Health inspection·February 14, 2023

F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility P&P review, the facility failed to inform and provide the written information regarding the rights to formulate the advance directive to one of 25 final sampled residents (Resident 5). This had the potential for violating the resident's rights to formulate an advance directive. Findings: Review of the facility's P&P titled Advance Directives dated 9/22 showed the section for If the Resident Does not have an Advance Directive showing if the resident or representative indicates that he or she has not established advance directives, the facility staff will offer assistance in establishing advance directives. Nursing staff will document in the medical record the offer to assist and the resident's decision to accept or decline assistance. Review of Resident 5's medical record was initiated on 2/7/23. Resident 5 was readmitted to the facility on [DATE]. Review of the Physician H&P examination and Progress note dated 11/22/22, showed Resident 5 had the capacity to understand and make decisions. Review of the Quarterly MDS dated [DATE], showed Resident 5 had a BIMS of 10 (eight to 12 suggests moderately impaired). Review of the Physician Orders for Life Sustaining Treatment (POLST) dated 2/6/23, showed under Section D, Resident 5 had no advance directive. The POLST did not show the advance directive was offered and discussed with Resident 5. On 2/7/23 at 1603 hours, an interview with concurrent record review was conducted with the SSD. The SSD stated there was no documentation an advance directive was offered to Resident 5. The SSD stated the advance directive should have been offered and advanced healthcare directive acknowledgment form should have been filled out. On 2/8/23 at 1118 hours, an interview was conducted with Resident 5. Resident 5 was asked if someone had explained and offered her to formulate an advance directive. Resident 5 stated she did not know what an advance directive was and no one had offered her to formulate one. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055459 If continuation sheet Page 2 of 31 Printed: 05/15/2026 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 055459 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Buena Vista Care Center 1440 S Euclid Avenue Anaheim, CA 92802 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 0641 Ensure each resident receives an accurate assessment. Level of Harm - Potential for minimal harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and medical record review, the facility failed to accurately complete the MDS for one of 25 final sampled residents (Resident 43). This posed the risk of the resident not receiving an individualized plan of care based on the resident's specific needs. Residents Affected - Some * Resident 43 was dependent on oxygen. The facility failed to code the use of oxygen in the quarterly MDS dated [DATE]. Findings: Medical record review for Resident 43 was initiated on 2/13/23. Resident 43 was admitted to the facility on [DATE]. On 2/6/23 at 0952 hours, Resident 43 was observed in bed lying on her back with oxygen at 2 liters per minute via nasal cannula. Review of Resident 43's Order Summary Report dated 2/7/23, showed a physician's order dated 10/7/22, for oxygen at 2 liters per minute via nasal cannula continuously for shortness of breath. Review of the Medication Administration Record for October 2022 showed an order for oxygen at 2 liters per minute via nasal cannula continuously for shortness of breath. Review of the Quarterly MDS dated [DATE], showed the resident's shortness of breath and use of oxygen were not coded. On 2/13/23 at 1611 hours, an interview and concurrent medical record review was conducted with the MDS Coordinator. The MDS Coordinator verified the above findings and stated it was missed and the MDS was inaccurate. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055459 If continuation sheet Page 3 of 31 Printed: 05/15/2026 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 055459 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Buena Vista Care Center 1440 S Euclid Avenue Anaheim, CA 92802 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and medical record review, the facility failed to ensure the necessary treatment and services were provided to prevent the risk of contractures for one of 25 final sampled residents (Resident 30). * Resident 30's splints were not applied to her bilateral elbows as ordered. This failure posed the risk for this resident to develop complications from immobility and not achieve their highest practicable level of independence. Findings: Medical record review for Resident 30 was initiated on 2/6/23. Resident 30 was admitted to the facility on [DATE]. Review of the MDS dated [DATE], showed Resident 30 had cognitive impairment. Resident 30 received RNA program using a splint. Review of the Physician's Order Summary Report dated 1/30/23, showed an order, RNA order for bilateral elbow extension splints. Review of the care plan addressing Resident 30's increased risk of joint immobility in bilateral elbows showed the interventions to provide bilateral elbow extension splints. On 2/6/23 at 0850 hours, during the initial tour, Resident 30 was observed lying in her bed. Resident 30 was sleeping with her arms crossed across her chest. Resident 30's bilateral elbow extension braces were not observed on the resident. On 2/6/23 at 1108 hours, Resident 30 was observed lying in her bed. Resident 30's bilateral elbow extension splints were not observed on the resident. On 2/6/23 at 1251 hours, a concurrent interview and observation was conducted with the DSD. The DSD verified that Resident 30 did not have bilateral elbow extension splints applied. The DSD verified that Resident 30 had a physician's order for bilateral elbow extension splints. The DSD was able to perform bilateral elbow extension for Resident 30 while she was laying in bed. The DSD stated he would speak with the rehabilitation department to apply them. On 2/7/23 at 1003 hours, an interview was conducted with RNA 2. RNA 2 stated he did not apply the bilateral elbow extension splints on Resident 30 on 2/6/23. On 2/7/23 at 1019 hours, an interview was conducted with the DSD. The DSD stated Resident 30 was at risk for contractures if the bilateral splints were not applied as per the physician's order. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055459 If continuation sheet Page 4 of 31 Printed: 05/15/2026 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 055459 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Buena Vista Care Center 1440 S Euclid Avenue Anaheim, CA 92802 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 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services for the GT feeding for one of 25 final sampled residents (Resident 74). * The facility failed to ensure Resident 74 received the accurate amount of water in between medications during the medication administration. This failure posed the risk for complications related to the use of the GT. Findings: Review of the facility's P&P titled Administering Medications through an Enteral Tube revised 11/2018 showed the purpose of the procedure was to provide guidelines for the safe administration of medications through an enteral tube. The P&P further showed if administering more than one medication, flush with 15 ml warm purified water (or prescribed amount) between medications. Medical record review for Resident 74 was initiated on 2/7/23. Resident 74 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of the Order Summary Report showed a physician's order dated 1/2/23, for NPO and may crush all crushable medications administered via GT. Further review of the Order Summary Report showed the physician's orders dated 1/2/23, for the following medications: - apixaban (anticoagulant) tablet 5 mg via GT two times a day related to long-term (current) use of anticoagulants. - famotidine (medication that blocks acid release in the stomach) tablet 20 mg via GT every 12 hours related to GERD without esophagitis (an inflammation that damages the tube running from the throat to the stomach). - levetiracetam (anticonvulsant) solution 500 mg/5 ml 5 ml via GT two times a day related to conversion disorder with seizures or convulsions. -metoprolol tartrate (medication to treat high blood pressure) tablet 25 mg one tablet via GT two times a day related to essential (primary) hypertension, hold if SBP less than 110 mmHg or HR less than 60 beats per minute. However, the Order Summary Report did not show a specific amount of water to be flushed in between medication administration. On 2/7/23 at 0901 hours, a medication pass observation was conducted with LVN 1 for Resident 74. LVN 1 prepared the apixaban, famotidine, levetiracetam, and metoprolol medications. LVN 1 crushed each tablet, placed in an individual medication cup, and diluted the crushed medications with 5 ml of water. LVN 1 then proceeded to Resident 74's room to administer the medications via GT. LVN 1 administered the diluted levetiracetam, famotidine, apixaban, and metoprolol medications one after another (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055459 If continuation sheet Page 5 of 31 Printed: 05/15/2026 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 055459 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Buena Vista Care Center 1440 S Euclid Avenue Anaheim, CA 92802 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 0693 via GT. LVN 1 did not flush water in between the medications administration. Level of Harm - Minimal harm or potential for actual harm On 2/7/23 at 1251 hours, an interview and concurrent facility P&P review was conducted with LVN 1. When asked regarding the process of the administration medications via GT, LVN 1 stated the medication administration needed to be done via gravity, check for placement, check for residual, and to administer 30 ml of water before and after medication administration. When asked regarding the process of administering multiple medications, LVN 1 stated she poured all the medications via GT, one after another. When asked if LVN 1 was aware that she needed to flush 15 ml of warm purified water in between medications as per the facility's P&P, LVN 1 stated she was not aware. