Health inspection·December 22, 2023

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the supplemental oxygen was administered as ordered by the physician and by the competent staff for four of five sampled residents (Residents 1, 2, 3, and 5). Residents Affected - Some * Supplemental oxygen was not administered as ordered for Residents 1, 2, and 3. * Resident 5's supplemental oxygen was administered and removed by a CNA. These failures had the potential to put the residentsat risk of respiratory complications. Findings: Review of the facility's P&P titled Oxygen Administration revised October 2020 showed to verify and review the physician's order before administering the oxygen and after the oxygen set up or adjustment. 1. Closed medical record review for Resident 1 was initiated on 12/20/23. Resident 1 was admitted to the facility on [DATE], and discharged on 12/4/23. On 12/20/23 at 0913 hours, a telephone interview was conducted with Family Member 1. Family Member 1 stated one day when they arrived around 0900 hours to visit Resident 1, they found him up in his wheelchair in the activity room without any supplemental oxygen. Family Member 1 stated there was no oxygen tank or tubing with Resident 1. Family Member 1 stated the staff told her Resident 1 was brought to the activity room around 0800 hours. Review of Resident 1's physician's orders showed an order dated 11/28/23, for continuous supplemental oxygen to be administered at 2-5 lpm. On 12/20/23 at 1449 hours, a concurrent interview and closed record review was conducted with the MDS Coordinator. The MDS Coordinator stated in the morning of Resident 1's care conference meeting, Family Member 1 informed the MDS Coordinator that Resident 1 was in the activity room without supplemental oxygen. The MDS Coordinator stated she notified the ADON and put in a work order request for the maintenance staff to install an oxygen cylinder holder on the resident's wheelchair. The MDS Coordinator reviewed Resident 1's medical record and verified Resident 1's Resident Care Conference Review was held on 12/1/23. Review of the Facility's Nursing Assignment for 12/1/23,showed CNA 4 was assigned to Resident 1 for (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 10 Event ID: 055575 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 12/22/2023 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)