Inspection visit
Health inspection
34 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 34 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0550
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or
her rights.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Review of
the facility's P&P titled Resident Rights revised 2016 showed employee shall treat all the residents with
kindness, respect, and dignity. Further review of the P&P showed federal and state laws guarantee certain
basic rights to all residents of the facility, the rights included the resident right to a dignified existence,
privacy and confidentiality.
On 4/5/24 at 1020 hours, CNA 4 was observed wheeling Resident 5 in a shower chair into Resident 5's
room. Resident 5's hair was observed wet, and a white blanket was under Resident 5's chin covering her
chest, arms, and legs. The blanket was observed not fully covering Resident 5's left side of her body
exposing about 10 to 12 inches of Resident 5's lower back, hip, and upper thigh.
Medical record review for Resident 5 was initiated on 4/5/24. Resident 5 was admitted to the facility on
[DATE].
Review of Resident 5's H&P examination dated 10/3/23, showed Resident 5 had the capacity to understand
and make decisions.
Review of Resident 5's MDS dated [DATE], showed Resident 5 was cognitively intact.
On 4/5/24 at 1021 hours, the Administrator and CNA 4 verified the above observation in Resident 5's room
while Resident 5 sat on the shower chair.
On 4/5/2024 at 1021 hours, an interview was conducted with the Administrator. The Administrator
confirmed the resident's buttock area was uncovered with the blanket and exposed. The Administrator
confirmed Resident 5 was wheeled from the shower room to the resident's room, which was about 40 feet
away and involved wheeling the resident pass the nurses station with several staff at the station and
Resident 12 sitting in the hallway across the nurses' station. Resident 12 was alert and oriented. The
Administrator stated the resident's buttock area should not have been uncovered to honor the resident's
dignity.
On 4/5/24 at 1115 hours, an interview with Resident 5 was conducted. Resident 5 stated she did not know
her back, buttock, hip, and thigh area uncovered while she was in the shower chair and wheeled from the
shower room to her room. Resident 5 stated it made her feel embarrassed to hear that her body was not
fully covered while in the hallway and she needed to be covered to ensure her modesty was protected.
Based on observation, interview, medical record review, and facility P&P review, the facility
(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 87
Event ID:
055671
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
055671
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/10/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Parkview Healthcare Center
1514 E. Lincoln Avenue
Anaheim, CA 92805
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 0550
failed to ensure the staff provided care and promoted dignity and respect for three of 11 residents reviewed
for dignity and respect (Residents 5, 8, and 35).
Level of Harm - Minimal harm
or potential for actual harm
* CNA 3 was observed standing over Resident 8 while assisting the resident with meals.
Residents Affected - Few
* CNA 2 was observed standing over Resident 35 while assisting the resident with meals.
* The facility failed to ensure Resident 5's body was fully covered while being transported from the shower
room to her room.
These failures had the potential to negatively impact the residents' well-being.
Findings:
Review of the facility's P&P titled Assistance with Meals revised July 2017 showed the residents who
cannot feed themselves will be fed with attention to safety, comfort, and dignity, for example: not standing
over residents while assisting them with meals.
1. During the dining observation on 4/2/24 at 1233 hours, CNA 3 was observed standing over Resident 8's
right side of the bed while assisting on feeding Resident 8's lunch meal.
Medical record review was initiated on 4/2/24. Resident 8 was readmitted to the facility on [DATE].
Review of Resident 8's H&P examination dated 10/3/23, showed Resident 8 could make needs known but
not make medical decisions.
On 4/2/24 at 1242 hours, an interview was conducted with CNA 3. CNA 3 stated standing was harder while
feeding Resident 8 due to her bed. CNA 3 stated Resident 8 would see her better if she was standing. CNA
3 stated the staff was suppose to sit while assisting on feeding the residents.
On 4/2/24 at 1249 hours, an interview was conducted with the DSD. The DSD stated the staff needed to
prompt the residents up to prepare for meal if required assistance with their meals. The DSD further stated
the staff was supposed to sit with eye level and talk to the residents who required assistance with their
meal.
On 4/5/24 at 1530 hours, the DON was informed and acknowledged the above findings.
2. On 4/3/24 at 0828 hours, CNA 2 was observed standing over Resident 35 while assisting in feeding
Resident 35 with her breakfast meal.
Medical record review for Resident 35 was initiated on 4/3/24. Resident 35 was readmitted to the facility on
[DATE].
Review of Resident 35's H&P examination dated 5/10/23, showed Resident 35 had the capacity to
understand and make decisions.