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055459 If continuation sheet Page 6 of 31 Printed: 05/15/2026 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 055459 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Buena Vista Care Center 1440 S Euclid Avenue Anaheim, CA 92802 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 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and medical record review, the facility failed to provide the necessary respiratory care for one of 25 final sampled residents (Resident 24). Residents Affected - Few * The facility failed to follow a physician's order for the administration of continuous oxygen for Resident 24. This failure had the potential to negatively impact Resident 24's medical condition. Findings: Medical record review for Resident 24 was initiated on 2/6/23. Resident 24 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 24's acute care hospital Pulmonary Consultation Note dated 1/10/23 at 1206 hours, showed Resident 24 received a consultation for pneumonia and respiratory failure. Review of Resident 24's physician's order dated 1/12/23, showed to administer continuous oxygen at 2 liters per minute via nasal cannula for shortness of breath. Review of Resident 24's care plan problem titled Impaired Respiratory Function Related to COPD and Pneumonia initiated on 1/16/23, showed an intervention to administer the prescribed oxygen. On 2/6/23 at 0845 hours, an observation and concurrent interview was conducted with Resident 24. Resident 24 was observed awake lying in bed. Resident 24 was observed without supplemental oxygen (continuous oxygen at 2 liters per minute) as ordered by Resident 24's physician. The oxygen concentrator was observed adjacent to Resident 24's bed and not turned on. The nasal cannula and oxygen tubing were observed in a clear plastic bag, adjacent to Resident 24's bed. Resident 24 stated he had pneumonia and utilized oxygen continuously for shortness of breath. On 2/6/23 at 0930 hours, an observation and concurrent interview was conducted with RN 2. RN 2 verified Resident 24 had a physician's order to administer continuous oxygen at 2 liters per minute via nasal cannula for shortness of breath. RN 2 verified Resident 24 did not receive continuous oxygen at 2 liters per minutes as per the physician's order. Review of Resident 24's medical record failed to show documentation Resident 24 had refused the administration of continuous oxygen or explanation why the oxygen was not administered as per the physician's order. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055459 If continuation sheet Page 7 of 31 Printed: 05/15/2026 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 055459 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Buena Vista Care Center 1440 S Euclid Avenue Anaheim, CA 92802 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 0698 Provide safe, appropriate dialysis care/services for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility P&P review, the facility failed to ensure the necessary care and services were provided for one of 25 final sampled residents (Resident 27). Residents Affected - Few * The facility failed to notify the physician when Resident 27's medications were not administered during dialysis days. In addition, the facility failed to ensure the physician's order for a 1200 ml fluid restriction (a diet which limits the amount of daily fluid consumption) was followed and carried out accordingly. This had the potential to negatively impact the resident's well-being. Findings: Review of the facility's P&P titled End-Stage Renal Disease, Care of a Resident With revised 9/2010 showed the residents with end-stage renal disease (ESRD) will be cared for according to currently recognized standards of care. Further review of the P&P showed the education and training of staff includes specifically (f)-timing and administration of medications, particularly those before and after dialysis care. a. Medical record review for Resident 27 was initiated on 2/14/23. Resident 27 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 27's admission Record showed diagnoses of end stage renal disease and dependence on renal dialysis. Review of the Order Summary Report showed a physician's order dated 9/5/22, for dialysis at Dialysis Center A every Tuesday, Thursday, and Saturday with the pick-up time at 0330 hours. Review of the Medication Administration Record for February 2023 showed the following medications: - carvedilol tablet 25 mg one tablet by mouth two times a day related to essential (primary) HTN, hold if SBP less than 110 mmHg or HR less than 60 beats per minute, and give with food. The medication had the order date of 8/9/22. - calcium acetate (Phosphate Binder) oral capsule 667 mg one capsule by mouth with meals related to ESRD, to give with meals. The medication had the order date of 2/7/23. - Insulin Lispro Solution 100 unit/ml per sliding scale subcutaneously before meals. The medication had the order date of 8/9/22. Further review of the February MAR showed the Chart Codes/Follow Up Codes including 5 = Hold Meds (Dialysis). The MAR showed the following medications were coded as 5: - On 2/9 and 2/11/23, the carvedilol 25 mg was coded as 5 at 0700 hours. - On 2/9 and 2/11/23, the calcium acetate 667 mg was coded as 5 at 0700 hours - On 2/4/23, the Insulin Lispro entry had the blank boxes for blood sugar result and dose administration at 0630 hours. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055459 If continuation sheet Page 8 of 31 Printed: 05/15/2026 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 055459 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Buena Vista Care Center 1440 S Euclid Avenue Anaheim, CA 92802 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 0698 Level of Harm - Minimal harm or potential for actual harm - On 2/11/23, the Insulin Lispro entry had the blood sugar result of 157 mg/dl; however, the 0630 hours insulin dose was coded as 5. Review of the Order Summary Report dated 2/14/23, did not show an order to hold Resident 27's medications during dialysis days. Residents Affected - Few On 2/14/23 at 1134 hours, an interview and concurrent medical record review was conducted with LVN 4. LVN 4 verified Resident 27 had scheduled dialysis on Tuesdays, Thursdays, and Saturdays with the pick-up time from the facility between 0330-0400 hours, and returned to the facility between 0830-0900 hours. The MAR codes were discussed with LVN 4 and he verified Code 5 meant the medication was not given due to dialysis. LVN 4 also verified Resident 27 did not have a physician's order to hold the medications during dialysis days. When asked if the medications should have been held without a physician's order, LVN 4 stated the medications were held if overdue, over an hour, or too early. LVN 4 stated the medications needed to be administered an hour before or after the scheduled time. When asked what the process was when Resident 27 missed medications, LVN 4 stated it was documented as Resident 27 was out of the facility. When asked if the physician should have been notified regarding the missed medications, LVN 4 stated yes. When asked what the blank box meant in the MAR for the Insulin Lispro on 2/4/23, LVN 4 stated the nurse may have forgotten to click the actual medication in the eMAR to record the medication administration. When asked regarding the documentation in the MAR on 2/11/23 at 0630 hours, when it was coded as 5 for the Insulin Lispro at 0630 hours with blood sugar result of 157 mg/dl, LVN 4 stated he did not know why there was documented blood sugar result when Resident 27 was out on pass for dialysis. b. Review of Resident 27's Physician History and Physical examination dated 4/5/22, showed Resident 27 did not have the capacity to understand and make decisions. Review of Resident 27's physician's order showed an order dated 8/9/22, for fluid restriction of 1200 ml/24 hours/day (dietary was to provide 840 ml and nursing was to provide 360 ml). Review of Resident 27's Medication Administration Record for January and February 2023, showed fluid restriction of 1200 ml/24 hours/day (dietary was to provide 840 ml and nursing was to provide 360 ml). Review of the care plan problem addressing the resident's dialysis dated 8/15/22, showed Resident 27's fluid restriction was 1200 ml per 24 hours as follows: * For nursing, to provide 360 ml of fluid as follows: - 120 ml for the 11-7 shift - 120 ml for the 7-3 shift - 120 ml for the 3-11 shift * For dietary, to provide 840 ml of fluid Review of Resident 27's meal ticket for dinner dated 2/15/23 showed for fluid restriction of 1200 ml/24 hours/day (dietary was to provide 840 ml), add Nepro (a supplemental drink for people with end stage renal failure to provide extra calories and protein). