Other·August 6, 2019

F000 INITIAL COMMENTS

F000 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Amended The following reflects the findings of the California Department of Public health during an ABBREVIATED Survey for COMPLAINT Nos: CA00637700 and CA00638316. Inspection was limited to the complaints investigated and does not represent the findings of a full inspection of the facility. Representing the California Department of Public Health: Surveyor 33464, HFEN. FOR COMPLAINT NO. CA00637700: THE DEPARTMENT WAS ABLE TO PARTIALLY SUBSTANTIATE THE COMPLAINT ALLEGATIONS. FINDINGS WERE CITED AT

F623 AND F626 FOR RESIDENT 1 AND F625 FOR RESIDENTS 1 AND 2. FOR COMPLAINT NO. CA00638316: THE DEPARTMENT WAS ABLE TO SUBSTANTIATE THE COMPLAINT ALLEGATIONS. FINDINGS WERE CITED AT

F623, F625, AND F626 FOR RESIDENT 1. GLOSSARY OF ABBREVIATIONS AND BRIEF DEFINITIONS: CEO / CNO - Chief Executive Officer / Chief Nursing Officer pneumonia - (an infection in the lungs) RN - Registered Nurse Seven-day bed-hold - (keeping a resident's bed available for their return for up to seven days of their hospitalization) 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: QC0B11 Facility ID: CA980001698 If continuation sheet 1 of 11 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: _______________ 555753 (X3) DATE SURVEY COMPLETED 07/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HEALTHBRIDGE CHILDREN'S HOSPITAL - ORANGE D/P SNF 393 S Tustin St Orange, CA 92866 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG

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

F623 SS=D PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE §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 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 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: QC0B11 Facility ID: CA980001698 If continuation sheet 2 of 11 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: _______________ 555753 (X3) DATE SURVEY COMPLETED 07/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HEALTHBRIDGE CHILDREN'S HOSPITAL - ORANGE D/P SNF 393 S Tustin St Orange, CA 92866 (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 (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; (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 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: QC0B11 Facility ID: CA980001698 If continuation sheet 3 of 11 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: _______________ 555753 (X3) DATE SURVEY COMPLETED 07/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HEALTHBRIDGE CHILDREN'S HOSPITAL - ORANGE D/P SNF 393 S Tustin St Orange, CA 92866 (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 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: noBased on interview and record review, the facility failed to notify one of two sampled residents (Resident 1) and the resident's legal representative of the resident's discharge and the reason for the discharge from the facility. * Resident 1's physician ordered to discharge Resident 1 from the facility following an emergent transfer of Resident 1 to the acute care hospital directly from his school. This failure of the facility to send a notice of discharge to the resident and resident representative prevented the resident or resident's representative the opportunity to participate in the decision making process for the resident's care. Findings: Medical record review for Resident 1 was initiated on 5/21/19. Resident 1 was admitted to the facility on 3/28/08. Review of Resident 1's Nurses Notes dated 4/18/19 at 1155 hours, showed RN 1 received a telephone call from Resident 1's school reporting emergency medical service had been FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: QC0B11 Facility ID: CA980001698 If continuation sheet 4 of 11 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: _______________ 555753 (X3) DATE SURVEY COMPLETED 07/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HEALTHBRIDGE CHILDREN'S HOSPITAL - ORANGE D/P SNF 393 S Tustin St Orange, CA 92866 (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 called and Resident 1 was transported to the acute care hospital emergency department. On 4/18/19 at 1435 hours, RN 1 received a call from the acute care hospital informing the facility Resident 1 was admitted to the acute care hospital for pneumonia and a urinary tract infection. Review of Resident 1's physician orders dated 4/18/19, showed an order to discharge the resident from the facility. Review of Resident 1's MDS dated 4/17/17, showed the resident was discharged without his return anticipated. Review of Resident 1's Case Management Notes dated 4/26/19, for 4/23/19, showed the acute care hospital notified the facility Resident 1 was ready to return to the facility. The CEO/CNO spoke with Resident 1's attending physician, the facility's Medical Director, and two alternate physicians all of whom refused to admit Resident 1 back to the facility, stating the facility was not an appropriate or a suitable level of care for Resident 1. Review of Resident 1's medical record failed to show documentation the facility issued a written notice of a seven-day bed hold or a written notice of transfer/discharge to Resident 1 or his legal representative. On 5/21/19 at 1600 hours, an interview was conducted with the CEO/CNO. The CEO/CNO verified the above findings and verified the facility kept the resident's bed available; however, the physician considered the discharge from the facility permanent. The CEO/CNO stated the facility's physicians had refused to readmit Resident 1 to the facility following his stay in the acute care hospital because the facility was not the appropriate FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: QC0B11 Facility ID: CA980001698 If continuation sheet 5 of 11 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: _______________ 555753 (X3) DATE SURVEY COMPLETED 07/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HEALTHBRIDGE CHILDREN'S HOSPITAL - ORANGE D/P SNF 393 S Tustin St Orange, CA 92866 (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 level of care required by Resident 1. On 5/20/19, Resident 1 was readmitted to the facility from the acute care hospital.

