F 0584
Level of Harm - Potential for
minimal harm
Residents Affected - Some
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited
to receiving treatment and supports for daily living safely.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview, and facility P&P review, the facility failed to maintain a clean and homelike
environment for one of four sampled residents (Resident 4).
* Resident 4's portable AC unit tubing was observed to be disconnected and lying on the floor, and visible
dust particles were observed on the surface of the tubing and floor. This failure had the potential to
negatively impact the resident's quality of life.
Findings:
Review of the facility's P&P titled Comfortable Environment revised 01/2018 showed it is the policy of the
facility to maintain a safe, clean, comfortable environment for the residents.
Medical record review for Resident 4 was initiated on 7/1/24. Resident 4 was admitted to the facility on
[DATE].
On 7/1/24 at 1230 hours, an observation and concurrent interview was conducted with the Maintenance
Assistant. The portable AC unit closest to Resident 4 was observed with the tubing lying on the floor with
visible dust particles on the surface of the tubing and floor. The Maintenance Assistant did not know how
the AC unit tubing got disconnected and stated he did not clean the portable AC unit as per the
manufacturer's guidelines.
On 7/1/24 at 1330 hours, an interview was conducted with the Administrator. The Administrator stated the
AC unit should be cleaned as per the manufacturer's guidelines.
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 2
Event ID:
055571
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
055571
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
07/02/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Buena Park Nursing Center
8520 Western Avenue
Buena Park, CA 90620
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 0604
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
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 one of four sampled
residents (Resident 1) was free from the physical restraints.
Residents Affected - Few
* The facility failed to obtain the informed consent prior to applying the hand mittens (mittens which look like
boxing gloves that immobilize the resident's fingers) and physician's order for the hand mitten use; and
develop a plan of care related to the use of the hand mittens. This failure posed the risk of compromising
the resident's independence and psychosocial well-being.
Findings:
Review of the facility's P&P titled Physical Restraints revised 1/2017 showed the restraints will only be used
with the informed consents from the residents, physicians, and/or representatives. Upon admission, the
residents shall be assessed for the need or lack of physical restraints. Written orders for the use of
restraints should specify the use of the restraints. An interdisciplinary assessment team in coordination with
the residents and his/her family or representatives develop and maintain the comprehensive care plans for
the residents. The use of restraints should be identified on the residents' plans of care.
Medical record review for Resident 1 was initiated on 7/1/24. Resident 1 was admitted to the facility on
[DATE], and discharged to the acute care hospital on 6/13/24.
Review of Resident 1's Restraint Assistive Device Assessment and Reduction Management Program dated
6/12/24, showed a possible approach of the hand mittens to prevent from pulling out the medical devices.
Review of Resident 1's MDS dated [DATE], showed Resident 1's cognitive skills for daily decision making
were severely impaired. Review of Resident 1's MDS, Section P, under the Physical Restraints, showed the
physical restraints were not used.
Review of Resident 1's Subacute Daily Progress Notes showed the hand mittens were applied on 6/12 and
6/13/24.
Further review of Resident 1's medical record show no documented evidence of the following:
- Informed consent was obtained prior to applying the hand mittens,
- Physician's order was obtained for the hand mittens, and
- Care plan was developed to address the hand mitten use.
On 7/1/24 at 1205 hours, an interview and concurrent medical record review was conducted with RN 1. RN
1 verified the above findings.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055571
If continuation sheet
Page 2 of 2