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055459 If continuation sheet Page 9 of 31 Printed: 05/15/2026 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 055459 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Buena Vista Care Center 1440 S Euclid Avenue Anaheim, CA 92802 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 0698 Level of Harm - Minimal harm or potential for actual harm Review of Resident 27's intake and output flow sheet dated 1/23 to 2/23 showed fluid restriction of 1200 ml/24 hours/day and total intake of 1200 ml. On 2/14/23 at 1542 hours, an interview was conducted with CNA 1. CNA 1 stated she was not sure of Resident 27's fluid restriction. CNA 1 verified Resident 27 received Nepro supplement. Residents Affected - Few On 2/14/23 at 1604 hours, an interview was conducted with LVN 5. LVN 5 stated Resident 27 was on fluid restriction of 1200 ml/day for both nursing and dietary. LVN 5 verified Resident 27 received Nepro one carton (237 ml/carton) as supplement. On 2/14/23 at 1636 hours, an interview was conducted with the DSS. The DSS stated Resident 27 was on fluid restriction of 1200 ml/ day. The DSS verified Resident 27 received Nepro one carton three times a day (711 ml per day) as supplement and it was not included in the fluid restriction. On 2/14/23 at 1658 hours, an interview was conducted with RN 2. RN 2 stated per the facility's dietitian, Nepro was not required to be added to the 1200 ml/day fluid restriction as it was considered as calorie and protein supplement. On 2/14/23 at 1730 hours, an interview was conducted with RN 2. RN 2 verified Resident 27 was on 1200 ml/day fluid restriction and intake and output flow sheet showed 1200 ml/day intake excluded the Nepro supplement. RN 2 stated the doctor should have been notified of Resident 27's exceeded 1200 ml/day fluid restriction. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055459 If continuation sheet Page 10 of 31 Printed: 05/15/2026 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 055459 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Buena Vista Care Center 1440 S Euclid Avenue Anaheim, CA 92802 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 0755 Level of Harm - Minimal harm or potential for actual harm Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on observation, interview, medical record review, and facility P&P review, the facility failed to administer the medications as ordered for one nonsampled resident (Resident 42). Residents Affected - Few * The facility staff failed to administer Resident 42's medications within 60 minutes of the scheduled time at 0900 hours. This placed the resident at risk for delays in treatment and increased risk of adverse events. Findings: Review of the facility's P&P titled Medication Administration revised April 2019 showed to administer the medications within 60 minutes of the scheduled time. On 2/7/23 at 1037 hours, observation and concurrent interview was conducted with LVN 1. LVN 1 stated the medications being passed were for 0900 hours. LVN 1 stated she was late in passing the medications for Resident 42 because she got busy, there were interruptions, and there was something that she had to do like restroom or something. LVN 1 stated Resident 42's medications were administered at 1050 hours, which was one hour and 50 minutes after the scheduled medication administration time at 0900 hours. Review of Resident 42's MAR for January 2023 showed the following medications were scheduled to be administered at 0900 hours: gabapentin, levetiracetam, and aspirin. However, LVN 1 had administered them at 1050 hours. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055459 If continuation sheet Page 11 of 31 Printed: 05/15/2026 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 055459 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Buena Vista Care Center 1440 S Euclid Avenue Anaheim, CA 92802 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility P&P review, the facility failed to ensure one of 25 final sampled residents (Resident 30) were free from unnecessary psychotropic medications. * Resident 27's psychiatrist failed to document the reason why the GDR for the use of Seroquel as recommended by the pharmacist was contraindicated for Resident 27. This failure had the potential for Resident 27 to experience adverse effects or receive unnecessary antipsychotic medications. Findings: Review of the facility's P&P titled Psychotropic Medication Use dated 6/2021 showed, Antipsychotic medications used to treat Behavioral or Psychological Symptoms of Dementia (BPSD) must be clinically indicated, be supported by an adequate rational for use and may not be used for a behavior with an unidentified cause. Antipsychotics used to treat BPSD must receive gradual dose reduction and behavioral interventions, unless contraindicated. GDR may be considered clinically contraindicated for reasons that include, but that are not limited to: The physician has documented the clinical rationale for why any additional attempted dose reduction at that time would be likely to impair the resident's function or increase distressed behavior. Medical record review for Resident 27 was initiated on 2/9/23. Resident 27 was admitted to the facility on [DATE]. Review of the History and Physical Examination dated 4/5/22, showed Resident 27 had a diagnosis of dementia. Review of the Note to Attending Physician/Prescriber dated 8/26/22, showed Resident 27's psychiatrist disagreed with the GDR for the use of Seroquel recommended by the pharmacist; however, the psychiatrist failed to document a rationale. Review of the Psychiatric Evaluation Note dated 10/27/22, failed to show Resident 27's psychiatrist addressing the recommended GDR. Review of the MDS dated [DATE], showed Resident 27 had impaired cognitive impairment. The MDS also showed Resident 27 had a GDR clinically contraindicated documented by a physician on 10/27/22. On 2/9/23 at 1339 hours, a concurrent interview and medical record review for Resident 27 was conducted with the DON. The DON was unable to show the psychiatrist documented a clinical rationale for disagreeing with the GDR for the use Seroquel medication. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055459 If continuation sheet Page 12 of 31 Printed: 05/15/2026 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 055459 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Buena Vista Care Center 1440 S Euclid Avenue Anaheim, CA 92802 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 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the medication error rate was below 5%. Residents Affected - Few * The facility's medication error rate was 20.5 %. This had the potential to negatively impact the residents' health outcomes. Findings: Review of the facility's P&P titled Administering Medications revised April 2019 showed the medications are administered in a safe and timely manner, and as prescribed. Medications are administered in accordance with prescriber orders, including any required time frame. Medications are administered within one hour of their prescribed time unless otherwise specified (for example, before and after meal orders). The individual administering medications verifies the resident's identity before giving the resident his/her medications. Methods of identifying the resident include checking identification band; checking photograph attached to medical record; and if necessary, verifying the resident identification with other facility personnel. The P&P also showed the staff is to follow established the facility infection control procedures (e.g., hand washing, antiseptic technique gloves, isolation precautions, etc). * On 2/7/23 at 0901 hours, a medication administration observation for Resident 74 was conducted with LVN 1. LVN 1 was observed preparing by crushing the following