Health inspection·July 17, 2023

F 0660 will be safely discharged . Level of Harm - Minimal harm or potential for actual harm Review of the facility ' s P&P titled Discharge Summary and Plan revised 12/2016 showed when a resident ' s discharge is anticipated, a discharge summary and post-discharge plan will be developed to assist the resident to adjust to their new living environment. When the facility anticipates a resident ' s discharge to a private residence, a discharge summary and post-discharge plan will be developed, which will assist the resident to adjust to their new living environment. Residents Affected - Few Closed medical record review for Resident 1 was initiated on 6/5/23. Resident 1 was admitted to the facility on [DATE], and discharged home on 8/23/22, with a physician ' s order for home health RN/PT services. Review of Resident 1 ' s Braden Scale for Predicting Pressure Sore Risk dated 7/28/22, showed Resident 1 was at risk for pressure sores related to slightly limited sensory perception, chairfast degree of physical activity and slightly limited mobility. Review of Resident 1 ' s Care Plan titled ADL Self-Care Performance Deficit related to impaired mobility initiated 7/8/22, showed Resident 1 had diagnoses which included, dementia, weakness, history of falls at home on [DATE] & 3/20/22). Resident 1 required extensive to total assistance with bed mobility, transfers, eating, and toilet use. Review of the physician ' s orders (from Physician 1) showed an order dated 8/18/22, for Resident 1 to be discharged home on 8/23/22, with home health services which included RN and PT services. Review of Resident 1 ' s medical record showed Resident 1 had no pressure ulcers when she was discharged home on 8/23/22, as evidenced by the following documentation: - Review of Resident 1 ' s Skilled Evaluation dated 8/20/22 at0940 hours, showed Resident 1 had no skin issues. - Review of Resident 1 ' s Discharge Instructions/Teaching dated 8/23/22 at 1100 hours, showed Resident 1 was discharged home on 8/23/22, a body check showed Resident 1 had intact skin. On 6/6/23 at 1516 hours, an interview and concurrent closed medical record review was conducted with the SSD. The SSD verified Resident 1 was discharged home on 8/23/22, with a physician ' s order for home health services which included RN and PT services. The SSD stated once the home health services were in place for Resident 1, a licensed nurse would then visit Resident 1 at home, at which time a physical assessment would be performed, a medication review would be conducted, and the type of care provided to Resident 1 would be determined. The SSD stated she hadfaxed a home health referral to Home Health Agency 1 on 8/18/22. The SSD stated she placed a follow-up call to Home Health Agency 1 on 8/22/22. The SSD stated the outcome of her call to Home Health Agency 1 was for the home health services to be confirmed and Resident 1 ' s home health services were to begin on 8/24/22. The SSD stated she documented this information on Resident 1 ' s Final Discharge Plan dated 8/18/22. Review of Resident 1 ' s Final Discharge Plan dated 8/18/22, showed the following documentation: a home health referral for Resident 1 was sent to Home Health Agency 1 on 8/18/22. A follow-up call was made to Home Health Agency 1 on 8/22/22, at which time confirmation of service was made. Resident 1 was discharged home on 8/23/22, with home health services to begin on 8/24/22. The SSD verified she documented this information. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055575 If continuation sheet Page 2 of 4 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 07/17/2023 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 0660 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Further review of Resident 1 ' s Final Discharge Plan dated 8/18/22, failed to show the SSD documented the name of the contact person (in the contact section of the form) at Home Health Agency 1 that she spoke to (on 8/22/22) to verify confirmation of Resident 1 ' s home health services which were to begin on 8/24/22. The SSD verified the findings and stated she never documented a name of the contact person on the contact person section of the Final Discharge Plan form, rather, she documented a phone number of the Home Health Agency, in which she confirmed home health services. The SSD was then asked the name of the individual from Home Health Agency 1, with whom she confirmed home health services were in place (on 8/22/22) for Resident 1 (to begin on 8/24/22), to which the SSD replied, I do not know. On 6/6/23 at 1530 hours, an interview was conducted with Representative 1 from Home Health Agency 1. Representative 1 stated she received a referral from the facility on 8/19/22, for home health services to be provided to Resident 1. However, Representative 1 stated Home Health Agency 1 did not admit Resident 1 and did not provide home health services for Resident 1. Representative 1 stated Home Health Agency 1 attempted to contact Resident 1 ' s responsible party (Family Member 1) to coordinate Home Health Services for Resident 1; however, Home Health Agency 1 was unable to contact Family Member 1 utilizing the phone number provided by the facility. Representative 1 stated Home Health Agency 1 then contacted the facility for assistance with contacting Family Member 1; however, the facility did not provide any additional contact information for Family