Other·August 26, 2020

F000 INITIAL COMMENTS

F000 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The following reflects the findings of the California Department of Public Health during an ABBREVIATED survey for COMPLAINT No: CA00677093 and FACILITY REPORTED INCIDENT (FRI) No: CA00677126. Inspection was limited to the specific complaint and FRI investigated and did not represent the findings of a full inspection of the facility. Representing the California Department of Public Health: Surveyor 37955, HFEN. FOR COMPLAINT No: CA00677093: THE DEPARTMENT WAS ABLE TO PARTIALLY SUBSTANTIATE THE COMPLAINT ALLEGATIONS. FINDINGS WERE CITED AT

F622 and F624 FOR RESIDENT 1. FOR FACILITY REPORTED INCIDENT No: CA00677126: THE DEPARTMENT WAS ABLE TO SUBSTANTIATE THE FRI THAT DID NOT CONSTITUTE A VIOLATION OF THE REGULATIONS. HOWEVER, DURING THE INVESTIGATION, THE DEPARTMENT DETERMINED THERE WAS A VIOLATION OF THE REGULATIONS UNRELATED TO THE COMPLAINT. FINDINGS WERE CITED AT F623 FOR RESIDENT 1. GLOSSARY OF ABBREVIATIONS: MDS - Minimum Data Set (a standardized assessment tool) SNF - Skilled nursing facility SSD - Social Services Director

