Advanced Rehab Center of Tustin

In the surveyor’s words

From the most serious findings on record at Advanced Rehab Center of Tustin, in the surveyor’s own words.

• Actual harm, isolatedF600Sep 17, 2024

  Based on interview, medical record review, facility document review, and facility P&P review, the facility failed to protect the residents' (Residents 2 and 4) rights to be free from the sexual abuse by another resident (Resident 3). * The facility failed to monitor and provide Resident 3 with the 1:1 (one staff to one resident) supervision as per the care plan after an incident of Resident 3 grabbing Resident 2's breasts on 9/6/24, resulting in Resident 3 continuing to fondle Resident 4's breasts during the activities in the dining room on 9/8/24. This failure resulted in Resident 3 continuing to sexually abuse other residents. […]

• Actual harm, isolatedF692Nov 9, 2023

  Based on observation, interview, medical record review and facility document and P&P review, the facility failed to implement a systematic approach to ensure effective monitoring of acceptable parameters of nutritional status for one of 19 final sampled residents (Resident 6) when: 1. The severe weight loss of - 10 lbs. (7.7%) from 7/20/23 to 9/25/23, and - 14 lbs. (10.4%) from 5/28/23 to 9/25/23, was not assessed and monitored by the IDT (Interdisciplinary team - members of the care team including but not limited to: the attending physician, nurses, a member of the food and nutrition services staff, social workers, rehabilitation therapists and the resident or the resident's legal representative). 2. […]

• No harm, potential for more than minimal, widespreadF812Jan 25, 2022

  Based on observation, interview, and facility P&P review, the facility failed to ensure the sanitary requirements were met in the kitchen. * The facility failed to ensure the meat slicer was free of food debris prior to storing. * The facility failed to ensure the food trays, dishwasher crates, and baking sheet pans were clean and in good condition. * The facility failed to ensure the fan used in the food prep area was clean. * Multiple kitchen equipment were rusted and had crack and chipped areas. * Black substances on the wall and floor tiles under the three-compartment sink. * Dietary Aide 2 failed to air dry utensils prior to storing. […]

• No harm, potential for more than minimal, patternF578May 8, 2026

  Based on interview, medical record review, and facility P&P review, the facility failed to ensure assistance in the formulation of an advance directive for four of six final sampled residents (Residents 10, 89, 93, and 118) reviewed for advance directive. * The facility failed to ensure assistance in the formulation of an advance directive was offered for Residents 10, 89, and 118. * The facility failed to follow up on advance directive status after providing educational materials to the resident's representative for Resident 93. […]

• No harm, potential for more than minimal, patternF684May 8, 2026

  Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services to meet the resident care needs for four of 20 final sampled residents (Residents 4, 83, 123, and 147). * The facility failed to routinely monitor Resident 4 for bleeding and urinary changes per the resident's care plan and clinical history. * The facility failed to rotate the insulin injection sites for Resident 83. In addition, the facility failed to follow the physician's order for hydralazine (a medication used to treat high blood pressure). * The facility failed to consistently complete the Change of Condition assessment for Resident 123 despite having multiple episodes of refusing blood sugar checks. […]