Health inspection·June 29, 2023

F 0623 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the facility's P&P titled Transfer or Discharge Notice revised 12/2016 showed the facility shall provide the resident and/or the resident's representatives with a 30-day written notice of an impending transfer or discharge. Under the following circumstances, the notice will be given as soon as it is practicable but before the transfer or discharge: the transfer is necessary for the resident's welfare and the resident's needs cannot be met in the facility. An immediate transfer or discharge is required by the resident's urgent medical needs. The resident and/or representative will be notified in writing of the following information: - The reason for the transfer or discharge; the name, address, email, and telephone number of the agency responsible for the protection and advocacy of residents with intellectual and developmental or related disabilities. - The name, address, email, and telephone number of the agency responsible for the protection and advocacy of residents with a mental disorder or related disabilities. Review of the facility's P&P titled Transfer or Discharge Documentation revised 12/2016 showed when the resident is transferred or discharged from the facility, the following information will be documented in the medical record: that an appropriate notice is provided to the resident and/or legal representative. If a resident exercises his right to appeal a transfer or discharge notice, he/she will not be transferred or discharged while the appeal is pending, unless the failure to discharge or transfer would endanger the health or safety of the resident or other individuals in the facility. If the resident is transferred or discharged despite his pending appeal, the danger that failure to transfer or discharge would pose will be documented. Review of the facility's P&P titled Admission, Transfer, and Discharge revised 12/2020 showed the facility's SSD will coordinate the discharge planning with the resident together with the IDT, including the physician and placement to ensure the resident will be safely discharged . Discharges can be frightening to the resident. On 6/14/23 at 1324 hours, an interview was conducted with the complainant. The complainant stated the facility had transferred Resident 1 to the acute care hospital; however, once Resident 1 was ready to be transferred back to the facility, the facility refused to accept Resident 1. Closedmedical record review for Resident 1 was initiated on 6/5/23. Resident 1 was admitted to the facility on [DATE], and discharged on 3/28/23. Review of Resident 1's History and Physical Examination dated 12/8/22, showed Resident 1 had severe intellectual disability. The document showed Caregiver 1 (the Administrator of a Board and Care Facility 1 where the resident had resided was called for collateral information. Resident 1's DPOA was Family Member 1. Per Caregiver 1, the family was involved, but Family Member 1 had limited availability as he was also a caregiver for other family members; therefore, Caregiver 1 was the immediate point of contact. Review of Resident 1's Social Service Assessment admission dated 12/8/22 at 1358 hours, showed Family Member 1 and Caregiver 1 were aware of Resident 1's medical condition and in agreement with current placement. Per the Administrator, Resident 1 was not conserved. Resident 1 had a family member (Family Member 1). Review of Resident 1's MDS dated [DATE], showed Resident 1 had severely impaired cognition. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055575 If continuation sheet Page 2 of 7 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 055575 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/29/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pacific Haven Subacute and Healthcare Center 12072 Trask Ave. Garden Grove, CA 92843 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)

F 0623 Level of Harm - Minimal harm or potential for actual harm Review of Resident 1's Psychiatric Evaluation Note dated 2/20/23, showed Resident 1 had a diagnosis of paranoid schizophrenia. Review of Resident 1's Psychiatric Evaluation Note dated 3/3/23, showed Resident 1 had a diagnosis of bipolar disorder. Residents Affected - Few Further review of Resident 1's medical record showed the resident had a behavior of hitting himself, and as a result of this behavior, the facility had initiated the transfers of Resident 1 to the acute care hospital with subsequent readmissions to the facility and discharged the resident from the facility as follows: * Transferred to Acute Care Hospital 1 on 1/18/23, and readmitted to the facility on [DATE]. * Transferred to Acute Care Hospital 1 on 1/24/23, and readmitted to the facility on [DATE]. * Transferred to Acute Care Hospital 2 on 3/20/23, and readmitted to the facility on [DATE]. * Transferred to Acute Care Hospital 3 on 3/21/23, and discharged from the facility on 3/28/23. Review of Resident 1's Notice of Transfer/discharge date d 1/18, 1/24, 3/20, and 3/21/23, showed Resident 1's Caregiver 1 was notified when Resident 1 was transferred to the acute care hospitals on 1/18, 1/24, 3/20, and 3/21/23. * However, the notices did not contain all required contact information specific to filing an appeal for an inappropriate facility proposed transfer and/or discharge. The