Health inspection·December 18, 2025

F 0561 Level of Harm - Potential for minimal harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete their face, legs, and arms. On 12/18/25 at 1109 hours, facility document review was conducted with the DSD. The DSD showed the competency check list titled Certified Nursing Assistant Skills Evaluation/Orientation Checklist for CNA 2 dated 8/4/25. Review of the skills checklist showed CNA 2 was signed off as satisfactory for shaving, which included underarms as verified by the DSD. On 12/18/25 at 1109 hours, an interview was conducted with the Administrator, DON, and Regional Nurse Resource. The Administrator, DON, and Regional Nurse Resource were informed and acknowledged the above findings. Event ID: Facility ID: 055459 If continuation sheet Page 2 of 36 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 12/18/2025 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 0605 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function. **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 the residents were free from unnecessary psychotropic drugs for one final sampled resident (Resident 2) and two nonsampled residents (Residents 5 and 7) reviewed for unnecessary medications. * The facility failed to document the nonpharmacological interventions to be attempted prior to administering Resident 2's alprazolam (antianxiety) medication. * The facility failed to document the nonpharmacological interventions to be attempted prior to administering Resident 5's trazodone medication. * The facility failed to implement the nonpharmacological interventions prior to administering the trazodone (antidepressant medication) to Resident 7. In addition, the facility failed to ensure Resident 7's orthostatic blood pressure was accurately monitored as ordered by the physician for the use of the olanzapine (antipsychotic medication). These failures had the potential for adverse effects from the psychotropic medications, not providing the correct data to the prescriber to adjust the dosage of the medications and to negatively impact the residents' well-being.Findings: Review of the facility's P&P titled Antipsychotic Medication Use revised July 2022 showed: - A psychotropic medication is any medication that affects brain activity associated with mental processes and behavior including, anti-psychotics, anti-depressants, anti-anxiety medications and hypnotics. Residents will not receive medications that are not clinically indicated to treat a specific condition. - Nonpharmacological approaches are used (unless contraindicated) to minimize the need for medications, permit the lowest possible dose, and allow for discontinuation of medications when possible. - Nursing staff shall monitor for and report any of the following side effects and adverse consequences of antipsychotic medications to the attending physician: Cardiovascular; orthostatic hypotension. The physician shall respond appropriately by changing or stopping problematic doses or medications or clearly documenting why the benefits of the medication outweigh the risks or suspected or confirmed adverse consequences. 1. a. Medical record review for Resident 7 was initiated on 12/16/25. Resident 7 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 7's H&P examination dated 10/30/25, showed the resident was non-competent. Review of Resident 7's MDS assessment dated [DATE], showed a BIMS score of 7, indicating severe cognitive impairment. Review of Resident 7's Order Summary Report dated 12/18/25, showed the following physician's orders: - dated 10/16/25, to administer trazodone hydrochloride 50 mg by mouth at bedtime for depression manifested by inability to sleep. However, further review of Resident 7's medical record failed to show a physician's order or documented evidence the nonpharmacological interventions were implemented for Resident 7's use of a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055459 If continuation sheet Page 3 of 36 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 12/18/2025 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 0605 routine antidepressant. Level of Harm - Minimal harm or potential for actual harm On 12/18/25 at 1125 hours, an interview and concurrent medical record review was conducted with the DON. The DON was asked about the nonpharmacological interventions provided for the use of Resident 7's antidepressant medication. The DON stated the facility did not provide the nonpharmacological interventions for the residents who were on routine antidepressant medications, but only with antidepressant medications prescribed as needed. Residents Affected - Few b. Review of Resident 7's Order Summary Report showed the following physician's orders: - dated 10/16/25, to administer olanzapine 2.5 mg by mouth one time a day for schizoaffective disorder manifested by verbalization that people are going to steal her clothes; - dated 10/16/25, to monitor the orthostatic B/P (lying ) every day shift every on Saturdays for the olanzapine medication use. Review of Resident 7's MAR dated 12/17/25, showed the following: -on 12/6/25, the BP reading for the lying position was 132/60 mmHg; and -on 12/13/25, the BP reading for the lying position was 146/60 mmHg. However, further review of Resident 7's medical record failed to show a physician's order or documented evidence the orthostatic blood pressure for the sitting and standing positions were being monitored. On 12/18/25 at 1415 hours, an interview and concurrent medical record review was conducted with RN 2. RN 2 stated the facility was monitoring Resident 7 for orthostatic hypotension with sitting, standing, and lying positions prior to Resident 7 transferring to the acute care hospital in October 2025, however, since Resident 7 returned from the acute care hospital on [DATE], the facility had only been monitoring for one position (lying). On 12/18/25 at 1125 hours, an interview and concurrent medical record review was conducted with the DON. The DON verified there was no physician's order to monitor Resident 7's orthostatic BP in the sitting and standing position after Resident 7 was readmitted from the acute care hospital on [DATE]. 2. Medical record review for Resident 5 was initiated on 12/15/25. Resident 5 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 5's H&P examination dated 9/26/25, showed Resident 5 had no capacity to understand and make decisions. Review of Resident 5's Order Summary Report dated 9/16/25, showed a physician's order to administer trazodone HCl 50 mg one tablet by mouth at bedtime for depression manifested by inability to sleep. Review of Resident 5's MDS assessment dated [DATE], under Section I, showed Resident 5 had a diagnosis of depression. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055459 If continuation sheet Page 4 of 36 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 12/18/2025 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 0605 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few However, further review of Resident 5's medical record failed to show the nonpharmacological interventions attempted prior to the administration of Resident 5's trazodone medication. On 12/17/25 at 1419 hours, an interview and concurrent medical record review for Resident 5 was conducted with LVN 3. When asked about Resident 5's trazodone medication use, LVN 3 stated Resident 5 was taking the trazodone medication for their inability to sleep. When asked there were documented evidence to show the nonpharmacological interventions provided to Resident 5 prior to the use of the trazadone medication, LVN 3 stated no. LVN 3 verified the above findings. On 12/17/25 at 1459 hours, an interview and concurrent medical record review for Resident 5 was conducted with RN 2. RN 2 verified the above findings. RN 2 stated Resident 5 had a physician's order for the risperidone (anti-psychotic medication) medication and a physician's order for the nonpharmacological interventions for the use of the risperidone medication. However, RN 2 further stated the risperidone and trazodone medications should have different nonpharmacological interventions because the two medications were two different medication classes and had different targeted behaviors. On 12/18/25 at 1447 hours, an interview was conducted with the Administrator, DON, and Regional Nurse Resource. The Administrator, DON, and Regional Nurse Resource were informed and acknowledged the above findings. 3. Medical record review for Resident 2 was initiated on 12/15/25. Resident 2 was admitted to the facility on [DATE]. Review of Resident 2's H&P examination dated 11/26/25, showed Resident 2 had no capacity to understand and make decisions. Review of Resident 2's Order Summary Report dated 12/18/25, showed Resident 2 had a physician's order dated 12/15/25, to administer alprazolam 0.5 mg one tablet every 12 hours as needed for agitation/fidgeting in bed causing distress via GT for 14 days. However, further review of Resident 2's medical record failed to show the nonpharmacological interventions attempted prior to the administration of Resident 2's alprazolam medication. On 12/17/25 at 1155 hours, an interview and concurrent medical record review for Resident 2 was conducted with RN 2. When asked about Resident 2's alprazolam medication use, RN 2 stated Resident 2 was taking the alprazolam medication for agitation/fidgeting in bed causing distress. When asked about the documented evidence to show the nonpharmacological interventions attempted prior to the administration of the alprazolam medication, RN 2 verified there was no documented evidence in the resident's medical record. On 12/18/25 at 1102 hours, an interview was conducted with the Administrator and DON. The Administrator and DON were informed and acknowledged the above findings. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055459 If continuation sheet Page 5 of 36 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 12/18/2025 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to develop the resident-centered care plans to reflect the individual care needs of two of 19 final sampled residents (Residents 8 and 52). * The facility failed to develop a care plan for a new diagnosis of a UTI [a common bacterial infection in the urinary system (kidneys, bladder, ureters, urethra)] for Resident 8 when the resident returned from the acute care hospital. * The facility failed to develop a comprehensive individualized care plan to address Resident 52's weight loss of 21 lbs. in six months. These failures posed the risk of not providing appropriate and individualized care to Residents 8 and 52 to meet their highest practicable mental health and well-being.Findings: Review of the facility's P&P titled Care Plan, Comprehensive Person-Centered revised 3/2022 showed a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. The comprehensive, person -centered care plan: - describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. - reflects currently recognized standards of practice for problem areas and conditions. Review of facility's P&P titled Weight Assessment and Intervention revised 3/2022 showed the residents' weights are monitored for undesirable or unintended weight loss or gain. The threshold for significant unplanned and undesired weight loss will be based on the following criteria: a. One month – 5% weight loss is significant; greater than 5% is severe; b. Three months – 7.5% weight loss is significant; greater than7. 5% is severe; and c. Six months - 10% weight loss is significant; greater than 10% is severe. Care planning for weight loss or impaired nutrition is a multidisciplinary effort and includes the physician, nursing staff, the dietitian, the consultant pharmacist, and the resident or resident's legal surrogate. Individualized care plans shall address to the extent possible: a. The identified causes of weight loss; b. Goals and benchmarks for improvement; and c. Timeframes and parameter for monitoring and reassessment. 