Kindred Hospital Brea D/P SNF

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary GT care and services for one of four sampled residents (Resident 1). * The facility failed to ensure Resident 1 was positioned safely at 30 to 45 degrees during the GT feeding administration. This failure placed Resident 1 at risk for complications related to the GT feeding, including aspiration.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to comply with State law requirements for one of four sampled residents (Resident 4). * Resident 4's discontinued respiratory orders were not signed by the physician. This failure had the potential to prevent the resident from receiving necessary care and services to meet the resident's assessed needs.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure five of five final sampled residents (Residents 1, 7, 13, 22, and 40) reviewed for unnecessary medications were appropriately monitored for the identified manifested episode of behavior and provided with the non pharmacological interventions for the use of psychotropic medications. [...]

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the medications were administered as ordered by the physician, properly accounted for, and destroyed per pharmaceutical protocols. * Resident 7's Ativan (a controlled medication for anxiety) administration log did not match the administration record and the physician's orders. * Resident 7's midodrine (a medication to treat low blood pressure) was administered outside of the ordered parameters.* Resident 13's midodrine was administered outside of the ordered parameters.* The facility failed to ensure medication destruction was completed by two licensed nurses.* Resident 46's controlled medication log did not match the administration record. [...]

Inspectors wroteBased on observation, interview, record review, and facility P&P review, the facility failed to ensure the proper storage and labeling of medications and biologicals in one of one medication rooms observed (Medication Room A), and two of five medication carts observed (Medication Carts A and B) and at two non-sampled residents bedside (Residents 35 and 41) were followed. * Medication Room A's medication destruction incinerator container was not secured, and the medications were not effectively destroyed. * Two bottles of compounded Vancomycin (medication to treat infections), past their labeled use by date, were in Medication Room A's refrigerator. * RN 7 left Medication Cart B unlocked and unattended.* An open bottle of glucometer test strips in Medication Cart B was not labeled with the date opened and the use-by date. [...]

Inspectors wroteBased on observation and interview, the facility failed to ensure the sanitation in the kitchen was maintained. * There was no thermometer inside the reach in refrigerator,* One box of opened gloves and two boxes of aluminum sheets were stored inside the reach in refrigerator.* Two racks inside the reach in refrigerator had brown discoloration.* Expired items were stored on the kitchen countertop.* Two bottles of expired Ensure were stored inside the residents' refrigerator * One sanitizer bucket was stored near food items.* Food stored in the steam table did not reach the appropriate temperatures.* Temperature log for dish washing machine was not completed for 2 days.* Two staff did not know the location of the emergency food storage. [...]

Inspectors wroteBased on observation, interview, medical record review, facility document review, and facility P&P review, the 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 maintain an accurate infection control surveillance program for November and December 2025, and January 2026. The facility conducted surveillance only for the residents who exhibited signs and symptoms of infection and were prescribed antimicrobial medications. * The facility failed to ensure the staff performed hand washing after changing trash liner in a room with Clostridium difficile (a bacteria that causes diarrhea, and is usually a side-effect of taking antibiotics) for Resident 3. [...]

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure the education regarding the risks and benefits of the influenza and pneumococcal vaccinations were reviewed with the resident and/or resident representative for five of six residents (Residents 27, 8, 1, 18, and 3) reviewed for immunization. * The facility failed to ensure Resident 1 was provided with the education on the risks, benefits, and potential side effects of pneumococcal vaccination before the administration of the pneumococcal vaccination to Resident 1. In addition, the facility failed to ensure the updated VIS (Vaccination Information Sheet) was provided to Resident 1 before the administration of the pneumococcal vaccination. [...]

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure the education on the risks and benefits of the COVID-19 vaccinations were reviewed with the resident and/or resident representative for three of three final sampled residents (Residents 1, 3 and 18) and two nonsampled residents (Residents 8 and 27) reviewed for immunization. * The facility failed to ensure the residents or their representatives wer provided education on the risk, benefits and potential side effects of COVID-19 vaccination before administration of the COVID-19 vaccination to Residents 1 and 3. * The facility failed to ensure the residents or their representative were provided education on the risk, benefits and potential side effects of COVID-19 vaccination when the resident's representative declined the COVID-19 vaccination for Residents 8, 27 and 18. [...]