sections for the contact information (mailing address, email address, and telephone number) for the agencies responsible for the protection and advocacy of individuals with developmental disabilities and mental disorders were left blank. On 6/19/23 at 1211 hours, an interview was conducted with Caregiver 1. Caregiver 1 stated she was the Administrator of Board and Care Facility 1. Caregiver 1 stated Resident 1 had resided at her facility from 2019 until he was transferred to Acute Care Hospital 1 in November of 2022 (in order to receive a surgical procedure). Caregiver 1 stated Resident 1's Family Member 1 was Resident 1's responsible party specific to any medical decisions involving Resident 1. Caregiver 1 stated she informed the SSD at the facility that Resident 1's responsible party was Family Member 1. Caregiver 1 stated Family Member 1 had given the consent for Resident 1's surgical procedure performed at Acute Care Hospital 1. Caregiver 1 was asked if the facility provided her with contact information for the agencies responsible for the protection and advocacy of individuals with developmental disabilities and mental disorders, specific to filing an appeal for an inappropriate facility proposed transfer when Resident 1 was transferred to the acute care hospitals on 1/18, 1/24, 3/20, and 3/21/23, to which Caregiver 1 replied no. Caregiver 1 stated the facility did not inform her or provide her with a notice of discharge specific to Resident 1 being discharged from the facility at any time. Caregiver 1 stated Resident 1 had a Case Coordinator from the State Agency for the Developmentally Disabled (State Agency 1) who coordinated services and provided support for Resident 1. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055575 If continuation sheet Page 3 of 7 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 055575 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/29/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pacific Haven Subacute and Healthcare Center 12072 Trask Ave. Garden Grove, CA 92843 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)

F 0623 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 6/20/23 at 1138 hours, an interview was conducted with Resident 1's Case Coordinator from State Agency 1. The Case Coordinator stated Resident 1's Family Member 1 wasResident 1's responsible party specific to any medical decisions involving Resident 1. On 6/19/23 at 1231 hours, an interview was conducted with Family Member 1. Family Member 1 was asked if the facility provided him with a notice of transfer/discharge and information specific to filing an appeal for an inappropriate facility proposed transfer and/or discharge when Resident 1 was transferred to the acute care hospitals on 1/18, 1/24, 3/20, and 3/21/23, and discharged by the facility on 3/28/23, to which Family Member 1 replied no. Family Member1 stated he had contacted the facility and was informed Resident 1 was transferred from the facility to an acute care hospital. Family Member 1 stated Resident 1 currently resided in Los Angeles County, and he wanted Resident 1 to reside in Orange County. On 6/22/23 at 1403 hours, an interview and concurrent closed medical record review was conducted with the SSD. The SSD stated Caregiver 1 was Resident 1's responsible party for medical decisions. The SSD stated she determined Caregiver 1 was Resident 1's responsible party based on Caregiver 1 having cared for Resident 1 in the past, being present for Resident 1's admission to the facility, answering phone calls from the facility, and calling the facility to check on Resident 1. However, during the review of Resident 1's History and Physical Examinationdated 12/8/22, with the SSD, the SSD verified it showed Resident 1's DPOA was Family Member 1. The SSD was asked if she attempted to contact Family Member 1 in order to verify if Family Member 1 was Resident 1's DPOA, specific to medical decisions involving Resident 1, to which the SSD replied no. The SSD was asked if she attempted to contact State Agency 1 or any prior medical facilities Resident 1 had resided to determine if Family Member 1 was Resident 1's DPOA, specific to medical decisions involving Resident 1, to which the SSD replied she had not. The SSD verified Resident 1's medical record failed to show Family Member 1 received a notice of transfer and/or discharge and information specific to filing an appeal for an inappropriate facility proposed transfer and/or discharge when Resident 1 was transferred to the acute care hospitals on 1/18, 1/24, 3/20, and 3/21/23, and discharged by the facility on 3/28/23. The SSD verified Resident 1's Notice of Transfer/discharge date d 1/18, 1/24, 3/20, and 3/21/23, showed Caregiver 1 was notified when Resident 1 was transferred to the acute care hospitals on 1/18, 1/24, 3/20, and 3/21/23. However, the notices did not contain all required contact information specific to filing an appeal for an inappropriate facility proposed transfer and/or discharge. The sections for the contact information (mailing address, email address, and telephone number) for the agencies responsible for the protection and advocacy of individuals with developmental disabilities and mental disorders were left blank. On 6/22/23 at 1538 hours, an interview and concurrent closed medical record review was conducted with the DON. The DON stated Resident 1 was admitted to the facility on [DATE]. The DON verified Resident 1 was transferred to the acute care hospitals (for behaviors which included hitting himself) on 1/18, 1/24, 3/20, and 3/21/23, and discharged by the facility on 3/28/23. The DON stated the facility could not manage Resident 1's behaviors. The DON stated Resident 1 was not self-responsible (for medical decisions) due to severe intellectual disability. