck] tie, change of condition manifested by elevated temperature, and blister
on the left foot. This failure posed the risk of not providing appropriate, consistent, and individualized care to
Resident 1.
Findings:
Closed medical record review for Resident 1 was initiated on 2/27/24. Resident 1 was admitted to the
facility on [DATE].
Review of Resident 1's H&P examination note dated 5/25/23, showed Resident 1 had tracheostomy and
ventilator dependent.
a. Review of Resident 1's Order Summary Report between 5/1/23 through 6/30/23, showed a physician's
order dated 5/27/23, to apply mepilex (a foam absorbent dressing use to treat wounds) to both sides of the
resident's neck under the tracheostomy ties and apply PolyMem (a wound dressing use on wet or moist
areas of the skin) to the back of the resident's neck and around the tracheostomy site every day shift for
skin redness on the neck under the tracheostomy ties.
Review of Resident 1's Skin Progress Record dated 5/27/23, showed the left and right sides of neck with
mild redness under the tracheostomy ties.
Review of Resident 1's plan of care failed to show documented evidence a care plan problem was
developed to address Resident 1's left and right neck redness under the tracheostomy ties.
b. Review of Resident 1's Nursing Progress note dated 6/6/23 at 0650 hours, showed Resident 1 had
elevated body temperature of 40 degrees Celsius (104 degrees Fahrenheit), oxygen saturation level of
73%, labored breathing, nasal flaring, and retractions on 6/6/23 at 0550 hours. In addition, the progress
note showed a physician's order was obtained to administer Motrin (medication use to relieve pain and
fever) 10 mg/kg every six hours for elevated temperature and elevated heart rate.
Review of Resident 1's Order Summary Report between 5/1/23 through 6/30/23, showed a physician's
(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 5
Event ID:
555753
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
555753
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/29/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Healthbridge Children's Hospital - Orange D/P Snf
393 S Tustin St
Orange, CA 92866
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 0656
Level of Harm - Potential for
minimal harm
Residents Affected - Some
order dated 6/6/23, to administer ibuprofen (medication use to relieve pain and fever) 118 mg via J-tube
every six hours as needed for fever or elevated heart rate.
Review of Resident 1's plan of care failed to show documented evidence a care plan problem was
developed to address Resident 1's change of condition for elevated body temperature, low oxygen
saturation level, labored breathing, nasal flaring, and retractions.
c. Review of Resident 1's Nursing Progress note dated 6/10/23 at 0542 hours, showed Resident 1
developed a one cm fluid filled blister on the left foot after blood draw was done. The progress note also
showed the blister was caused by the flashlight used to locate Resident 1's vein.
Review of Resident 1's Skin Only Evaluation note dated 6/10/23 at 0637 hours, showed Resident 1 had a
fluid filled blister on the left medial ankle measuring 1.5 cm (length) x 1.5 cm (width).
Review of Resident 1's plan of care failed to show documented evidence a care plan was developed to
address Resident 1's left foot blister.
On 2/29/24 at 1015 hours, a telephone interview was conducted with RN 4. RN 4 stated there was no care
plan initiated for Resident 1's left foot blister. RN 4 stated Resident 1's change of condition or incident
should have been written in the care plan.
On 2/29/24 at 1445 hours, an interview and concurrent medical record review was conducted with the
Administrator. The Administrator was informed and verified the above findings.
Cross reference to F684.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
555753
If continuation sheet
Page 2 of 5
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
555753
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/29/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Healthbridge Children's Hospital - Orange D/P Snf
393 S Tustin St
Orange, CA 92866
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 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
interview, medical record review, facility document review, and facility P&P review, the facility failed to
provide the necessary care and services to attain or maintain the highest practicable well-being for one of
six sampled residents (Resident 1).
Residents Affected - Few
* The facility failed to ensure the licensed nurse used the approved devices to locate Resident 1's vein
during the blood draw as per the facility's P&P. Resident 1 sustained a blister to the left foot from the
licensed nurse's LED (light emitting diode) flashlight used during the blood draw. This failure had the
potential to negatively impact the resident's well-being.
Findings:
Review of the facility's P&P titled Phlebotomy revised May 2022 showed phlebotomy (procedure in which a
needle is used to take blood from a vein, usually for laboratory testing) is a nursing responsibility. If vein is
not visible, see Ultrasound Guided Vein Localization policy.
Review of the facility's P&P titled Ultrasound Guided Vein Localization revised May 2022 showed the policy
outlines the guidelines and procedures for the safe and effective use of ultrasound technology for vein
localization in pediatric patients undergoing blood draws. The aim is to minimize discomfort, improve
success rates, and ensure patient safety during venipuncture procedures. This policy applies to all
healthcare providers involved in pediatric blood draws within the facility. Under the Training and
Competency section showed the following:
a. Healthcare providers must receive appropriate training and demonstrate competency in
ultrasound-guided vein localization techniques before performing procedures on pediatric patients.
b. Competency assessment must be conducted periodically to ensure proficiency is maintained. Under the
Equipment and Environment section showed the following:
- Only FDA (Food and Drug Administration) - approved ultrasound devices specifically designed for
pediatric use should be utilized and
- No other light devices should be used besides the approved ultrasound.
Review of the facility's P&P titled Change in Resident's Condition or Status revised February 2022 showed
the facility promptly notifies the resident, his or her attending physician, and the resident representative of
changes in the resident's medical/mental condition and/or status. The policy also showed the following:
1. The nurse will notify the resident's attending physician or physician on call when there has been a(an):
a. accident or incident involving the resident;
b. discovery of injuries of an unknown source;
c. adverse reaction to medication;
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
555753
If continuation sheet
Page 3 of 5
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
555753
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/29/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Healthbridge Children's Hospital - Orange D/P Snf
393 S Tustin St
Orange, CA 92866
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 0684
d. significant change in the resident's physical/emotional/mental condition;
Level of Harm - Minimal harm
or potential for actual harm
e. need to alter the resident's medical treatment significantly;
f. refusal of treatment or medications two (2) or more consecutive times);
Residents Affected - Few
g. need to transfer the resident to a hospital/treatment center;
h. discharge without proper medical authority; and/or
i. specific instruction to notify the physician of changes in the resident's condition.
