Health inspection·February 25, 2025

F 0622 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility P&P review, the facility failed to ensure the preparation for a safe and orderly discharge for one of two sampled residents (Resident 1). * Resident 1 was transferred to an acute care hospital without the hospital being notified and without the medical records being sent. * Resident 1 was transferred to an acute care hospital without the transferring nurse providing any report to the nurse at the receiving facility. * Resident 1's personal and demographic information, H&P examination, medication list, physician's orders, and POLST were not provided to Acute Care Hospital 1. These failures posed the resident at risk for not meeting the resident's medical needs when the receiving facility did not receive the needed documents for the transfer with the necessary medical information. Findings: Review of the facility's P&P titled Transfer or Discharge, Emergency revised 8/2018 showed if it is necessary to make an emergency transfer or discharge to a hospital or other related institution, the receiving facility must be notified that the transfer was being made. The P&P also showed the residents medical records must be forwarded to the medical records office of the receiving facility within 24 hours of the transfer or discharge. Closed medical record review for Resident 1 was initiated on 2/24/25. Resident 1 was admitted to the facility on [DATE], and discharged on 2/6/25. Review of Resident 1's H&P examination dated 1/29/25, did not address Resident 1's capacity to understand and make medical decisions. Resident 1 had diagnoses including PTSD and a TBI from an MVA. Review of Resident 1's MDS dated [DATE], showed the resident had severe cognitive impairment. Review of Resident 1's Change in Condition Evaluation dated 2/6/25 at 2100 hours, showed the resident had increased confusion, combative behaviors, and required a one-to-one sitter. Review of Resident 1's Order Summary Report showed a physician's order dated 2/6/25, for Resident 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 2 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 02/25/2025 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)