Inspection visit
Health inspection
5 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 5 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0686
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Level of Harm - Potential for
minimal 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 to prevent the development of new pressure ulcers and promote the healing of
existing pressure injuries for one of three sampled residents (Resident 2).
Residents Affected - Some
* The facility failed to provide Resident 2 with an alternating pressure pad as recommended by the Wound
Consultant. This failure posed the risk for worsening of the existing pressure injuries or development of new
pressure injuries for this resident.
Finding:
Review of the facility's P&P titled Pressure Ulcers/Skin Breakdown-Clinical Protocol dated 4/2018, showed
the physician will order pertinent wound treatments, including pressure reduction surfaces, wound
cleansing and debridement approaches, dressings (occlusive, absorptive, etc.), and application of topical
agents. During resident visits, the physician will evaluate and document the progress of wound
healing-especially for those with complicated, extensive, or poorly-healing wounds. The physician will guide
the care plan as appropriate, especially when wounds are not healing as anticipated or new wounds
develop despite existing interventions.
Closed medical record review for Resident 2 was initiated on 12/19/24. Resident 2 was admitted to the
facility on [DATE]; readmitted on [DATE], with the diagnosis of Type 2 Diabetes Mellitus; and discharged on
10/25/24.
Review of Resident 2's H&P examination dated 4/28/24,showed Resident 2 had no capacity to understand
and make decisions.
Review of Resident 2's MDS dated [DATE], showed Resident 2 was at risk for developing the pressure
ulcers/injuries and had diabetic foot ulcers.
Review of Resident 2's Wound Consultant's Progress Notes dated 7/23 and 8/20/24, showed Resident 2
had a right and left heel diabetic ulcer. The section for Recommendations showed to offload the heels on
the pillows and apply the heel protectors and alternating pressure pad.
Review of Resident 2's Wound Consultant's Progress Notes dated 9/17/24, showed Resident 2 had the left
lateral medial heel and right heel diabetic ulcers, and left lateral lower leg arterial ulcer. Thesection for
Recommendations showed to offload the heels on the pillows and apply the heel protectors and alternating
pressure pad.
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 10
Event ID:
055459
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
12/23/2024
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 0686
Level of Harm - Potential for
minimal harm
Further review of Resident 2's medical record failed to show aphysician's order for the alternating pressure
pad.
Review of Resident 2's progress notes failed to show documentation Resident 2 had an alternating
pressure pad as recommended by the Wound Consultant.
Residents Affected - Some
On 12/23/24 at 1300 hours, an interview was conducted with the Central Supply Staff. The Central Supply
Staff stated for the ordering of the special mattresses for the residents, the treatment nurse would inform
him,and he would contact the mattress rental company.
On 12/23/24 at 1315 hours, an interview and concurrent closed medical record review for Resident 2 was
conducted with LVN 1. LVN 1 stated she conducted weekly wound rounds with the Wound Consultant. LVN
1 stated she was responsible for reviewing the Wound Consultant's weekly progress notes to ensure the
recommendations were followed. LVN 1 reviewed the above Wound Consultant's Progress Notes and
acknowledged there were recommendations to provide Resident 2 with an alternating pressure pad.
However, the facility did not have the alternating pressure pads. LVN 1 was asked if she had clarified the
recommendation with the Wound Consultant. LVN 1 stated she did not and that she should have. When
asked if the resident was on any special mattress, LVN 1 verified there was no order for any special
mattress for the Resident 2.
On 12/23/24 at 1330 hours, a follow-up interview was conducted with the Central Supply Staff. The Central
Supply Staff stated he contacted the mattress rental company and verified there were no records of any
special mattress ordered for Resident 2.
On 12/23/24 at 1650 hours, a telephone interview was conducted with the Wound Consultant. The Wound
Consult stated he expected the recommendations on his progress notes to be carried out. The Wound
Consult stated if the facility did not have the recommended mattress, he expected the facility to inform him
or to clarify the recommendation for an alternative mattress.
On 12/23/24 at 1715 hours, the DON was informed and acknowledged the above findings.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055459
If continuation sheet
Page 2 of 10
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
12/23/2024
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 0687
Provide appropriate foot care.
Level of Harm - Minimal harm
or potential for actual harm
**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 to maintain the highest physical well-being for one of five sampled residents
(Resident 5).