medications, placing them in an individual cup, and administering them via GT: - Eliquis 5 mg one tablet - famotidine 20 mg one tablet - levetiracetam 100 mg/5 ml - metoprolol Tart 25 mg one tablet During this observation, LVN 1 stated she administered the Keppra (brand name for levetiracetam), Pepcid (brand name for famotidine), Eliquis, and metoprolol. LVN 1 did not flush the GT with water in between the medications administration. On 2/7/23 at 0944 hours, after the medication administration, four medication cups were observed. One cup had some white powder residue in it and LVN 1 verified that white powder residue in the cup was Pepcid. * On 2/7/23 at 1039 hours, a medication administration observation for Resident 42 was conducted with LVN 1. LVN 1 prepared and administered Resident 42 the following medications: - one tablet of aspirin 81 mg - one capsule of gabapentin 300 mg - one tablet of levetiracetam 500 mg (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055459 If continuation sheet Page 13 of 31 Printed: 05/15/2026 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 055459 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Buena Vista Care Center 1440 S Euclid Avenue Anaheim, CA 92802 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 0759 An interview with LVN 1 was conducted on 2/7/23 at 1050 hours. LVN 1 verified that these medications were for 0900 hours, and she had past the cut off time at 1000 hours. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055459 If continuation sheet Page 14 of 31 Printed: 05/15/2026 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 055459 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Buena Vista Care Center 1440 S Euclid Avenue Anaheim, CA 92802 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 0760 Ensure that residents are free from significant medication errors. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and medical record review, the facility failed to ensure one of 25 final sampled residents (Resident 27) received two medications scheduled at 0900 hours as per the physician's orders and facility's P&P. This failure had the potential for negatively affect the resident's well-being. Residents Affected - Few Findings: Review of the facility's P&P titled Administering Medications revised April 2019 showed the medications are to be administered in accordance with the prescriber's orders, including any required time frame. During a medication administration observation on 2/14/23 at 0859 hours, with LVN 4, the following medications were prepared and administered to Resident 27 by LVN 4: - clopidogrel (blood thinner) 75 mg one tablet - amlodipine (antihypertensive) 75 mg one tablet - quetiapine fumarate (antipsychotic) 50 mg one tablet - clonidine HCL (antihypertensive) 0.1 mg one tablet - hydralazine HCL (antihypertensive) 100 mg one tablet - divalproex (anticonvulsant) 125 mg one capsule - buspirone HCL (antianxiety) 5 mg one tablet - Clear Lax (laxative) 17 gm for bowel movement - sevelamer (used to control high level of phosphorus) 2.4 gm powder one packet mix with 60 ml of water with meals During the medication reconciliation on 2/14/23 at 0955 hours, showed the orders for carvedilol 25 mg one tablet by mouth two times a day related to essential hypertension and calcium acetate (Phos Binder) 667 mg one capsule by mouth with meals. However, these two medications were not administered during the above medication administration observation. On 2/14/23 at 1137 hours, an interview and medical record review was conducted with LVN 4. LVN 4 was made aware and verified the above findings. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055459 If continuation sheet Page 15 of 31 Printed: 05/15/2026 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 055459 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Buena Vista Care Center 1440 S Euclid Avenue Anaheim, CA 92802 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, interview, and facility P&P review, the facility failed to ensure the medications were safely stored and properly labeled. These had the potential for medication errors. Findings: Review of the facility's P&P titled Interpretation and Implementation revised April 2019 showed the labels for stock medications include all necessary information, such as: (c) the expiration date when applicable. 1. On 2/8/23 at 1434 hours, during a medication cart observation in Station 1 and concurrent interview with LVN 2, the following medications were observed: - Allergy Relief Diphenhydramine HCl 25 mg bottle did not have any visible expiration date. - Senna S with the expiration date of January 2023 - valproic acid solution bottle was sticky. LVN 2 verified the above findings. 2. On 2/8/23 at 1452 hours, during the medication storage observation in Medication Room A and concurrent interview with LVN 2, the following was observed: - one box of Refresh tears was stored next to these oral medications: loratadine 10 mg, magnesium oxide 400 mg, folic acid 100 mcg, and loperamide 2 mg. LVN 2 verified the artificial tear should not be stored with the oral medications. 3. On 2/9/23 at 1430 hours, during a medication cart observation in Medication Room B and concurrent interview with LVN 3, a bottle of Banophen 25 mg was observed with no expiration date. LVN 3 verified the finding. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055459 If continuation sheet Page 16 of 31 Printed: 05/15/2026 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 055459 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Buena Vista Care Center 1440 S Euclid Avenue Anaheim, CA 92802 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 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. Based on observation, interview, and facility document review, the facility failed to notify the residents of a change in the lunch menu when Brussel sprouts were not available for lunch as per the facility's menu. This failure resulted in the residents not receiving their meal as per the menu, which had the potential to negatively impact the residents' well-being. Findings: On 2/6/23 at 1220 hours, an observation of the residents' lunch menu was conducted. The residents' lunch menu was posted in the hallway adjacent to the nursing station. The residents' lunch menu for 2/6/23, showed the lunch menu included savory Brussel sprouts. On 2/6/23 at 1226 hours, an observation and concurrent interview was conducted with Resident 24. Resident 24 was observed eating his lunch in his room. Resident 24's lunch tray was observed without savory Brussel sprouts as per the lunch menu. Resident 24's lunch tray was observed with peas (not reflected on the menu). Resident 24 was asked if he liked Brussel sprouts, to which he replied, yes, Brussel sprouts are healthy. Resident 24 was asked if he was informed by the facility that his lunch would not include Brussel sprouts. Resident 24 stated he was not informed by the facility that his lunch would not include Brussel sprouts and peas would be provided as a substitute. On 2/6/23 at 1240 hours, an observation and concurrent interview was conducted with the DM. The DM verified the lunch menu (for 2/6/23) showed Brussel sprouts were to be served for lunch. The DM stated the kitchen was out of Brussel sprouts and no residents received Brussel sprouts with lunch. The DM stated the facility served the residents peas as a substitution for Brussel sprouts. The DM stated as of Thursday 2/2/23, he was aware the facility did not have Brussel sprouts available. The DM was asked if the facility notified the residents of the change in the menu, to which the DM replied no, the residents were not informed of the menu change. Review of the facility's Resident Census and Conditions of Residents form dated 2/6/23, showed 90 residents received food prepared in the kitchen. The DM verified only one resident in the facility was not scheduled to receive Brussel Sprouts with lunch (due to an order for a liquid diet). Therefore, 89 residents were scheduled to receive Brussel sprouts with lunch in accordance with the menu. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055459 If continuation sheet Page 17 of 31 Printed: 05/15/2026 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 055459 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Buena Vista Care Center 1440 S Euclid Avenue Anaheim, CA 92802 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 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and facility document review, the facility failed to ensure the food safety and sanitation requirements were met in the kitchen as evidenced by the following: Residents Affected - Some * The facility failed to air dry the blender during the puree preparation. * The facility failed to ensure the kitchen utensils had smooth cleanable surface. * The facility failed ensure the appropriate food grade sanitizing wipes were used to disinfect countertops and tables where the food was prepared. * The facility failed to ensure the chlorine test strips had not expired. * The facility failed to ensure the kitchen staff performed hand hygiene and changed gloves during dishwashing. * The facility failed to ensure the labeling and dating of the foods stored in the refrigerator, freezer, and open, dry storage area. These failures had the potential to cause foodborne illnesses in a medically vulnerable resident population who consumed food prepared in the kitchen. Findings: Review of the Form CMS-672 titled Resident Census and Conditions of Residents completed by the facility dated 2/6/23, showed 90 of 95 residents residing in the facility received food prepared in the kitchen. 