A list of the most recent deficiencies for Kindred Hospital Brea D/p Snf. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Provide and implement an infection prevention and control program. | Health | 2023-11-30 | 2023-12-26 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-12-01 | 2023-12-26 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-12-01 | 2023-12-26 | N |
| 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. | Health | 2023-12-01 | 2023-12-26 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2023-12-01 | 2023-12-26 | N |
| 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. | Health | 2023-12-01 | 2023-12-26 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-12-01 | 2023-12-26 | N |
| Dispose of garbage and refuse properly. | Health | 2023-12-01 | 2023-12-26 | N |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2023-12-01 | 2023-12-26 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-12-05 | 2023-12-15 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-12-05 | 2023-12-15 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-10-26 | 2023-11-26 | Y |
| Dispose of garbage and refuse properly. | Health | 2023-10-26 | 2023-11-26 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-08-01 | 2023-09-08 | Y |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2023-06-06 | 2023-06-27 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-01-23 | 2023-02-14 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2023-01-23 | 2023-02-14 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-01-23 | 2023-02-14 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-01-23 | 2023-02-14 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-01-23 | 2023-02-14 | N |
| 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. | Health | 2023-01-23 | 2023-02-14 | N |
| Provide for the safe, appropriate administration of IV fluids for a resident when needed. | Health | 2023-01-23 | 2023-02-14 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-01-23 | 2023-02-14 | N |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2023-01-23 | 2023-02-14 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-01-23 | 2023-02-14 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2023-01-23 | 2023-02-14 | N |
| 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. | Health | 2023-01-23 | 2023-02-14 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-01-23 | 2023-02-14 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-01-23 | 2023-02-14 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-01-23 | 2023-02-14 | N |
| Implement a program that monitors antibiotic use. | Health | 2023-01-23 | 2023-02-14 | N |
| Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame. | Health | 2023-01-23 | 2023-02-14 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2023-01-25 | 2023-02-13 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-01-25 | 2023-02-13 | N |
| Properly provide smoke detection systems in areas open to corridors. | Fire Safety | 2023-01-25 | 2023-02-13 | N |
| Properly install and monitor supervisory attachments on automatic sprinkler systems. | Fire Safety | 2023-01-25 | 2023-02-13 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-01-25 | 2023-02-13 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2023-01-25 | 2023-02-13 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-01-25 | 2023-02-13 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2023-01-25 | 2023-02-13 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-01-25 | 2023-02-13 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-02-08 | 2022-02-24 | Y |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2021-07-09 | 2021-07-22 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-07-09 | 2021-07-22 | Y |
| Address patient/client population and determine types of services needed. | Fire Safety | 2019-07-30 | 2019-08-13 | N |
| Include a process for Emergency Preparedness collaboration. | Fire Safety | 2019-07-30 | 2019-08-13 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2019-07-30 | 2019-08-13 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2019-07-30 | 2019-08-13 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2019-07-30 | 2019-08-13 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2019-07-30 | 2019-08-13 | N |
| Implement emergency and standby power systems. | Fire Safety | 2019-07-30 | 2019-08-13 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2019-07-30 | 2019-08-13 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-07-30 | 2019-08-13 | N |
| Properly install and monitor supervisory attachments on automatic sprinkler systems. | Fire Safety | 2019-07-30 | 2019-08-13 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-07-30 | 2019-08-13 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-07-30 | 2019-08-13 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-07-30 | 2019-08-13 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2019-06-28 | 2019-07-23 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-06-28 | 2019-07-23 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2019-06-28 | 2019-07-23 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2019-06-28 | 2019-07-23 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2019-06-28 | 2019-07-23 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2019-06-28 | 2019-07-23 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2019-06-28 | 2019-07-23 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2019-06-28 | 2019-07-23 | N |
| 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. | Health | 2019-06-28 | 2019-07-23 | N |
| Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law. | Health | 2019-06-28 | 2019-07-23 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-06-28 | 2019-07-23 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-06-28 | 2019-07-23 | N |