On 4/3/24 at 0832 hours, an interview was conducted with CNA 2. CNA 2 stated when she had time, she
would sit. CNA 2 verified she was supposed to sit while feeding the residents with their meals.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055671
If continuation sheet
Page 2 of 87
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
055671
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/10/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Parkview Healthcare Center
1514 E. Lincoln Avenue
Anaheim, CA 92805
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 0550
On 4/5/24 at 1530 hours, the DON was informed and acknowledged the above 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:
055671
If continuation sheet
Page 3 of 87
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
055671
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/10/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Parkview Healthcare Center
1514 E. Lincoln Avenue
Anaheim, CA 92805
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 0552
Ensure that residents are fully informed and understand their health status, care and treatments.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. On 4/2/24
at 0824 hours, an observation and concurrent interview was conducted with Resident 32. Resident 32 was
observed laying in bed, alert and awake, and the bilateral half side rails were observed elevated. Resident
32 stated he did not use the side rails that attached to the bed since he got admitted in the facility.
Residents Affected - Few
On 4/4/24 at 0723 hours, a concurrent observation and interview was conducted with LVN 1. Resident 32
was observed alert, awake in bed with bilateral half side rails elevated. LVN 1 verified the observation.
Medical record review for the Resident 32 was initiated on 4/2/24. Resident 32 was admitted to the facility
on [DATE].
Review of the Resident 32's MDS dated [DATE], showed Resident 32 was cognitively intact.
Review of Resident 32's Physician Order Summary dated 4/2/24, showed the physician's order for bilateral
half side rails up when in bed for mobility and repositioning.
On 4/4/24 at 0833 hours, an interview and concurrent medical record review for Resident 32 was
conducted with the IP. When asked about the bed inspection process, the IP stated she and the
Administrator checked if there was a gap between the mattress and side rails, using the bed system
measurement device annually. When asked if she and the Administrator inspected the bed when the side
rails were initially ordered and installed. The IP stated the facility only conducted the bed inspection
annually. The IP stated when the new resident admitted to a bed with the siderails attached and if the
resident requested the side rails to be elevated, then she looked back to the measurements and determine
for possible entrapment risk.
Review of the Bed Inspection (Measurements) dated 1/3/24, showed, Bed #15. The IP verified Bed #15
corresponded to the bed that Resident 32 was currently using, to which she and the Administrator had
checked the bedframe length, mattress length, mattress height, zone passed, and zone, which failed for the
use of the siderails. Further review of the document showed Bed #15 failed Zone 6.
Review of Resident 32's medical record titled Facility Verification of Informed Consent dated 4/2/24, for the
use of bilateral half side rails did not show if Resident 32 was notified of Zone 6 of the bed failed the
inspection.
The IP verified the above findings and stated Resident 32 was notified of the overall entrapment risk for the
use of siderails; however, the IP was not able to show if Resident 32 was notified of the bed failed for the
Zone 6 entrapment assessment.
On 4/4/24 at 1346 hours, an interview and concurrent record review was conducted with the Administrator.
The Administrator verified the above findings and stated Resident 32's bed failing Zone 6 entrapment
assessment meant there was a risk that Resident 32's head might get entrapped in that zone. The
Administrator stated an informed consent was obtained from Resident 32 explaining the overall entrapment
risk for the use of siderails; however, he was not able to show if Resident 32 was informed of his bed
measurement failing on entrapment Zone 6 and risk of possible entrapment in that zone.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055671
If continuation sheet
Page 4 of 87
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
055671
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/10/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Parkview Healthcare Center
1514 E. Lincoln Avenue
Anaheim, CA 92805
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 0552
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
On 4/4/24 at 1626 hours, an interview was conducted with the DON. The DON acknowledged above
findings.
Cross reference to F909 for example # 1.
Based on observation, interview, facility P&P review, and facility document review, the facility failed to fully
inform the resident or responsible party of their bed with side rails, the entrapment assessment for Zone 6,
and the treatment alternatives or options for two of four sampled residents (Residents 9 and 32). This failure
had the potential for Residents 9 and 32 and their responsible parties to not make the informed decisions
regarding the care and treatment of bed side rail use.
