Health inspection·October 30, 2025

F 0693 Level of Harm - Actual harm Residents Affected - Few Gastroparesis can delay digestion, which can lead to various symptoms and complications. Complications of gastroparesis may include dehydration due to repeated vomiting malnutrition due to poor absorption of nutrients, blood glucose, also called blood sugar, levels that are harder to control, which can worsen diabetes. https://www.niddk.nih.gov/health-information/digestive-diseases/gastroparesis/definition-facts Review of an article published in National Library of Medicine titled A Study of Variations of the Stomach in Adults and Growth of the Fetal Stomach dated 8/28/22, showed the stomach's capacity varies from 30 ml at birth, increases to 1000 ml at puberty, and 1500 ml in adults https://pmc.ncbi.nlm.nih.gov/articles/PMC9515405/ On 10/23/25 at 1148 hours, a telephone interview was conducted with Resident Representative 1. Resident Representative 1 stated Resident 1's GJ tube was clogged in the facility then Resident 1 was transferred to the acute care hospital where they found his blood sugar dropped to the critical level of 36 where he could have died. Resident Representative 1 further stated the doctor from the acute care hospital told her Resident 1's J tube was clogged with large amount of medications.Closed medical record review for Resident 1 was initiated on 10/23/25. Resident 1 was admitted to the facility on [DATE] and discharged on 10/15/25.Review of Resident 1's H&P examination dated 10/9/25, showed Resident 1 had no capacity to understand and make decisions. Review of the H&P further showed Resident 1 had diagnoses which included diabetes, gastroparesis and ventilator-dependent respiratory failure; and had a tracheostomy tube and GJ tube .Review of Resident 1's MDS assessment dated [DATE], showed Resident 1 was dependent on facility staff for his activities of daily living. Further review of the MDS showed Resident 1 had a feeding tube and received more than 51% calorie through the parenteral or tube feeding.Review of Resident 1's Order Summary Report showed the following physician's orders:- dated 10/8/25, (a) give Nepro (a feeding formula) at 55 ml/hour for 16 hours through the J tube via enteral pump to provide 880 ml/1584 calorie in 24 hours. To start at 1300 hours, and to stop at 0500 hours, or until dose limit is completed, (b) insulin Glargine (an insulin) subcutaneous solution 100 unit/ml, to administer 25 units subcutaneously at bedtime for diabetes mellitus, and (c) insulin lispro (rapid-acting insulin used to manage blood sugar levels in people with diabetes mellitus) injection solution 100 unit/ml, to inject as per sliding scale subcutaneously every six hours for diabetes mellitus if blood sugar:less than 70, to notify medical doctor,70-149 mg/dl, to give 0 units;150-200 mg/dl, to give 3 units;201-250 mg/dl, to give 6 units;251-300 mg/dl, to give 9 units;301-350 mg/dl, to give 12 units;351-400 mg/dl, to give 15 units;401 mg/dl or more, to give 18 units and to notify the MD;- dated 10/9/25, J tube water flush 10 ml per hour via enteral pump to provide 160ml in 24 hours. To start at 1300 hours, and to stop at 0500 hours, or until dose limit is completed; and- dated 10/15/25, to transfer Resident 1 to the Acute Care Hospital for J tube replacement. Review of Resident 1's MAR for October 2025 showed Resident 1 received the insulin Glargine 25 units on 10/14/25 at 2100 hours, and insulin lispro 3 units on 10/15/25 at 0000 hours for the blood sugar of 152 mg/dl. In addition, the MAR showed Resident 1 had a blood sugar level of 84 on 10/15/25 at 0600 hours.Review of Resident 1's Nurses Progress Notes entry by RN 3 dated 10/15/25 showed the following:- at 0720 hours, night shift reported Resident 1's J tube was clogged but the G tube was functional. Upon assessment Resident 1's J tube was clogged and resistance noted when flush. The note showed Resident 1 was awake, alert and responsive through mouth words, had no complaints of pain and discomfort, abdomen was soft, non-tender, no nausea and vomiting. The notes further showed the staff notified the nurse practitioner;- at 0930 hours, the staff received orders from the nurse practitioner to transfer Resident 1 to an acute care hospital; - at 0945 hours, the MD ordered to transfer Resident 1 to the acute care hospital for J tube replacement; - at 1120 hours, Resident 1 was transferred to the acute care hospital; and- at 1530 hours, the contact (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055571 If continuation sheet Page 2 of 5 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 10/30/2025 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 0693 Level of Harm - Actual harm Residents Affected - Few was made with the acute care hospital via telephone and the facility staff confirmed Resident 1 had been admitted with diagnoses of jejunostomy malfunction and hypoglycemia (low blood sugar). Review of Resident 1's Recent Laboratory results from the acute care hospital dated 10/15/25 at 1239 hours, showed the blood glucose level of 36 mg/dl. Review of Resident 1's ED Notes dated 10/15/25 at 1249 hours, showed the staff attempted to flush Resident 1's J tube with 20 ml of water and unable to flush completely clogged. Review of Resident 1's Order from the acute care hospital dated 10/16/25 at 0840 hours, showed an order for IR Jejunal Feeding Tube Replacement. The order further showed the reason for exam was Resident1 had a clogged GJ J-tube, the G tube was functional but J tube was clogged. On 10/24/25 at 0944 hours, a telephone interview was conducted with LVN 1. LVN 1 stated Resident 1 had a GJ tube with two ports. LVN 1 stated one port was a J tube for the enteral feeding and the other port was a G tube to be used to administer the medications. LVN 1 stated