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure the informed consent was obtained for the use of psychotropic medications (any drug prescribed to stabilize or improve mood, mental status, or behavior) for one of five final sampled residents reviewed for unnecessary medications (Resident 1 ). * The facility failed to ensure the informed consent was obtained from Resident 1 or their responsible party when the frequency of the trazodone (antidepressant) was changed. This failure posed the risk of Resident 1 and his responsible party to not be informed and understand the risks and benefits of the treatment and medications.

Inspectors wroteBased on interview and medical record review, the facility failed to ensure a copy of the resident's advanced directive was available in their medical record for one of one final sampled resident (Resident 13) investigated for Advanced Directives. * The facility failed to obtain a copy of Resident 13's advance directive and place in the resident's medical record. This failure had the potential for the resident's wishes for medical care and choice of healthcare agent not being communicated effectively in the event the resident was unable to make her own medical decisions.

Inspectors wroteBased on interview and medical record review, the facility failed to ensure the appropriate bed hold process was followed for one of one sampled resident (Resident 42) reviewed for bed hold. * Resident 42's bed hold was cancelled prior to the end of the seven-day bed hold. This failure resulted in Resident 42 not being allowed to return to the facility when Resident 42 was transferred to the acute care hospital.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure the resident or resident's representative was provided with the required information when the resident was transferred and/or discharged for two of three sampled residents (Residents 39 and 42) reviewed for transfer and discharge. * The facility failed to ensure Resident 39 and/or their representative were notified of the transfer and reasons for the transfer in writing when the resident was discharged to an Assisted Living Facility. * The facility failed to provide facility's bed hold policy and notice of transfer when Resident 42 was transferred to the acute care hospital and was not permitted to readmit to the facility. These failures resulted in the interested parties not having the complete information related to the discharge and transfer process. [...]

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to develop detailed resident centered care plans for two of 12 final sampled residents (Residents 1 and 22).* The facility failed to ensure a care plan was developed to address the use of insulin (medication to lower blood sugar) for Residents 1 and 22. These failures posed the risk of not providing appropriate, consistent, and individualized care to these residents.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide the individualized and ongoing activity program to meet the needs and interests for one of one final sampled resident (Resident 18) reviewed for activities. * The facility failed to provide documentation Resident 18 received meaningful activities from the facility for December 2025 and January 2026. This failure had the potential to affect the resident's psychosocial well-being.

Inspectors wroteBased on observation and interview, the facility failed to ensure one of four sampled residents (Resident 2) reviewed for pressure injuries received the care and services to heal the resident's pressure injuries. * Resident 2's special mattress was not functioning properly. In addition, there was no physician's order for the use of the special mattress. This failure posed the risk of delay in healing for Resident 2's pressure injuries.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure one of one nonsampled resident (Resident 27) reviewed for limited range of motion received the appropriate treatment and services. * The RNA services and instructions for Resident 27 were not completed. This failure had the potential to result in the decline in Resident 27's range of motion which could lead to further deterioration in the resident's physical well- being.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure the proper pain assessment, implementation of non pharmacological interventions, and appropriate pain medication administration per physicians' orders for two of five residents (Residents 7 and 13) reviewed for unnecessary medications. * Resident 7's admission pain assessment was incomplete. The resident did not have physicians' orders to appropriately address and treat the resident's pain level, and the facility failed to document and implement NPI for pain management. * Resident 13 did not have documented use of non pharmacological interventions for pain management. These failures had the potential to put the residents at risk for ineffective pain management and adverse effects related to the use of unnecessary pain medications.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the nursing staff were competent. * The facility failed to ensure LVN 2 diluted the crushed medications before administering them via GT for one of two nurses observed for GT medication administration. * The facility failed to ensure the IP/DSD was aware about the VIS (Vaccination Information Sheet) and the need to provide the residents and and their representative with the education on risks, benefits, and potential side effects from the influenza, pneumococcal, and COVID-19 vaccinations. These failures had the potential for a partial dose being administered or the tube becoming clogged. [...]