1. According to the USDA Food Code 2017, Section 4-901.11, Equipment and Utensils, Air-Drying Required, items must be allowed to drain and to air-dry before being stacked or stored. Stacking wet items prevents them from drying and may allow an environment where microorganism can begin to grow. On 2/7/23 at 1020 hours, an observation of puree preparation was conducted with [NAME] 1. [NAME] 1 was observed taking the blender from the dishwashing machine which was not fully air dried prior to use. On 2/7/23 at 1055 hours, the finding was verified with [NAME] 1 and had no comment. On 2/7/23 at 1100 hours, the finding was verified with the DSS who stated the blender should have been air dried before use to prevent moisture or water mixing with the food and can caused bacteria. 2. According to the USDA Food Code 2017, Section 4-101.11, Multiuse, Characteristics, materials that are used in the construction of utensils and food contact surfaces of equipment may not allow the migration of deleterious substances or impart colors, odors, or tastes to food and under normal use conditions shall be durable, corrosion-resistant, nonabsorbent, finished to have a smooth, easily cleanable surface, and resistant to pitting, chipping, crazing, scratching, scoring, distortion, and decomposition. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055459 If continuation sheet Page 18 of 31 Printed: 05/15/2026 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 055459 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Buena Vista Care Center 1440 S Euclid Avenue Anaheim, CA 92802 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some On 2/7/23 at 1100 hours, an observation and concurrent interview was conducted with the DSS. Two flipper spatulas were observed to be worn off, chipped, discolored, with melted handle. The DSS verified the findings. The DSS stated it should not be used as it could mix with the resident's food and it could be ingested. 3. According to the USDA Food Code 2017, 4-701.10, Food Contact Surfaces and Utensils, effective sanitization procedures destroy organisms of public health importance that may be present on wiping cloths, food equipment, or utensils after cleaning, or which have been introduced into the rinse solution. On 2/7/23 at 1221 hours, an observation and concurrent interview was conducted with the DSS. There were no red buckets used for sanitizing the countertops and tables. The DSS verified the findings and stated the antibacterial hand sanitizing alcohol wipes were used to sanitize the countertops and tables. On 2/7/23 at 1550 hours, an observation and concurrent interview was conducted with the DSS. The DSS stated the antibacterial hand sanitizing alcohol wipes were not appropriate for cleaning the countertops and tables; and the residents could possibly get ill when the countertops and tables used to prepare food were not sanitized with the correct disinfectant wipes and solution. 4. According to the USDA Food Code 2017, Section 4-501.116, Warewashing Equipment, Determining Chemical Sanitizer Concentration, concentration of the sanitizing solution shall be accurately determined by using a test kit or other device. On 2/7/23 at 1228 hours, an observation and concurrent interview was conducted with the DSS regarding the chlorine solution test. The DSS checked the concentration of the chlorine using a paper test strip taken from a bottle of chlorine test strips. The chlorine test strip container had an expiration date of February 2021. The DSS verified the findings and stated the test result may be inaccurate. 5. According to the USDA Food Code 2017, 2-301, When to Wash, food employees shall clean their hands and exposed portions of their arms immediately before engaging in food preparation, including working with exposed food, clean equipment, and utensils, and unwrapped single-service and single use articles; after handling soiled equipment or utensils; during food preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks; before donning gloves to initiate a task that involves working with food; and after engaging in other activities that contaminate the hands. On 2/9/23 at 0825 hours, an observation was conducted with [NAME] 2 during dishwashing. [NAME] 2 was observed wearing gloves and scraping food from the dirty plates and meal trays for dishwashing; and while wearing the same pair of gloves, [NAME] 2 was observed sorting the clean dishes. [NAME] 2 then touched the clean plates and cups with the same gloves. On 2/9/23 at 0834 hours, an interview was conducted with [NAME] 2. [NAME] 2 verified the findings and stated there was usually another kitchen staff to help with dishwashing, but they were short staff. [NAME] 2 stated he should have changed gloves to prevent the spread of bacteria. On 2/7/23 at 0836 hours, the above findings were verified with the DSS. The DSS stated there were usually two kitchen staff for dishwashing, one staff to handle the dirty dishes and another staff for (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055459 If continuation sheet Page 19 of 31 Printed: 05/15/2026 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 055459 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Buena Vista Care Center 1440 S Euclid Avenue Anaheim, CA 92802 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some the clean dishes. The DSS stated [NAME] 2 should have changed his gloves for infection control purposes and to prevent cross contamination. 6. According to the FDA Food Code 2017, Section 3-501.17 Ready-To-Eat, Time/Temperature Control for Safety Food, Date Marking: Marking the date or day the original container is opened with a procedure to discard the food on or before the last date by which the food must be consumed. During the initial kitchen tour on 2/6/23 at 0817 hours, the following food items were identified: - Refrigerator #1 had three prepared half peanut butter and jelly sandwiches with no prepared date and no best by date. - Refrigerator #2 had cut lettuces, bag of red grapes, prepared corn in a container and prepared jello with no received date, open date, and prepared date. - Freezer #1 had five bags of waffle and an open bag of green beans with no received date, open date, and prepared date. - Freezer #2 had turkey breast wrapped in a plastic wrap undated, and an open bags of garden burgers and hamburgers in a plastic bag with no open date. - In the dry storage room, an open, unsealed bag of coconut flakes was undated. - In the kitchen area, a large rolling floor container bin for uncooked rice with no open and expiration dates. On 2/6/23 at 0817 hours, an interview was conducted with the Assistant Dietary Supervisor. The Assistant Dietary Supervisor acknowledged the above findings. When asked how they could tell when the food items were expired, the Assistant Dietary Supervisor stated there was no way to know when the food items were expired if the bags of the food items were not dated. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055459 If continuation sheet Page 20 of 31 Printed: 05/15/2026 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 055459 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Buena Vista Care Center 1440 S Euclid Avenue Anaheim, CA 92802 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 0814 Dispose of garbage and refuse properly. Level of Harm - Potential for minimal harm Based on observation and interview, the facility failed to ensure the garbage and refuse (nonhazardous solid waste) were properly stored for two of the three garbage dumpsters. The lid of one garbage dumpster was missing and the lid of the other dumpster was left partially open. This failure had the potential to harbor pests or rodents which carry diseases. Residents Affected - Some Findings: According to the US Food Code 2013, 5-501.113, Covering Receptacles, receptacle units for refuse shall be kept covered with tight fitting lids after they are filled. On 2/7/23 at 0949 hours, an observation and concurrent interview was conducted with the Maintenance Supervisor. Two dumpsters located adjacent to the kitchen were observed: one dumpster without the lid and the other with the lid partially propped open. Multiple garbage bags filled with trash and used box were observed sticking out of the dumpsters, preventing the garbage lids from closing completely. The Maintenance Supervisor verified the above findings. The Maintenance Supervisor stated the dumpsters had to be fully closed to prevent rats and rodents from getting to it and for infection control purposes. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055459 If continuation sheet Page 21 of 31 Printed: 05/15/2026 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 055459 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Buena Vista Care Center 1440 S Euclid Avenue Anaheim, CA 92802 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 0842 Level of Harm - Minimal harm or potential for actual harm Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 5. Medical record review for Resident 41 was initiated on [DATE]. Resident 41 was admitted to the facility on [DATE]. Residents Affected - Few Review of Resident 41's undated POLST showed the resident's date of birth and physician's signature. However, the remaining sections of the POLST form were left blank. On [DATE] at 1528 hours, an interview and concurrent medical record review was conducted with RN 2. RN verified Resident 41's POLST was not completed and should have been discussed with the resident during admission and care conference. 6. Medical record review for Resident 73 was initiated on [DATE]. Resident 73 was admitted the facility on [DATE], and readmitted on [DATE]. Review of Resident 73's POLST dated [DATE], showed a signature of the physician/nurse practitioner/physician assistant. However, there was no documentation of the physician's name, phone number, license number, and date when the POLST was signed. On [DATE] at 1628 hours, an interview and concurrent medical record review was conducted with RN 2. RN 2 stated she knew Resident 73's physician's signature and verified it was Resident 73's physician who signed the POLST. When RN 2 was asked who was responsible for ensuring the POLST form was complete, RN 2 replied it was the nurse on duty when the physician signed the POLST form. RN 2 stated the POLST form should have the physician's information. 7. Review of the facility's P&P titled Bath, Shower/Tub revised 2/2018 showed to document the following: - The date and time the shower/tub bath was performed. - The name and title of the individual(s) who assisted the resident with the shower/tub bath. - All assessment data (e.g., any reddened areas, sores, etc., on the resident's skin) obtained during the shower/tub bath. - How the resident tolerated the shower/tub bath. - If the resident refused the shower/tub bath, the reason(s) Medical record review for Resident 48 was initiated on [DATE]. Resident 48 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of the facility's Shower Schedule showed to provide Resident 48 shower every Tuesday and Fridays during the 0700 to 1500 hours shift. Review of the documentation related to Resident 48 shower showed documentation as to whether Resident 48 was provided a shower or not and if the resident was unavailable or refused. However, there was no documentation whether there was any skin problem identified during the shower. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055459 If continuation sheet Page 22 of 31 Printed: 05/15/2026 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 055459 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Buena Vista Care Center 1440 S Euclid Avenue Anaheim, CA 92802 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On [DATE] at 1541 hours, an interview and concurrent record review was conducted with RN 2. RN 2 verified Resident 48's shower schedule. When RN 2 was asked how the CNAs would communicate to the licensed nurses if the residents had any skin issues observed during showers, RN 2 stated the CNAs would document in the shower log whether there was any skin issue identified. During the interview with RN 2, the DSD had also participated in the interview. Both RN 2 and the DSD verified there were no shower logs to show skin checks were completed for Resident 48 during her shower. 4. Medical record review for Resident 11 was initiated on [DATE]. Resident 11 was admitted to the facility on [DATE]. Review of Resident 11's Advanced Healthcare Directive Acknowledgement Form dated [DATE], showed Resident 11 had formulated an Advanced Healthcare Directive and the facility had requested a copy. However, review of Resident 11's POLST dated [DATE], showed the section to complete if the resident had formulated an advance directive was left blank. On [DATE] at 1020 hours, an interview and concurrent medical record review was conducted with RN 2. RN 2 verified the finding and stated she would complete the advance directive section on Resident 11's POLST. 2. Medical record review for Resident 69 was initiated on [DATE]. Resident 69 was admitted to the facility on [DATE]. Review of Resident 69's POLST dated [DATE], showed the section for the physician's signature was left blank. On [DATE] at 1547 hours, an interview and concurrent medical record review was conducted with the SSD. The SSD verified the finding and stated the licensed nurse who initiated the POLST should ensure the physician signed the POLST. The SSD further stated she was unsure as to why the physician's signature was missed. 3. Medical record review for Resident 74 was initiated on [DATE]. Resident 74 was readmitted to the facility on [DATE]. Review of the form titled Social Service Review dated [DATE], under the resident information section, showed Resident 74 did not have an advance directive. However, review of Resident 74's POLST dated [DATE], showed the section to mark if the resident did not have an advance directive was left blank. On [DATE] at 1608 hours, an interview and concurrent medical record review was conducted with the SSD. The SSD verified the finding and stated Resident 74 did not have an advance directive. Based on interview and medical record review, the facility failed to ensure the medical records for six of 25 final sampled residents (Residents 11, 33, 41, 69, 73, and 74) and one nonsampled resident (Resident 48) were accurate and complete. This failure had the potential for the residents' care needs not being met as their medical information was incomplete. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055459 If continuation sheet Page 23 of 31 Printed: 05/15/2026 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 055459 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Buena Vista Care Center 1440 S Euclid Avenue Anaheim, CA 92802 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 0842 Findings: Level of Harm - Minimal harm or potential for actual harm 1. Medical record review for Resident 33 was initiated on [DATE]. Resident 33 was admitted to the facility on [DATE]. Residents Affected - Few Review of Resident 33's POLST dated [DATE], showed to attempt resuscitation/CPR and provide full treatment with trial artificial treatment options. However, the section for the physician's signature was left blank. On [DATE] at 1632 hours, an interview and concurrent medical record review was conducted with the SSD. The SSD acknowledged Resident 33's POLST did not have the physician's signature. The SSD stated there was a physician's order to perform CPR and provide full treatment. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055459 If continuation sheet Page 24 of 31 Printed: 05/15/2026 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 055459 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Buena Vista Care Center 1440 S Euclid Avenue Anaheim, CA 92802 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, facility document review, and facility P&P review, the facility failed to implement their infection control surveillance program in accordance with the facility's P&P. Residents Affected - Some * The facility failed to implement their infection control surveillance program for the months of [DATE] through [DATE]. The facility conducted surveillance of resident infections based on whether the residents were prescribed antimicrobial medications. The facility failed to determine whether the residents who exhibited signs and/or symptoms of infections and were not prescribed antimicrobial medications met the facility's criteria for infection (McGeer's Criteria), and thus failed to include these residents in the facility's infection control surveillance program. * The facility failed to include COVID-19 positive residents in their infection control surveillance program for the month of [DATE] as per the facility's P&P, for one of 25 final sampled residents (Resident 61) and nine nonsampled residents (D, G, H, I, J, K, 32, 39, and 77). * The facility failed to ensure the disinfectant wipes had not expired. * The facility failed to ensure LVN 4 performed hand hygiene in between changing gloves during the medication administration for Resident 27 who was on the enhanced precaution which required to use appropriate PPE. * The facility failed to ensure the furnitures in the Special Care Unit were maintained in a good condition for proper