Health inspection·January 15, 2025

F 0623 Level of Harm - Potential for minimal harm Residents Affected - Some Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and medical record review, the facility failed to send a copy of the notice of the transfer/discharge to the representative of the Office of the State Long-Term Care Ombudsman for two of three sampled residents (Residents 1 and 2). This failure posed the risk of the Ombudsman not being aware of the circumstances of the residents' transfer/discharge should the appeal be filed or requested by the residents or their representatives regarding the transfers. Findings: 1. Medical record review for Resident 1 was initiated on 1/10/25. Resident 1 was admitted to the facility on [DATE], transferred to the acute care hospital on [DATE],and readmitted to the facility on [DATE]. Review of Resident 1's H&P examination dated 12/30/24, showed Resident 1 had impaired judgment and did not have mental capacity to make decisions. Review of Resident 1's progress note dated 12/12/24, showed the physician assessed Resident 1 and ordered for Resident 1's transfer to the acute care hospital. Further review of Resident 1's medical record failed to show the copy of the written notice of transfer/discharge was sent to the LTC Ombudsman on 12/12/24. 2. Medical record review for Resident 2 was initiated on 1/15/25. Resident 2 was admitted to the facility on [DATE], transferred to the acute hospital on [DATE] and readmitted to the facility on [DATE]. Review of Resident 2's H&P examination dated 1/13/25, showed Resident 2 had mental capacity to make decisions. Review of Resident 2's SBAR Communication Form-General dated 12/26/24, showed under the nursing notes, the physician assessed the resident and ordered to transfer Resident 2 to the acute care hospital. Further review for Resident 2's medical record failed to show the copy of the written notice of transfer/discharge was sent to the LTC Ombudsman. On 1/15/25 at 1040 hours, an interview and concurrent medical review was conducted with RN 1. RN 1 (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 3 Event ID: 055330 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055330 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/15/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Advanced Rehab Center of Tustin 2210 E. First Street Santa Ana, CA 92705 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)