Findings:
According to the Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment, the
term entrapment describes an event in which a patient/resident is caught, trapped, or entangled in the
space in or about the bed rail, mattress, or hospital bed frame. Patient entrapments may result in deaths
and serious injuries. These entrapment events have occurred in openings within the bed rails, between the
bed rails and mattresses, under bed rails, between split rails, and between the bed rails and head or foot
boards. The population most vulnerable to entrapment are elderly patients and residents, especially those
who are frail, confused, restless, or who have uncontrolled body movement. The seven areas in the bed
system where there is a potential for entrapment are:
- Zone 1: within the rail;
- Zone 2: under the rail, between the rail supports or next to a single rail support;
- Zone 3: between the rail and the mattress;
- Zone 4: under the rail, at the ends of the rail;
- Zone 5: between split bed rails;
- Zone 6: between the end of the rail and the side edge of the head or foot board; and
- Zone 7: between the head or foot board and the mattress end.
The FDA issued a Safety Alert entitled Entrapment Hazards with Hospital Bed Rails showed residents most
at risk for entrapment are those who are frail or elderly or those who have conditions such as agitation,
delirium, confusion, pain, uncontrolled body movement, hypoxia, fecal impaction, acute urinary retention,
etc., that may cause them to move about the bed or try to exit from the bed. Entrapment may occur when a
resident is caught between the mattress and bed rail or in the bed rail itself. Inappropriate positioning or
other care related activities could contribute to the risk of entrapment.
Review of the facility's P&P titled Proper Use of Side Rails revised on 12/2016 showed an assessment will
be made to determine the resident's symptoms, risk of entrapment and reason for using side rails. The risks
and benefits of side rails will be considered for each resident. The P&P further showed consent for side rail
use will be obtained from the resident or legal representative, after presenting potential benefits and risks.
(Note: Federal regulations do not require written consent for
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055671
If continuation sheet
Page 5 of 87
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
055671
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/10/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Parkview Healthcare Center
1514 E. Lincoln Avenue
Anaheim, CA 92805
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 0552
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
using restraints. Signed consent forms do not relieve the facility from meeting the requirements for restraint
use, including proper assessment and care planning. While the resident or family (representative) may
request a restraint, the facility is responsible for evaluating the appropriateness of that request). Moreover,
the P&P showed the resident will be checked periodically for safety relative to side rail use.
Review of the facility's P&P titled Bed Safety revised on 12/2007 showed the resident's sleeping
environment shall be assessed by the interdisciplinary team, considering the resident's safety, medical
conditions, comfort, and freedom of movement, as well as input from the resident and family regarding
previous sleeping habits and bed environment. Furthermore, the P&P showed when using side rails for any
reason, the staff shall take measures to reduce related risks and if side rails are used, there shall be an
interdisciplinary assessment of the resident, consultation with the attending physician, and input from the
resident and/or legal representative.
Review of the facility's P&P titled Resident Rights revised 12/2016 showed the residents have the right to
be informed of and participate in, his or her care planning and treatment.
Review of the facility's document titled Safety Assessment for Siderail Usage showed Zone 6
measurements was between the end of the rail and the side edge of the head or foot board or any
V-shaped opening between the end of the rail and the head or foot board (risk of entrapment due to
wedging).
1. Medical record review for Resident 9 was initiated on 4/2/24. Resident 9 was admitted to the facility on
[DATE], and readmitted back to the facility on 5/20/23.
Review of the facility's document titled Side Rail Order (undated) showed Resident 9 had the left 1/2 (half)
side rail padded.
Review of the facility's document titled Bed Inspection (Measurement) dated 1/3/24, showed Bed Number
27 was assigned to Resident 9 and had failed Zone 6 measurement. Further review of Resident 9's medical
record showed the resident had a consent for a padded left side rail dated 9/14/23.
On 4/2/24 at 0842 hours, an initial tour of the facility was conducted. Resident 9 was observed in bed with
padded left side rail. Resident 9 was observed able to move the upper extremities.
On 4/4/24 at 1602 hours, a concurrent interview and facility document review with the Administrator was
conducted. The Administrator verified Resident 9's bed had a failed Zone 6 measurement as documented
on the facility document titled Bed Inspection (Measurement) dated 1/3/24. When asked if the resident or
the resident's family member was notified and made aware of the failed Zone 6 measurement, the
Administrator stated they were not. The Administrator further stated he could not provide documented
evidence Resident 9's or family were notified of the failed Zone 6 measurement.
On 4/5/24 at 1550 hours, an interview with the DON was conducted. The DON acknowledged above
findings.
Cross reference to F909 for example #2.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055671
If continuation sheet
Page 6 of 87
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
055671
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/10/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Parkview Healthcare Center
1514 E. Lincoln Avenue
Anaheim, CA 92805
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 0558
Reasonably accommodate the needs and preferences of each resident.
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
reasonable accommodations to meet the care needs for one nonsampled residents of 38 residents in the
facility (Resident 37).