on 10/14/25 at around 2100 to 2200 hours, when she went to administer Resident1's medication, Resident 1's enteral feeding was running through one port and she assumed the other port was the G tube for medication administration. LVN 1 stated when she attempted to pass the medication through the port, she felt a resistance so she reported to RN 2. LVN 1 stated RN 2 attempted to administer the medication through the same port and was able to administer the medication even though she felt some resistance. When asked if LVN 1 was able to identify the correct J and G tube ports of Resident 1's GJ tube, LVN 1 stated the G and J tube ports were not labeled, so she was not able to identify and verify if the feeding was running through the J tube port. LVN 1 stated she did not change the port where Resident 1's enteral feeding was running from. LVN 1 stated when she reported to RN 2, RN 2 also attempted to administer the medication through the same port she had attempted and RN 2 also was not able to verify the correct port. When asked what she could have done to identify and verify if the Resident was receiving the enteral feeding through the correct port, LVN 1 stated she should have called the doctor. LVN 1 further stated she did not call to verify with the doctor if the Resident was receiving the enteral feeding through the correct port. When asked if she received an in-service training before being assigned and care for Resident 1 who had a GJ tube, LVN 1 stated no.On 10/24/25 at 1123 hours, a telephone interview was conducted with RN 2. RN 2 stated Resident 1 was admitted with a GJ tube and had G tube drainage bag attached to one port and the enteral feeding was running on the other port. RN 2 stated on 10/14/25, she was notified by LVN 1 of Resident 1's tube being blocked and LVN 1 could not give the medication. RN 2 stated she went to check Resident 1 and observed Resident 1 was not connected to the G tube drainage bag and one port was connected to the enteral feeding. RN 2 stated when she attempted to administer the medication through the other port, she confirmed the tube was hard to flush but was able to administer the medication. When asked if she was able to correctly identify the two ports of Resident 1's GJ tube, RN 2 stated the two ports of the GJ tube were not labeled and she could not identify the ports. RN 2 stated Resident 1 should receive the enteral feeding through the J tube and she assumed the port connected to the enteral feeding was the J tube, so she attempted to administer the medication through the other port which was blocked. RN 2 stated she did not change the port where the enteral feeding was running from. RN 2 stated she could not verify if Resident 1 was receiving the enteral feeding from the J tube. When asked why Resident 1 required the J tube feeding, RN 2 stated because Resident1 had gastroparesis and Resident 1 could not pass or had delays in passing the feeding from the stomach to the small intestine which could result in nausea, vomiting, risk of aspiration and if he was diabetic, he might have a low blood sugar. RN 2 stated the process was to notify the doctor when she could not identify the correct ports of the GJ tube and make sure Resident 1 was receiving the enteral feeding from the J tube. When asked if she had notified (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055571 If continuation sheet Page 3 of 5 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 10/30/2025 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 0693 Level of Harm - Actual harm Residents Affected - Few the doctor, RN 2 stated she did not notify the doctor or reach out to the person who could identify the ports correctly to make sure Resident 1 was receiving the enteral feeding through the J port of the GJ tube as ordered by the physician. RN 2 stated she should have notified the doctor right away instead of waiting for next shift to give the report when she could not identify the correct port and could not confirm if the resident received the enteral feeding through the J tube. When asked if RN 2 received an in-service training before being assigned and care for a resident with a GJ-tube, RN 2 stated no.On 10/27/25 at 1100 hours, an interview was conducted with RN 3. RN 3 stated during the night shift on 10/15/25, the nurse reported Resident 1's tube was clogged. She stated she verified with the night nurse that the J tube port of Resident 1's GJ tube was clogged. She stated she was familiar with the GJ tube. RN 3 stated the straight port was the J tube with MIC (a brand name) written on it, and the right port was the G tube. RN 3 stated when she checked, she saw there was a Lopez valve with the enteral feeding connected to the G tube port. RN 3 stated she asked the charge nurse to stop the feeding because that was not the correct port for the enteral feeding. When asked what could happen if Resident 1 receives feeding from the wrong port, RN 3 stated Resident 1 had gastroparesis, and he could not tolerate the feeding in his stomach and could result to nausea, vomiting and hypoglycemia. On 10/28/25 at 0903 hours, a follow up interview and concurrent medical record review for Resident 1 was conducted with RN 3. RN 3 verified Resident 1 was diabetic and had received inulin glargine 25 units on 10/14/25 at 2100 hours and insulin lispro 3 units at 10/15/25 at 0000 hours. RN 3 verified Resident 1's blood sugar on 10/15/25 at 0600 hours was 84 mg/dl. RN 3 was not able to show documentation if Resident 1's blood sugar was checked before he was transferred to the acute care hospital on [DATE] at 1120 hours. RN 3 stated the feeding for Resident 1 was stopped after she found it was connected to the wrong port on 10/15/25 at around 0800 hours. When asked if she received the in-service training regarding taking care of