1. Medical record review for Resident 52 was initiated on 12/15/25. Resident 52 was admitted to the facility on [DATE]. and readmitted to the facility on [DATE]. Review of Resident 52's H&P examination dated 7/28/25, showed Resident 52 had no capacity to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055459 If continuation sheet Page 6 of 36 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 12/18/2025 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 0656 understand and make decisions due to dementia. Level of Harm - Minimal harm or potential for actual harm Review of Resident 52's Weight Summary showed the following dates and weights: - on 6/1/25, the resident had a weight of 165 lbs; Residents Affected - Few - on 7/2/25, the resident had a weight of 163 lbs; - on 8/2/25, the resident had a weight of 147 lbs; - on 9/3/25, the resident had a weight of 150 lbs; - on 10/1/25, the resident had a weight of 143 lbs; - on 11/1/25, the resident had a weight of 143 lbs; and - on 12/2/25, the resident had a weight of 144 lbs. (a loss of 21 lbs./12.7% in six months} Review of Resident 52's Order Summary Report showed a physician's order dated 8/13/25, for fortified/high protein/consistent-carbohydrate-no added salt diet, with pureed texture and mildly thick consistency. Review of Resident 52's Care Plan Report showed a care plan revised 8/22/25, addressing the resident's impaired nutritional and hydration status related to dysphagia and mechanically altered diet. The goal included the residents to not exhibit signs and symptoms of dehydration and will not have significant weight change. However, further review of the resident's plan of care failed to show documented evidence a care plan problem was developed to address the resident's weight loss of 21 lbs. in six months. On 12/17/25 at 1130 hours, an interview and concurrent medical record review was conducted with the RD. The RD stated she was not involved in the resident's care planning and stated the DON was responsible for the nutrition care plan for the residents. On 12/17/25 at 1626 hours, an interview and concurrent medical record review was conducted with RN 2. RN 2 verified the above findings. RN 2 stated the Dietary Department should address the resident's weight loss. On 12/18/25 at 1102 hours, an interview was conducted with the Administrator and DON. The Administrator and DON were informed and acknowledged the above findings. 2. Medical record review for Resident 8 was initiated on 12/17/25. Resident 8 was admitted on [DATE], and readmitted on [DATE]. Review of Resident 8's progress note dated 10/13/25 at 2239 hours, showed Resident 8 was readmitted to the facility with a new diagnosis of a UTI. Review of Resident 8's COC documentation dated 10/19/25 at 1715 hours, showed Resident 8 with increased weakness and decline in ADL function. The MD was notified and had ordered Resident 8 to be sent (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055459 If continuation sheet Page 7 of 36 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 12/18/2025 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 0656 to the acute care hospital. Level of Harm - Minimal harm or potential for actual harm Review of Resident 8's MAR for October 2025 showed a physician's order to administer triaxone (antibiotic) sodium injection solution reconstituted 1 gm at 100 ml/hr intravenously every 24 hours for UTI for seven days. Residents Affected - Few However, further review of Resident 8's plan of care, there was no documented evidence the facility developed and implemented a comprehensive person-centered care plan to address Resident 8's UTI diagnosis. On 12/17/25 at 1057 hours, an interview and concurrent medical record review was conducted with LVN 1. LVN 1 stated when a resident returned from the acute care hospital, the RN supervisor updated the resident's care plan. LVN 1 stated when a resident was admitted with a new diagnosis, the care plan should include the goals and interventions addressing the new diagnosis. LVN 1 was informed and verified the above findings. LVN 1 stated the importance of having the diagnosis on the resident's care plan was to know what interventions were being provided, if the interventions were effective, and if the physician's orders were up to date. LVN 1 further stated the importance of a care plan was to keep track of what was being done and monitoring the resident's care. On 12/17/25 at 1111 hours, an interview and concurrent medical record review was conducted with RN 1. RN 1 verified Resident 8's care plan did not reflect the new diagnosis of a UTI. RN 1 stated there should be a UTI care plan along with the interventions in the resident's medical record. On 12/18/25 at 1001 hours, an interview and concurrent medical record review as conducted with the DON. The DON stated when a resident returned from the acute care hospital with new orders, the facility carried out the new orders and modified the care plan to address the diagnosis. The DON stated the importance of developing the resident's care plan was to ensure the interventions were being carried out, to monitor the effectiveness of the interventions, and to inform the MD of the residents' care. On 12/18/25 at 1245 hours, an interview was conducted with the Administrator, DON and Regional Nurse Resource. The Administrator, DON, and Regional Nurse Resource were 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 36 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 12/18/2025 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 0679 Provide activities to meet all resident's needs. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, facility document review, and facility P&P review, the facility failed to provide the individualized and ongoing activity program to meet the needs and interests of one of three final sampled residents (Resident 67) reviewed for activities. * The facility failed to provide room visits for Resident 67 as per the activities plan of care. This failure had the potential for the resident to experience feelings of social isolation.Findings: Review of the facility's P&P titled Individual Activities and Room Visit Program revised 6/2018 showed the following:- Individual activities will be provided for those residents whose situation or condition prevents participation in other types of activities, and for those residents who do not wish to attend group activities. Residents who are able to maintain an independent program will have supplies available to them.- It is recommended that resident with in-room activity programs receive, at a minimum, three in room visits per week. A typical in-room visit is ten-fifteen minutes in length, but may be longer if appropriate for the resident. On 12/15/25 at 1017 hours, during the initial tour of the facility, Resident 67 was observed lying in bed. The television was observed to be off and there was no other sensory stimulation observed. Medical record review for Resident 67 was initiated on 12/15/25. Resident 67 was admitted to the facility on [DATE], and was readmitted on [DATE]. Review of Resident 67 ‘s plan of care showed a care plan problem dated 11/14/24, addressing the resident's little or no activity involvement related to immobility and physical limitation. The care plan further showed Resident 67 would be provided with sensory stimulation such as music therapy, and hand massage, listening to music (Spanish), family visits and visiting the patio on occasion. The Activity staff would continue to provide room visit three times per week or as necessary. The interventions included to modify the resident's daily schedule treatment plan as needed to accommodate activity participation. Review of Resident 67's MDS Quarterly assessment dated [DATE], showed Resident 67 had severe cognitive impairment and needed substantial/maximal assistance from the facility staff for mobility. Further review of Resident 67's medical record failed to showed documentation sensory stimulation activities and/or room visits were provided to Resident 67. On 12/16/25 at 1031 hours, observed Resident 67 was lying in bed awake. The television was observed to be off. On 12/16/25 at 1134 hours, an observation and concurrent interview for Resident 67 was conducted with CNA 4. CNA 4 stated Resident 67 did not attend any activities and only got Resident 67 out of bed during shower days. On 12/16/25 at 1515 hours, an interview and concurrent medical record review was conducted with Activity Assistant. When asked what activities were provided to Resident 67, the Activity Assistant stated the activity staff provided room visits. When asked to review any documentation to show the activities provided to Resident 67 during the room visits, the Activity Assistant failed to show documentation of the activities provided during the room visits. On 12/16/25 at 1528 hours, an interview and concurrent medical record review was conducted with Activity Director. The Activity Director verified the facility had no activity notes when the activity staff provided the room visit for the residents. On 12/18/25 at 1102 hours, an interview was conducted with the Administrator and DON. The Administrator and DON were informed and acknowledged the above findings. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055459 If continuation sheet Page 9 of 36 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 12/18/2025 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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. 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 ensure the quality care and services were provided for one final sampled resident (Resident 64) and two nonsampled residents (Residents 66 and 77) observed for blood glucose monitoring. * LVN 1 failed to discard the first drop of blood during the blood glucose check for Residents 64, 66 and 77. * LVN 1 failed to rotate the injection site when administering the insulin (medication to help lower blood sugar) to Resident 64. These failures had the potential for the residents not to receive the necessary care and services to maintain their highest physical well-being.Findings: Review of the facility's P&P titled Obtaining a Fingerstick Glucose Level revised October 2011 showed the purpose of this procedure is to obtain a blood sample to determine the resident's blood glucose level. Obtain a blood sample by using a sterile lancet. Discard the first drop of blood if alcohol is used to clean the fingertips because alcohol may alter the results. 1.a. Medical record review for Resident 64 was initiated on 12/15/25. Resident 64 was admitted to the facility on [DATE]. Review of Resident 64's H&P examination dated 12/3/25, showed Resident 64 was able to understand and make treatment decisions. Review of Resident 64's Order Summary Report dated 12/15/25, showed the following physician's orders:- dated 11/26/25, to administer insulin regular human injection solution 100 unit/ml (insulin regular human) subcutaneously per sliding scale before meals and at bedtime for DM. Rotate the injection sites. On 12/15/25 at 1119 hours, LVN 1 was observed performing a blood glucose check on Resident 64. LVN 1 was observed cleaning Resident 64's finger with an alcohol pad. LVN 1 then obtained a blood sample using a sterile lancet. However, LVN 1 did not waste the first drop of blood and used the first drop of blood for the test sample. b. Medical record review for Resident 66 was initiated on 12/15/25. Resident 66 was admitted to the facility on [DATE]. Review of Resident 66's H&P examination dated 11/7/25, showed Resident 66 was able to make decisions. Review of Resident 66's Order Summary Report dated 12/15/25, showed the following physician's order dated 11/6/25, to administer insulin regular human injection solution pen-injector 100 unit/ml (insulin regular human) subcutaneously per sliding scale before meals and at bedtime for DM. On 12/15/25 at 1202 hours, LVN 1 was observed performing a blood glucose check on Resident 66. LVN 1 was observed cleaning Resident 66's finger with an alcohol pad. LVN 1 then obtained a blood sample using a sterile lancet. However, LVN 1 did not waste the first drop of blood and used the first drop of blood for the test sample. c. Medical record review for Resident 77 was initiated on 12/15/25. Resident 77 was admitted to the facility on [DATE]. Review of Resident 77's H&P examination dated 1/20/25, showed Resident 77 was able to make very simple decisions. Review of Resident 77's Order Summary Report dated 12/15/25, showed the following physician's order dated 9/7/25, to administer Humalog solution 100 unit/mL (insulin/lispro) subcutaneously per sliding scale before meals and at bedtime for DM. On 12/15/25 at 1138 hours, LVN 1 was observed performing a blood glucose check on Resident 77. LVN 1 was observed cleaning Resident 64's finger with an alcohol pad. LVN 1 then obtained a blood sample using a sterile lancet. However, LVN 1 did not waste the first drop of blood and used the first drop of blood for the test sample. 