F625 SS=D Notice of Bed Hold Policy Before/Upon Trnsfr CFR(s): 483.15(d)(1)(2)

F625 §483.15(d) Notice of bed-hold policy and return§483.15(d)(1) Notice before transfer. Before a nursing facility transfers a resident to a hospital or the resident goes on therapeutic leave, the nursing facility must provide written information to the resident or resident representative that specifies(i) The duration of the state bed-hold policy, if any, during which the resident is permitted to return and resume residence in the nursing facility; (ii) The reserve bed payment policy in the state plan, under § 447.40 of this chapter, if any; (iii) The nursing facility's policies regarding bedhold periods, which must be consistent with paragraph (e)(1) of this section, permitting a resident to return; and (iv) The information specified in paragraph (e) (1) of this section. §483.15(d)(2) Bed-hold notice upon transfer. At the time of transfer of a resident for hospitalization or therapeutic leave, a nursing facility must provide to the resident and the resident representative written notice which specifies the duration of the bed-hold policy described in paragraph (d)(1) of this section. This REQUIREMENT is not met as evidenced by: provideBased on interview and record review, the facility failed to provide a notice of the facility's bed-hold policy within 24 hours of an emergency transfer to the acute care hospital FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: QC0B11 Facility ID: CA980001698 If continuation sheet 6 of 11 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: _______________ 555753 (X3) DATE SURVEY COMPLETED 07/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HEALTHBRIDGE CHILDREN'S HOSPITAL - ORANGE D/P SNF 393 S Tustin St Orange, CA 92866 (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 for two of two sampled residents (Resident 1 and Resident 2). This failure had the potential for the resident and the resident's representative to be unaware of the resident's right to return to the facility following the stay in the acute care hospital. Findings: 1. Medical record review for Resident 1 was initiated on 5/21/19. Resident 1 was admitted to the facility on 3/28/08, and transferred to the acute care hospital from the resident's school via paramedics on 4/18/19. Resident 1 was admitted to the acute care hospital and was readmitted to the facility from the acute care hospital on 5/20/19. Review of Resident 1's Nurses Notes dated 4/18/19 at 1155 hours, showed RN 1 received a telephone call from the resident's school. The school called the paramedics and Resident 1 was transported to the acute care hospital emergency department. On 4/18/19 at 1435 hours, RN 1 received a call from the acute care hospital informing the facility Resident 1 was admitted to the acute care hospital for pneumonia and a urinary tract infection. Review of Resident 1's physician order dated 4/18/19, showed an order to discharge the resident from the facility. The physician orders failed to include an order for a seven-day bed hold for Resident 1. Review of Resident 1's medical record failed to show documentation a written notice of a bed hold was provided to the resident's responsible party. On 5/21/19 at 1600 hours, an interview was conducted with the CEO/CNO. The CEO/CNO stated an administrative designee was FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: QC0B11 Facility ID: CA980001698 If continuation sheet 7 of 11 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: _______________ 555753 (X3) DATE SURVEY COMPLETED 07/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HEALTHBRIDGE CHILDREN'S HOSPITAL - ORANGE D/P SNF 393 S Tustin St Orange, CA 92866 (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 responsible to obtain a physician's order for a bed hold when a resident was admitted to the acute care hospital and provide the resident's responsible party with the notice of a bed hold. The CEO/CNO verified Resident 1/ resident's representative was not issued a bed hold when the resident was admitted to the acute care hospital on 4/18/19. The CEO/CNO stated the on call physician and the medical director for the facility refused to give an order for the bed hold. The CEO/CNO stated though there was no physician order or written notice of a bed hold, Resident 1's room was left unoccupied with all of the resident's belongings kept in place the entire time the resident was in the acute care hospital. (Cross reference to F626) 2. Medical record review for Resident 2 was initiated 5/21/19. Resident 2 was admitted to the facility on 2/4/19, and readmitted on 4/12/19. Review of Resident 2's physician's orders showed an order dated 4/9/19, to discharge Resident 2 to the acute care hospital for a surgical procedure. There was no physician's order for a seven-day bed hold. Review of Resident 2's medical record failed to show documentation a seven-day bed hold had been offered when the resident was discharged to the acute care hospital. On 5/21/19 at 1600 hours, an interview was conducted with the CEO/CNO. The CEO/CNO verified the above findings. The CEO/CNO stated the facility's Medical Director refused to order a seven-day bed hold for Resident 1 because the facility would not be reimbursed. The CEO/CNO confirmed there was no bedhold order or a written seven-day bed hold notice issues to Resident 1 or Resident 2. The CEO/CNO stated Resident 2 was readmitted to FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: QC0B11 Facility ID: CA980001698 If continuation sheet 8 of 11 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: _______________ 555753 (X3) DATE SURVEY COMPLETED 07/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HEALTHBRIDGE CHILDREN'S HOSPITAL - ORANGE D/P SNF 393 S Tustin St Orange, CA 92866 (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 on 4/12/19.

