Health inspection·January 30, 2026

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to provide the pharmaceutical services to one of six sampled residents (Resident 1) as ordered by the physician. * The facility failed to ensure Resident 1's Refresh Plus (eye lubricant), Timoptic ophthalmic solution (a prescription eye drop used to lower high fluid pressure within the eye) and Lumify (an eye drop used to reduce eye redness) were available for administration as ordered by the physician. In addition, the facility failed to ensure Resident 1's physician was made aware when the medications were not available for administration. These failures had the potential to affect resident's health status and wellbeing.Findings: Review of the facility's P&P titled Medication Administration revised 5/2019 showed it is the policy of the facility that medications for residents be administrated in a safe and timely manner and as prescribed. Medications must be administered in accordance with the physician orders, including any required time frame.Medical record review for Resident 1 was initiated on 1/15/26. Resident 1 was admitted to the facility on [DATE] and readmitted to facility on 3/13/25 with medical history including glaucoma. Review of Resident 1's H&P examination dated 3/15/25, showed Resident 1 had no capacity to understand and make decisions. Review of Resident 1's Order Summary Report showed the following physician's orders:- dated 3/29/25, to administer Refresh Plus ophthalmic solution one drop in both eyes every two hours for dry eyes, ocular surface irritation;- dated 6/27/25, to administer Timoptic Ophthalmic solution (timolol) one drop in both eyes two times a day for uncontrolled primary open angle glaucoma; and- dated 7/30/25, to administer Lumify ophthalmic solution (brimonidine tartrate) one drop in both eyes two times a day for ocular hyperemia (red eye). Review of Resident 1's MAR showed the following medications were not administered on the following dates:- dated 3/29/25, Refresh Plus administration was coded 5 (indicating hold/see progress notes) at 1600 hours and coded 4 (indicating the vitals were outside of the parameters for administration) at 2000 hours. However, the administration progress note failed to show the reason why the medication was not administered and what parameters of administration.- dated 6/1/25, Refresh Plus was not administered 12 times from 0000 to 2200 hours. Further review of the MAR progress note showed awaiting medication from pharmacy. In addition, review of the nursing progress note dated 6/1/25, showed that pharmacy was contacted and requested for refill; however, there was no documentation if the physician was informed regarding multiple missed doses.- dated 6/2/25, Refresh Plus was not administered nine times from 0000 to 1600 hours. Further review of the MAR progress note showed awaiting medication from pharmacy.- dated 8/11/25, Timoptic ophthalmic solution administration for 1700 hours was coded 9 (indicating to see the progress note). However, reviewed of the administration progress note failed to show a reason why the medication was not administered - dated 9/3/25, Timoptic ophthalmic solution administration for 1700 hours was coded 9 (indicating to see the progress note). Review of the administration progress note showed awaiting for delivery.- dated 10/15/25, Lumify ophthalmic solution administration for 0900 hours was coded 9 (indicating to see progress note). Review of the nursing progress note showed three nursing documentation indicating that follow up phone calls were made with the pharmacy; however, pharmacy does not have stock of Lumify medication. On 1/27/26 at 1500 hours, an interview and concurrent medical record review was conducted with RN 1. RN 1 acknowledged the above findings and stated it was the responsibility of the charge nurse to submit a request for refill five days before the medication runs out. RN 1 further stated the physician should have also been notified when the medication was not administered as ordered. On 1/30/26 at 1315 hours, an interview was conducted with the DON and Administrator. The DON (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 01/30/2026 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 0755 and Administrator were informed and acknowledged the findings. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055571 If continuation sheet Page 3 of 3