2. Review of the facility document titled Competency Assessment titled Obtaining a Fingerstick Glucose Level dated 4/3/25, and authorized by the DON on 4/3/25, showed LVN 1 was competent in all categories of obtaining a fingerstick glucose level. On 12/15/25 at 1119 hours, LVN 1 was observed administering insulin to Resident 64. During the insulin administration, LVN 1 asked Resident 64 where the resident wanted the insulin injected. Resident 64 wanted the insulin injection in the right arm. However, LVN 1 did not verify the previous insulin injection sites. On 12/16/25 at 1144 hours, an interview was conducted with LVN 1. LVN Residents Affected - Few (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055459 If continuation sheet Page 10 of 36 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 12/18/2025 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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete 1 verified she was aware of the facility's policy to discard the first drop of blood during a blood glucose test but failed to do so for Residents 64, 66, and 77. LVN 1 also stated she was aware of the physician's order to rotate insulin injection sites for Resident 64. On 12/18/25 at 1125 hours, an interview was conducted with the DON. The DON was unaware of the facility's policy to waste the first drop of blood when obtaining a blood sample for the blood glucose monitoring. However, the DON verified the licensed nurses should be rotating the injection sites when administering insulin. On 12/18/25 at 1458 hours, an interview was conducted with the DSD. The DSD stated the competency for obtaining a fingerstick glucose level was conducted by the DON. The DSD further stated the licensed nurses were required to perform the task on a resident to be checked off for the competency and if there were any identified issues, the DON had the license nurse repeat the test. Event ID: Facility ID: 055459 If continuation sheet Page 11 of 36 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 12/18/2025 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 Provide appropriate pressure ulcer care and prevent new ulcers from developing. 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 to prevent the development or worsening of pressure injuries (damage to the skin and underlying tissue from prolonged pressure, often over bony areas) for one of two final sampled residents (Resident 69) reviewed for pressure injuries. * The facility failed to ensure Resident 69 had weekly assessments documented for a Stage 2 pressure injury (partial-thickness skin loss where the epidermis and part of the dermis are damaged) to the coccyx. This had the potential for Resident 69's Stage 2 pressure injury to worsen and not provided appropriate care.Findings: Review of the facility's P&P titled Pressure Injuries Overview revised February 2024 showed a Stage 2 pressure injury is partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-intact blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. Commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel. This stage should not be used to describe moisture-associated skin damage including continence-associated dermatitis, intertriginous dermatitis, medical adhesive-related skin injury, or traumatic wounds (skin tears, burns, abrasions). Review of the facility's P&P titled Charting and Documentation revised July 2017 showed all services provided to the resident, 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. Documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate. Documentation of procedures and treatments will include care-specific details, including: the date and time the procedure/treatment was provided; the name and title of the individual(s) who provided the care; the assessment data and/or any unusual findings obtained during the procedure/treatment; how the resident tolerated the procedure/treatment; whether the resident refused the procedure/treatment; notification of family, physician or other staff, if indicated; and the signature and title of the individual documenting. Review of the facility's P&P titled Pressure Ulcers/Skin Breakdown - Clinical Protocol revised April 2018 showed the nurse shall describe and document/report the following: full assessment of pressure sore including location, stage, length, width and depth, presence of exudates or necrotic tissue; pain assessment; resident's mobility status' current treatments, including support surfaces, and all active diagnoses. Medical record review for Resident 69 was initiated on 12/16/25. Resident 69 was admitted to the facility on [DATE]. Review of Resident 69's Admission/readmission Data Tool dated 11/12/25 at 1651 hours, showed the resident had a sacrococcyx Stage 2 pressure injury, measuring 4.0 cm by 2.0 cm by x 0.1cm. The description showed the pressure injury was a shallow open wound with red wound bed, no drainage and no signs and symptoms of infection. Review of Resident 69's progress note dated 12/14/25, showed the MD was notified regarding the evaluation on the sacrococcyx Stage 2 pressure injury's improvement with no signs and symptoms of infection. The progress note showed Resident 69 had denied pain or discomfort during wound treatment and a new order from the physician was obtained to continue the current treatment to the sacrococcyx Stage 2 pressure injury as follows: to cleanse with normal saline, pat dry, apply zinc oxide cream (over the counter skin protectant) and cover with foam dressing daily for 30 days. However, further review of Resident 69's progress note dated 12/14/25, failed to show documented assessment of the pressure injury, including the measurements for length, width and depth, presence of exudates or necrotic tissue as per the facility's P&P. On 12/17/25 at 1402 hours, an interview and concurrent medical record review was conducted with LVN 2. LVN 2 stated the facility was providing Residents Affected - Few (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055459 If continuation sheet Page 12 of 36 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 12/18/2025 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 - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete wound treatment for Resident 69's sacrococcyx Stage 2 pressure ulcer injury. LVN 2 verified Resident 69's initial assessment for the pressure injury was documented on the resident's Admission/readmission Data Tool dated 11/12/25, and the reevaluation assessment was done on 12/14/25. LVN 1 verified the reassessment documentation failed to show thorough documentation, including the measurements/size of the wound and only showed the pressure injury was improving. On 12/18/25 at 1022 hours, an interview was conducted with the DON. The DON stated an assessment of a pressure injury was completed at the time of the resident's admission and then weekly assessments were completed. The DON was informed of the incomplete wound assessments and documentation for Resident 69's sacrococcyx Stage 2 pressure injury as per the facility's P&P and verified above the findings. Event ID: Facility ID: 055459 If continuation sheet Page 13 of 36 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 12/18/2025 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 FORM CMS-2567 (02/99) Previous Versions Obsolete 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 interview and medical record review, the facility failed to ensure the necessary care and services were provided for one of one final sampled resident (Resident 1) reviewed for accident hazards. * The facility failed to timely monitor and document the neurological assessments for Resident 1's unwitnessed fall incident on 5/1/25. This failure had the potential to place the resident at risk for serious injury.Findings: Medical record review for Resident 1 was initiated on 12/15/25. Resident 1 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 1's eINTERACT Change in Condition Evaluation - V 5.1 dated 5/1/25 at 0310 hours, showed Resident 1 had an unwitnessed fall and was found sitting on the floor beside his bed. Resident 1 was noted to have a small amount of blood and a small bump at the right temporal area (near the temples of the head) of his head. Resident 1 was on an anticoagulant (blood thinner) medication but Resident 1 refused an acute care hospital transfer. Resident 1's responsible party was made aware of the fall incident. Review of Resident 1's Neuro Check Flowsheet - V 4 dated 5/1/25, showed under Section 3 every one hour four times. The first assessment for every hour monitoring was obtained on 5/1/25 at 0730 hours. However, the second assessment for every hour monitoring was obtained on 5/1/25 at 1132 hours (four hours after the first assessment) and the third assessment for every hour monitoring was obtained on 5/1/25 at 1530 hours (four hours after the second assessment). Review of Resident 1's H&P examination dated 8/18/25, showed Resident 1 was unable to understand and make treatment decisions due to dementia. On 12/17/25 at 0951 hours, an interview and concurrent medical record review for Resident 1 was conducted with LVN 3. LVN 3 stated the neurological assessments were obtained after a fall incident to monitor the resident's level of consciousness. LVN 3 verified the above findings. LVN 3 stated the neurological assessment was not completed in a timely manner because the assessment should have been obtained every hour for four hours for Resident 1. On 12/18/25 at 1447 hours, an interview was conducted with the Administrator, DON, and Regional Nurse Resource. The Administrator, DON, and Regional Nurse Resource were informed and acknowledged the above findings. Event ID: Facility ID: 055459 If continuation sheet Page 14 of 36 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 12/18/2025 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 Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **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 pharmaceutical services to ensure accurate reconciliation and administration of the medications. * The facility failed to ensure the oral and IV emergency medication kits were replaced timely. * The facility failed to ensure the administration of the controlled medications for Residents 53 and 81 were documented in the MAR. * LVN 4 failed to administer the full dose of the cranberry supplement via GT for Resident 2. These failures had the potential for diversion of the controlled medication, medication administration error, and negative residents outcomes.Findings: Review of the facility's P&P titled Administering Medications revised April 2023 showed:- Medications are administered in a safe and timely manner, and as prescribed.- The individual administering the medication initials the resident's MAR on the appropriate line or EMAR after giving each medication and before administering the next ones. Review of the facility's P&P titled Medication Ordering and Receiving from Pharmacy revised January 2025 showed:- When an emergency dose of medication is needed, the nurse unlocks the container and removes the required medication. After removing the medication, complete the emergency e-kit slip and re-seal the emergency supply. An entry is made in the emergency logbook containing all required information.- As soon as possible, the nurse records the medication use on the medication order form and notified the pharmacy for replacement of the emergency drug supply by faxing a request utilizing the prescription refill sticker.- If exchanging kits, the used sealed kits are replaced with the new sealed kits within 72 hours of opening. 1. On 12/15/25 at 1512 hours, an interview and concurrent inspection of Medication Room A was conducted with RN 2. The oral and IV emergency kits were observed to be sealed with yellow locks. RN 2 stated the yellow locks indicated the emergency kits were previously opened and waiting to be replaced by the pharmacy. RN 2 was asked to open both emergency kits. Review of the emergency kit pharmacy log for the oral emergency kit indicated the kit was opened on 12/10/25. Review of the emergency kit pharmacy log for the IV emergency kit indicated it was opened on 11/30/25. RN 2 stated she called the pharmacy to follow up on the replacement of the emergency kits but verified the emergency kits were past the facility's 72-hour policy. On 12/18/25 at 1125 hours, an interview was conducted with the DON. The DON was informed and verified the above findings. 