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 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: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: QC0B11 Facility ID: CA980001698 If continuation sheet 9 of 11 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: _______________ 555753 (X3) DATE SURVEY COMPLETED 07/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HEALTHBRIDGE CHILDREN'S HOSPITAL - ORANGE D/P SNF 393 S Tustin St Orange, CA 92866 (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 anBased on interview and record 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 Resident 1 was ready for discharge from the acute care hospital. This caused Resident 1 to remain in the acute care hospital for approximately 27 additional days. Resident 1 had lived in this facility for 11 years and considered his home. Findings: Medical record review for Resident 1 was initiated on 5/21/19. Resident 1 was admitted to the facility on 3/28/08, and transferred to the acute care hospital on 4/18/19. Review of Resident 1's Nurses Notes dated 4/18/19 at 1155 hours, showed RN 1 received a telephone call from the resident's school. The school called emergency medical services and Resident 1 was transported to the acute care hospital. On 4/18/19 at 1435 hours, RN 1 received a call from the acute care hospital informing the facility Resident 1 was admitted to the acute care hospital for pneumonia and a urinary tract infection. Review of Resident 1's physician order dated 4/18/19, showed an order to discharge the resident from the facility. Review of Resident 1's Case Management Notes dated 4/26/19, for 4/23/19, showed the acute care hospital notified the facility Resident 1 was ready to return to the facility; however, the facility refused to allow him to return. The CEO/CNO spoke with Resident 1's attending physician, the facility's Medical Director, and two alternate physicians all of whom refused to readmit Resident 1, stating the facility was not an appropriate or suitable level of care for FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: QC0B11 Facility ID: CA980001698 If continuation sheet 10 of 11 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: _______________ 555753 (X3) DATE SURVEY COMPLETED 07/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HEALTHBRIDGE CHILDREN'S HOSPITAL - ORANGE D/P SNF 393 S Tustin St Orange, CA 92866 (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 Resident 1. On 4/23/19, Resident 1's representative filed an appeal with the State of California, California Department of Health Care Services, Office of Administrative Hearings and Appeals due to the facility's failure allow Resident 1 be readmitted to the facility. The appeal was granted and the facility was notified the facility must immediately readmit Resident 1 to his bed. On 5/20/19, Resident 1 was readmitted to the facility. On 5/21/19 at 1600 hours, an interview was conducted with the CEO/CNO. The CEO/CNO verified the above findings. The CEO/CNO stated the facility was ready and willing to readmit Resident 1; however, none of the facility's physicians, including their Medical Director would give readmission orders. When asked, the CEO/CNO verified the facility's Medical Director was responsible to assume the role of Resident 1's physician until replaced by an alternate physician. The CEO/CNO stated Resident 1 was readmitted to the facility on 5/20/19, under the care of the Medical Director. (Cross reference to F623 and F625) FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: QC0B11 Facility ID: CA980001698 If continuation sheet 11 of 11