Health inspection·June 12, 2025

F 0805 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. **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 one of six sampled residents reviewed for dining (Resident 1) received food prepared in a form to meet the resident's individual dietary needs. * The facility failed to ensure Resident 1 was provided with the chopped vegetables as per the physician's diet order. This failure had the potential for Resident 1 not liking the food based on the dietary modification and could affect the resident's quality of life. Findings: Review of the facility's P&P titled Nutrition Management of Dysphagia dated 2023 showed in the section for dysphagia mechanical diet, all cooked vegetables should be chopped approximately half inch and cooked, soft to a mashable texture. Medical record review for Resident 1 was initiated on 6/12/25. Resident 1 was admitted to the facility on [DATE]. Review of Resident 1's H&P examination dated 5/25/25, showed Resident 1 had the capacity to understand and make decisions. Review of Resident 1's Speech Therapy Treatment Encounter Note dated 6/2/25, showed Resident 1 had mild oropharyngeal dysphagia caused by reduced mastication impacted by reduced dentition and delayed swallow initiation. The Speech Therapy's recommendations showed to continue the mechanical soft, chopped diet for ease of oral phase. Review of Resident 1's Physician Order Summary showed an order dated 6/7/25, for fortified, no added salt diet, mechanical soft texture, thin liquids consistency, chopped meats/veggies, Asian menu, and renal diet. Further review of the physician's order showed restriction to dairy products, tomatoes, bananas, oranges, cantaloupe, and honeydew. Review of Resident 1's admission Record dated 6/12/25, showed Resident 1 had diagnoses which included dysphagia oropharyngeal phase. Review of Resident 1's meal ticket for lunch dated 6/12/24,showed mechanical soft Asian menu, fortified, no added salt, and chopped meat/veggies. (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: 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 06/12/2025 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)