Residents Affected - Few
* The facility failed to ensure Resident 37's call light was within the resident's reach. This failure had the
potential to negatively impact the resident's psychosocial well-being or result in a delay to provide care and
services to the resident.
Findings:
Review of the facility's P&P titled Call System, Resident revised September 2022 showed each resident is
provided with a means to call staff directly for assistance from his/her bed, from toileting and bathing
facilities and from the floor.
During the initial tour on 4/2/24 at 0807 hours, Resident 37's call light was observed on the floor on the
right side of her bed.
Medical record review for Resident 37 was initiated on 4/2/24. Resident 37 was admitted to the facility on
[DATE].
Review of Resident 37's H&P examination dated 9/25/23, showed Resident 37 had no capacity to
understand and make decisions.
Review of Resident 37's MDS dated [DATE], showed the following:
-roll left and right in bed was coded 01, which meant dependent assistance and helper would do all the
effort; and
-chair/bed-to-chair transfer was coded 01, which meant dependent assistance and helper would do all the
effort.
On 4/2/24 at 0811 hours, an observation and concurrent interview was conducted with CNA 1. CNA 1
verified Resident 37's call light was on the floor. CNA 1 stated she did not notice Resident 37's call light was
on the fall when she raised her bed. CNA 1 stated the call light should be within the resident's reach.
On 4/3/24 at 0745 hours, an interview was conducted with the DON. The DON stated her expectation was
for the call lights to be answered within two minutes and the call lights should always be within the
resident's reach.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055671
If continuation sheet
Page 7 of 87
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
055671
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/10/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Parkview Healthcare Center
1514 E. Lincoln Avenue
Anaheim, CA 92805
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 0561
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Honor the resident's right to and the facility must promote and facilitate resident self-determination through
support of resident choice.
**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 ensure one of one
resident (Resident 26) reviewed for resident's choice and food preferences with meals was honored. This
failure had the potential risk for a diminished quality of life and impact resident's well-being.
Findings:
Review of the facility's P&P titled Resident Food Preferences revised July 2017 showed when possible, the
staff will interview the resident directly to determine current food preferences based on history and life
patterns related to food and mealtimes.
Review of the facility's P&P titled Resident's Rights revised December 2016 showed Federal and State laws
guarantee certain basic rights to all residents to this facility. These rights include the resident's right to: e.
self-determination.
During the dining observation on 4/2/24 at 1253 hours, Resident 26 was observed sitting up in his
wheelchair in the dining room with his lunch meal tray in front of him. Resident 26's plate was observed with
untouched white rice. Resident 26 stated he did not like rice. Resident 26 stated he had not eaten rice for
two years. Resident 26's meal tray ticket was observed and showed fortified diet, no added salt (NAS),
mechanical soft texture, lactose free and no corn, zucchini, rice, wheat bread, and lettuce for lunch as his
preference.
Medical record review for Resident 26 was initiated on 4/2/24. Resident 26 was readmitted to the facility on
[DATE].
Review of Resident 26's H&P examination dated 10/7/23, showed Resident 26 had the capacity to
understand and make decisions.
Review of Resident 26's Nutritional Screening and assessment dated [DATE], showed the resident's food
dislikes were liver, corn, squash, zucchini, egg noodles, grits, and rice.
On 4/2/24 at 1255 hours, an observation and concurrent interview was conducted with the SSD. The SSD
verified there was untouched rice on Resident 26's plate and his meal ticket showed no rice as his
preference for lunch.
On 4/5/24 at 1530 hours, the DON was informed and acknowledged the above findings.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055671
If continuation sheet
Page 8 of 87
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
055671
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/10/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Parkview Healthcare Center
1514 E. Lincoln Avenue
Anaheim, CA 92805
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 0578
Level of Harm - Minimal harm
or potential for actual harm
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to
participate in experimental research, and to formulate an advance directive.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Medical
record review for Resident 12 was initiated on 4/2/24. Resident 12 was admitted to the facility on [DATE].
Residents Affected - Few
Review of Resident 12's H&P examination dated 1/11/24, showed Resident 12 had the capacity to
understand and make decisions.
Review of the MDS dated [DATE], showed Resident 12 was cognitively intact.
Review of Resident 12's POLST dated 1/10/24, showed Resident 12's advance directive was not available.
Review of Resident 12's Psychosocial assessment dated [DATE], showed Resident 12 had a power of
attorney and the resident's family member to provide the copy to the facility.
Further review of Resident 12's medical record failed to show a copy of Resident 12's advance directive
and the facility had followed up with the resident's family member to have a copy of the advance directive in
file readily available.