Residents Affected - Few
* The facility failed to provide the wound care treatments for Resident 5's left foot wounds as ordered by the
physician. This failure had the potential for Resident 5 to not receive the appropriate care and services to
treat his left foot wounds.
Finding:
Review of the facility's P&P titled Pressure Ulcers/Skin Breakdown- Clinical Protocol dated 4/2018 showed
the physician will order pertinent wound treatments, including pressure reduction surfaces, wound
cleansing and debridement approaches, dressings (occlusive, absorptive, etc.), and application of topical
agents.
Medical record review for Resident 5 was initiated on 12/19/24. Resident 5 was admitted to the facility on
[DATE], and readmitted on [DATE].
Review of Resident 5's H&P examination dated 7/22/24, showed Resident 5 had no capacity to understand
and make decisions and had a diagnosis of Type 2 Diabetes Mellitus with other diabetic kidney
complications.
Review of Resident 5's Plan of Care showed the care plan problems initiated on 10/13/24, addressing the
following:
- Resident 5's altered skin integrity for the left 5th metatarsal. The interventions included to administer the
treatment as ordered.
- Resident 5's altered skin integrity for the left mid lateral foot. The interventions included to administer the
treatment as ordered.
Review of Resident 5's TAR for December 2024 showed a physician's order dated 12/18/24, for the
following:
- for the left mid to lateral foot diabetic ulcer, to cleanse with normal saline, pat dry, apply Betadine external
solution 10% topically (antiseptic solution), apply an ABD pad (a highly absorbent sterile dressing), wrap
with a kerlix roll of gauze, and secure with tape, every day during the day shifts for 14 days.
- for the left 5th metatarsal head diabetic ulcer, to cleanse with normal saline, pat dry, apply Betadine
external solution 10% topically, apply an ABD pad, wrap with a kerlix roll or gauze, and secure with tape
every day during the day shifts for 14 days.
On 12/23/24 at 1015 hours, a wound care observation for Resident 5 was conducted with LVN 1. LVN 1
was observed cleansing Resident 5's left foot wounds with the Gentell wound cleanser spray (a no rinse
wound cleanser) and a gauze.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055459
If continuation sheet
Page 3 of 10
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
12/23/2024
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 0687
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
On 12/23/24 at 1040 hours, a concurrent interview and medical record review for Resident 5 was
conducted with LVN 1. LVN 1 reviewed Resident 2's treatment orders for the left foot and stated the
physician's order was to cleanse Resident 5's left foot diabetic wounds with normal saline. When asked
about the wound cleansers, LVN 1 stated the normal saline and Gentellwound cleanser were not the same.
LVN 1 verified she used the Gentell dermal wound cleanser to cleanse Resident 5's left foot wounds. LVN 1
further stated the wound treatments should be administered to the residents as ordered by the physician.
On 12/23/24 at 1338 hours, an interview as conducted with the DON. The DON stated the licensed nurses
were expected to administer the wound treatments as ordered by the physician, to accurately reflect the
resident's care. The DON further stated the Gentell wound cleanser and normal saline were not the same,
and if the treatment nurse was using something other than what was ordered, the nurse should clarify the
order with the physician.
On 12/23/24 at 1715 hours, the DON was informed and acknowledged the above findings.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055459
If continuation sheet
Page 4 of 10
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
12/23/2024
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 0689
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to
prevent accidents.
**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 ensure one of
three sampled residents (Resident 3) remained free from the accident hazards.
* The facility failed to implement the bilateral floor mats as per the physician's order and plan of care for
Resident 3 who was a high risk for falls and had a history of falls with injuries. This failure had the potential
to place Resident 3 at risk for serious injury.
Findings:
Review of the facility's P&P titled Falls and Fall Risk, Managing revised 3/2018 showed the staff member,
with the input of the attending physician, will implement a resident-centered fall prevention plan to reduce
the specific risk factor(s) of falls for each resident at risk or with a history of falls.
Medical record review for Resident 3 was initiated on 12/23/24. Resident 3 was admitted to the facility on
[DATE], and readmitted on [DATE].
Review of Resident 3's H&P examination dated 9/13/24, showed Resident 3 was confused but was able to
make her needs known.
Review of Resident 3's Post-Fall Review dated 9/7/24, showed on 9/7/24 at 1000 hours, Resident 3 had a
fall in her room. The form showed Resident 3 was found sitting on the floor next to her bed with swelling on
her left cheek, purplish discoloration on her left eye and left shoulder, and a left-hand skin tear.
