Foothill Regional Medical Center D/P SNF

In the surveyor’s words

From the most serious findings on record at Foothill Regional Medical Center D/P SNF, in the surveyor’s own words.

• Actual harm, isolatedF693Feb 10, 2023

  Based on interview, medical record review, and facility document review, the facility failed to ensure one of two sampled residents (Resident 1), who were fed by enteral means, received the appropriate treatment and services to prevent complications of the enteral feeding. * CNA 1 administered G-tube feeding to Resident 1 but erroneously connected the G-tube feeding to the saline (instillation) port of the resident's closed suction system (the closed suction system was connected to the resident's tracheostomy tube and provided direct access to the trachea and lungs). The G-tube feeding infused for approximately 30 minutes directly into the resident's lungs until CNA 1 had observed that white fluid was leaking around Resident 1's tracheostomy stoma. […]

• No harm, potential for more than minimal, patternF656Feb 5, 2026

  Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the comprehensive care plan was developed to reflect the individual care needs for five of nine final sampled residents (Residents 1, 5, 6, 9, and 15). * The facility failed to develop a care plan for Resident 15's use of lorazepam (antianxiety medication) and diazepam (antianxiety medication). * The facility failed to develop a care plan for Resident 1's GT feeding and use of insulin lispro (medication to lower blood sugar). * The facility failed to develop a care plan to address the use of GJ tube feeding for Resident 5. * The facility failed to develop a care plan for Resident 6's use of the duloxetine (antidepressant medication) and trazadone (antidepressant medication). […]

• No harm, potential for more than minimal, patternF812Feb 5, 2026

  Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the food safety and sanitation requirements were met in the kitchen. * The facility failed to ensure food was properly labeled in the refrigerator. * The facility failed to ensure items in the kitchen were discarded after the use-by/expiration date. * The facility failed to ensure the kitchen equipment was stored or kept in sanitary conditions. * The facility failed to ensure the kitchen equipment was air-dried. * The facility failed to ensure the microwave was kept in clean and sanitary condition. * The facility failed to ensure the food preparation sinks had an air gap. […]

• No harm, potential for more than minimal, patternF880Feb 5, 2026

  Based 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 January 2025. The facility conducted surveillance only on the residents who exhibited signs and symptoms of an infection and were prescribed antimicrobial medications. […]

• No harm, potential for more than minimal, patternF880Feb 3, 2025

  Based on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the appropriate infection control practices designed to provide the safe and sanitary environment were implemented. * The facility failed to record all the residents with infection on the facility's infection surveillance tool. The facility's infection surveillance tool did not include all the residents identified with infections. Only the residents with positive culture results were identified as having infection and were listed on the surveillance list. * The facility failed to ensure Resident 8's water pitcher was clean. * LVN 1 failed to disinfect the stethoscope after use on Resident 9 and prior to exiting the room. […]