Health inspection·October 17, 2023

F 0558 Level of Harm - Minimal harm or potential for actual harm 2. During the initial facility tour on 10/13/23 at 0903 hours, an observation and concurrent interview was conducted with Resident B. Resident B was observed awake and lying in bed. Resident B was observed not having a call light button around her bed or within her reach. The wall towards Resident B's bed was observed with a call light socket; however, there was no call light cord attached to it. Resident B was asked if she knew where her call light button was, and Resident B stated she did not know. Residents Affected - Few Medical record review for Resident B was initiated on 10/13/23. Resident B was admitted to the facility on [DATE]. Review of Resident B's MDS dated [DATE], showed Resident B had severely impaired cognition and required extensive assistance of one person for bed mobility and transfer. On 10/13/23 at 0917 hours, an observation and concurrent interview was conducted with RN 1. RN 1 verified the above findings. RN 1 stated there should be a call light cord attached to the wall socket. RN 1 stated the maintenance staff probably forgot to return the call light cord after painting the wall. 3. On 10/13/23 at 1315 hours, Room A's light was illuminated outside the top part of the room's door and overhead paging system announcing Room A required assistance. CNA 2 was observed in the hallway one room away from Room A. The DSD was observed standing in Nursing Station 1 with the other nurses. At 1317 hours, the Medical Records Director was observed walking past Room A's room whilethe call light indicator outside of Room A's door was illuminated. On 10/13/23 at 1318 hours, an interview was conducted with Resident C. Resident C stated she was the one who had pressed the call light button. Resident C stated she wanted to get up to her wheelchair and required assistance from the facility staff. Resident C stated CNA 2 answered her call light earlier. However, Resident C stated CNA 2 came in her room, turned off the call light, and stated she would come back. Resident C stated CNA 2 did not come back and she decided to press her call light button again. Medical record review for Resident C was initiated on 10/13/23. Resident C was readmitted to the facility on [DATE]. Review of Resident C's History and Physical examination dated 2/9/23, showed Resident C had the capacity to understand and make decisions. Review of Resident C's MDS dated [DATE], showed Resident C required extensive assistance of one staff for bed mobility and transfer. On 10/13/23 at 1329 hours, the SSD was observed opening Room A's door and asked if the residents needed assistance. On 10/13/23 at 1335 hours, an interview was conducted with LVN 2. LVN 2 stated she heard the overhead page for Room A but did not get up from the nursing station because the SSD went to answer Room A's call light. On 10/13/23 at 1341 hours, an interview was conducted with CNA 2. CNA 2 stated Resident C was not in her assignment. CNA 2 stated she answered Resident C's call light earlier. CNA 2 stated she did (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055459 If continuation sheet Page 2 of 3 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 10/17/2023 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 0558 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few not get her up because she knew Resident C would want to smoke and it was not the scheduled smoking time yet. CNA 2 stated when the light outside the resident's room was on, the staff neededto attend the residents. On 10/13/23 at 1343 hours, an interview was conducted with the Medical Records Director. The Medical Records Director stated she did not see the call light was on for Room A. The Medical Records Director stated everyone was responsible in answering the residents' call light. On 10/13/23 at 1346 hours, an interview was conducted with the DSD. The DSD stated staff would know if a resident needed assistance when the light was on outside each resident's room. The DSD further stated there was a call light panel on the wall for each nursing station where the light would turn on next the resident's room number and an overhead page wouldtrigger if the resident's call light was initiated. The DSD stated everyone was responsible to answering the resident's call light. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055459 If continuation sheet Page 3 of 3