Other·September 9, 2019

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 represents the findings of the California Department of Public Health during an ABBREVIATED survey for COMPLAINT No: CA00646909. Inspection was limited to the specific complaint investigated and does not represent the findings of a full inspection of the facility. Representing the California Department of Public Health: Surveyor 33453, HFEN. THE DEPARTMENT WAS ABLE TO SUBSTANTIATE THE COMPLAINT ALLEGATION. FINDINGS WERE CITED AT

F626 FOR RESIDENT 1. GLOSSARY OF ABBREVIATIONS AND BRIEF DEFINITIONS: CDC - Centers for Disease Control and Prevention Candida auris - a multidrug-resistant yeast DON - Director of Nursing MDRO - Multi-drug resistant organism (bacteria (germs) that is resistant to multiple types of antibiotics) PHN - Public Health Nurse P&P - policy and procedure SNF - skilled nursing facility

F626 SS=D Permitting Residents to Return to Facility CFR(s): 483.15(e)(1)(2)

F626 §483.15(e)(1) Permitting residents to return to facility. A facility must establish and follow a written policy on permitting residents to return to the 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: 2G5L11 Facility ID: CA060000147 If continuation sheet 1 of 7 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: _______________ 555035 (X3) DATE SURVEY COMPLETED 08/07/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PARK ANAHEIM HEALTHCARE CENTER 3435 W Ball Rd Anaheim, CA 92804 (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 facility after they are hospitalized or placed on therapeutic leave. The policy must provide for the following. (i) A resident, whose hospitalization or therapeutic leave exceeds the bed-hold period under the State plan, returns to the facility to their previous room if available or immediately upon the first availability of a bed in a semiprivate room if the resident(A) Requires the services provided by the facility; and (B) Is eligible for Medicare skilled nursing facility services or Medicaid nursing facility services. (ii) If the facility that determines that a resident who was transferred with an expectation of returning to the facility, cannot return to the facility, the facility must comply with the requirements of paragraph (c) as they apply to discharges. §483.15(e)(2) Readmission to a composite distinct part. When the facility to which a resident returns is a composite distinct part (as defined in § 483.5), the resident must be permitted to return to an available bed in the particular location of the composite distinct part in which he or she resided previously. If a bed is not available in that location at the time of return, the resident must be given the option to return to that location upon the first availability of a bed there. This REQUIREMENT is not met as evidenced by: Based on interview, medical record review, facility document review, and facility P&P review, the facility failed to allow one of two sampled residents (Resident 1) to return and resume residence in the facility after the acute care hospital determined the resident was ready for discharge from the acute care hospital. Resident 1 had been a resident at the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2G5L11 Facility ID: CA060000147 If continuation sheet 2 of 7 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: _______________ 555035 (X3) DATE SURVEY COMPLETED 08/07/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PARK ANAHEIM HEALTHCARE CENTER 3435 W Ball Rd Anaheim, CA 92804 (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 facility for five years. Not allowing Resident 1 to return to her residence had the potential for psychosocial harm. Findings: On 7/26/19 at 0948 hours, a telephone interview was conducted with Resident 1's family member. Resident 1's family member stated the resident had been in the acute care hospital for three months. The resident's family member stated they were told the facility did not have a bed available due to Resident 1 having an infection which required a private isolation room and did not want other residents to get infected. Resident 1's family member stated Resident 1 had lived at the facility for five years, it was her home, and wanted Resident 1 to return to the facility. Review of the facility's P&P titled Bed Hold Notification dated 1/2004 showed the facility shall readmit a Medicaid resident requiring SNF services immediately upon the first availability of a bed in a semiprivate room when his/her hospitalization or therapeutic leave exceeds the bed hold period. Closed medical record review for Resident 1 was initiated on 7/29/19. Resident 1's original admission to the facility was 7/8/14, and was discharged on 4/21/19, to the acute care hospital. On 7/29/19 at 1336 hours, an interview and concurrent facility document review was conducted with the Admissions Director. The Admissions Director was asked what the process was for readmitting a resident after the bed hold was exhausted. The Admissions Director stated the hospital's Discharge Planner would call the facility when the resident was ready to return and would ask if a bed was FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2G5L11 Facility ID: CA060000147 If continuation sheet 3 of 7 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: _______________ 555035 (X3) DATE SURVEY COMPLETED 08/07/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PARK ANAHEIM HEALTHCARE CENTER 3435 W Ball Rd Anaheim, CA 92804 (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 available, or the facility would call the hospital's Discharge Planner for a discharge date. The Admissions Director was asked where the information was documented. The Director stated the information would be documented on an inquiry form and not in the resident's medical record. Review of the inquiry form showed the information was sent to the facility on 5/29/19. The information included the resident required isolation and there was no discharge date. On 7/29/19 at 1345 hours, an