Healthbridge Children's Hospital - Orange D/P SNF

In the surveyor’s words

From the most serious findings on record at Healthbridge Children's Hospital - Orange D/P SNF, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF880Mar 14, 2024

  Based on interview, facility documemt review, and facility P&P review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe and sanitary environment to help prevent the transmission of communicable diseases and infections. * The facility failed to ensure the water management program was established and implemented to include an assessment of the facility water systems to identify where Legionella (a bacterium commonly found in natural and man-made aquatic environments, warm stagnant water) and other opportunistic pathogens can grow and spread; implementation of measures to prevent the growth of Legionella and other opportunistic pathogens; and a way to monitor the measures they have in place. […]

• No harm, potential for more than minimal, widespreadF909Mar 14, 2024

  Based on observation, interview, medical record review, and facility document 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 1, 7, 9, 10, 17, and 22). These failures had the potential to negatively impact the residents resulting in possible entrapment, serious injury, and death. Findings: According to the Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment, the term entrapment describes an event in which a patient/resident is caught, trapped, or entangled in the space in or about the bed rail, mattress, or hospital bed frame. […]

• No harm, potential for more than minimal, patternF686Apr 30, 2026

  Based on observation, interview, medical record review, document review, and facility P&P review, the facility failed to ensure the necessary care and services were provided to prevent the risk and development of pressure injuries for two of three final sampled residents (Residents 19 and 23) reviewed for pressure injuries. * The facility failed to ensure Resident 19's low air loss mattress setting was accurate and on alternate mode setting. * The facility failed to ensure Resident 23's low air loss mattress settings were accurate and failed to obtain a physician's order specifying the low air loss mattress setting. […]

• No harm, potential for more than minimal, patternF693Apr 30, 2026

  Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure appropriate care and services were provided for six of 19 residents (Residents 1, 6,10, 11, 17, and 22) receiving enteral feeding. * LVN 3 failed to verify GT placement prior to administering medications for Residents 1 and 17. * RN 3 failed to verify GT placement prior to administering medications for Resident 6. * LVN 4 failed to verify GT placement prior to administering medications for Resident 10. * The facility failed to ensure Resident 11's HOB (head of bed) was elevated to a minimum of 30 degrees during NGT feeding. * The facility failed to ensure Resident 22's HOB was elevated to a minimum of 30 degrees during the GT feeding. […]

• No harm, potential for more than minimal, patternF726Apr 30, 2026

  Based on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure three of four licensed nurses observed for medication administration demonstrated competency verifying GT placement prior to administering medications (LVNs 3 and 4 and RN 3). * LVN 3 failed to verify the GT placement prior to administering the medications for Residents 1, 17, and 22. * RN 3 failed to verify the GT placement prior to administering the medications for Resident 6. * LVN 4 failed to verify the GT placement prior to administering the medications for Resident 10. These failures had the potential to place the residents at risk for unsafe and improper care, including aspiration and complications related to incorrect tube placement. […]