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055575 If continuation sheet Page 4 of 7 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 055575 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/29/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pacific Haven Subacute and Healthcare Center 12072 Trask Ave. Garden Grove, CA 92843 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)

F 0623 Level of Harm - Minimal harm or potential for actual harm The DON stated Caregiver 1 from Board and Care Facility 1 (where Resident 1 had previously resided) was Resident 1's responsible party for medical decisions. The DON was asked if the facility had obtained a copy of Resident 1's Advance Directive or any written instructions, including a living will or DPOA for health care showing Caregiver 1 was responsible for medical decisions involving Resident 1, to which the DON replied the facility had not. Residents Affected - Few Review of Resident 1's History and Physical Examination dated 12/8/22, was conducted with the DON. The DON verified it showed Resident 1's DPOA was Family Member 1. The DON was asked if the facility attempted to contact the State Agency for the Developmentally Disabled (State Agency 1) who had assisted with the coordination of Resident 1's care in order to determine if Resident 1's family member was the DPOA for healthcare. The DON stated she attempted to reach out to State Agency 1; however, State Agency 1 did not return her call. The DON was asked if she documented her attempt to contact State Agency 1 in Resident 1's medical record. The DON reviewed Resident 1's medical record and was unable to locate documentation of her attempted contact of State Agency 1. The DON then stated Family Member 1 had called the facility one evening, approximately 1 month after the resident had already admitted to the facility and stated he was currently caring for another family member and no longer desired to be responsible for Resident 1's care any longer. The DON was asked if this information was documented in Resident 1's medical record, to which she replied she believed so. The DON then reviewed Resident 1's closed medical record and was unable to locate any documentation showing Family Member 1 had no longer desired to be responsible for Resident 1's care. The DON verified Resident 1's medical record failed to show Family Member 1 received a notice of transfer and discharge and information specific to filing an appeal for an inappropriate facility proposed transfer and/or discharge when Resident 1 was transferred to the acute care hospitals on 1/18, 1/24, 3/20, and 3/21/23, and when the facility discharged Resident 1 on 3/28/23, while Resident 1 was at Acute Care Hospital 3. The DON verified Resident 1's Notices of Transfer/discharge date d 1/18, 1/24, 3/20, and 3/21/23, showed Caregiver 1 was notified when Resident 1 was transferred (facility initiated) to the acute care hospitals on 1/18, 1/24, 3/20, and 3/21/23. However, the notices did not contain all required contact information specific to filing an appeal for an inappropriate facility proposed transfer and/or discharge. The sections for the contact information (mailing address, email address, and telephone number) for the agencies responsible for the protection and advocacy of individuals with developmental disabilities and mental disorders were left blank. The DON verified Resident 1's closed medical record failed to show Caregiver 1 received notice of discharge and information specific to filing an appeal for an inappropriate facility proposed discharge when the facility discharged Resident 1 on 3/28/23, while Resident 1 was at Acute Care Hospital 3. The DON stated a function of the notice of transfer/discharge requirements wasto ensure Resident 1's responsible party was informed of the information necessary to appeal involuntary proposed transfer/discharges, in which the responsible party believed it was inappropriate. On 6/22/23 at 1425 hours, an interview and concurrent closed medical record review was conducted with the Administrator. The Administrator stated Resident 1 was admitted to the facility on [DATE]. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055575 If continuation sheet Page 5 of 7 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 055575 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/29/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pacific Haven Subacute and Healthcare Center 12072 Trask Ave. Garden Grove, CA 92843 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)