Review of Resident 3's Order Summary Report dated 12/23/24, showed a physician's order dated 9/12/24,
to implement the bilateral floor mats while the resident was in bed for fall management.
Review of Resident 3's Plan of Care showed a care plan problem dated 9/12/24, addressing Resident 3's
high risk for falls and injuries. The interventions included to implement bilateral floor mats as ordered and to
apply bilateral floor mats while in bed for fall management.
On 12/23/24 at 1010 and 1109 hours, Resident 3 was observed lying in bed with the floor mat on the left
side of the bed. A floor mat was not observed on the right side of Resident 3's bed.
On 12/23/24 at 1110 hours, a concurrent observation and interview was conducted with CNA 2. CNA 2
stated Resident 3 was a fall risk and had a fall in the past. CNA 2 verified Resident 3 only had a floor mat
on the left side of the bed. CNA 2 stated Resident 3 had attempted to get out of bed unassisted in the past
and there was a potential risk that Resident 3 would attempt to get out of bed on the right side.
On 12/23/24 at 1115 hours, an observation, interview, and concurrent medicalrecord review for Resident 3
was conducted with the DSD. The DSD verified the above findings. The DSD stated the resident should
have the bilateral floor mats as ordered by the physician. The DSD further stated the purpose of the floor
mats wasto mitigate any injuries in the event the resident had a fall.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055459
If continuation sheet
Page 5 of 10
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
12/23/2024
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 0689
On 12/23/24 at 1338 hours, an interview and concurrent medical record review for Resident 3 was
conducted with the DON. The DON was informed and acknowledged the above findings.
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 6 of 10
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
12/23/2024
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 0697
Provide safe, appropriate pain management 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 appropriate pain
management was provided for one of three sampled residents (Resident 2).
Residents Affected - Few
* The facility failed to ensure Resident 2 was consistently provided the non-pharmacological pain
interventions prior to the administration of acetaminophen (analgesic) medication. This failure had the
potential to put Resident 2 at risk for ineffective pain management and adverse effects related to the use of
unnecessary pain medication.
Finding:
Review of the facility's P&P titled Pain Assessment and Management revised 10/2022 showed the
non-pharmacological interventions may be appropriate alone or in conjunction with medications.
Pharmacologic interventions (i.e. analgesic) may be prescribed to manage pain, however they do not
usually address the cause of pain and can have adverse effects on the resident (e.g. drowsiness, increased
risk of falling; loss of appetite).
Closed medical record review for Resident 2 was initiated on 12/19/24. Resident 2 was admitted to the
facility on [DATE], readmitted on [DATE], and discharged on 10/25/24.
Review of Resident 2's H&P examination dated 4/28/24, showed Resident 2 had no capacity to understand
and make decisions.
Review of Resident 2's Order Summary Report dated 12/23/24, showed the following physician's orders
dated 4/26/24:
- to monitor for the highest pain level from the pain scale level of 0-10 (0 = no pain and 10 = worst pain)
every shift,
- for the non-pharmacological pain interventions: to record any non-drug intervention used to prevent or
relieve pain, which were coded as follows:
0 - No Non-Drug Interventions Needed
1 - Music/Radio
2 - 1:1 Conversation/Listening
3 - Repositioned for comfort
4 - Activity/Exercise/Stretch
5 - Rest Period/Sleep
6 - Verbal cues/Prompting/Reassuring
7 - Redirection/Refocus/Diversion
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055459
If continuation sheet
Page 7 of 10
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
12/23/2024
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 0697
8 - Deep Breathing/Relaxation
Level of Harm - Minimal harm
or potential for actual harm
9 - Remove from Stimuli/Problem solving
10 - Other, as needed
Residents Affected - Few
- to administer acetaminophen 325 mg two tablets by mouth every six hours as needed for mild pain (pain
levels of 1-3) to moderate pain (pain levels of 4-6)
Review of Resident 2's Plan of Care showed a care plan problem dated 4/26/24, addressing Resident 2's
alteration in comfort. The interventions included to documentany non-drug interventions used to prevent or
relieve pain.
Review of Resident 2's MAR for September 2024 showed Resident 2 was administered acetaminophen
325 mg two tablets as needed for pain on the following dates: 9/9, 9/13, 9/19, 9/20, 9/21, 9/22, and 9/23/24.