On 4/4/24 at 0920 hours, an interview and a concurrent record review was conducted with the SSD. The
SSD verified the above findings and stated during the initial care plan meeting, Resident 12's family
member informed her that Resident 12 had an advance directive, and she requested the copy of advance
directive. The SSD stated the social services staff was responsible for obtaining the copies of the advance
directives from the resident or their families. The SSD was not able to verify if she followed up to obtain a
copy of the advance directive from Resident 12's family member. The SSD acknowledged she should have
followed up with Resident 12's family member to obtain a copy of the advance directive readily available in
file.
On 4/4/24 at 1626 hours, an interview was conducted with the DON. The DON acknowledged above
findings.
Based on interview, medical record review, and facility P&P review, the facility failed to inform and provide
the written information regarding the rights to formulate the advance directives to one of three reviewed
residents (Resident 35). In addition, the facility failed to ensure the copy of the advance directives was
readily available in the residents' charts for two of three reviewed residents for advance directives
(Residents 10 and 12). These failures had the potential for the facility to provide treatment and services
against the resident's wishes.
Findings:
Review of the facility's P&P titled Advance Directives revised December 2016 showed upon admission, the
resident will be provided with written information concerning the right to refuse or accept medical or
surgical treatment and to formulate an advance directive if he or she chooses to do so. Written information
will include a description of the facility's policies to implement advance directives and applicable state law. If
the resident becomes able to receive and understand this information later, he or she will be provided with
the same written materials as described above, even if his or her legal representative had already been
given the information. Prior to or upon admission of a
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055671
If continuation sheet
Page 9 of 87
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
055671
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/10/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Parkview Healthcare Center
1514 E. Lincoln Avenue
Anaheim, CA 92805
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 0578
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
resident, the Social Services Director or designee will inquire of the resident, his/her family members and/or
his or her legal representative, about the existence of any written advance directives. Information about
whether or not the resident has executed an advance directive shall be displayed prominently in the
medical record.
1. Medical record review for Resident 35 was initiated on 4/3/24. Resident 35 was readmitted to the facility
on [DATE].
Review of Resident 35's H&P examination dated 5/10/23, showed Resident 35 had the capacity to
understand and make decisions.
Review of Resident 35's POLST dated 5/10/23, showed Resident 35 had no advance directive.
Further review of Resident 35's medical record did not show documented evidence Resident 35
acknowledged she was offered and received the information regarding the formulation of an advance
directive or having an advance directive.
On 4/3/24 at 0846 hours, an interview was conducted with the SSD. The SSD stated upon a resident's
admission, she would see the resident's H&P examination if the resident had the capacity to understand
and make decision. The SSD stated she would interview the residents regarding the advance directive if the
resident had an advance directive or request to formulate one. The SSD stated if the resident had an
advance directive, she would request a copy from the resident or the resident's family members to place in
the resident's medical record. The SSD stated if the resident requested to formulate an advance directive,
she would then assist the resident by providing and explaining information about the advance directive and
contact the Ombudsman to further assist the resident for the completion of formulating an advance
directive.
On 4/3/24 at 0858 hours, a follow-up interview and concurrent medical record review was conducted with
the SSD. The SSD verified the above findings and stated she was not able to provide documentation to
show she had offered and provided the information about the formulation of an advance directive to
Resident 35.
2. Medical record review for Resident 10 was initiated on 4/2/24. Resident 10 was readmitted to the facility
on [DATE].
Review of Resident 10's H&P examination dated 2/3/24, showed Resident 10 had the capacity to
understand and make decisions.
Review of Resident 10's POLST under Section D dated 2/5/24, showed Resident 10 had an advance
directive available.
Further review of Resident 10's medical record did not show a copy of advance directive.
On 4/3/24 at 0846 hours, an interview and concurrent medical record review was conducted with the SSD.
The SSD showed a copy of Resident 10's advance directive. However, the SSD had Resident 10's copy of
advance directive in a separate binder in her office drawer. The SSD reviewed Resident 10's electronic and
paper medical record and did not find a copy of Resident 10's advance directive. The SSD stated Resident
10 was sent in the hospital and the copy of the resident's advance directive was not placed back in his new
medical record. The SSD stated the copy of Resident 10's advance directive
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055671
If continuation sheet
Page 10 of 87
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
055671
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/10/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Parkview Healthcare Center
1514 E. Lincoln Avenue
Anaheim, CA 92805
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 0578
should be readily accessible in the resident's medical record.
