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. Page 1 of 2 055742 055742 04/10/2025 Harbor Villa Care Center 861 S. Harbor Blvd Anaheim, CA 92805

F 0622 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 4/10/25 at 1306 hours, an interview and concurrent closed medical record review was conducted with the SSD. The SSD verified there was no physician's documentation to show Resident 1's basis for the discharge. On 4/15/25 at 1314 hours, an interview was conducted with the Administrator. The Administrator was informed and acknowledged the discharge planning did not correlate with the physician's progress notes on 3/2/25. 055742 Page 2 of 2