Health inspection·August 1, 2024

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 provide the necessary care and services to attain or maintain the highest practicable well-being for one of three sampled residents (Resident 1). Residents Affected - Few * The facility failed to ensure Resident 1 was assessed and monitored by a licensed nurse regarding bruises. In addition, the facility failed to ensure the physician or Resident 1's representative was notified of the bruises. This failure had the potential for not providing necessary care and services for the resident. Findings: Review of the facility's P&P titled Change in Condition dated 3/2021 showed it is the policy of this facility that any changes in a resident's condition be thoroughly assessed and evaluated with physician notification for early clinical management to avoid unnecessary readmissions to acute hospitals. If there is a significant change in the resident's physical or mental condition, a thorough assessment of the resident's condition must be done by a licensed nurse. The assessment results should assist the physician in determining the course of clinical management for the resident. Review of the facility's P&P titled Abuse Reporting and Prevention dated 4/2024 showed under the section for Reporting Procedure, the Administrator or designee shall make a reasonable attempt to reach a conclusion as to the cause of the injury and to take corrective actions during an investigation to provide a safe environment for the resident(s). Closed medical record review for Resident 1 was initiated on 8/1/24. Resident 1 was admitted to the facility on [DATE], and discharged to the acute care hospital on 6/28/24. Review of Resident 1's H&P examination dated 6/7/24, showed Resident 1 did not have the capacity to understand and make decisions. Review of Resident 1's Initial Nursing History and assessment dated [DATE], showed Resident had right upper cheek redness skin discoloration and right forehead redness. Review of Resident 1's Order Summary Report showed a physician's order dated 6/7/24, to administer Eliquis (blood thinner) 2.5 mg tablet one tablet by mouth two times a day for atrial fibrillation (irregular and very rapid heart rhythm). Review of the facility's investigation documents related to fall and purplish bilateral lower legs (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 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 08/01/2024 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)