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to follow-up on the Pharmacist Consultant's Medication Regimen Review (MRR) recommendations for one of five residents investigated for Unnecessary Medications. * The facility failed to provide an in-service education to the staff per the Pharmacist Consultant's Report recommendation to remind the staff of administering/holding medications within the ordered parameters. This failure resulted in the continued deficient practice of midodrine (medication to treat low blood pressure) being administered to the residents (Residents 7 and 13) outside of the ordered parameters.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the medication error rate was below 5%. The facility's medication error rate was 32%. Two of five licensed staff (LVN 2 and RN 4) were found to have made errors during the medication administration observations.* LVN 2 failed to administer the complete dose for four of Resident 13's crushed medications when medication residues were observed in the medication pouches. * RN 4 failed to administer the complete dose for four of Resident 18's crushed medications when the medication residues were observed in the medication pouches and cups. These failures had the potential to negatively affect the residents' health.

Inspectors wroteBased on interview and medical record review, the facility failed to ensure complete and accurate medical records for one of five final sampled residents reviewed for unnecessary medications (Resident 7), and one of three final sampled residents reviewed for pressure injuries (Resident 4). * Resident 7's documented pain level for each shift did not show the resident's highest pain level for the shift on multiple shifts.* Resident 3's Stage 4 pressure injury was incorrectly documented on their weekly assessment as a DTI (Deep Tissue Injury). These failures resulted in inaccurate medical records for Residents 4 and 7.

Inspectors wroteBased on observation, interview, and facility document review, the facility failed to maintain the essential equipment in a clean, sanitary, and safe operating condition for two of two sinks (Sinks 1 and 2) inspected. * The facility failed to ensure Sink 1 was working properly. * The facility failed to ensure Sink 2 had no missing knobs on the faucet. These failures resulted in the essential equipment not in operating condition and not to function in the way it was intended, which could expose the residents to unsafe practices.

Inspectors wroteBased on interview, closed medical record review, and facility P&P review, the facility failed to meet the professional standards of care for one of three sampled resident (Resident 1) reviewed for change of condition. * RT 1 failed to follow the professional standards of care when he attended Resident 1's change of condition. This failure posed the risk of not providing the appropriate and necessary care and services to the resident during a change of condition.

Inspectors wroteBased on interview, closed medical record review, and facility P&P review, the facility failed to ensure the quality care and services were provided for one of five sampled residents (Resident 1). * The facility failed to obtain the physician's orders and informed consents prior to the beside debridement (the medical removal of dead, damage, or infected tissue to improve the healing potential of the remaining tissue) for Resident 1's scrotal and perineal/perianal wounds. In addition, the facility failed to ensure the wound assessments were completed after the bedside debridement. These failures had the potential for Resident 1 to not receive the necessary care and services to maintain the resident's highest physical well-being.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the necessary care and services related to pressure injuries (areas of damaged skin caused by staying in one position for a long time which reduces blood flow to the area and causes the skin to die and develop a sore to promote wound healing) were provided to three of three sampled residents (Residents 1, 2, and 3) reviewed for wound management. * The facility failed to ensure the physician was informed and a change of condition was initiated when there was an increase in the wound size and necrotic tissue for Resident 1's sacrococcyx (fused bone at the very end of the spine) pressure injury. * The facility failed to ensure the LAL mattress setting was consistent with Residents 2 and 3's weight. These failures posed the risk for complications and delayed wound healing.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the least restrictive alternatives were attempted prior to the use of side rails for six of 12 final sampled residents (Residents 10, 17, 25, 32, 33, and 239) and five nonsampled residents (Residents 8, 12, 19, 27, and 28) reviewed for side rails use. This failure had the potential to put the residents at risk for entrapment and serious injury.

Inspectors wroteBased on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the sanitary requirements were met in the kitchen as evidenced by: * The facility failed to ensure the ice machine utilized for the residents and staff was maintained in a sanitary condition. * The facility failed to ensure the microwave utilized to warm up the food was in sanitary condition and free of food residue. * The facility failed to ensure the sanitary condition of the hood over the stove was maintained. * The facility failed to ensure the kitchen utensils had a smooth cleanable surface and in good condition. * The facility failed to ensure the kitchenware and kitchen utensils were clean and free of food particle or residue. * The facility failed to ensure the cutting board was kept in a sanitary condition and with cleanable surface. [...]

