Health inspection·April 10, 2025

F 0622 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and the facility P&P review, the facility failed to ensure the discharge process was properly followed for Resident 1. * Resident 1's closed medical record failed to show the physician's documentation to show Resident 1 was ready for discharge. This failure had the potential for Resident 1 to unsafely discharge from the facility. Findings: Review of the facility's P&P titled Transfer or Discharge, Facility Initiated dated 10/22 showed should the resident be transferred or discharge for any of the following reasons, the basis for the transfer or discharge is documented in the resident's clinical record by the resident's attending physician: 1. The transfer or discharge is necessary for the resident's welfare, and the resident's needs cannot be met in the facility; or 2. The transfer or discharge is appropriate because the resident's health has improved sufficiently so the resident no longer needs the services provided by the facility. Closed medical record review for Resident 1 was initiated on 4/10/25. Resident 1 was admitted to the facility on [DATE], and transferred to the acute care hospital on 3/23/25. Review of Resident 1's Order Summary Report showed a physician's order dated 2/21/25, for the resident's LCD of 2/23/25, and to discharge from the facility to the community on 2/24/25. Review of Resident 1's H&P examination dated 3/2/25, showed the following: - for the section if the resident required in-patient therapy five times a week to make reasonable progress, Yes was circled. - for the section if in-patient therapy was not indicated and to refer the resident to Home Health Out-Patient, No was circled. Further review of Resident 1's medical record failed to show Resident 1's physician documented the basis for the resident's discharge prior to providing the resident with the LCD. (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: 055742 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 055742 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/10/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Harbor Villa Care Center 861 S. Harbor Blvd Anaheim, CA 92805 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)