However, the MAR failed to show documented evidence the non-pharmacological pain interventions were
providedon 9/9, 9/13, 9/20, 9/22, and 9/23/24, prior to the administration of the pain medication.
On 12/23/24 at 1338 hours, an interview and concurrent closed medical record review for Resident 2 was
conducted with the DON. The DON verified the above findings. The DON stated prior to the administration
of the pain medications, the nurses were expected to attempt and document the non-pharmacologic pain
interventions provided to the residents.
On 12/23/24 at 1715 hours, the DON was informed and acknowledged the above findings.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055459
If continuation sheet
Page 8 of 10
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
12/23/2024
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 - Potential for
minimal harm
Residents Affected - Some
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** Based on
interview, medical record review, and facility P&P review, the facility failed to ensure the medical record for
one of five sampled resident (Resident 2) was complete and accurate.
* The facility failed to ensure the attempts to obtain and schedule a vascular consult for Resident 2 were
documented. This failure had the potential for the resident's care needs not being met as their medical
information was incomplete and inaccurate.
Findings:
Review of the facility's P&P titled Charting and Documentation revised 7/2017 showed all services provided
to the resident, the progress toward the care plan goals, or any changes in the resident's medical, physical,
functional, or psychosocial condition, shall be documented in the resident's medical record. The medical
record should facilitate communication between the interdisciplinary team regarding the resident's condition
and response to care. The following information is to be documented in the resident's medical record:
a. Objective observations;
b. Medications administered;
c. Treatments or services performed;
d. Changes in the resident's condition;
e. Events, incidents, or accidents involving the resident; and
f. Progress toward or changes in the care plan goals and objectives.
Closed medical record review for Resident 2 was initiated on 12/19/24. Resident 2 was admitted to the
facility on [DATE]; readmitted on [DATE], with a diagnosis of Type 2 Diabetes Mellitus; and discharged on
10/25/24.
Review of Resident 2's H&P examination dated 4/28/24, showed Resident 2 had capacity to understand
and make decisions.
Review of Resident 2's Order Summary Report dated 12/23/24, showed a physician's order dated 9/10/24,
for a vascular consultation.
Review of Resident 2's closed medical record failed to show documentation Resident 2 was seen and
evaluated by a vascular consultant.
Review of Resident 2's Progress Notes failed to show documentation the physician's order for a vascular
consult was carried out.
On 12/23/24 at 1615 hours, an interview was conducted with the Medical Record Director. The Medical
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055459
If continuation sheet
Page 9 of 10
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
12/23/2024
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 - Potential for
minimal harm
Residents Affected - Some
Record Director stated the nurses were responsible for carrying out the physician's order for the vascular
consult.
On 12/23/24 at 1625 hours, an interview and concurrent record review was conducted with the DON. The
DON stated at the time RN 1 received the physician's order, RN 1 was responsible for carrying out the
order for the vascular consult. The DON was asked to show the documentation if RN 1 had attempted to
find a vascular consultation for Resident 2. The DON stated she was unable to find the documentation.
On 12/23/24 at 1645 hours, a telephone interview was conducted with RN 1. RN 1 stated she received the
physician's order for the vascular consult for Resident 2. RN 1 stated she attempted to schedule a vascular
consult for Resident 2; however, the earliest appointment was two to three months from that time. RN 1
stated she had informed Nurse Practitioner 1 and was instructed to continue to find a vascular surgeon who
could see the resident as soon as possible. When asked if RN 1 documented when she informed Nurse
Practitioner 1, RN 1 stated she did not document in Resident 2's medical record her attempts to schedule a
vascular consult and/or her notification to Nurse Practitioner 1.
On 12/23/24 at 1715 hours, the DON was informed and acknowledged the above findings.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055459
If continuation sheet
Page 10 of 10
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Back to topCitations
5 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F686 - Skin Integrity
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
F687 - Foot care
Provide appropriate foot care.
F689 - Accidents
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
F697 - Pain Management
Provide safe, appropriate pain management for a resident who requires such services.
F842 - Resident-identifiable information
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
FAQ · About this visit
Common questions about this visit
What happened during the December 23, 2024 survey of BUENA VISTA CARE CENTER?
This was a inspection survey of BUENA VISTA CARE CENTER on December 23, 2024. The surveyor cited 5 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at BUENA VISTA CARE CENTER on December 23, 2024?
Yes, 5 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Provide appropriate pressure ulcer care and prevent new ulcers from developing."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.
Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.