Inspectors wroteBased on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure the residents' entrapment assessments were complete and the measurements were recorded during the bed inspection when identifying areas of possible entrapment with the use of side rails for six of 12 final sampled residents (Residents 10, 17, 25, 32, 33, and 239) and five nonsampled residents (Residents 8, 12, 19, 27, and 28) reviewed for side rails use. These failures had the potential to negatively impact the residents resulting in possible entrapment, serious injury, and death.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the proper GT care was provided for three of eight final sampled residents (Residents 17, 24, and 32) and one nonsampled resident (Resident 15) reviewed for enteral tubing. * The facility failed to ensure Residents 15 and 24 had the proper labeling of name and date of the GT feeding bottle, water irrigation bag and irrigation set. * The facility failed to ensure Residents 17 and 32's GT dressings were changed daily as ordered. These failures posed the risk for developing complications related to the residents' GT.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services to maintain the intravenous accesses for one nonsampled resident (Resident 30). * The facility failed to ensure the PICC line external catheter and arm circumference measurements were completed and documented in the medical record for Resident 30. In addition, the facility failed to develop a plan of care for the use of PICC line. These failures had the potential to delay the identification of catheter related complications for the resident.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure four of 12 final sampled residents (Residents 13, 23, 25, and 33) and seven nonsampled residents (Resident 2, 8, 12, 19, 26, 30, and 27) reviewed for respiratory care were provided with the appropriate respiratory care when: * The facility failed to ensure the nasal cannula was dated and properly stored for Residents 12 and 33. There was no signage for oxygen usage for Resident 33's room. * The facility failed to ensure the nebulizer mask, tubing, and bag were labeled with the date when it was changed and properly stored for Resident 23. * The facility failed to ensure Residents 2, 13, 25, 26,and 30's nasal cannula tubings were labeled, dated, and not touching the floor. In addition, there should date and label the set-up bags for nasal cannula tubings and nebulizer mask. [...]

Inspectors wroteBased on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the medications were properly stored and labeled. * The facility failed to ensure accuracy and complete records of the Medication Room and Medication Refrigerator temperature log. * The facility failed to dispose of an empty bottle of Hy[DATE] (Sodium Hypochlorite Solution) in the Treatment Cart. * The facility failed to ensure Medication Cart 1 was maintained in a sanitary condition. * The facility failed to ensure the medications were labeled with an opened date in accordance with the facility's policy for Resident 22. These failures had the potential to negatively impact the residents' well-being.

Inspectors wroteBased on observation, interview, and facility document review, the facility failed to ensure the pureed recipes were followed for two residents who received pureed food from the kitchen. * The facility failed to ensure the puree recipe for steamed green beans was followed. This failure had the potential for not providing nutritional meals to meet the needs of residents who were on a pureed diet.

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to ensure the resident's right was promoted for one of 12 final sampled resident (Resident 10). * Resident 10's catheter drainage bag was not placed in the dignity bag. This failure had the potential to affect the privacy and dignity of the resident.

Inspectors wroteBased on observation, interview, and facility P&P review, the facility failed to ensure the garbage was properly stored in four of nine garbage dumpsters. This failure had the potential to attract pest/rodents that carried diseases.

Inspectors wroteBased on interview, medical record review, facility document review, and facility P&P review, the facility failed to protect the resident's rights to be free from the verbal abuse by CNA 1 for one of two sampled residents (Resident 1) when CNA 1 yelled at Resident 1. Additionally, the facility staff failed to report the incident and intervene in the timely manner as per the facility's P&P. These failures had the potential to cause psychosocial harm to the residents.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services to ensure the resident maintained their highest physical well-being for one of two sampled residents (Resident 2). * Resident 2 had a new skin discoloration on her wrist. The facility failed to create a change in condition, notify the physician, develop a care plan, and monitor Resident 2's skin discoloration on her right wrist area. This failure had the potential for the resident to not receive the appropriate care and services needed.

Inspectors wroteBased on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the sanitary requirements were met in the kitchen as evidenced by: * The facility failed to ensure the ice machine utilized for the residents and staff was maintained in a sanitary condition. * The facility failed to ensure the microwave utilize to warm up the residents' food was in sanitary condition and free of food residue. * The facility failed to ensure the cutting boards were kept in a sanitary condition and with cleanable surface. * The facility failed to ensure the kitchen equipment was air dried prior to storage. * The facility failed to ensure the kitchen utensils had a smooth cleanable surface and were in good conditions. * The facility failed to ensure the kitchen utensils were clean and free of food particle or residue. [...]