Level of Harm - Minimal harm
or potential for actual harm
On 4/5/24 at 1530 hours, the DON was informed and acknowledged the above findings.
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055671
If continuation sheet
Page 11 of 87
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
055671
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/10/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Parkview Healthcare Center
1514 E. Lincoln Avenue
Anaheim, CA 92805
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 0623
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman,
before transfer or discharge, including appeal rights.
**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 notify the resident and/or their
representative of the transfer/discharge and reasons for the transfer in writing for one of five residents
reviewed for hospitalization (Resident 32). This failure had the potential for the resident and their
representative not knowing about the appeal process should the resident and their representative believe
the transfer or discharge was inappropriate or involuntary.
Findings:
Review of the facility's P&P titled Transfer or Discharge Notice revised December 2016 showed the facility
shall provide a resident and/or the resident representative with a 30 day written notice of an impending
transfer or discharge. The notice will be given as soon as it is practicable but before the transfer or
discharge when an immediate transfer or discharge is required by the resident urgent medical needs.
Further review of the P&P showed the resident and/or representative will be notified in writing of the
information which included following:
- The reason for transfer or discharge;
- The effective date of the transfer or discharge;
- The location to which the resident is being transferred or discharged ;
- A statement of the resident's right to appeal the transfer or discharge including;
- Name address, email and telephone number of the entity which receives such request;
- Information on how to obtain complete and submit an appeal form; and
- How to get assistance completing the appeal process.
Medical record review for Resident 32 was initiated on 4/2/24. Resident 32 was admitted to the facility on
[DATE], and readmitted to the facility on [DATE].
Review of Resident 32 's H&P examination dated 2/3/24, showed Resident 32 had the capacity to
understand and make decisions.
Review of Resident 32's Physician's Order dated 1/17/24, showed an order for bed hold for seven days,
Resident 32 was transferred from the medical appointment to acute care hospital.
Review of Resident 32's Progress Note dated 1/17/24 at 1816 hours, showed the facility contacted
Resident 32 on his cell phone to ask for the status of his medical appointment when he did not return to the
facility, and Resident 32 informed the facility that he was being admitted to the acute care hospital for his
medical need.
Further review of Resident 32's medical record did not show if Resident 32 and/or their representative were
provided notification of the transfer and reasons for the transfer in writing.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055671
If continuation sheet
Page 12 of 87
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
055671
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/10/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Parkview Healthcare Center
1514 E. Lincoln Avenue
Anaheim, CA 92805
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 0623
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
On 4/4/24 at 1440 hours, an interview was conducted with the SSD. The SSD stated she was responsible
to provide the written notification of the transfer discharge to the resident and/or their representative. The
SSD verified the above findings and stated the facility did not provide the written notification to Resident 32
and/or their representative when he was transferred to the acute care hospital from his routine medical
appointment. The SSD stated she should have provided the written notification and reason for the transfer
in writing to Resident 32 and/or the resident's representative.
On 4/4/24 at 1626 hours, an interview was conducted with the DON. The DON was informed and
acknowledged the above findings.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055671
If continuation sheet
Page 13 of 87
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
055671
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/10/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Parkview Healthcare Center
1514 E. Lincoln Avenue
Anaheim, CA 92805
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 0625
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Notify the resident or the resident’s representative in writing how long the nursing home will hold the
resident’s bed in cases of transfer to a hospital or therapeutic leave.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. Medical
record review for Resident 32 was initiated on 4/2/24. Resident 32 was admitted to the facility on [DATE],
and readmitted to the facility on [DATE].
Review of the H&P examination dated 2/3/24, showed Resident 32 had the capacity to understand and
make decisions.
Review of the Resident 32's Physician Order dated 1/17/24, showed an order for bed hold for 7 days,
Resident 32 was transferred to from medical appointment to acute care hospital.
Review of the Resident 32's General Nurses Notes dated 1/ 17/24 at 1816 hours, showed the facility
contacted Resident 32 on his cell phone to ask about the status of his medical appointment when he did
not return to the facility, and Resident 32 informed facility that he was being admitted to the acute care
hospital for his medical need. Further review of the progress notes showed Resident 32 was put on bed
hold.
Further review of Resident 32's medical record did not show if Resident 32 and/or their representative were
provided with the written information regarding the facility's bed-hold policy.
On 4/4/24 at 1415 hours, an interview and concurrent record review was conducted with the RN 1. RN 1
was not able to show if Resident 32 was provided with the written information regarding the facility's
bed-hold policy when he was transferred to the acute care hospital on 1/17/24.