a resident with a GJ tube before she was assigned to Resident 1 who had a GJ tube, RN 3 stated no. RN 3 further stated she thought that was the standard of her nursing practice.On 10/28/25 at 1406 hours, a telephone interview was conducted with the MD. The MD verified Resident 1 was transferred to the acute care hospital due to the J tube being clogged. The MD verified Resident 1 had a GJ tube. When asked which tube Resident 1 should receive his enteral feeding, the MD stated Resident 1 should have received the feeding through his J tube because Resident 1 had gastroparesis which could cause a delay in emptying of the gastric content. When asked what could happen if Resident 1 received the feeding from his G tube, the MD stated giving the enteral feeding through the G tube could cause nausea, vomiting and risk of aspiration for Resident 1. When asked if giving the enteral feeding through the G tube could cause low blood sugar for Resident 1, the MD stated, yes that could cause hypoglycemia. The MD was informed of the night shift licensed nurses not being able to confirm if Resident 1 received the feeding through the correct port, the next shift nurse found Resident 1's enteral feeding was connected to the G tube port of Resident 1's GJ tube, Resident 1 received insulin glargine 25 units on 10/15/25 at 2100 hours and lispro 3 units on 10/14/25 at 0000 hours, the enteral feeding was disconnected on 10/15/25 at 0800 hours and Resident 1 was transferred to the acute care hospital on [DATE] at 1120 hours with a blood sugar level result of 36 mg/dl at 1229 hours. When asked if the above incidents could cause the blood sugar to dropped critically low to 36 mg/dl, the MD stated, yes that could possibly cause low blood sugar.On 10/30/25 at 1115 hours, an interview and concurrent medical record review for Resident 1 was conducted with the DON. The DON was informed of the above findings and stated Resident 1 should not receive the feeding from the G tube because of his gastroparesis, and licensed nurses should have followed the physician's order for the enteral feeding. The DON further stated if the staff could not (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055571 If continuation sheet Page 4 of 5 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 10/30/2025 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 0693 Level of Harm - Actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete identify the correct ports of the GJ tube, they could always reach out to the doctor, clinical coordinator and herself. The DON stated the staff should not assume and should have confirmed Resident 1's enteral feeding was being provided via J tube as ordered by the physician. When asked what could happen if Resident 1 received the feeding form the G tube, the DON stated Resident 1 had gastroparesis, the feeding would stay in his stomach, and could cause discomfort, vomiting, hypoglycemia, and death. The DON was asked if she provided the in-service training to the staff before assigning the residents with a GJ tube, the DON stated she did not provide the in-service training. The DON acknowledged she should have provided the in-service training and made sure the staff were competent to take care of the residents with a GJ tube.On 10/30/25 at1332 hours, an interview was conducted with the Nurse Practitioner. The Nurse Practitioner stated Resident 1 was transferred to the acute care hospital due to his J tube being clogged. The Nurse Practitioner was informed of the above findings, the Nurse Practitioner stated Resident 1 should have received his enteral feeding through the J tube as ordered by the physician, because of his gastroparesis. When asked what could happen if Resident 1 was given enteral feeding from the G tube port, he stated if Resident 1 was not having nausea and vomiting he would think the feeding was being passed down to the small intestine. When asked if he was able to confirm Resident 1's enteral feeding was being passed down to the small intestine on 10/15/25, The Nurse Practitioner stated he could not confirm. When asked what could have caused Resident 1's blood sugar to drop as low as 36 mg/dl on 10/15/25, the Nurse Practitioner was not able to answer.2. Review of Resident 1's Nurses Notes showed the following:dated 10/8/25 at 1935 hours, showed the routine admission and body check was done. Resident 1 was started on feeding via J tube and G tube with medication and attached to drainage bag for any residual, and- dated 10/9/25 at 1000 hours, Resident 1 was seen and evaluated by the nurse practitioner with new order d/c G tube draining. On 10/24/25 at 1123 hours, a telephone interview was conducted with RN 2. RN 2 stated Resident 1 was admitted to the facility with a drainage bag connected to his G tube port, and he was receiving feeding from his J tube port.Further review of Resident 1's medical record did not show the physician's orders for the G tube drainage bag and how the G tube drainage bag would be managed. In addition, there was no physician's order to discontinue Resident 1's G tube drainage bag. On 10/29/25 at 1012 hours, an interview and concurrent medical record review was conducted with RN 3. RN 3 verified this findings. RN 3 stated Resident 1 was admitted with the G tube drainage bag attached; however, she was not able to find if the physician's order was obtained for the maintenance of the G tube drainage bag. RN 3 stated the G tube drainage bag required a physician's order and staff should have obtained the physician's order for the G tube drainage bag maintenance and discontinuation.On 10/30/25 at 1551 hours, an interview was conducted with the DON and Administrator. The DON and Administrator were informed and acknowledged the above findings. Event ID: Facility ID: 055571 If continuation sheet Page 5 of 5