F622 Transfer and Discharge Requirements

F622 SS=D LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE 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. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IJE811 Facility ID: CA060000124 If continuation sheet 1 of 12 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055674 (X3) DATE SURVEY COMPLETED 03/23/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HEALTHCARE CENTER OF ORANGE COUNTY 9021 Knott Ave Buena Park, CA 90620 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE CFR(s): 483.15(c)(1)(i)(ii)(2)(i)-(iii) §483.15(c) Transfer and discharge§483.15(c)(1) Facility requirements(i) The facility must permit each resident to remain in the facility, and not transfer or discharge the resident from the facility unless(A) The transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in the facility; (B) 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; (C) The safety of individuals in the facility is endangered due to the clinical or behavioral status of the resident; (D) The health of individuals in the facility would otherwise be endangered; (E) The resident has failed, after reasonable and appropriate notice, to pay for (or to have paid under Medicare or Medicaid) a stay at the facility. Nonpayment applies if the resident does not submit the necessary paperwork for third party payment or after the third party, including Medicare or Medicaid, denies the claim and the resident refuses to pay for his or her stay. For a resident who becomes eligible for Medicaid after admission to a facility, the facility may charge a resident only allowable charges under Medicaid; or (F) The facility ceases to operate. (ii) The facility may not transfer or discharge the resident while the appeal is pending, pursuant to § 431.230 of this chapter, when a resident exercises his or her right to appeal a transfer or discharge notice from the facility pursuant to § 431.220(a)(3) of this chapter, unless the failure to discharge or transfer would endanger the health or safety of the resident or other individuals in the facility. The facility must document the danger that failure to transfer or discharge would pose. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IJE811 Facility ID: CA060000124 If continuation sheet 2 of 12 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055674 (X3) DATE SURVEY COMPLETED 03/23/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HEALTHCARE CENTER OF ORANGE COUNTY 9021 Knott Ave Buena Park, CA 90620 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE §483.15(c)(2) Documentation. When the facility transfers or discharges a resident under any of the circumstances specified in paragraphs (c)(1)(i)(A) through (F) of this section, the facility must ensure that the transfer or discharge is documented in the resident's medical record and appropriate information is communicated to the receiving health care institution or provider. (i) Documentation in the resident's medical record must include: (A) The basis for the transfer per paragraph (c) (1)(i) of this section. (B) In the case of paragraph (c)(1)(i)(A) of this section, the specific resident need(s) that cannot be met, facility attempts to meet the resident needs, and the service available at the receiving facility to meet the need(s). (ii) The documentation required by paragraph (c)(2)(i) of this section must be made by(A) The resident's physician when transfer or discharge is necessary under paragraph (c) (1) (A) or (B) of this section; and (B) A physician when transfer or discharge is necessary under paragraph (c)(1)(i)(C) or (D) of this section. (iii) Information provided to the receiving provider must include a minimum of the following: (A) Contact information of the practitioner responsible for the care of the resident. (B) Resident representative information including contact information (C) Advance Directive information (D) All special instructions or precautions for ongoing care, as appropriate. (E) Comprehensive care plan goals; (F) All other necessary information, including a copy of the resident's discharge summary, consistent with §483.21(c)(2) as applicable, and any other documentation, as applicable, to ensure a safe and effective transition of care. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IJE811 Facility ID: CA060000124 If continuation sheet 3 of 12 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055674 (X3) DATE SURVEY COMPLETED 03/23/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HEALTHCARE CENTER OF ORANGE COUNTY 9021 Knott Ave Buena Park, CA 90620 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE This REQUIREMENT is not met as evidenced by: Based on interview and medical record review, the facility failed to ensure the transfer for one of three sampled residents (Resident 1) was necessary. Resident 1 was transferred from one SNF to another SNF without an appropriate justification. This failure resulted in Resident 1 experiencing an unnecessary transfer, which caused the resident confusion and a potential to negatively affect the resident's psychosocial well-being. Findings: Review of Resident 1's medical record was initiated on 2/21/20. Resident 1 was admitted to the facility on 1/16/20, and discharged to another facility on 2/19/20. Review of the MDS dated 1/22/20, showed Resident 1 had moderate cognitive impairment. Resident 1 needed extensive assistance from staff for mobility, transfers, ambulation, and eating. Resident 1 was incontinent of bowel and bladder and totally dependent on staff for hygiene and bathing. Review of the physician's order dated 2/13/20, to provide skin treatment to Resident 1's sacrococcyx and right buttock wounds. Resident 1 had orders to provide physical therapy, occupational therapy, and speech therapy. Review of Resident 1's Notice of Transfer/Discharge form dated 2/19/2020, showed Resident 1 was transferred to Skilled Nursing Facility B on 2/19/2020. The notice showed Resident 1's transfer was necessary and the transfer/discharge was appropriate because his health had improved sufficiently FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IJE811 Facility ID: CA060000124 If continuation sheet 4 of 12 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055674 (X3) DATE SURVEY COMPLETED 03/23/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HEALTHCARE CENTER OF ORANGE COUNTY 9021 Knott Ave Buena Park, CA 90620 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE and no longer required the services provided by the facility. Review of the physician's order dated 2/19/2020 at 1353 hours, showed an order to transfer Resident 1 to Skilled Nursing Facility B with all medications and belongings. The physician's order did not indicate the medical necessity or reason for Resident 1's discharge from this SNF to another SNF. Review of the Physician's Progress Notes dated 1/272020 and 2/17/2020, did not show indication or reasons for a possible need to transfer Resident 1 to another SNF. Review of Departmental Note dated 2/19/2020 at 1433 hours, showed Resident 1 was transferred to SNF B at 1433 hours. There was no documentation to show the reason for Resident 1's transfer. On 2/28/2020 at 1328 hours, an interview was conducted with the DON at Skilled Nursing Facility B. When asked about the services the facility was providing to Resident 1. The DON stated Resident 1 was receiving physical therapy, occupational therapy and wound care. On 2/28/2020 at 1400 hours, a telephone interview was conducted with Resident 1. Resident 1 stated he was upset and did not understand why he was discharged from one skilled nursing facility to another skilled nursing that was so far away from his family. Resident 1 stated he did not receive any documentation or information from the facility related to his discharge or that he had the right to appeal the discharge. Resident 1 stated the facility told him about the transfer on the day he was discharged. On 2/28/2020 at 1500 hours, a telephone FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IJE811 Facility ID: CA060000124 If continuation sheet 5 of 12 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055674 (X3) DATE SURVEY COMPLETED 03/23/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HEALTHCARE CENTER OF ORANGE COUNTY 9021 Knott Ave Buena Park, CA 90620 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE interview was conducted with SSD 1. SSD 1 stated Resident 1 had requested to be transferred to another facility because he wanted to smoke more often. SSD 1 stated the facility's smoking schedule was every two hours. SSD 1 stated Resident 1 wanted more activities and more smoking time. When asked what particular activities was Resident 1 asking for that the facility was not able to provide, SSD 1 was not able to answer. On 3/4/2020 at 1232 hours, a telephone interview and concurrent medical record review was conducted with SSD 1. SSD 1 verified the Notice of Transfer/Discharge dated 2/19/2020, showed Resident 1's condition had improved and did not require the services provided by the facility. SSD 1 acknowledged the reason for Resident 1's discharge was not appropriate since Resident 1 continued to need the same care.