On 4/4/24 at 1420 hours, an interview and concurrent record review was conducted with the SSD. The SSD
verified the above findings and stated the facility did not provide Resident 32 and/or their responsible party
the written information regarding the facility's bed-hold policy.
On 4/4/24 at 1626 hours, an interview was conducted with the DON. The DON was informed and
acknowledged the above findings.Based on interview, medical record review, and facility P&P review, the
facility failed to notify five of five residents reviewed for bed hold notification (Residents 10, 22, 32, 35, and
38) of their rights to a bed hold (holding or reserving a resident's bed while the resident in the acute care
hospital) policy upon transfer to the acute care facility. This failure had the potential for residents or their
representatives to be unaware of his or her rights to request a bed hold upon transfer.
Findings:
Review of the facility's P&P titled Bed-Holds and Returns revised March 2017 showed prior to transfer and
therapeutic leaves, the residents or resident representatives will be informed in writing of the bed-hold and
return policy. The policy interpretation and implementation states that residents may return to and resume
residence in the facility after hospitalization or therapeutic leave as outlined in this policy. Prior to transfer,
written information will be given to the residents and the resident representative that explains in detail:
a. The rights and limitations of the resident regarding bed-holds.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055671
If continuation sheet
Page 14 of 87
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
055671
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/10/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Parkview Healthcare Center
1514 E. Lincoln Avenue
Anaheim, CA 92805
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 0625
b. The reserve bed payment policy as indicated by the state plan (Medicaid residents)
Level of Harm - Minimal harm
or potential for actual harm
c. The facility per diem rate required to hold a bed (non-Medicaid residents), or to hold a bed beyond the
state bed-hold period (Medicaid residents); and
Residents Affected - Some
d. The details of the transfer (per the Notice of Transfer).
1. Medical record review for Resident 10 was initiated on 4/2/24. Resident 10 was readmitted to the facility
on [DATE].
Review of Resident 10's H&P examination dated 2/3/24, showed Resident 10 had the capacity to
understand and make decisions.
Review of Resident 10's Physician's Order dated 1/29/24, showed may transfer Resident 10 to Hospital A
via 911 for further evaluation, and bed hold for seven days if admitted .
Review of Resident 10's Notice of Transfer/discharge date d 1/29/24, showed Resident 10 was transferred
to Hospital A.
Review of Resident 10's General Nurses' Notes for January 2024 did not show documented evidence
Resident 10 or his representative was provided information about the bed hold policy or their rights to
request for bed hold upon transfer to an acute hospital.
On 4/4/24 at 1102 hours, an interview was conducted with LVN 1. LVN 1 stated when a resident was
transferred to the acute hospital, the licensed nurse prepared a packet containing the resident's medical
information, notify the physician and receive an order to transfer the resident and a bed hold for seven days
if the resident was admitted to the acute hospital.
2. Medical record review for Resident 22 was initiated on 4/3/24. Resident 22 was readmitted to the facility
on [DATE].
Review of Resident 22's H&P examination dated 3/21/24, showed Resident 22 had the capacity to
understand and make decisions.
Review of Resident 22's Physician's Order showed the following orders:
- dated 1/9/24, to transfer Resident 22 to Hospital B emergency department for left hip hemiarthroplasty (a
surgical operation that replaces half of a joint with an artificial replacement and leaves the other part in its
natural state), and bed hold for seven days if admitted .
- dated 3/16/24, to transfer Resident 22 to Hospital B with orthopedic doctor (examines, diagnoses, and
treats diseases and injuries to the musculoskeletal system) for left hip replacement due to broken hip and
failed screws.
Review of Resident 22's General Nurses' Notes for January and March 2024 did not show documented
evidence Resident 22 or her representative was provided with the information about the bed hold policy or
their rights to request for bed hold upon transfer to an acute hospital.
On 4/4/24 at 1523 hours, an interview and concurrent medical record review was conducted with the
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055671
If continuation sheet
Page 15 of 87
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
055671
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/10/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Parkview Healthcare Center
1514 E. Lincoln Avenue
Anaheim, CA 92805
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 0625
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
MDS Nurse. The MDS Nurse verified the above findings. The MDS Nurse stated when a resident was
transferred to the emergency department, the bed hold should be offered to the resident or resident's
representatives.
3. Medical record review for Resident 35 was initiated on 4/3/24. Resident 35 was readmitted to the facility
on [DATE].
Review of Resident 35's H&P examination dated 5/10/23, showed Resident 35 had the capacity to
understand and make decisions.