2. On 12/16/25 at 1013 hours, an inspection of Medication Cart D was conducted with LVN 4. During the inspection of Medication Cart D, a random inspection of the controlled medications was conducted. Review of Medication Cart D's Antibiotic or Controlled Drug Record showed the following:a. Resident 53's Antibiotic or Controlled Drug Record for the oxycodone/APAP (narcotic pain medication) 7.5-325 mg medication showed one tablet of the oxycodone/APAP 7.5-325 mg tablet was removed on 12/9/25 at 1545 hours. Review of Resident 53's MAR for December 2025 was conducted with LVN 4 and the MAR failed to show the oxydodone/APAP 7.5-325 mg medication was administered on 12/9/25 at 1545 hours to Resident 53. b. Review of Resident 81's Antibiotic or Controlled Drug Record for the hydrocod/APAP (narcotic pain medication) 10-325 mg medication showed one tablet of the hydrocod/APAP 10-325 mg tablet was removed on 12/9/25 at 2050 hours. Review of Resident 81's MAR for December 2025 was conducted with LVN 4 and the MAR failed to show the hydrocode/APAP 10-325 mg medication was administered on 12/9/25 at 2050 hours to Resident 81. LVN 4 verified the MAR entries for Residents 53 and 81 were missing and stated all the medications should be documented in the resident's MAR upon administration. On 12/18/25 at 1125 hours, an interview was conducted with the DON. The DON verified all controlled drug administration should be documented in the MAR. 3. Medical record review for Resident 2 was initiated on 12/15/25. Resident 2 was admitted to the facility on [DATE], (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055459 If continuation sheet Page 15 of 36 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 12/18/2025 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 Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete and readmitted on [DATE]. Review of Resident 2's H&P examination dated 11/26/25, showed Resident 2 was able to understand and make treatment decisions. An addendum note was added on 12/16/25, which showed Resident 2 was unable to understand and make treatment decisions due to dementia and encephalopathy (any disease or disorder that alters brain function or structure). Review of Resident 2's Order Summary Report dated 12/15/25, showed a physician's order dated 11/25/25, to administer cranberry (supplement) oral tablet 450 mg via GT one day a day for UTI prophylaxis. On 12/15/25 at 0818 hours, a medication administration observation for Resident 2 was conducted with LVN 4. LVN 4 was observed crushing the cranberry supplement tablet and administering the supplement to Resident 2 via GT. However, upon completion of the administration, there was significant tablet residue in the medication cup, which was not administered to Resident 2. On 12/15/25 at 1457 hours, an interview was conducted with LVN 4. LVN 4 verified the above findings and stated leaving the medication residue in the medication cups resulted in the resident not receiving the correct dose. Event ID: Facility ID: 055459 If continuation sheet Page 16 of 36 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 12/18/2025 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 **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 the medication error rate was below 5%. The facility's medication error rate was 23.08% (for six medication errors out of 26 total opportunities). One of six licensed nurses (LVN 4) who were observed during medication administration was found to have errors. * LVN 4 failed to ensure all the medication residual was administered via GT to Resident 2 for six of 14 medications administered. This failure had the risk for the resident to have potential side effects or complications related to the medications.Findings: On 12/15/25 at 0818 hours, a medication administration observation for Resident 2 was conducted with LVN 4. LVN 4 prepared and administered the following medications to Resident 2:- One tablet of amlodipine (used to treat high blood pressure) 5 mg;- One tablet of aspirin (used to relieve pain, fever and inflammation; acts as a blood thinner) 81 mg;- One tablet of atenolol (used to treat high blood pressure) 50 mg;- One tablet of cranberry 450 mg;- Restasis (used to treat chronic dry eyes) eye drops 0.5%;- One tablet of apixaban (blood thinner) 2.5 mg;- One tablet of furosemide (diuretic) 20 mg;- One tablet of losartan 9(used to treat high blood pressure) 100 mg;- One tablet of magnesium oxide (supplement) 400 mg;- One tablet of meloxicam (used to relieve pain, swelling and stiffness) 15 mg;- One tablet of multivitamin with minerals (supplement);- One tablet of prednisone (used to reduce inflammation and suppress the immune system) 5 mg;- 30 ml of Pro-stat (supplement) liquid;- Refresh tears (used to treat dry eyes) eye drops.- One capsule of venlafaxine (antidepressant) 75 mg; and- One tablet of vitamin C (supplement) 500 mg.LVN 4 prepared and administered the above medications to Resident 2. However, following the medication administration, six medication cups were found to have significant medication residue in them. LVN 4 verified the medication residue in the cups. The medications observed with residue were: - aspirin 81 mg;- magnesium oxide 400 mg;- multivitamin with minerals- prednisone 5 mg;- venlafaxine 75 mg; and- vitamin C 500 mg. Medical record review for Resident 2 was initiated on 12/15/25. Resident 2 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 2's H&P examination dated 11/26/25, showed Resident 2 was able to understand and make treatment decisions. An addendum note was added on 12/16/25, which showed Resident 2 was unable to understand and make treatment decisions due to dementia and encephalopathy. Review of Resident 2's Order Summary Report dated 12/15/25 ,showed the following physician's orders dated 11/25/25:- To administer amlodipine 5 mg tablet via GT one time a day;To administer aspirin 81 mg tablet via GT one time a day;- To administer atenolol 50 mg tablet via g GT one time a day;- To administer cranberry (supplement) 450 mg tablet one time a day;- To administer Restasis ophthalmic emulsion 0.5% one drop in each eye every 12 hours;- To administer apixaban 2.5 mg tablet via GT two times a day;- To administer furosemide 20 mg tablet via GT one time a day;- To administer losartan 100 mg tablet via GT one time a day;- To administer magnesium oxide 400 mg tablet via GT one time a day;- To administer meloxicam 15 mg tablet via GT one time a day;- To administer multivitamin with minerals tablet via GT one time a day;-To administer prednisone 5 mg tablet via GT one time a day;-To administer Pro-stat (supplement) 30 ml liquid via GT one time a day;-To administer Refresh tears ophthalmic solution 0.5% one drop in each eye four times a day;-To administer venlafaxine 75 mg tablet via GT one time a day; and-To administer vitamin C 500 mg tablet via GT one time a day. On 12/15/25 at 1457 hours, an interview was conducted with LVN 4. LVN 4 verified the above findings and stated leaving medication residue in cups resulted in the resident not receiving the correct doses. On 12/18/25 at 1125 hours, an interview was conducted with the DON. The DON verified the licensed nurses should be administering the complete dose of the medications and stated the failure to administer the full doses of the medications could result Residents Affected - Few (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055459 If continuation sheet Page 17 of 36 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 12/18/2025 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 in the resident not getting the full effect of the medication. 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 18 of 36 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 12/18/2025 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 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, facility document review, and facility P&P review, the facility failed to ensure food served was palatable, attractive, and at a safe and appetizing temperature for two of 87 Residents (Residents 53 and 81) who received food prepared in the kitchen. * Resident 53 and 81's meals were delivered and served cold. * Resident 53's beef was tough to cut with a knife and difficult to chew. These failures had the potential for decreased meal intake which could result in weight loss, decreased nutritive value, and negatively impact the residents' quality of life for all 87 residents who received food prepared in the kitchen. Findings: Review of the facility's Resident Matrix (list of all the residents currently in the facility and care areas triggered) received on 12/15/25, showed 87 out of 89 residents consumed food prepared in the kitchen. Review of the facility's policy titled Food Preparation and Service revised 11/2022 showed under Food Preparation, Cooking and Holding Time/Temperatures (1) The danger zone for food temperatures is above 41 F and below 135 F. This temperature range promotes the rapid growth of pathogenic microorganisms that cause foodborne illness. (3) . danger zone the greater the risk for growth of harmful pathogens.maintained at or below 41 F or at or above 135 F. (7) Fresh, . fruits and vegetables are cooked to a holding temperature of 135 F. 1. On 12/15/25 at 1035 hours, an interview was conducted with Resident 53. Resident 53 stated that the food was always cold and lacked taste. Medical record review for Resident 53 was initiated on 12/15/25. Resident 53 was admitted to the facility on [DATE], and was readmitted on [DATE]. On 12/16/25 at 1230 hours, an interview and concurrent trayline observation was conducted with the DS. The DS stated they did not have a warming element on the residents' trays to keep the plates warm. On 12/16/25 at 1250 hours, during lunch observation, two test trays were placed on the final meal cart (a Regular diet and a Pureed texture diet). On 12/16/25 at 1300 hours, after the last tray was served to the residents, the two test trays were removed from the meal cart. The food items tested included Roast Beef, Baked Potato, and Seasoned [NAME] Beans. The foods on the regular diet tray did not hold temperatures above 114 degrees Fahrenheit for beef, potato, and vegetables. The beef was tough to cut with a knife and difficult to chew. The DS acknowledged the findings. 2. On 12/17/25 at 0945 hours, an interview was conducted with Resident 81. Resident 81 stated the steak and pork were too tough, hard to eat, and the breakfast eggs in the morning were sometimes cold. Medical record review for Resident 81 was initiated on 12/15/25. Resident 81 was admitted to the facility on [DATE], and was readmitted on [DATE]. On 12/17/25 at 1130 hours, an interview was conducted with the Dietary Supervisor (DS). The DS stated anything above 110 degrees for food service was acceptable. A weekly test tray was done; however, there were not specific parameters on the test tray audit for the acceptable temperatures. The DS acknowledged the findings. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055459 If continuation sheet Page 19 of 36 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 12/18/2025 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 FORM CMS-2567 (02/99) Previous Versions Obsolete 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 P&P review, the facility failed to ensure the food safety and sanitation requirements were met in the kitchen. * The facility failed to ensure the kitchen equipment was kept in sanitary condition. * The facility failed to ensure the kitchen equipment was cleaned properly. * The facility failed to ensure the hair restraints were worn. These failures had the potential to pose the risk for exposure to food-borne illnesses in a medically vulnerable population of 87 residents who received food prepared in the kitchen. Findings: Review of the facility's Resident Matrix (list of all the residents currently in the facility and care areas triggered) received on 12/15/25, showed 87 of 89 residents consumed food prepared in the facility's kitchen. 1. According to the USDA Food Code 2022, Section 4-101.11, Multiuse, Characteristics, for 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 safe, durable, corrosion-resistant, nonabsorbent, finished to have a smooth, easily cleanable surface, and resistant to pitting, chipping, crazing, scratching, scoring, distortion, and decomposition. Review of the facility's P&P titled Sanitation revised 11/2022 showed the food service area is maintained in a clean and sanitary manner. All utensils, counters, shelves, and equipment are kept clean, maintained in good repair and are free from breaks, corrosion, open seams, cracks and chipped areas that may affect their use or proper cleaning. On 12/16/2025 at 1022 hours, during an observation of the kitchen with the Dietary Supervisor (DS), a shelving unit was observed with peeling paint. The DS acknowledged the findings. 