F623 SS=D Notice Requirements Before Transfer/Discharge CFR(s): 483.15(c)(3)-(6)(8)

F623 §483.15(c)(3) Notice before transfer. Before a facility transfers or discharges a resident, the facility must(i) Notify the resident and the resident's representative(s) of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand. The facility must send a copy of the notice to a representative of the Office of the State LongTerm Care Ombudsman. (ii) Record the reasons for the transfer or discharge in the resident's medical record in accordance with paragraph (c)(2) of this FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IJE811 Facility ID: CA060000124 If continuation sheet 6 of 12 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055674 (X3) DATE SURVEY COMPLETED 03/23/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HEALTHCARE CENTER OF ORANGE COUNTY 9021 Knott Ave Buena Park, CA 90620 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE section; and (iii) Include in the notice the items described in paragraph (c)(5) of this section. §483.15(c)(4) Timing of the notice. (i) Except as specified in paragraphs (c)(4)(ii) and (c)(8) of this section, the notice of transfer or discharge required under this section must be made by the facility at least 30 days before the resident is transferred or discharged. (ii) Notice must be made as soon as practicable before transfer or discharge when(A) The safety of individuals in the facility would be endangered under paragraph (c)(1)(i)(C) of this section; (B) The health of individuals in the facility would be endangered, under paragraph (c)(1)(i)(D) of this section; (C) The resident's health improves sufficiently to allow a more immediate transfer or discharge, under paragraph (c)(1)(i)(B) of this section; (D) An immediate transfer or discharge is required by the resident's urgent medical needs, under paragraph (c)(1)(i)(A) of this section; or (E) A resident has not resided in the facility for 30 days. §483.15(c)(5) Contents of the notice. The written notice specified in paragraph (c)(3) of this section must include the following: (i) The reason for transfer or discharge; (ii) The effective date of transfer or discharge; (iii) The location to which the resident is transferred or discharged; (iv) A statement of the resident's appeal rights, including the name, address (mailing and email), and telephone number of the entity which receives such requests; and information on how to obtain an appeal form and assistance in completing the form and submitting the appeal hearing request; FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IJE811 Facility ID: CA060000124 If continuation sheet 7 of 12 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055674 (X3) DATE SURVEY COMPLETED 03/23/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HEALTHCARE CENTER OF ORANGE COUNTY 9021 Knott Ave Buena Park, CA 90620 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE (v) The name, address (mailing and email) and telephone number of the Office of the State Long-Term Care Ombudsman; (vi) For nursing facility residents with intellectual and developmental disabilities or related disabilities, the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with developmental disabilities established under Part C of the Developmental Disabilities Assistance and Bill of Rights Act of 2000 (Pub. L. 106-402, codified at 42 U.S.C. 15001 et seq.); and (vii) For nursing facility residents with a mental disorder or related disabilities, the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with a mental disorder established under the Protection and Advocacy for Mentally Ill Individuals Act. §483.15(c)(6) Changes to the notice. If the information in the notice changes prior to effecting the transfer or discharge, the facility must update the recipients of the notice as soon as practicable once the updated information becomes available. §483.15(c)(8) Notice in advance of facility closure In the case of facility closure, the individual who is the administrator of the facility must provide written notification prior to the impending closure to the State Survey Agency, the Office of the State Long-Term Care Ombudsman, residents of the facility, and the resident representatives, as well as the plan for the transfer and adequate relocation of the residents, as required at § 483.70(l). This REQUIREMENT is not met as evidenced by: Based on interview and medical record review, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IJE811 Facility ID: CA060000124 If continuation sheet 8 of 12 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055674 (X3) DATE SURVEY COMPLETED 03/23/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HEALTHCARE CENTER OF ORANGE COUNTY 9021 Knott Ave Buena Park, CA 90620 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE the facility failed to ensure one of three sampled residents (Resident 1) was provided with a discharge notice in a timely manner. Resident 1 was transferred to another SNF on 2/18/2020. This resulted in Resident 1 and his legal representative to be deprived of the resident's right to file an appeal of the discharge. Findings: On 2/20/2020 at 1521 hours, a telephone interview was conducted with Family Member 1. Family Member 1 stated she was not aware Resident 1 was being transferred to another SNF. Family Member 1 stated she had been visiting Resident 1 routinely and not informed of the pending discharge. The family member stated due to the distance, she would no longer be able to visit Resident 1 because that facility was too far away. On 2/20/2020 at 1525 hours, a telephone interview was conducted with Family Member 2. Family Member 2 stated Resident 1 was his own responsible party; however, his family was involved and visited him regularly. Family Member 2 stated Resident 1 was transferred to SNF B but did not receive any notice of discharge or transfer prior to being discharged. Family Member 2 stated Resident 1 had informed her he has was being "forced" by the facility to transfer to another facility and had not receive any papers to sign or instructions. Family Member 2 stated Resident 1 had resided in SNF A for over a month. Review of Resident 1's Notice of Transfer/Discharge form dated 2/19/20, showed Resident 1 was notified on 2/18/20, and discharged on 2/19/20 to SNF B. Review of Social Services Notes from FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IJE811 Facility ID: CA060000124 If continuation sheet 9 of 12 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055674 (X3) DATE SURVEY COMPLETED 03/23/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HEALTHCARE CENTER OF ORANGE COUNTY 9021 Knott Ave Buena Park, CA 90620 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 2/10/2020 through 2/20/2020, failed to show any documentation the facility informed Resident 1's right to appeal, explain the process for appeal the discharge, or assist Resident 1 in filling out the appeal form if he wished to do so. On 2/28/20 at 1400 hours, an interview was conducted with Resident 1. Resident 1 stated he did not receive any document from the facility when he was discharged to explain why he was being discharged or his right to appeal. On 2/28/2020 at 1500 hours, a telephone interview was conducted with the SSD 1. When asked if she informed Resident 1's of his right to appeal his transfer/discharge, SSD 1 stated she did not. SSD 1 acknowledged Resident 1 was not informed of his right to appeal and the process on how to file an appeal.