Member 1. Representative 1 stated Home Health Agency 1 would have conducted a home health visit to Resident 1 ' s home within 48 hours of discharge from the facility; however, this did not occur as Home Health Agency 1 was unable to contact Resident 1 ' s responsible party (Family Member 1). On 6/13/23 at 1600 hours, an interview was conducted with Family Member 1. Family Member 1 stated Resident 1 was discharged home from the facility on 8/23/22. Family Member 1 stated Resident 1 needed assistance with walking, medications, and nursing care. Family Member 1 stated the facility staff told him a nurse would visit Resident 1 at home to assess and assist with providing care to Resident 1; however, a nurse never arrived at Resident 1 ' s home. Family Member 1 stated approximately three days after Resident 1 was discharged home from the facility, he contacted the facility and informed the facility that a nurse never arrived at Resident 1 ' s home to provide home health services. Family Member 1 stated the facility advised him to contact Resident 1 ' s primary care physician (not Physician 1 who cared for Resident 1 at the facility). Family Member 1 then contacted Resident 1 ' s primary care physician (Physician 2). Family Member 1 stated Physician 2 then contacted Home Health Agency 2 and set up home health services for Resident 1. Family Member 1 stated it took approximately 25 days (from the discharge date ) for a nurse to arrive at Resident 1 ' s home to initiate home health services, and as a result of this delay, Resident 1 developed a pressure ulcer on her sacrum. Family Member 1 stated Resident 1 then had to be transferred to Acute Care Hospital 1 for treatment of her wound. On 6/6/23 at 1140 hours, an interview was conducted with the Intake Coordinator from Home Health Agency 2. The Intake Coordinator stated Resident 1 was admitted to Home Health Agency 2 on 9/16/22, at which time a licensed nurse performed an initial assessment of Resident 1 at her home. The Intake Coordinator stated during the licensed nurse ' s initial assessment of Resident 1, a wound was observed and photographed on her sacral area. Review of Resident 1 ' s Home Health Certification and Plan of Care (Home Health Agency 2) dated 9/16/22, showed Resident 1 had a stage 4 pressure ulcer on her sacral region. Review of Resident 1 ' s physician ' s order Summary Report (Home Health Agency 2) dated 10/12/22, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055575 If continuation sheet Page 3 of 4 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 07/17/2023 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 0660 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few showed Resident 1 was transferred and admitted to Acute Care Hospital 1 for further wound evaluation and treatment. On 6/22/23 at 1423 hours, an interview and concurrent closed medical record review was conducted with the DON. The DON verified Resident 1 was discharged home on 8/23/22, with a physician ' s order for home health RN and PT services dated 8/18/22. The DON stated the SSD was responsible for ensuring home health services were in place before Resident 1 was discharged home from the facility. The DON stated the home health services ordered by the physician were to be provided by Home Health Agency 1 as ordered by the physician. The DON stated home health services would include a licensed nurse visiting Resident 1 ' s home and performing a physical assessment of Resident 1, conducting a review Resident 1 ' s medications, conducting a safety assessment of Resident 1 ' s home, performing an assessment of Resident 1 ' s skin, and obtaining necessary orders and treatments from Resident 1 ' s home health physician. The DON reviewed and verified Resident 1 ' s Final Discharge Plan dated 8/18/22, showed documentation a home health referral for Resident 1 was sent to Home Health Agency 1 on 8/18/22, and a follow-up call was made to Home Health Agency 1 on 8/22/22, at which time confirmation of service was made. The documentation showed Resident 1 was discharged home on 8/23/22, with home health services to begin on 8/24/22. The DON verified Resident 1 ' s Final Discharge Plan dated 8/18/22, failed to show documentation for the contact person at Home Health Agency 1, who confirmed home health services were in place, scheduled to begin on 8/24/22. The DON stated the section titled Contact Person on Resident 1 ' s Final Discharge Plan Dated 8/18/22, should have shown who was contacted at Home Health Agency 1, to confirm home health services were in place before Resident 1 was discharged home. The DON was then informed Family Member 1 and Home Health Agency 1 were contacted, and they stated Resident 1 was not admitted to Home Health Agency 1 and did not receive the services from Home Health Agency 1. The DON stated her expectation was home health services would be in place before Resident 1 was discharged home as per Resident 1 ' s physician ' s order. The DON was asked if Family Member 1 or Home Health Agency 1 had contacted the facility (after Resident 1 was discharged from the facility on 8/23/22) in an attempt to coordinate Home Health Services, to which the DON replied, no. The DON stated she was unaware that Home Health Agency 1 did not admit Resident 1 and Resident 1 did not receive home health services from Home Health Agency 1. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055575 If continuation sheet Page 4 of 4