2. According to the USDA Food Code 2022, 4-601.11 Equipment, Food - Contact Surfaces, Nonfood Contact Surface, and Utensils, the equipment food-contact surfaces and utensils shall be clean to sight and touch, the food-contact surfaces of cooking equipment and pans shall be kept free of encrusted grease deposits and other soil accumulations; and the nonfood- contact surface of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris. Review of the facility's P&P titled Sanitation revised 11/2022 showed the food service area is maintained in a clean and sanitary manner. All utensil, counters, shelves and equipment are kept clean, maintained in good repair and are free from breaks, corrosion, open seams, cracks and chipped areas that may affect their use or proper cleaning. On 12/16/2025 at 1022 hours, during an observation of the kitchen with the DS, two dishes that were stored with clean dishes had yellow food debris on the sides. The DS acknowledged the findings. 3. Review of the facility's P&P titled Preventing Foodborne Illness: Employee Hygiene and Sanitary practices revised 11/2022 showed food and nutrition services employees follow appropriate hygiene and sanitary procedures to prevent the spread of foodborne illness. Hair nets or caps and/or beard restraints are worn when cooking, preparing, or assembling food to keep hair from contacting exposed food, clean equipment, utensils, and linens. On 12/15/25 at 0853 hours, an observation was conducted in the kitchen. Dietary Aides 1 and 2 were observed with uncovered facial hair while working in the kitchen. On 12/15/2025 1011 hours, an interview was conducted in the kitchen with the DS. The DS was asked about the facility's policy regarding hair restraints. The DS stated facial hair should be covered. The DS was informed of Dietary Aides 1 and 2 with uncovered facial hair and the DS confirmed all facial hair should be covered with a hair restraint. Event ID: Facility ID: 055459 If continuation sheet Page 20 of 36 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 12/18/2025 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 0813 Have a policy regarding use and storage of foods brought to residents by family and other visitors. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, facility P&P review, and document review, the facility failed to ensure the facility's P&P on Foods Brought by Family/Visitors was followed. * The facility failed to ensure the safe food handling practices of outside food were explained to family/visitors in a language and format they understood. This failure had the potential to cause foodborne illness to the medically vulnerable resident population who consumed food [NAME] from outside resources.Findings: Review of CMS S&C-09-39 dated 5/29/09, showed the residents had the right to choose to accept food from visitors, family, friends, or other guests according to their rights to make choices. The CMS guideline further showed the facility has the responsibility under the food safety regulation to help the visitors to understand safe food handling practices such as not holding or transporting foods containing perishable ingredients at temperatures above 41 degrees Fahrenheit. Review of the facility's P&P titled Foods Brought by Family/ Visitors revised 8/2024 showed the food brought to the facility by visitors and family is permitted. Facility staff will strive to balance resident choice and a homelike environment with the nutritional and safety needs of the residents. Safe food handling practices are explained to family/visitors in a language and format that they understand. On 12/16/2025 at 0926 hours, an interview was conducted with LVN 4. LVN 4 stated she informed the families who brought in food from home of the resident's diet. The food can be kept in the refrigerator for two days then discarded. The food can be warmed up by the staff. LVN 4 added she had received an in-service regarding food brought to the facility from the family and visitors. When asked who gave the families information on safe food handling, LVN 4 stated, it was the role of the Director of Staff Development (DSD). On 12/16/2025 at 0945 hours, an interview and concurrent record review was conducted with the DSD. The facility record conducted to the staff by the DSD titled Education Program Lesson Plan for Food Brought in by Family/ Visitors dated 3/20/25, was reviewed with the DSD. When asked about the in-services/ education provided to the staff regarding safe food handling practices, the DSD stated it was the role of the nurses on the floor and the admissions department to provide information on safe food handling to the family and visitors. The education program's lesson plan did not include safe food handling information for the family and visitors. On 12/16/2025 at 1000 hours, an interview was conducted with the Admissions Director. The Admissions Director stated the residents received an admission packet which included the policy and procedure on food brought in by the family and visitors. When asked if it included education on safe food handling, the Admissions Director responded, no. On 12/16/2025 at 1010 hours, an interview was conducted with the Administrator. The Administrator stated there was a poster on the wall near the nursing station that educated the families and visitors regarding safe food handling. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055459 If continuation sheet Page 21 of 36 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 12/18/2025 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 observation, interview, medical record review, and facility P&P review, the facility failed to ensure the medical record for two of 19 final sampled residents (Residents 9 and 13) were complete and accurately documented. * The facility failed to ensure Resident 9's blood pressure (BP) access site was accurately documented in the resident's medical record. *The facility failed to ensure Resident 13's POLST Section D was completed and the social services' documentation was accurate. These failures had the potential for the residents' care needs not being met as their medical information was inaccurate. Findings: Review of the facility's P&P titled Hemodialysis Catheters - Access and Care of, revised 2/2023 showed to prevent infection and/or clotting do not use the access site arm to take blood samples, administer IV fluids, or give injections. Do not use the access arm to take blood pressure. 1. Medical Record Review for Resident 9 was initiated on 12/15/25. Resident 9 was admitted to the facility on [DATE], and was readmitted on [DATE]. Review of Resident 9's Plan of Care dated 7/22/25, showed a care plan problem with Focus Impaired Renal Function End Stage Renal Disease, on hemodialysis. The care plan included an intervention for no BP check or blood draw on the left arm. Review of Resident 9's Order Summary Report showed a physician's order dated 10/20/25, for no BP check or blood draw on the left upper arm. Review of Residents 9's MDS quarterly assessment dated [DATE], showed a BIMS score of 12, meaning moderately cognitively impaired. Review of Resident 9's documentation of BP showed: - On 11/30/25 at 1200 hours, a BP reading of 132/76 mmHg on the left arm; - On 12/3/25 at 0939 hours, a BP reading of 136/70 mmHg on the left arm; - On 12/4/25 at 1323 hours, a BP reading of 130/70 mmHg on the left arm; - On 12/5/25 at 0837 hours, a BP reading of 130/78 mmHg on the left arm; - On 12/5/25 at 1350 hours, a BP reading of 136/70 mmHg on the left arm; - On 12/5/25 at 1535 hours, a BP reading of 130/74 mmHg on the left arm; - On 12/6/25 at 0859 hours, a BP reading of 138/78 mmHg on the left arm; - On 12/6/25 at 1528 hours, a BP reading of 130/74 mmHg on the left arm; - On 12/8/25 at 1138 hours, a BP reading of 138/84 mmHg on the left arm; (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055459 If continuation sheet Page 22 of 36 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 12/18/2025 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 - On 12/12/25 at 0851 hours, a BP reading of 138/70 mmHg on the left arm; Level of Harm - Potential for minimal harm - On 12/13/25 at 0724 hours, a BP reading of 136/72 mmHg on the left arm; - On 12/13/25 at 1316 hours, a BP reading of 134/70 mmHg on the left arm; Residents Affected - Some - On 12/14/25 at 0912 hours, a BP reading of 126/70 mmHg on the left arm; - On 12/14/25 at 1314 hours, a BP reading of 130/76 mmHg on the left arm; - On 12/15/25 at 0745 hours, a BP reading of 132/74 mmHg on the left arm; - On 12/15/25 at 1024 hours, a BP reading of 128/70 mmHg on the left arm; and - On 12/16/25 at 0638 hours, a BP reading of 138/80 mmHg on the left arm. On 12/16/25 at 1220 hours, an interview and concurrent medical record review for Resident 9 was conducted with LVN 4. LVN 4 verified Resident 9 had an AV shunt on the left arm, and the licensed nurses' documentation of the Resident 9's was on the left arm. On 12/16/25 at 1307 hours, an interview was conducted with Resident 9. Resident 9 stated that he never allowed the licensed nurses to take his BP on the left upper arm. On 12/17/25 at 1556 hours, an interview for Resident 9 was conducted with RN 2. RN 2 verified the findings and stated the BP should not be taken on the left upper arm to prevent infection and risk for blood clot. On 12/18/25 at 1102 hours, an interview was conducted with the Administrator and DON. The Administrator and DON were informed and acknowledged the above findings. 2. Review of the facility's P&P titled POLST (undated), showed the POLST is a physician order form that complements an advance directive (a legal document that states a person's wishes about receiving medical care if that person is no longer able to make decisions) by converting an individual's wishes regarding life-sustaining treatment and resuscitation into physician's orders. Review of the facility's P&P titled Charting and Documentation revised 7/2017 showed documentation in the medical record will be objective, complete, and accurate. Medical record review for Resident 13 was initiated on 12/15/25. Resident 13 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 13's POLST dated 10/12/20, showed Section D for the advance directive was not completed. Furthermore, review of Resident 13's Social Service Review v1 – v3 dated 1/24/25, Section A, showed Resident 13 had issued an advance directive about her care and treatment. Review of Resident 13's H&P examination dated 1/25/25, showed Resident 13 had no capacity to make decisions. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055459 If continuation sheet Page 23 of 36 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 12/18/2025 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 On 12/17/25 at 1030 hours, an interview and concurrent medical record review for Resident 13 was conducted with the SSD. The SSD verified the above findings. The SSD stated Section D of Resident 13's POLST was left blank and should have been completed. In addition, the SSD stated Resident 13 had no advanced directive and verified the Social Service Review document was inaccurate. Furthermore, the SSD showed documented evidence of Resident 13's Multidisciplinary Care Conference v2 dated 5/13/24, that the resident's responsible party declined to create an advanced directive. On 12/18/25 at 1447 hours, an interview was conducted with the Administrator, DON, and Regional Nurse Resource. The Administrator, DON, and Regional Nurse Resource were informed and acknowledged the above findings. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055459 If continuation sheet Page 24 of 36 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 12/18/2025 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 observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to maintain the infection control practices to help prevent the development and transmission of diseases and infection. * The facility's Infection Prevention and Control Surveillance Logs for 2025 were incomplete and inaccurate. * The facility's Infection Control Committee Meeting Minutes and data presented were inaccurate for 2025. * LVN 4 failed to ensure the GT syringe was properly cleaned prior to storage. * The facility failed to ensure N95 masks stored in Medication Cart C were not expired. * LVN 1 failed to perform hand hygiene during the blood glucose check monitoring for Residents 64 and 77. Additionally, LVN 3 failed to perform hand hygiene during the blood glucose check monitoring for Residents 1 and 43. * LVN 1 failed to properly sanitize insulin pen during insulin administration for Resident 77. * The facility failed to ensure the EBP signage was posted outside Resident 35's door. * Staff personal belongings were kept in the clean linen area in the laundry room. * The facility failed to ensure Resident 18's bed control remote was sanitized prior to use, when it was on the floor. Additionally, CNA 4 did not perform hand hygiene after picking up the remote and providing care to the resident. These failures posed the risk of not identifying the residents' infections and thereby preventing the implementation of interventions, and control the potential transmission of communicable diseases to other residents in the facility.Findings: Residents Affected - Some Review of the facility's Policies and Practices – Infection Control P&P revised [DATE] showed objectives are to detect, investigate, and control infections in the facility. To maintain records of incidents and corrective actions related to infections. Review of the facility's Surveillance of Infections P&P revised [DATE] showed surveillance is used to identify cases and trends of significant organisms and HAI, to guide appropriate interventions, and prevent future infections. 1.a. Review of the facility's Infection Prevention and Control Surveillance Logs showed the following:[DATE] showed for 15 residents with suspected infections, 10 residents did not meet McGeer's Criteria. [DATE] showed for 24 residents with suspected infections, 15 residents' information were incomplete to show if the infections met McGeer's criteria. Nine were listed as HAI, and 15 as CAI. - February 2025 showed 21 residents with suspected infections, all 21 residents' information were incomplete to show if the infections met McGeer's criteria. All 21 were listed as CAI.- [DATE] showed 18 residents with suspected infections, all 18 residents' information were incomplete to show if the infections met McGeer's criteria. All 18 were listed as CAI.- [DATE] showed 18 residents with suspected infections, 16 residents' information were incomplete to show if the infections met McGeer's criteria. Two were listed as HAI, and 16 as CAI.[DATE] showed 26 residents with suspected infections, all 26 residents' information were incomplete to show if the infections met McGeer's criteria. All 26 were listed as CAI.- [DATE] showed 30 residents with suspected infections, 29 residents' information were incomplete to show if the infections met McGeer's criteria. One was listed as HAI, and 29 as CAI.- [DATE] showed 22 residents with suspected infections, all 22 residents' information were incomplete to show if the infections met McGeer's criteria. All 22 were listed as CAI.- [DATE] showed 28 residents with suspected infections, all 28 residents' information were incomplete to show if the infections met McGeer's criteria. All 28 were listed as CAI. - [DATE] showed 37 residents with suspected infections, all 37 residents' information were incomplete to show if the infections met McGeer's criteria. All 37 were listed as CAI. - [DATE] showed 29 residents with suspected infections, all 29 residents' information were incomplete to show if the infections met McGeer's criteria. All 28 were listed as CAI. - [DATE] showed 27 residents with suspected infections, 25 residents' information (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055459 If continuation sheet Page 25 of 36 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 12/18/2025 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 were incomplete to show if the infections met McGeer's criteria. Two were listed as HAI and 25 as CAI.[DATE] showed 9 residents with suspected infections, seven residents' information were incomplete and two showed N/A to show if the infections met McGeer's criteria. Two were listed as HAI and seven as CAI. On [DATE] at 1012 hours, an interview and concurrent facility document review was conducted with the IP. The IP stated she went to print 2025's Infection Prevention and Control Surveillance Logs earlier in the week and had technical issues resulting in lost data. The IP stated the residents' names and antibiotics were accurate since they auto populated. The IP stated the spreadsheet defaults to CAI if there was any missing data, which was why there were so many CAI's on the printed spreadsheets. The IP verified the log was incomplete and inaccurate for 2025. The IP stated some data was able to be retrieved, so any completed infections should be accurate (other than CAIs). b. On [DATE] at 1056 hours, an interview, medical record review, and concurrent facility document review was conducted with the IP. Review of the facility's [DATE]'s Infection Prevention and Control Surveillance Logs showed Resident 65 started antibiotics on [DATE], for a UTI. The IP stated she recalled the resident's infection meeting McGeer's Criteria even though the log was still incomplete. Review of Resident 65's medical record failed to show a clinical data to support the resident's infection met McGeer's Criteria. The IP verified the findings. c. On [DATE] at 1542 hours, an interview, medical record review and concurrent facility document review was conducted with the IP. Review of the facility's [DATE]'s Infection Prevention and Control Surveillance Logs showed Resident 46 started antibiotics on [DATE], for a UTI. The log showed it met McGeer's Criteria. Review of Resident 46's medical record failed to show clinical data to support the resident's infection met McGeer's Criteria. The IP verified the findings. d. On [DATE] at 1542 hours, an interview, medical record review and concurrent facility document review was conducted with the IP. Review of the facility's [DATE]'s Infection Prevention and Control Surveillance Logs showed Resident 47 started antibiotics on [DATE], for a UTI. The log failed to show if it met McGeer's Criteria. Review of Resident 47's medical record failed to show clinical data to support the resident's infection met McGeer's Criteria. The IP verified the findings. 2. Review of the facility's Infection Control Committee Meeting Minutes for 2025 showed the following:dated [DATE], a total of 17 infections in January, with six HAI and 12 CAI. The minutes failed to show how many infections met McGeer's Criteria Infection Control Committee Meeting Minutes. The data presented did not match the data on the Infection Prevention and Control Surveillance Logs for [DATE] (15 infections, with 12 HAI and three CAI) or [DATE] (24 infections, with nine HAI and 15 CAI), as shown in 1.a. above. dated [DATE], a total of 13 infections in February. The minutes failed to show how many infections met McGeer's Criteria and were HAI or CAI. The data presented did not match the data on the Infection Prevention and Control Surveillance Logs for January (24 infections, with nine HAI and 15 CAI) or February (21 infections, with 21 CAI) 2025, as shown in 1.a. above. - dated [DATE], a total of 13 infections, with four HAI and nine CAI. The minutes failed to show how many infections met McGeer's Criteria. The data presented did not match the data on the Infection Prevention and Control Surveillance Logs for February (21 infections, with 21 CAI) or March (18 infections, with 18 CAI) 2025, as shown in 1.a. above.- dated [DATE], a total of 16 infections, with two HAI and 16 CAI. The minutes failed to show how many infections met McGeer's Criteria. The data presented did not match the data on the Infection Prevention and Control Surveillance Logs for March (18 infections, with 18 CAI) or April (18 infections, with two HAI and16 CAI) 2025, as shown in 1.a. above.- dated [DATE], a total of 5 infections, with two HAI and three CAI. The minutes failed to show how (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055459 If continuation sheet Page 26 of 36 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 12/18/2025 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 many infections met McGeer's Criteria. The data presented did not match the data on the Infection Prevention and Control Surveillance Logs for April (18 infections, with two HAI and16 CAI) or May (26 infections, with 26 CAI) 2025, as shown in 1.a. above. - dated [DATE], a total of seven infections, with three HAI and four CAI. The minutes failed to show how many infections met McGeer's Criteria. The data presented did not match the data on the Infection Prevention and Control Surveillance Logs for May (26 infections, with 26 CAI) or June (30 infections, with one HAI and 29 CAI) 2025, as shown in 1.a. above. dated [DATE], showed for the month of July there were 16 infections, with 14 HAI and two CAI. The minutes failed to show how many infections met McGeer's Criteria. The data presented did not match the data on the Infection Prevention and Control Surveillance Logs for June (30 infections, with one HAI and 29 CAI) or July (22 infections, with 22 CAI) 2025, as shown in 1.a. above. - dated [DATE], a total of 27 infections, with 19 HAI and 9 CAI. The minutes failed to show how many infections met McGeer's Criteria. The data presented did not match the data on the Infection Prevention and Control Surveillance Logs for July (22 infections, with 22 CAI) or August (28 infections, with 28 CAI) 2025, as shown in 1.a. above. - dated [DATE], for the month of September a total of 37 infections. The minutes failed to show how many infections were HAI/CAI and if they met McGeer's Criteria. The data presented did not match the data on the Infection Prevention and Control Surveillance Logs for August (28 infections, with 28 CAI) or September (37 infections, with 37 CAI) 2025, as shown in 1.a. above. - dated [DATE], for the month of October a total of 27 infections. The minutes failed to show how many infections were HAI/CAI and if they met McGeer's Criteria. The data presented did not match the data on the Infection Prevention and Control Surveillance Logs for September (37 infections, with 37 CAI) or October (29 infections, with 29 CAI) 2025, as shown in 1.a. above.- dated [DATE], a total of 25 infections, with two HAI and three CAI. The minutes failed to show how many infections were HAI/CAI and if they met McGeer's Criteria. The data presented did not match the data on the Infection Prevention and Control Surveillance Logs for October (29 infections, with 29 CAI) or November (27 infections, with 2 HAI and 25 CAI) 2025, as shown in 1.a. above.- dated [DATE], showed a total of 24 infections in November, with 16 HAI and 8 CAI. The minutes failed to show how many infections met McGeer's Criteria. The data presented did not match the data on the Infection Prevention and Control Surveillance Logs for November (27 infections, with 2 HAI and 25 CAI) 2025, as shown in 1.a. above. On [DATE] at 1043 hours, an interview was conducted with the Administrator. The Administrator stated the monthly Infection Control Committee Meetings review the previous month's data and should include all suspected infections as well as infections that did not meet McGeer's Criteria. On [DATE] at 1542 hours, an interview and concurrent facility document review was conducted with the IP. The IP stated the data presented at the monthly Infection Control Committee Meetings is from the previous month, and any months where it showed the current month's data was being reviewed were incorrect. The IP stated for the monthly meeting, she reports all suspected infections with antibiotic use, not the infections that meet McGeer's Criteria. In addition, the IP verified the above findings and stated the data presented in all of 2025's monthly Infection Control Committee meetings did not match the data in the Infection Prevention and Control Surveillance Logs. 3. Review of the facility's P&P titled Handwashing/Hand Hygiene revised [DATE] showed the following: - This facility considers hand hygiene the primary means to prevent the spread of healthcare-associated infections. - All personnel are expected to adhere to hand hygiene policies and practices to help prevent the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055459 If continuation sheet Page 27 of 36 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 12/18/2025 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 spread of infections to other personnel, residents, and visitors. Level