cleaning. These failures posed the risk for not identifying resident infections and not conducting surveillance of resident infections in the facility and had the potential to inhibit the implementation of interventions to control potential transmission of communicable diseases to the residents and staff in the facility. Findings: Review of the facility's P&P titled Surveillance for Infections revised date 9/2017 showed the infection preventionist will conduct ongoing surveillance for healthcare-associated infections (HAIs) and other epidemiologically significant infections that have substantial impact on potential resident outcome and that may require transmission-based precautions and other preventative interventions. The purpose of the surveillance of infections is to identify both individual cases and trends of epidemiologically significant organisms and HAIs, to guide appropriate interventions, and to prevent future infections. The criteria for such infections are based on the current standard definitions of infections. Nursing staff will monitor residents for signs and symptoms that may suggest infection, according to current criteria and definitions of infection, and will document and report suspected infections to the charge nurse as soon as possible. The infection preventionist or designated infection control personnel is responsible for gathering and interpreting surveillance data. For targeted surveillance follow these guidelines: Record detailed information about the resident and the infection (daily) on an individual infection report form. Collect information from the individual resident infection reports (monthly) and enter a line listing of infections by resident, for the entire month. Consider how increases or decreases (specific to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055459 If continuation sheet Page 25 of 31 Printed: 05/15/2026 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 055459 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Buena Vista Care Center 1440 S Euclid Avenue Anaheim, CA 92802 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some infection rate) might relate to recent process changes, events, or activities in the facility (i.e., change in handwashing preparations, increased turnover in personnel or residents). 1. On [DATE] at 1001 hours, an interview, facility document review, and medical record review was conducted with IP 1. IP 1 stated she served as the facility's IP from [DATE] through [DATE]. IP 1 was asked to describe the facility's infection surveillance program. IP 1 stated when a resident was prescribed antimicrobial medications and exhibited signs and/or symptoms of an infection, the licensed nurse who received the antimicrobial order would then initiate the facility's Surveillance Data Collection - Infection Control form. IP 1 stated the Surveillance Data Collection - Infection Control form contained information specific to McGeer's criteria. IP 1 stated the facility utilized McGeer's criteria to determine if a resident required antibiotics and stated the physician determined whether a resident had an infection. IP 1 stated for residents who met McGeer's criteria, she would make a determination as to whether a resident infection was a HAI or CAI. IP 1 stated a resident HAI occurred when a resident was prescribed antimicrobial medication and the physician determined the resident had an infection. IP 1 stated she documented this information on the facility's monthly Infection Prevention and Control Surveillance Log, in order to conduct surveillance of the residents with infections, who were prescribed antimicrobial medications. IP 1 stated she was responsible for surveillance of the resident infections in the facility. IP 1 stated the infection surveillance was necessary to identify how the increase or decrease of the facility infection rates may be related to recent process changes and infection control practices by the facility staff. IP 1 stated the identification of resident infections in the facility was necessary to treat the resident infections and implement interventions to mitigate the transmission of infections to the residents and staff. Review of the facility's monthly Infection Prevention and Control Surveillance Logs from [DATE] through [DATE], showed the following residents infection surveillance data for the HAIs and CAIs: 1/2022, HAI - 24 and CAI - 8 2/2022, HAI - 12 and CAI - 12 3/2022, HAI - 18 and CAI - 18 4/2022, HAI - 4 and CAI - 8 5/2022, HAI - 8 and CAI - 18 6/2022, HAI - 18 and CAI - 18 7/2022, HAI - 11 and CAI - 6 8/2022, HAI - 5 and CAI - 9 9/2022, HAI - 11 and CAI - 8 10/2022, HAI - 12 and CAI - 10 11/2022, HAI - 12 and CAI - 11 12/2022, HAI - 21 and CAI - 12 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055459 If continuation sheet Page 26 of 31 Printed: 05/15/2026 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 055459 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Buena Vista Care Center 1440 S Euclid Avenue Anaheim, CA 92802 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 0880 1/2023, HAI - 9 and CAI - 11 Level of Harm - Minimal harm or potential for actual harm Further review of the facility's monthly Infection and Prevention and Control Surveillance Logs from [DATE] through [DATE] showed documentation that all residents included on the surveillance logs were also prescribed antimicrobial medications. Residents Affected - Some IP 1 was asked when the residents at the facility presented with signs and/or symptoms of infection, or in the event a resident was diagnosed with an infection (i.e., COVID-19), and were not prescribed antimicrobial medications, if the facility included these residents in the facility's infection surveillance program (for the months of [DATE] through [DATE]). IP 1 stated the facility conducted surveillance of the resident infections based on whether the residents were prescribed antimicrobial medications. IP 1 stated the facility did not include the residents (in the facility's infection surveillance program from 1/22 through 1/23) who exhibited signs and/or symptoms of infections (or were diagnosed with an infection, i.e., COVID-19), unless these residents were prescribed antimicrobial medications. IP 1 was asked how many residents in the facility had infections (met McGeer's criteria or were diagnosed with an infection) and were not prescribed antimicrobial medications (from [DATE] through [DATE]). IP 1 stated she was unable to make that determination. 2. Further review of the facility's monthly Infection Prevention and Control Surveillance Log for [DATE] was conducted with IP 1 and showed only three residents (Residents F, 21, and 28) had a COVID-19 infection. However, a medical record review showed documentation an additional 10 residents (Residents D, G, H, I, J, K, 32, 39, 61, and 77) had tested positive for COVID-19 in 11/2022. IP 1 verified these residents were not included in the facility's monthly Infection Prevention and Control Surveillance log for 11/2022. 2. On [DATE] at 0901 hours, during the medication administration observation and concurrent interview with LVN 1, LVN 1 was observed cleaning the stethoscope and sphygmomanometer with alcohol germicidal wipes ethyl alcohol 73% with expiration date of 10/22. During an interview with LVN 1, LVN 1 stated she used this alcohol wipe tub for more than 10 residents. LVN 1 stated, it's not sanitizing when expired On [DATE] at 1123 hours, during a medication cart observation and concurrent interview with LVN 2 in Station 1, a tub of Micro One Germicidal Alcohol wipes had an expiration date of 10/22 and LVN 2 verified the finding. LVN 2 stated she used this new alcohol wipe tub for at least 30 residents. On [DATE] at 1447 hours, during a medication cart observation and concurrent interview with LVN 3 in Station 3, a bottle of Micro Kill One Alcohol wipes was unsealed and had an expiration of 10/22. LVN 3 verified the finding. 3. On [DATE] at 0855 hours, a medication administration observation of Resident 27 was conducted with LVN 4. LVN 4 came out of the room with gloves still on and recorded Resident's 27 blood pressure in his computer. LVN 4 failed to properly discard the used gloves prior to leaving Resident 27's room which was on enhance precaution. LVN 4 also failed to perform hand hygiene after discarding the used (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055459 If continuation sheet Page 27 of 31 Printed: 05/15/2026 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 055459 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Buena Vista Care Center 1440 S Euclid Avenue Anaheim, CA 92802 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some gloves. LVN 4 also failed to sanitize the sphygmomanometer after being used on the resident who was on the enhanced precaution. LVN 4 went back to Resident 27's room with gloves on but did not don a yellow gown, wearing the surgical mask and face shield. LVN 4 was observed checking Resident 27's temperature and pulse. Then, LVN 4 was observed discarding his used gloves without proper hand hygiene and placing the thermometer and pulse oximeter in his medication cart without sanitized them after used. In addition, LVN 4 was observed not performing hand hygiene prior to preparing the medications. An interview was conducted with LVN 4 on [DATE] at 1137 hours. LVN 4 stated he did not know that Resident 27 was on the enhanced precaution. 