interview and concurrent medical record review was conducted with the DON. The DON stated when an inquiry was received by the Admissions staff, the DON would review the information to ensure the facility could care for the resident. The DON reviewed Resident 1's inquiry information which showed Resident 1 had an MDRO, and the DON stated the facility did not have an isolation room. The DON was asked if she had spoken to Resident 1's family regarding the resident returning to the facility. The DON stated the Social Service staff would communicate with the resident's family and document in the medical record. Resident 1's medical record was reviewed and the DON verified there was no documentation to show the Social Service staff had communicated with Resident 1's family member or the acute care hospital's Discharge Planner. On 7/29/19 at 1425 hours, an interview was conducted with the Administrator. The Administrator stated she received a call on 7/16/19, from the Case Manager at the acute care hospital. The Administrator stated she was told by the acute care hospital's Case Manager, Resident 1 was not ready for discharge yet. The Administrator stated she informed the acute care hospital's Case Manager the facility did not have a bed FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2G5L11 Facility ID: CA060000147 If continuation sheet 4 of 7 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: _______________ 555035 (X3) DATE SURVEY COMPLETED 08/07/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PARK ANAHEIM HEALTHCARE CENTER 3435 W Ball Rd Anaheim, CA 92804 (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 available. The Administrator stated she had spoken to Resident 1's family member last week and informed Resident 1's family member a private room was needed due to Resident 1's infection (Candida auris). The Administrator stated she informed the acute care hospital's Case Manager the facility would readmit Resident 1 when a negative culture for Candida auris was obtained. The Administrator stated the facility staff received training on 5/1/19, from the Orange County Public Health Department and were given information to follow the CDC's guidelines of providing a private isolation room for residents with Candida auris. The Administrator was asked for a documentation regarding the inquiry information from the acute care hospital and communication with the resident's family member. The Administrator stated she had her own notes, which were not in Resident 1's closed medical record. Review of the facility's admissions from April to 7/29/19, showed eight residents were admitted to the facility's Subacute unit since 5/29/19. The Administrator stated the facility could not readmit Resident 1 until a private room was available. On 7/31/19 at 0940 hours, a telephone interview was conducted with PHN 1 at the Orange County Public Health. PHN 1 stated the protocol for residents with Candida auris in a SNF were as follows: a. a private room was preferred, b. if a private room was not available, the CDC recommended placing residents with the same infection together, or c. place another resident without infection and use dedicated equipment for each resident, treating each bed space as separate rooms. On 7/31/19 at 1756 hours, the Administrator FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2G5L11 Facility ID: CA060000147 If continuation sheet 5 of 7 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: _______________ 555035 (X3) DATE SURVEY COMPLETED 08/07/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PARK ANAHEIM HEALTHCARE CENTER 3435 W Ball Rd Anaheim, CA 92804 (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 sent an e-mail which showed the Administrator's recollection of the communication with the acute care hospital and Resident 1's family. The document showed the following: * 5/29/19, the facility received an inquiry for Resident 1, which included the resident had an MDRO and tested positive for scabies. The facility had informed the acute care hospital they had no isolation bed available at the time. * Early to mid-July, 2019, the acute care hospital had inquired if there was a bed available for Resident 1. The facility had been informed by the hospital of Resident 1 had tested positive for Candida auris. The Administrator informed the acute care hospital there were no female beds available at the time. On 8/1/19 at 1036 hours, a telephone interview was conducted with the Director of Case Management at the acute care hospital. The Director of Case Management stated she spoke with the Administrator twice, two weeks ago, to inquire about the bed availability and provided an update on Resident 1's condition. The Administrator informed her the facility did not have an available bed. The Director of Case Management stated the physician documented Resident 1 was stable for discharge. On 8/6/19 at 1000 hours, a follow-up interview was conducted with the facility's Admissions Director. The Admissions Director stated she had received an inquiry on 8/1/19, from the acute care hospital for an available bed for Resident 1. The acute care hospital was informed the facility had no available isolation room. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2G5L11 Facility ID: CA060000147 If continuation sheet 6 of 7 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: _______________ 555035 (X3) DATE SURVEY COMPLETED 08/07/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PARK ANAHEIM HEALTHCARE CENTER 3435 W Ball Rd Anaheim, CA 92804 (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 On 8/6/19 at 1005 hours, an interview was conducted with the DON. The DON was asked if Resident 1 had returned to the facility. The DON stated the facility did not readmit Resident 1 due to not having an isolation room. The DON stated the facility's Subacute unit had two open beds at this time, a female and a male bed. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2G5L11 Facility ID: CA060000147 If continuation sheet 7 of 7