Inspectors wroteBased on observation, interview, medical record review, and facility's P&P review, the facility failed to ensure three of 14 final sampled residents (Residents 3, 14, and 33) remained free from accident hazards. * The facility failed to continue to monitor and document assessment every shift for 72 hours post fall incident for Resident 33. * The facility failed to provide bilateral floor mats to Resident 3 as ordered by the physician and according to Resident 3's care plan interventions. * Resident 14's had bilateral upper and lower side rails in place with a physician's order for only the bilateral upper side rails. These failures had the potential to place the residents at risk for serious injuries.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services for GT management for two of 14 final sampled residents (Residents 3 and 32) and two nonsampled residents (Residents 13 and 586). * The facility failed to ensure Residents 3, 13, and 586's GT placement was verified as per the facility's P&P prior to administering the medications via GT. * The facility failed to ensure Resident 586's GT medication was administered by gravity. * The facility failed to ensure Resident 32's GT dressing was labeled with date, time, and initial of the nurse as per the facility's P&P. These failures posed the risk for the residents to experience complications related to their GT.

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to ensure the medication error rate was below 5%. The facility's medication error rate was 7.41%. Two of three licensed nurses (LVNs 2 and 3) who were observed during the medication administration were found to have made errors. * LVN 3 administered the potassium chloride (electrolyte/potassium supplement) liquid without dissolving the medication with water or juice as per the pharmacy instruction label. * LVN 2 administered the tamsulosin (used to treat enlarged prostate) oral capsule by opening the capsule and mixing the granules with water. However, the pharmacy note on the bubble pack showed to swallow the medication whole. These failures had the potential to negatively affect the residents' health conditions.

Inspectors wroteBased on observation, interview, facility document review, and facility P&P review, the facility failed to store the drugs and biologicals in a safe manner. * The facility failed to dispose the expired and discontinued medications and supplies in Medication room [ROOM NUMBER] and Medication Cart 1. This failure had the potential for the medications to be accidentally administered and/or diverted. * The facility failed to ensure the blood glucose strips containers in Medication Carts 2 and 3 were labeled with the opened date and discard date. This failure had the potential to result in adverse consequences for the residents. * The facility failed to ensure the medications were not left unattended by LVN 2. This failure had the potential for the medications to be diverted.

Inspectors wroteBased on observations, interviews, facility document review, and facility P&P review, the facility failed to ensure two of two IP Nurses completed 10 hours of continuing education annually as recommended by CDPH. This failure had the potential for the IP nurses to not have current and updated infection control training and the potential to provide inaccurate information to the staff.

Inspectors wroteBased on observation, interview, and facility P&P review, the facility failed to ensure the wound dressing was labeled with date and initial as per the facility's P&P for one of 14 final sampled residents (Resident 32). This failure posed the risk for Resident 32's wound not possibly assessed for absence or presence of signs and symptoms of infection.

Inspectors wroteBased on observation and interview, the facility failed to ensure three of five garbage dumpsters with lids were properly closed. The failure had the potential to attract pest/rodents that carried diseases.

Inspectors wroteBased on observation, interview, facility document review, and facility P&P review, the facility failed to implement the infection control practices designed to provide the safe and sanitary environment and help prevent the development and transmission of diseases and infections for two of sampled residents (Residents 1 and 2). * The facility failed to ensure the staff practiced the contact isolation precautions when entering the room of one sampled resident (Resident 1) who was on contact isolation precautions * The facility failed to ensure the staff practiced the enhanced barrier precautions during high contact-care for one sampled resident (Resident 2) who was on enhanced barrier precautions. These failures posed the risk for the transmission of diseases-causing microorganisms.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure the necessary care and services were provided to prevent the development and worsening of pressure ulcers for one of the five sampled residents (Resident 3). * Resident 3's right heel pressure injury was not reassessed for improvement or deterioration. There were no treatment order and care plan developed to address the resident's right heel pressure injury. This failure had the potential for Resident 3 to not receive the appropriate wound treatment.

Inspectors wroteBased on observation and interview, the facility failed to ensure the garbage was properly stored in five of five garbage dumpsters. The failure had the potential to attract pest/rodents that carried diseases.