Health inspection·August 5, 2025

F 0656 Level of Harm - Potential for minimal harm Residents Affected - Some Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **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 develop the comprehensive plans of care to reflect the individual care needs for two of five sampled residents (Residents 1 and 5). * The facility failed to develop a care plan to address Resident 1's laceration to the right temporal area. * The facility failed to develop a care plan to address Resident 5's skin tear to the left forearm. These failures had the potential risk of not providing appropriate, consistent, and individualized care to these residents.Findings: Review of the facility's P&P titled Care Plans, Comprehensive Person-Centered revised 12/2016 showed a comprehensive person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. 1. Closed medical record review for Resident 1 was initiated on 7/16/25. Resident 1 was readmitted to the facility on [DATE], and discharged on 6/19/25. Review of Resident 1's H&P examination dated 2/27/25, showed the resident had no capacity to understand and make decisions. Review of Resident 1's SBAR Communication Form - General dated 3/11/25, showed the resident had an unwitnessed fall and had a laceration to the right temporal area. Review of Resident 1's plan of care failed to show a care plan was developed to address the resident's laceration to the right temporal area. On 8/1/25 at 1453 hours, an interview and concurrent closed medical record review was conducted with RN 2. RN 2 was not able to show a care plan was developed to address Resident 1's laceration to the right temporal area. RN 2 stated the licensed nurse should have made a care plan for Resident 1's fall because it was a change of condition. On 8/5/25 at 1400 hours, an interview and concurrent closed medical record review was conducted with the DON. The DON verified Resident 1 had unwitnessed fall with laceration to the right temporal area on 3/11/25, however there was no care plan to address the resident's laceration to the right temporal area. The DON stated Resident 1 was transferred out to acute care hospital for further evaluation and the licensed nurse did not do the care plan. The DON stated the care plan should have been initiated to reflect the interventions provided prior to Resident 1's transfer to the acute care hospital. 2. Medical record review for Resident 5 was initiated on 7/17/25. Resident 5 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 5's H&P examination dated 4/26/25, showed the resident had no capacity to make decisions. Review of Resident 5's SBAR Communication Form - General dated 7/1/25, showed the resident had unwitnessed fall with skin tear on the left forearm. Review of Resident 5's plan of care failed to show a care plan to address the resident's skin tear to the left forearm. On 8/1/25 at 1128 hours, an interview and concurrent medical record review was conducted with LVN 3. LVN 3 verified there was no care plan for Resident 5's skin tear on the left forearm. LVN 3 stated the licensed nurse should have initiated the care plan after doing the SBAR. On 8/5/25 at 1339 hours, an interview and concurrent medical record review was conducted with the DON. The DON verified Resident 5 had left forearm skin tear from an unwitnessed fall on (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 4 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 08/05/2025 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)