Health inspection·October 31, 2025

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few CRE every shift a. On 10/3/25 at 0810 hours, Resident A's room was observed with an EBP sign posted showing Resident A was on isolation precautions. The EBP sign showed the following: - Everyone is to perform hand hygiene before entering and when leaving the room. - Providers and staff are to wear gloves and a gown for high-contact resident care activities such as dressing, bathing/showering, transferring, changing linens, providing hygiene, changing briefs or assisting with toileting, device care or use (central line, urinary catheter, feeding tube, tracheostomy), or wound care (any skin opening requiring a dressing). Additionally, Room A had a second red colored isolation sign posted showing Resident A was on EBP isolation. The RED sign showed the following: - Staff are to wash hands before and after resident care, wear gloves, wear a gown, and an N-95 mask. b. On 10/3/25 at 0812 hours, Room B was observed with an EBP sign posted showing Residents B, C, E, and F), were on isolation precautions. The EBP sign showed the following: - Everyone is to perform hand hygiene before entering and when leaving the room. Providers and staff are to wear gloves and a gown for high-contact resident care activities such as dressing, bathing/showering, transferring, changing linens, providing hygiene, changing briefs or assisting with toileting, device care or use (central line, urinary catheter, feeding tube, tracheostomy), or wound care (any skin opening requiring a dressing). Additionally, Room B had a second pink colored isolation sign posted showing Residents B, C, E, and F), were on EBP isolation. The pink colored sign showed the following: - Staff are to wash hands before and after resident care, wear gloves, wear a gown, and wear mask (when likely to get splashed). c. On 10/3/25 at 0830 hours, Room C was observed with an EBP sign posted showing Residents D and G were on isolation precautions. The EBP sign showed the following: Everyone is to perform hand hygiene before entering and when leaving the room. - Providers and staff are to wear gloves and a gown for high-contact resident care activities such as dressing, bathing/showering, transferring, changing linens, providing hygiene, changing briefs or assisting with toileting, device care or use (central line, urinary catheter, feeding tube, tracheostomy), or wound care (any skin opening requiring a dressing). Additionally, Room C had a second red colored isolation sign posted showing Residents D and G were on EBP isolation. However, the red sign posted outside Room C's room showed different information from the red sign posted outside Room A. Room C's red colored posting showed the following information: Staff are to wash hands before and after contact with resident or potentially contaminated articles, gloves are indicated when giving direct patient care, and gowns are indicated when providing direct care or in contact with resident equipment. On 10/3/25 at 0815 hours, an interview and concurrent observation of the isolation postings was conducted with LVN 1. LVN 1 was not able to verify the meaning of the red sign. LVN 1 verified the standard EBP sign did not require the staff to wear a mask, however, the red colored EBP sign was requiring the staff to wear an N-95 mask. LVN 1 stated a surgical mask was the standard mask worn, but it was not required for EBP precautions. On 10/3/25 at 0822 hours, an interview and concurrent observation of the isolation postings was conducted with the Infection Preventionist (IP). The IP stated the additional red and pink signs were to let the staff know the resident had an additional infection besides standard EBP precautions and listed any additional PPE staff may need to don while caring for the resident. The IP stated the red colored EBP sign was for residents with CRE (carbapenem-resistant Enterobacteriaceae) and the pink colored sign was for residents with C. auris (candida auris). The IP verified the red colored sign posted outside Room A was wrong and the staff did not need to wear an N-95 mask when caring for residents with CRE as it was not necessary for EBP precautions. The IP stated the staff received multiple in-service training to determine what the different colored signs were used for. On 10/3/25 at 0826 hours, an interview was conducted with CNA 7. CNA 7 was unable to recall the difference between the red and pink (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055571 If continuation sheet Page 2 of 3 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 10/31/2025 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete colored isolation signs. CNA 7 stated a gown, surgical mask, and gloves were required for EBP precautions, however if the sign showed to wear an N-95 mask, then the staff were required to wear an N-95 mask. On 10/3/25 at 0834 hours, an interview was conducted with CNA 8. CNA 8 stated the red colored posted isolation sign was for C. auris (which was inconsistent with the information provided by the IP) and a gown, mask and gloves were required. CNA 8 further stated if there weren't masks in the PPE carts, they obtained them from the front desk or the medication carts. On 10/3/25 at 0834 hours, an interview and concurrent observation of the isolation posting was conducted with LVN 2. LVN 2 stated the red colored posted isolation sign was for C. auris (which was inconsistent with the information provided by the IP). LVN 2 stated C. auris needed contact isolation precaution so handwashing, gown, and gloves were required. LVN 2 verified as the charge nurse, she should know the difference between the pink and red signs. On 10/3/25 at 0837 hours, an interview and concurrent observation of the isolation posting was conducted with RN 2. RN 2 verified the red colored posted isolation sign was for CRE and the pink colored posted isolation sign was for C. auris (which were consistent with the information provided by the IP). RN 2 verified she rounded this morning and did not notice the incorrect sign posted outside Room A requiring the staff to wear an N-95 mask. On 10/14/25 at 1051 hours, an interview was conducted with the facility's PHN. The PHN stated she was aware of the facility's system of colored isolation signs. The PHN verified the proper PPE for C. auris was gloves, gown, and standard precautions; and the proper PPE for CRE was the same as C. auris. The PHN stated an N-95 mask was not required unless there was an additional diagnosis requiring transmission-based precautions (TBP) to be followed. On 10/29/25 at 1433 hours, an interview was conducted with the IP. The IP verified she was unable to provide specific training records to show staff were trained on the difference between red and pink isolation signs. The training records were specific to EBP precautions; however, it did not show the distinction between red and pink colored isolation signs. Event ID: Facility ID: 055571 If continuation sheet Page 3 of 3