4. On [DATE] at 0929 hours, an observation and concurrent interview was conducted with CNA 2 in the Special Care Unit. The activity room was observed to have two love seats and one couch with peeled surfaces and rough edges exposing inside material. Two residents were observed sitting in the love seats. CNA 2 verified the findings. On [DATE] 1407 hours, an observation and interview were conducted with Housekeeper 1. When asked what type of materials was used for cleaning the couche and love seats with peeled surfaces, Housekeeper 1 stated the Clorox spray was used in cleaning of the couches and love seats with peeled surfaces. Housekeeper 1 showed the Clorox container with the label showing for cleaning of the hard and nonporous surfaces. She stated the bottle of Clorox was given to her by her supervisor to use since COVID. On [DATE] at 1421 hours, Housekeeper 1 demonstrated how to clean the love seat with peeled surface by spraying the Clorox solution, then wiped. Housekeeper 1 stated the liquid from the spray went down and would accumulate microorganism as it was not wiped. Review of the manufacturer's information for Clorox Bleach Germicidal Spray showed the recommended use is for hard, non-porous surfaces. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055459 If continuation sheet Page 28 of 31 Printed: 05/15/2026 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 055459 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Buena Vista Care Center 1440 S Euclid Avenue Anaheim, CA 92802 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 0881 Implement a program that monitors antibiotic use. Level of Harm - Minimal harm or potential for actual harm Based on interview, medical record review, facility document review, and facility P&P review, the facility failed to accurately determine whether six of 25 final sampled residents (Residents 30, 33, 71, 74, 85, and 88) and seven non-sampled residents (Residents A, B, C, D, E, 22, and 31) who were prescribed antibiotics had met the McGeer's criteria. As a result, the facility failed to inform the residents' physicians that the residents did not meet McGeer's Criteria for true infections and potentially inhibited the residents' physicians from discontinuing the unnecessary antibiotics. This potentially resulting in adverse reactions associated with antibiotics and the development of antibiotic resistant bacteria. Residents Affected - Few Findings: According to the Centers for Disease Control and Infection, an estimated 70% of nursing home residents receive one or more courses of antibiotics during a year. Studies have shown that 40% to 75% of the antibiotics prescribed in nursing homes may be unnecessary or inappropriate. Frail and older adults are at significant risk of harm from antibiotic overuse including increased adverse drug events, increased drug interactions and infection with antibiotic-resistant organisms. The World Health Organization cites antibiotic resistance as one of the biggest threats to human health. Review of the facility's P&P titled Antimicrobial Stewardship Program undated, showed the facility policy is to implement an Antimicrobial Stewardship Program with the goal of optimizing clinical outcomes and to minimize unintended consequences of antimicrobial use, including toxicity. The facility's IP shall monitor the facility's antibiotic usage patterns, by routinely collecting and reviewing the antibiotics prescribed for HAI that did not meet McGeer's criteria. The facility's infection control committee shall provide feedback to attending physicians on their individual prescribing patterns of cultures ordered and antibiotics prescribed. Review of the facility's P&P titled Antibiotic Stewardship Orders for Antibiotics revised 12/16 showed antibiotics will be prescribed and administered to residents under the guidance of the facility's antibiotic stewardship program. Appropriate indications for use of antibiotics include criteria met for the clinical definition of active infection. On 2/7/23 at 0924 hours, an interview and concurrent medical record review and facility document review was conducted with IP 2. IP 2 stated within her role as the facility's infection preventionist, she was responsible for oversight of the facility's antibiotic stewardship program. IP 2 stated a component of the facility's antibiotic stewardship program consisted of conducting a review of residents prescribed antibiotics and determining whether those residents had met McGeer's criteria. IP 2 stated when a resident was prescribed antibiotics and failed to meet McGeer's criteria, the resident's physician would then be notified that the resident had not met McGeer's criteria for a true infection. IP 2 stated the rationale for notifying the physician when a resident prescribed antibiotics had not met McGeer's criteria, was to provide the physician with the opportunity to discontinue unnecessary antibiotics. IP 2 stated the unnecessary use of antibiotics was associated with resident adverse reactions and the development of MDROs. Review of the facility's Monthly Infection Prevention and Control Surveillance Logs for January 2022 through January 2023 was conducted with IP 2 and showed the following residents had acquired a HAI and were prescribed antibiotics: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055459 If continuation sheet Page 29 of 31 Printed: 05/15/2026 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 055459 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Buena Vista Care Center 1440 S Euclid Avenue Anaheim, CA 92802 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 0881 - Resident 31 (January 2022) Level of Harm - Minimal harm or potential for actual harm - Residents A and 22 (February 2022) - Resident B (May 2022) Residents Affected - Few - Resident C (September 2022) - Residents D and 85 (November 2022) - Resident 74 (December 2022) - Residents E, 30, 33, 71, and 88 (January 2023) Review of the facility's Surveillance Data Collection Infection Control forms (which contained the McGeer's criteria) and the residents' medical records was conducted with IP 2. IP 2 verified Residents A, B, C, D, E, 22, 30, 31, 33, 71, 74, 85, and 88 were prescribed antibiotics; however, they did not meet the McGeer's criteria for a true infection, in accordance with the facility's antibiotic stewardship program. Further review of the residents' medical records failed to show documented evidence the residents' physicians were notified that these residents did not meet the McGeer's criteria (thus potentially preventing the physicians from discontinuing the antibiotics for these residents). IP 2 verified the findings. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055459 If continuation sheet Page 30 of 31 Printed: 05/15/2026 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 055459 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Buena Vista Care Center 1440 S Euclid Avenue Anaheim, CA 92802 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 0908 Keep all essential equipment working safely. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and facility P&P review, the facility failed to ensure the freezer compartment inside the medication refrigerator was free of ice buildup. This had had the potential for the refrigerator not being maintained in a safe operating condition. Residents Affected - Few Findings: Review of the facility's P&P titled Storage of Medications revised date 11/2020 showed the facility stores all drugs and biologicals in a safe, secure, and orderly manner. The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. On 2/8/23 at 1108 hours, Medication Room A inspection and concurrent interview was conducted with LVN 2. On 2/8/23 at 1136 hours, the medication refrigerator was observed to have ice build in the freezer compartment. LVN 2 verified the findings and stated the ice build up in the freezer was indicated that the temperature may be too cold. LVN 2 stated she noticed the ice buildup in the freezer in the morning but did not do anything because she did not know what to do when there was an ice buildup in the freezer section of the refrigerator. On 2/9/23 at 1555 hours, an interview was conducted with the DON. The DON acknowledged the findings. When asked how often the medication refrigerator was cleaned and defrosted, the DON stated as needed. When asked who was responsible to defrost the medication refrigerator, the DON stated the morning and night shift RNs were responsible. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055459 If continuation sheet Page 31 of 31