of Harm - Minimal harm or potential for actual harm - Hand hygiene is indicated immediately before touching a resident, after touching a resident, after touching the resident's environment, and immediately after glove removal. Residents Affected - Some On [DATE] at 0818 hours, a medication administration observation for Resident 2 was conducted with LVN 4. LVN 4 prepared and administered the following medications to Resident 2: - One tablet of amlodipine (calcium channel blocker) 5 mg tablet via GT one time a day; - One tablet of aspirin (NSAID) 81 mg tablet via GT one time a day; - One tablet of atenolol (beta-blocker) atenolol 50 mg tablet via g GT one time a day; - One tablet of cranberry (supplement) 450 mg tablet one time a day via GT; - Restasis ophthalmic emulsion 0.5% one drop in each eye every 12 hours; - One tablet of apixaban (anticoagulant) 2.5 mg tablet via GT two times a day; - One tablet of furosemide (diuretic) 20 mg tablet via GT one time a day; - One tablet of losartan (antihypertensive) 100 mg tablet via GT one time a day; - One tablet of magnesium oxide (mineral) 400 mg tablet via GT one time a day; - One tablet of meloxicam (NSAID) 15 mg tablet via GT one time a day; - One tablet of multivitamin with minerals tablet via GT one time a day; - One tablet of prednisone (corticosteroid) 5 mg tablet via GT one time a day; - Pro-stat (supplement) 30 ml liquid via GT one time a day; - Refresh tears ophthalmic solution 0.5% one drop in each eye four times a day; - One capsule of venlafaxine (antidepressant) 75 mg tablet via GT one time a day; and - One tablet of vitamin C 500 mg tablet via GT one time a day. LVN 4 prepared and administered the medications to Resident 2. However, following the medication administration, LVN 4 placed the syringe used for GT medication administration back in the storage bag without cleaning it. LVN 4 was asked to remove the syringe from the bag. Upon inspection, the syringe was found to have medication residue on the black rubber portion of the plunger. On [DATE] at 1457 hours, an interview was conducted with LVN 4. LVN 4 verified the above findings and stated the syringe should be cleaned in the sink when there was visible residue. 4. On [DATE] at 0839 hours, an inspection of Medication Cart C and concurrent interview was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055459 If continuation sheet Page 28 of 36 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 12/18/2025 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 conducted with RN 2. During the inspection, a box of BYD Care N95 particulate respirators was found with an expiration date of [DATE]. There were twelve masks remaining of the twenty. RN 2 stated Medication Cart C was only used for storage of extra supplies and was not routinely checked. RN 2 stated supervisors and nurses have access to the supplies in Medication Cart C. RN 2 verified the N95 masks were expired and stated use of expired N95 masks can reduce the effectiveness of protecting the nurse. Residents Affected - Some 5. a. On [DATE] at 1119 hours, an observation for Resident 64 was conducted with LVN 1. LVN 1 donned gloves after sanitizing her medication cart without performing hand hygiene first. LVN 1 performed the blood glucose check and removed gloves to prepare insulin, without performing hand hygiene. LVN 1 administered insulin to Resident 64, removed her gloves and did not perform hand hygiene. Medical record review for Resident 64 was initiated on [DATE]. Resident 64 was admitted to the facility on [DATE]. Review of Resident 64's H&P examination dated [DATE], showed Resident 64 was able to understand & make treatment decisions. Review of Resident 64's Order Summary Report dated [DATE], showed an order dated [DATE], to administer insulin regular human injection solution 100 unit/ml (insulin regular human) per sliding scale, subcutaneously before meals and at bedtime for DM using lancets and test strips. Rotate injection sites. b. On [DATE] at 1138 hours, an observation for Resident 77 was conducted with LVN 1. LVN 1 removed her gloves after sanitizing her cart, proceeded to prepare testing supplies, closed Resident 77's curtain, and donned gloves without performing hand hygiene. LVN 1 completed Resident 77's blood glucose check and removed gloves without performing hand hygiene. LVN 1 prepared Resident 77's insulin and donned a new pair of gloves to administer insulin to Resident 77. Medical record review for Resident 77 was initiated on [DATE]. Resident 77 was admitted to the facility on [DATE]. Review of Resident 77's H&P examination dated [DATE], showed Resident 77 was able to make very simple decisions. Review of Resident 77's Order Summary Report dated [DATE], showed an order dated [DATE], to administer Humalog solution 100 unit/mL (insulin/lispro) per sliding scale subcutaneously before meals and at bedtime for DM. Finger stick AC and HS with lancet, test strips, rotate injection site. On [DATE] at 1144 hours, an interview was conducted with LVN 1. LVN 1 verified she was aware of the hand hygiene policy and should be washing her hands before and after performing resident care and when removing gloves. LVN 1 stated she failed to follow policy due to being nervous during the observation. c. On [DATE] at 1112 hours, an observation for Resident 1 was conducted with LVN 3. LVN 3 completed the blood glucose check and removed the gloves without performing hand hygiene immediately after removing the gloves. Medical record review for Resident 1 was initiated on [DATE]. Resident 1 was admitted to the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055459 If continuation sheet Page 29 of 36 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 12/18/2025 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 facility on [DATE], and readmitted to the facility on [DATE]. Level of Harm - Minimal harm or potential for actual harm Review of Resident 1's H&P examination dated [DATE], showed Resident 1 was unable to understand and make treatment decisions due to dementia. Residents Affected - Some Review of Resident 1's Order Summary Report showed an order dated [DATE], to administer insulin regular human injection solution 100 unit/mL (insulin regular/human) per sliding scale subcutaneously every six hours for DM using lancets and test strips. Rotate injection sites. d. On [DATE] at 1130 hours, an observation for Resident 43 was conducted with LVN 3. LVN 3 completed the blood glucose check and removed the gloves without performing hand hygiene immediately after removing gloves. Medical record review for Resident 43 was initiated on [DATE]. Resident 43 was admitted to the facility on [DATE]. Review of Resident 43's H&P examination dated [DATE], showed Resident 43 was noncompetent. Review of Resident 43's Order Summary Report dated [DATE], showed an order dated [DATE], to administer insulin regular human injection solution pen-injector 100 unit/mL (insulin regular/human) inject as per sliding scale subcutaneously before meals and at bedtime for DM. Finger stick AC meals and HS, with test strips, lancet, and rotate injection site. On [DATE] at 1052 hours, an interview was conducted with LVN 3. LVN 3 verified he was aware of the hand hygiene policy and should be washing his hands before and after performing resident care and when removing gloves. 6. Medical record review for Resident 77 was initiated on [DATE]. Resident 77 was admitted to the facility on [DATE]. Review of Resident 77's Order Summary Report dated [DATE], showed an order dated [DATE], to administer Humalog solution 100 unit/mL (insulin/lispro). Inject as per sliding scale: if 0 - 60 mg/dl = 0 Units, less than 60 mg/dl call MD; 61 - 150 mg/dl = 0 Units; 151 - 200 mg/dl = 2 Units; 201 - 250 mg/dl = 4 Units; 251 - 300 mg/dl = 6 Units; 301 - 350 mg/dl = 8 Units; 351 - 400 mg/dl = 10 Units; 401 - 999 mg/dl call MD, subcutaneously before meals and at bedtime for DM. Finger stick before meals and nightly with lancet, test trips, rotate injection site, call MD if blood glucose less than 70 mg/dl or greater than 400 mg/dl. Review of Resident 77's H&P examination dated [DATE], showed Resident 77 was able to make very simple decisions. On [DATE] at 1138 hours, an observation of Resident 77 was conducted with LVN 1. LVN 1 performed a blood glucose check on Resident 77. The result was 202 and based on the sliding scale, Resident 77 needed four units of insulin. LVN 1 removed Resident 77's insulin pen KwikPen from her cart. LVN 1 removed the cap of the kwikPen and attached it to a sterile needle. LVN 1 did not clean the top of the KwikPen with an alcohol swab prior to attaching it to the sterile needle. LVN 1 proceeded to administer four units of insulin to Resident 77. On [DATE] at 1144 hours, an interview was conducted with LVN 1. LVN 1 verified she was aware she (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055459 If continuation sheet Page 30 of 36 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 12/18/2025 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 should have cleaned the top of the KwikPen with alcohol prior to attaching it to the sterile needle but missed that step. On [DATE] at 1125 hours, an interview was conducted with the DON. The DON verified the nurses should be cleaning the syringe in the sink if the final flush of water does not remove the residue. The DON also verified there should not be expired masks available for use. The DON also verified nurses should be performing hand hygiene before and after resident care and when they remove their gloves. The DON also verified the nurses should be cleaning the top of the KwikPen with alcohol prior to attaching the sterile needle. 7. Review of the facility's P&P titled Enhanced Barrier Precautions dated 8/2022 showed the EBPs were utilized to prevent the spread of MDROs to the residents. The EBPs are indicated for residents with wounds regardless of MDRO colonization. Signs are posted on the door or wall outside of the resident room indicating the type of precaution and PPE required. On [DATE] at 0959 hours and 1134 hours, Resident 35 was observed laying on his bed, in his room. There was no EBP signage posted in his room nor by the door. Medical record review for Resident 35 was initiated on [DATE]. Resident 35 was admitted to the facility on [DATE] and readmitted on [DATE]. Resident 35 had a diagnosis of a stage 4 pressure ulcer of the sacral region. Review of Resident 35's Care Plan Report dated [DATE], showed a care plan for EBP related to the resident's wound infection with interventions including placing the EBP signage at the resident's door entry. Review of Resident 35's Order Summary Report showed a physician's order dated [DATE], for EBP due to Resident 35's wound. On [DATE] at 1138 hours, an observation, interview and concurrent medical record review for Resident 35 was conducted with LVN 3. LVN 3 verified the above findings. LVN 3 stated Resident 35 had the EBP due to his wound and the EBP signage should have been posted by the resident's door to inform the staff members. On [DATE] at 1447 hours, an interview was conducted with the Administrator, DON, and Regional Nurse Resource. The Administrator, DON, and Regional Nurse Resource were informed and acknowledged the above findings. 8. On [DATE] at 1033 hours, an inspection of the facility's clean laundry room was conducted with the Laundry Aide. A facility staff member's personal backpack, lunch bag, and tumbler were sitting inside of a rolling clothing rack and touching the residents' clean clothing. The Laundry Aide stated she should not have put her personal items touching the residents' clean clothing. The Laundry Aide verified the above findings. On [DATE] at 1114 hours, an interview was conducted with the Maintenance Supervisor. The Maintenance Supervisor stated the laundry staff were meant to keep their personal belongings in the facility's lockers. The Maintenance Supervisor stated the Laundry Aides should not have their personal items where the residents clean clothing is kept. The Maintenance Supervisor acknowledged the above findings. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055459 If continuation sheet Page 31 of 36 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 12/18/2025 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 9. Review of the facility P&P titled Handwashing/Hand Hygiene revised 10/2023 showed this facility considers hand hygiene the primary means to prevent the spread of healthcare-associated infections. Hand hygiene is indicated: after contact with blood, body fluids, or contaminated surfaces. On [DATE] at 1118 hours, during initial tour of the facility, CNA 3 was taking care of Resident 18. Resident 18's bed control remote was on the floor. CNA 3 picked up the bed control remote from the floor with gloves, and used the remote to lower the head and foot of the bed. CNA 3 gave the bed control remote to the resident without sanitizing the remote. CNA 3 then changed Resident 18 without changing the gloves. On [DATE] at 1125 hours, an interview was conducted with CNA 3. CNA 3 acknowledged he did not disinfect the bed control and used the same gloves when changing Resident 18's diaper. On [DATE] at 0755 hours, an interview was conducted with the DSD. The DSD stated the CNA should have disinfected the bed control before using it. The DSD further stated that CNA should have washed his hands and changed gloves before changing Resident 18 diaper to prevent infection. On [DATE] at 1102 hours, an interview was conducted with the Administrator and DON. The Administrator and DON were informed and acknowledged the above findings. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055459 If continuation sheet Page 32 of 36 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 12/18/2025 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 follow up with the physician regarding the residents on the antibiotic therapy who did not have true infections based on the McGeer's criteria listed in the Infection Prevention and Control Surveillance Logs for 2025 and for three nonsampled residents (Residents 46, 47, and 65) * Residents 46, 47, and 65's physicians' were not notified to reevaluate their antibiotics when their infections did not meet the McGeer's criteria. In addition, the facility's Infection Prevention and Control Surveillance Logs were incomplete and failed to show the dates/times when the IP followed up with the physicians for other residents who were prescribed antibiotics whose infections did not meet the McGeer's criteria. These failures had the potential for the residents to receive unnecessary antibiotic therapy and put them at risk for MDROs. Findings: 1. Review of the facility's Antibiotic Stewardship P&P revised 4/2025 showed the laboratory results and the current clinical situation will be communicated to the prescriber as soon as available to determine if antibiotic therapy should be started, continued, modified, or discontinued. a. Review of the facility's Infection Prevention and Control Surveillance Logs for 2025 showed the following:- January, showed comments that four infections did not meet McGeer's criteria, the physician was notified and ordered to continue the antibiotics. - February, failed to show if any of the 21 infections met the McGeer's criteria. There were no comments to show if the IP followed up with the physician.- March, failed to show if any of the 18 infections met the McGeer's criteria. There were no comments to show if the IP followed up with the physician.- April, failed to show if 16 of 18 infections failed to meet the McGeer's criteria, including one comment that culture results showed multiple organisms and MD ordered to continue antibiotics. - May, failed to show if any of the 26 infections met the McGeer's criteria. There were no comments to show if the IP followed up with the physician.- June, failed to show if 29 of 30 infections met the McGeer's criteria. There were no comments to show if the IP followed up with the physician.- July, failed to show if any of the 22 infections met the McGeer's criteria. There were no comments to show if the IP followed up with the physician.- August, failed to show if any of the 28 infections met the McGeer's criteria. There were no comments to show if the IP followed up with the physician.- September, failed to show if any of the 37 infections met the McGeer's criteria. There were no comments to show if the IP followed up with the physician.- October, failed to show if any of the 29 infections met the McGeer's criteria. There were no comments to show if the IP followed up with the physician.- November, failed to show if 25 of the 27 infections met the McGeer's criteria. There were no comments to show if the IP followed up with the physician.- December, failed to show if five of the nine infections were reviewed timely and if they met the McGeer's criteria. There were no comments to show if the IP followed up with the physician.A random review of the residents' medical record failed to show the physicians' orders were obtained to continue the antibiotic therapy after not meeting the McGeer's criteria. On 12/17/25 at 1012 hours, an interview and concurrent record review was conducted with the IP. The IP stated when infections did not meet the McGeer's criteria for infections, she called the physician and documented the outcome in the comment section of the surveillance log. The IP stated she did not document anywhere else, including the residents' medical record. The IP stated for the comments where she notified the physician/MD, and they ordered to continue the treatment, she did not actually obtain a physician's order and simply meant she notified the physician, and the physician wanted to continue with the antibiotics. The IP stated she did not document her discussion with the physician anywhere else, and did not have dates/times for her log's comments when she followed-up with the physician. The IP also stated she had technical issues and lost data for all of the 2025's surveillance logs. b. On Residents Affected - Some (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055459 If continuation sheet Page 33 of 36 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 12/18/2025 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete 12/17/25 at 1056 hours, a follow-up interview and record review was conducted with the IP. Review of the December 2025 facility's Infection Prevention and Control Surveillance Logs showed Resident 65 started antibiotics on 12/5/25, for a UTI. The IP stated she recalled the resident's infection meeting the McGeer's criteria even though the log was still incomplete, and therefore she did not need to call the physician to follow up on their antibiotic use. Review of Resident 65's medical record failed to show a clinical data to support the resident's infection met the McGeer's criteria. The IP verified the findings and stated she should have notified the physician to reevaluate the antibiotic use. c. On 12/17/25 at 1542 hours, a follow up interview and concurrent record review was conducted with the IP. Review of January 2025 facility's Infection Prevention and Control Surveillance Logs showed Resident 46 started antibiotics on 1/1/25, for a UTI. The log showed it met McGeer's Criteria. Review of Resident 46's medical record failed to show clinical data to support the resident's infection met the McGeer's criteria. The IP verified the findings and stated she should have followed up with the physician to reevaluate the antibiotic use. d. On 12/17/25 at 1542 hours, a follow up interview and concurrent record review was conducted with the IP. Review of November 2025 facility's Infection Prevention and Control Surveillance Logs showed Resident 47 started antibiotics on 11/17/25, for a UTI. The log failed to show if it met the McGeer's criteria. Review of Resident 47's medical record failed to show clinical data to support the resident's infection met the McGeer's criteria. The IP verified the findings and stated she should have followed up with the physician to reevaluate the antibiotic use. Event ID: Facility ID: 055459 If continuation sheet Page 34 of 36 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 12/18/2025 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 maintain the essential equipment in a clean, sanitary, and safe operating condition for one of two washing machines inspected (Washing Machine 1). * Washing Machine 1 was observed with dark red, green, and white build up on the inner door window. In addition, the rubber lining of the inside of the washing machine door was observed with thick brown and white build up. These failures had the potential for the essential equipment to not function in the way it was intended and expose the residents to unsafe practices.Findings: Review of the facility's P&P titled Maintenance Service revised 12/2009 showed the maintenance department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times. The Maintenance Director is responsible for developing and maintaining a schedule of maintenance service to assure that the buildings, grounds, and equipment are maintained in a safe and operable manner. 1. On 12/15/25 at 1046 hours, an interview and concurrent observation of Washing Machine 1 was conducted with the Laundry Aide. During the observation, the washing machine's inner door window was observed to have a dark red, green, and white build up. When the Laundry Aide was asked about the facility's process in cleaning the identified part of the washing machine's door, the Laundry Aide stated she was unable to clean the part of the door which was noted with dark red, green, and white build up since it was meant to be sealed off. The Laundry Aide stated they had no cleaning log for the washing machines. On 12/15/25 at 1510 hours, an interview was conducted with the Maintenance Supervisor. The Maintenance Supervisor stated the Laundry Aides were responsible for cleaning the two washing machines in the facility. The Maintenance Supervisor further stated if the cleaning needed to be done was more technical, he will have his assistant help clean it, or he will call a vendor to have them clean or fix the washing machine. The Maintenance Supervisor stated the washing machines were cleaned weekly with bleach. When asked if there was a log for cleaning the washing machines, the Maintenance Supervisor stated the laundry aides did not fill out a log when the washing machines have been cleaned. When the Maintenance Supervisor was asked about the washing machine's inner door window with the dark red, green, and white build up that was observed, he stated he noticed the buildup on the washing machine's inner door window and stated stated he brought it up to the management. When asked if he had documentation to show he addressed the issue with the management, the Maintenance Supervisor stated he did not have documentation to show he addressed the buildup observed from Washing Machine 1. On 12/16/25 at 0820 hours, an interview was conducted with the Maintenance Supervisor. The Maintenance Supervisor stated the dark red, green, and white buildup should not have been there. The Maintenance Supervisor verified the above findings. 2. On 12/15/25 at 1048 hours an interview and concurrent observation of Washing Machine 1 was conducted with the Laundry Aide. During the observation, the Laundry Aide was asked to open the washing machine door. Once the door was opened, a thick brown and white build up was observed on the rubber lining of the inside of the washing machine door. The Laundry Aide was asked about the facility's process in cleaning the identified part of the washing machine's door, she stated she cleaned the washing machine every week, and the last time she cleaned it was last Friday. When asked if there was a log for cleaning the washing machines, the Laundry Aide stated they did not have a log for cleaning the washing machines. On 12/15/25 at 1510 hours, an interview was conducted with the Maintenance Supervisor. The Maintenance Supervisor stated the Laundry Aides were responsible for cleaning the washing machines, and they should be cleaned every week. When asked if there was a log for cleaning the washing machines, he stated the laundry aides did not fill out a log when they have cleaned them. The Maintenance Supervisor was made aware and acknowledged the above findings. The Maintenance Supervisor stated the rubber lining inside Washing Machine 1 should have Residents Affected - Few (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055459 If continuation sheet Page 35 of 36 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 12/18/2025 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 Level of Harm - Minimal harm or potential for actual harm been cleaned. On 12/18/25 at 1102 hours, an interview was conducted with the Administrator, DON, and Regional Nurse Resource. The Administrator, DON, and the Regional Nurse Resource acknowledged the findings. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055459 If continuation sheet Page 36 of 36