Closed medical record review for Resident 1 was initiated on 2/27/24. Resident 1 was admitted to the
facility on [DATE].
Review of Resident 1's Order Summary Report between 5/1/23 through 6/30/23, showed a physician's
order dated 6/8/23, to obtain serial blood cultures from the central line and peripheral one time a day for
sepsis (severe body response to an infection) monitoring for seven days.
Review of Resident 1's Nursing Progress note dated 6/10/23 at 0542 hours, showed Resident 1 developed
a one cm fluid filled blister on the left foot after the blood draw was done. The progress note showed the
blister was caused by the flashlight used to locate the resident's vein and RN 4 would inform the rounding
physician in the morning if treatment was needed.
Review of Resident 1's Skin Evaluation note dated 6/10/23 at 0637 hours, showed Resident 1 had a fluid
filled blister on the left medial ankle measuring 1.5 cm x 1.5 cm. There was an increase of 0.5 cm in size
from the measurement obtained on 6/10/23 at 0542 hours.
Review of Resident 1's Nursing Progress notes dated 6/10/23 at 0653 hours, showed Resident 1's left
ankle blister developed during the blood draw and the licensed nurse would endorse to the oncoming
nurse.
Review of Resident 1's Physician Discharge Summary note dated 6/10/23 at 1223 hours, under the Skin
section, showed Resident 1 had no rashes.
Further review of the Resident 1's medical record failed to show Resident 1's physician was notified of
Resident 1's fluid filled blister on the left foot. In addition, there was no care plan developed to address
Resident 1's the left foot blister.
On 2/27/24 at 1430 hours, an interview was conducted with RN 1. RN 1 stated the night shift licensed
nurses were responsible to do the routine blood draws, unless specified in the physician's order. RN 1
stated she would use a regular flashlight to help locate veins for the blood draw.
On 2/28/24 at 1340 hours, an interview was conducted with RN 2. When asked, RN 2 stated if the vein was
not visible during a blood draw, the facility had an examination light called Eco light to help see the vein.
However, when RN 2 was asked to show the examination light, RN 2 stated she was not sure where it was
and would find out. RN 2 then stated she would use a penlight if she needed to locate the vein for blood
draw.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
555753
If continuation sheet
Page 4 of 5
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
555753
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/29/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Healthbridge Children's Hospital - Orange D/P Snf
393 S Tustin St
Orange, CA 92866
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 0684
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
On 2/28/24 at 1359 hours, an interview was conducted with RN 3. RN 3 stated he would palpate the vein
and used a flashlight if needed to help see the vein during blood draw.
On 2/28/24 at 1425 hours, an interview and concurrent closed medical record review was conducted with
the Administrator. The Administrator stated RN 4 brought in the LED flashlight used to locate the vein for
Resident 1. The Administrator stated Resident 1's skin was sensitive. The Administrator stated after the
incident with Resident 1, flashlights were not allowed to be used to locate veins during blood draws. The
Administrator stated there was an ultrasound guided light (uses sound waves to locate and image the
targeted vein) vein locator available for the staff to use. In addition, the Administrator verified there was no
documented evidence to show the physician was notified of Resident 1's left foot blister and whether a care
plan was developed to address the left foot blister.
On 2/29/24 at 1015 hours, a telephone interview was conducted with RN 4. RN 4 stated he used a
flashlight during blood draw because Resident 1's veins were very hard to find. RN 4 stated the flashlight
heated up and caused Resident 1's left foot skin to be redden and become warm. RN 4 stated he did not
use the ultrasound guided light vein locator provided by the facility because it was difficult to use. RN 4
stated he placed a cold compress on Resident 1's left foot for few minutes then the redness developed into
a blister. RN 4 stated he did not notify the physician at the time of the incident but endorsed to the morning
nurse to inform the physician who usually made rounds in the morning.
Review of RN 4's Annual Skills Day Competency Review and Verification dated 2/25/23 and Annual
Competency Validation and Evaluation dated 5/12/23, failed to show evaluation of RN 4's competency for
the use of ultrasound guided vein locator.
On 2/29/24 at 1100 hours, an interview and concurrent facility record review was conducted with the DSD.
The DSD verified the facility's in-service titled Ultrasound-Guided Vein Locator conducted by the
Administrator on 6/20/23, was provided to six licensed nurses but did not include RN 4. The DSD stated the
in-service was only provided to the team leaders.
On 2/29/24 at 1445 hours, an interview was conducted with the Administrator. The Administrator was
informed and acknowledged the above findings.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
555753
If continuation sheet
Page 5 of 5
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Back to topCitations
2 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.
F684 - Quality of care
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
F656 - Comprehensive Care Plans
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
FAQ · About this visit
Common questions about this visit
What happened during the February 29, 2024 survey of HEALTHBRIDGE CHILDREN'S HOSPITAL - ORANGE D/P SNF?
This was a inspection survey of HEALTHBRIDGE CHILDREN'S HOSPITAL - ORANGE D/P SNF on February 29, 2024. The surveyor cited 2 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at HEALTHBRIDGE CHILDREN'S HOSPITAL - ORANGE D/P SNF on February 29, 2024?
Yes, 2 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Provide appropriate treatment and care according to orders, resident’s preferences and goals."
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
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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.