Laguna Hills Health And Rehabilitation Center

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

conducted with LVN 2. LVN 2 stated CNA 2 had reported Resident 4 had a skin discoloration to her right eyebrow on 9/8/25 around 2100 to 2200 hours. LVN 2 stated he went to assess Resident 4 and Resident 4 had a coin-sized dark red in color discoloration to her right eyebrow. LVN 2 stated he was not sure where

the discoloration came from and stated he and CNA 2 did not witness when Resident 4 developed the discoloration. LVN 2 further stated he attempted to ask Resident 4 what had happened; however, Resident 4 did not answer any questions at that time. On 9/11/25 at 1607 hours, an interview and medical record

review was conducted with the DON. The DON was informed and acknowledged the findings. The DON stated Family Member 1 was notified at the time the discoloration was discovered, had visited Resident 4

on 9/10/25. The DON added Family Member 1 wanted the facility to investigate Resident 4's skin discoloration. The DON stated the facility did not know how Resident 4 got the skin discoloration and verified Resident 4 was unable to verbalize how she had gotten the skin discoloration. The DON stated the facility did not know the source of the injury until after the facility had conducted their investigation. On 9/15/25 at 1305 hours, an interview was conducted with the Administrator. The Administrator verified he was the facility's abuse coordinator and stated when someone reported an abuse, he would send the SOC 341 to the CDPH, L&C Program, ombudsman, and law enforcement if he was available. The Administrator stated he reported Resident 4's skin discoloration to her right eye because Family Member 1 wanted the facility to investigate. The Administrator stated Resident 4 did not remember how the skin discoloration happened and there were no witnesses. The Administrator stated it was unknown how Resident 4 got the skin discoloration and it would be reportable under normal circumstances. The Administrator stated Resident 4 was prone to accidents and reporting would be a gray area from his standpoint. On 9/15/25 at 1343 hours, an interview was conducted with the Administrator. The Administrator acknowledged the above findings.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/11/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Laguna Hills Health and Rehabilitation Center

24452 Health Center Drive Laguna Hills, CA 92653

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)

F 0627 Level of Harm - Minimal harm or potential for actual harm

resident about the timeframe for the services to be set-up. The SSD stated she did not communicate to Resident 1 the information regarding Resident 1's ineligibility for the DME. The SSD verified there was no documented evidence Resident 1 was notified regarding her DME services prior to or after her discharge from the facility. On 9/15/25 at 1343 hours, an interview was conducted with the Administrator. The Administrator acknowledged the above findings.

Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/11/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Laguna Hills Health and Rehabilitation Center

24452 Health Center Drive Laguna Hills, CA 92653

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)

F 0628 Level of Harm - Potential for minimal harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, closed medical record review, and facility P&P review, the facility failed to ensure a notice of transfer/discharge was provided to the resident or the resident's responsible party for one of six sampled residents (Resident 2) prior to the resident's discharge from the facility. * The facility failed to provide the written notice pf transfer/discharge to Resident 2 or the resident's responsible party prior to the resident's discharge from the facility. In addition, the facility failed to ensure a copy of Resident 2's notice of transfer/discharge was provided to the State Long-Term Care Ombudsman prior to the planned discharge date . This failure had the potential to violate Resident 1's rights to appeal their discharge. Findings: Review of the facility's P&P titled Transfer or Discharge, Facility-Initiated dated 10/2022 showed under the section notice of transfer or discharge (planned), showed the resident and his or her representative are given a thirty day advance written notice of an impending transfer or discharge from this facility. A copy of this notice is sent to the office of the State Long-Term Care Ombudsman at the same time the notice of transfer or discharge is provided to the resident and representative. Under the section notice of transfer or discharge (emergent or therapeutic leave), showed under the following circumstances, the notice is given as soon as it is practicable but before the transfer or discharge if the resident's health improves sufficiently to allow a more immediate transfer or discharge. Closed medical record review for Resident 2 was initiated

on 9/10/25. Resident 2 was readmitted to the facility on [DATE REDACTED], and discharged on 8/27/25. Review of Resident 2's medical record failed to show a notice of transfer/discharge was provided to Resident 2, Resident 2's representative, or to the LTC Ombudsman on or prior to his discharge on [DATE REDACTED]. On 9/10/25 at 1505 hours, an interview and concurrent closed medical record review was conducted with the SS Staff.

The SS staff stated she would provide the notice of transfer/discharge two days prior to the resident's discharge date or when the resident stated they wanted to go home. The SS staff stated Resident 2 was discharged on 8/27/25, per his wife's request. The SS Staff verified there was no documented evidence a notice of transfer/discharge was provided to Resident 2 or Resident 2's representative. On 9/11/25 at 1341 hours, an interview and concurrent closed medical record review was conducted with the SSD. The SSD stated the social services department was responsible for providing the notice of transfer/discharge. The SSD stated if the resident had requested to be discharged , the facility would provide the notice on the date

the resident requested to be discharged . The SSD stated Resident 2's wife had requested Resident 2 to be discharged , and the discharge order was placed on 8/26/25, for him to discharge on [DATE REDACTED]. The SSD verified there was no documented evidence a notice of transfer/discharge was provided to Resident 2, Resident 2's representative, or to the LTC ombudsman prior to his discharge from the facility.

Event ID:

Facility ID:

If continuation sheet