Health inspection·November 15, 2023

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few of Resident 1's Weights and Vitals Summary showed on 10/7/23 at 2106 hours, Resident 1's blood pressure was 196/90 mmHg. LVN 1 verified the findings and stated on 10/7/23 at 2106 hours, as per the physician's order, LVN 1 administered the PRN clonidine 0.1 mg orally for Resident 1's systolic blood pressure being greater than 160 mmHgHgH. However, review of Resident 1's medical record failed to show documentation LVN 1 conducted a change of condition assessment (specific to Resident 1's blood pressure measuring 196/90 mmHg) and failed to notify Resident 1's physician of Resident 1's blood pressure of 196/90 mmHg. LVN 1 stated she did not consider Resident 1's blood pressure of 196/90 mmHg to be a change of condition warranting an assessment or notification to Resident 1's physician as hypertension was an ongoing issue for Resident 1. LVN 1 was asked at what point she would conduct a change of condition assessment (specific to hypertension) for Resident 1. LVN 1 stated she would conduct a change of condition assessment specific to hypertension if Resident 1's blood pressure did not decrease after an hour. LVN 1 stated a change of condition assessment specific to hypertension would consist of a neurological assessment and whether Resident 1 had complaints of chest pain, shortness of breath, and/or respiratory distress. However, review of Resident 1's Weights and Vitals Summary showed Resident 1's next blood pressure was not obtained for several hours after (approximately 4 hours) Resident 1's blood pressure was measured at 196/90 mmHg on 10/7/23 at 2106 hours. Resident 1's blood pressure was next obtained on 10/8/23 at 0115 hours, which was measured at 168/100 mmHg. LVN 1 verified the findings and stated she should have obtained Resident 1's blood pressure within 1 hour of Resident 1 having received the dose of Clonidine 0.1 mg PRN (administered when Resident 1's blood pressure was 196/90 mmHg on 10/7/23 at 2106 hours). LVN 1 verified during her shift (on 10/7/23 1500 to 2300 hours) that she had not conducted a change of condition assessment, nor had she notified Resident 1's physician regarding Resident 1's blood pressure of 196/90 mmHg at 2106 hours on 10/7/23. LVN 1 verified she was also assigned to care for Resident 1 on 10/18/23, from 1500 to 2300 hours. Review of Resident 1's Weights and Vitals Summary showed on 10/18/23 at 1622 hours, Resident 1's blood pressure was measured at 180/86 mmHg; however, Resident 1's medical record failed to show documentation a change of condition assessment was performed specific to Resident 1's hypertension and failed to show documentation Resident 1's physician was notified of Resident 1's blood pressure of 180/86 mmHg. LVN 1 verified the findings. Review of Resident 1's Health Status Note dated 10/21/23 at 2043 hours, showed Resident 1's blood pressure was measured at 211/97 mmHg. Resident 1's significant other subsequently called the paramedics as Resident 1 was not feeling good. Resident 1 was subsequently transferred to Acute Care Hospital 1 by the paramedics. Review of Resident 1's Health Status Note dated 10/22/23 at 0323 hours, showed Resident 1 was admitted to Acute Care hospital 1 with hypertensive crisis. On 10/26/23 at 1635 hours, an interview and concurrent medical record review was conducted with the DON. The DON verified Resident 1 had a change of condition on 10/7/23 at 2106 hours, in which Resident 1's blood pressure was measured at 196/90 mmHg. The DON also verified Resident 1 also had a change of condition on 10/18/23 at 1622 hours, in which Resident 1's blood pressure was measured at 180/86 mmHg. The DON verified the facility failed to conduct a change of condition assessment specific to Resident 1's episodes of hypertension and failed to notify Resident 1's physician. The DON stated (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 11/15/2023 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 0580 Level of Harm - Minimal harm or potential for actual harm her expectation in accordance with the facility's P&P, was for the change of condition assessment be conducted for Resident 1's episodes of hypertension which should include any neurological changes, complaints of chest pain and/or palpitations, and/or complaints of shortness of breath, and having obtained Resident 1's vital signs every 15 minutes until Resident 1's blood pressure was within normal limits. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055459 If continuation sheet Page 3 of 3