F624 SS=D Preparation for Safe/Orderly Transfer/Dschrg CFR(s): 483.15(c)(7)

F624 §483.15(c)(7) Orientation for transfer or discharge. A facility must provide and document sufficient preparation and orientation to residents to ensure safe and orderly transfer or discharge from the facility. This orientation must be provided in a form and manner that the resident FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IJE811 Facility ID: CA060000124 If continuation sheet 10 of 12 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055674 (X3) DATE SURVEY COMPLETED 03/23/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HEALTHCARE CENTER OF ORANGE COUNTY 9021 Knott Ave Buena Park, CA 90620 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE can understand. This REQUIREMENT is not met as evidenced by: Based on interview and medical record review, the facility failed to ensure one of three sampled residents (Resident 1) was properly prepared for his discharge and informed of the destination of facility he was discharged to. Resident 1 was transferred to another SNF approximately 56 miles from Resident 1's home and his family. This had the potential to cause anxiety, depression, and maladjustment to a new living environment for Resident 1. Findings: Review of Resident 1's Notice of Transfer/Discharge form dated 2/18/2020, showed Resident 1 was notified on 2/18/2020, and would be transferred on 2/19/2020 to SNF B located 56 miles away from Resident 1's home. On 2/20/2020 at 1521 hours, a telephone interview was conducted with Family Member 1. Family Member 1 stated she was not able to visit Resident 1 because that facility was too far to visit. On 2/28/2020 at 1400 hours, a telephone interview was conducted with Resident 1. Resident 1 stated he was not provided any information about SNF B or where it was located. Resident 1 stated he was upset and he did not understand why he was discharged out of Orange County where he and his family resided to another county almost 60 miles away. On 3/4/2020 at 1232 hours, a telephone interview was conducted with SSD 1. SSD 1 was asked how she oriented Resident 1 with FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IJE811 Facility ID: CA060000124 If continuation sheet 11 of 12 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055674 (X3) DATE SURVEY COMPLETED 03/23/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HEALTHCARE CENTER OF ORANGE COUNTY 9021 Knott Ave Buena Park, CA 90620 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE the new facility, and what information about SNF B were provided to Resident 1. SSD 1 stated she informed Resident 1 about the services SNF B can provide. When asked if Resident 1 was made aware of its locations, SSD 1 stated she informed Resident 1 the facility was located in the nearby county. SSD 1 stated she was not aware how far the facility was from Resident 1's home and family. SSD acknowledge she did inform Resident 1 about the location of the other facility. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IJE811 Facility ID: CA060000124 If continuation sheet 12 of 12