F 0623 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few The Administrator stated Resident 1 had severe intellectual disabilities and exhibited the behavior of hitting himself. The Administrator verified Resident 1 was transferred to the acute care hospitals (for behaviors which included hitting himself) on 1/18, 1/24, 3/20, and 3/21/23, and the facility discharged the resident on 3/28/23. The Administrator stated Acute Care Hospital 3 attempted to transfer Resident 1 back to the facility; however, the facility informed Acute Care Hospital 3 that they could not meet Resident 1's needs at the facility. The Administrator was asked who Resident 1's responsible party was specific to medical decisions involving Resident 1. The Administrator stated the Administrator (Caregiver 1) from the board and care facility where Resident 1's had previously resided was Resident 1's responsible party for medical decisions. Review of Resident 1's History and Physical Examinationdated 12/8/22, was conducted with the Administrator. The Administrator verified it showed Resident 1's DPOA was Family Member 1. The Administrator was asked how she made the determination that Caregiver 1 was Resident 1's responsible party specific to medical decisions involving Resident 1. The Administrator stated the Activities Director informed her that Caregiver 1 was Resident 1's responsible party specific to medical decisions. The Administrator also stated the Activities Director informed her that Family Member 1 did not want anything to do with Resident 1's care while he was at the facility and directed the facility to contact Caregiver 1 for everything. Review of Resident 1's Activity assessment dated [DATE], was conducted with the Administrator. The Administrator verified Resident 1's Activity assessment dated [DATE], failed to show any documentation Family Member 1 did not want anything to do with Resident 1 while Resident 1 resided at the facility and had directed the facility to contact Caregiver 1 for everything. The Administrator was then asked if Resident 1's closed medical record contained any documentation showing Family Member 1 did not want anything to do with Resident 1 while he was at the facility, or any documentation showing Family Member 1 had directed the facility to contact Caregiver 1 for everything. The Administrator then reviewed Resident 1's medical record and stated she could not locate this documentation. During the Administrator's closed medical record review, the Administrator located Resident 1's Health Status Note dated 3/21/23 at 1627 hours, showing Family Member 1 called the facility and was made aware of Resident 1's behavior (hitting himself) and the plan for transfer (of Resident 1 to Acute Care Hospital 3) and (Family Member 1) agreed. The Administrator then stated Family Member 1 probably just wanted to know where Resident 1 was. The Administrator verified Resident 1's closed medical record failed to show Family Member 1 received notice of transfer and discharge and information specific to filing an appeal for an inappropriate facility proposed transfer and/or discharge when Resident 1 was transferred to the acute care hospitals on 1/18, 1/24, 3/20, and 3/21/23, and when the facility discharged Resident 1 on 3/28/23, while Resident 1 was at Acute Care Hospital 3. The Administrator verified Resident 1's Notices of Transfer/discharge date d 1/18, 1/24, 3/20, and 3/21/23, showed Caregiver 1 was notified when Resident 1 was transferred to the acute care hospitals on 1/18, 1/24, 3/20, and 3/21/23. However, the notices did not include all required contact information specific to filing an appeal for an inappropriate facility proposed transfer and/or discharge. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055575 If continuation sheet Page 6 of 7 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 055575 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/29/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pacific Haven Subacute and Healthcare Center 12072 Trask Ave. Garden Grove, CA 92843 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)

F 0623 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few The sections for the contact information (mailing address, email address, and telephone number) for the agencies responsible for the protection and advocacy of individuals with developmental disabilities and mental disorders were left blank. The Administrator verified Resident 1's closed medical record failed to show Caregiver 1 received notice of discharge and information specific to filing an appeal for an inappropriate facility proposed discharge when the facility had discharged Resident 1 on 3/28/23, while Resident 1 was at Acute Care Hospital 3. Further review of Resident 1's medical record failed to show the Ombudsman was notified of Resident 1's discharge and failed to show the Ombudsman was sent a copy of a discharge notice, before the facility discharged Resident 1 on 3/28/23, while Resident 1 resided at Acute Care Hospital 3. The Administrator verified the findings. The Administrator was asked where Resident 1 currently resided, to which she replied, I do not know. On 6/28/23 at 1325 hours, an interview was conducted with the Ombudsman. The Ombudsman was asked if the facility provided her with a notice of discharge for Resident 1 before he was discharged from the facility on 3/28/23, while he was hospitalized at Acute Care Hospital 3, to which she replied no. The Ombudsman stated the staff from Acute Care Hospital 3 had contacted her and informed her the facility would not readmit the resident, and Acute Care Hospital 3 could not find a facility who would accept Resident 1. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055575 If continuation sheet Page 7 of 7