Inspection·November 3, 2025

F 0552 Ensure that residents are fully informed and understand their health status, care and treatments. Level of Harm - Potential for minimal 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 informed consents for the use of psychotropic medications for one of five sampled residents (Resident 1) was obtained. * The facility failed to ensure Resident 1's informed consent for the Ativan (anti-anxiety medication) was obtained. This failure posed the risk for the residents to not be informed of their care and treatment. Findings: Residents Affected - Some Review of the facility's P&P titled Psychotherapeutic Drug Treatment revised 1/2017 showed the resident has the right to be free from unnecessary drugs and/or medications and protection from medication errors. Chemical restraint is defined as a psychotherapeutic drug that is used to treat medical symptoms. Psychotherapeutic drugs include antianxiety agents, antidepressants, sedatives, hypnotics, antipsychotics and other drugs that affect behavior. Moreover, the P&P further showed chemical restraints shall be used only after alternative methods have been tried unsuccessfully and only upon the written order of a physician and after informed consent has been obtained by the physician from the resident and/or his/her representative. The resident or his/her representative will be given information regarding the need for, the desired effects and the potential side effect of the medication. This enables the resident or his/her representative to make an informed decision regarding the use of any psychoactive medication. Closed medical record review for Resident 1 was initiated on 10/23/25. Resident 1 was admitted to the facility on [DATE], and was discharged to the acute care hospital on 3/2/25. Review of Resident 1's H&P examination dated 10/14/24, showed Resident 1 had no capacity to understand and make decisions. Review of Resident 1's Telephone Order Report dated 12/19/24, showed a physician's order to administer Ativan 0.5 mg, one tablet via GT every six hours as needed for 14 days for anxiety manifested by inability to relax. Review of Resident 1's medical record failed to show documented evidence an Informed Consent was obtained for use of the Ativan medication as ordered. On 10/30/25 at 0950 hours, an interview and concurrent closed medical record review for Resident 1 was conducted with RN 2. RN 2 reviewed Resident 1's medical record and stated Resident 1 was previously prescribed the Ativan medication for inability to relax for 14 days. RN 2 stated on 12/8/24, the Ativan medication was not renewed after 14 days. RN 2 further stated a new informed consent was not obtained when the Ativan medication was ordered by the physician on 12/19/24. (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 6 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 11/03/2025 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)