Review of Resident 35's Physician's Order, showed the following orders:
- dated 10/3/23, to transfer Resident 35 to Hospital A and bed hold for seven days of admitted .
- dated 2/7/24, to transfer Resident 35 to Hospital A for further evaluation and bed hold for seven days if
admitted .
Review of Resident 35's General Nurses' Notes for December 2023 and February 2024 did not show
documented evidence Resident 35 or her representative was provided with the information about the bed
hold policy or their rights to request for the bed hold upon transfer to an acute hospital.
On 4/4/24 at 1317 hours, an interview and concurrent record review was conducted with the MDS Nurse.
The MDS Nurse verified and acknowledged the above findings.
On 4/5/24 0839 hours, an interview was conducted with the DON. The DON verified the above findings and
stated the facility did not have a bed hold notification form and they only had a notice of transfer or
discharge form that was completed when a resident was discharged from the facility.
5. Medical record review of Resident 38 was initiated on 4/05/24. Resident 38 was admitted to the facility on
[DATE], and transferred to the acute care hospital on 3/26/24.
Review of Resident 38's MDS dated [DATE], showed Resident 38's cognitive skills for daily decision making
were severely impaired.
Review of Resident 38's Physician Discharge summary dated [DATE], showed Resident 38 was transferred
to acute for GT placement.
Review of Resident 38's Notice of Transfer / Discharge form dated 3/26/24, showed Resident 38 was to be
transferred to the acute care hospital. Further review of the form failed to show the written notice of the bed
hold was provided to Resident 38's responsible party.
On 4/05/24 at 0922 hours, an interview and concurrent record review was conducted with Business Office
Manager. The Business Office Manager verified Resident 38 was transferred to the acute hospital on
3/26/24. The Business Office Manager was asked to show the documentation that Resident 38 or the
responsible party was notified in writing of the bed hold policy at the time of transfer to the acute care
hospital. The Business Office Manager stated the facility did not have the bed hold notification to notify
Resident 38 or responsible party of bed hold policy.
On 4/05/24 at 0942 hours, an interview was conducted with DON. The DON verified there was no bed
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055671
If continuation sheet
Page 16 of 87
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
055671
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/10/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Parkview Healthcare Center
1514 E. Lincoln Avenue
Anaheim, CA 92805
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 0625
hold notification form to notify Resident 38 and/or responsible party of the bed hold.
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055671
If continuation sheet
Page 17 of 87
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
055671
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/10/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Parkview Healthcare Center
1514 E. Lincoln Avenue
Anaheim, CA 92805
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 0638
Assure that each resident’s assessment is updated at least once every 3 months.
Level of Harm - Potential for
minimal harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interview and medical record review, the facility failed to ensure the quarterly MDS assessment was
completed within 14 calendar days of the Assessment Reference Date (ARD) for one of one reviewed
resident (Resident 21). This failure had the potential of not identifying each resident's preferences and
goals of care, functional and health status, strengths and needs, as well as offering guidance for further
assessments once the health problems had been identified.
Residents Affected - Some
Findings:
Review of the Long-Term Facility Resident Assessment Instrument 3.0 User's Manual v1.18.11 dated
October 2023 showed a Quarterly (Non-Comprehensive) assessment completion date must be no later
than 14 calendar days of the MDS assessment's ARD and data submission must be no later than 14 days
of the assessment's completion date.
Medical record review for Resident 21 was initiated on 4/3/24. Resident 21 was admitted to the facility on
[DATE], and readmitted on [DATE].
Review of Resident 21's MDS Quarterly assessment dated [DATE], showed the assessment was initiated.
However, Resident 21's MDS Quarterly Assessment showed it was open and not submitted.
On 4/3/24 at 1611 hours, an interview and concurrent medical record review was conducted with the MDS
Nurse. The MDS Nurse verified Resident 21's MDS quarterly assessment had an ARD of 2/19/24, and had
an open status. The MDS Nurse stated when the assessment status showed open, it meant the
assessment was not completed. The MDS Nurse stated Resident 21's MDS quarterly assessment should
had been completed 14 days after the ARD on 3/4/24.
On 4/5/24 at 1530 hours, the DON was informed and acknowledged the above findings.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055671
If continuation sheet
Page 18 of 87
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
055671
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/10/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Parkview Healthcare Center
1514 E. Lincoln Avenue
Anaheim, CA 92805
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 0640
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Level of Harm - Potential for
minimal harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interview and medical record review, the facility failed to transmit the MDS timely for one of one resident
reviewed (Resident 14). This failure had the potential for not providing care to meet the resident's care
needs.
Residents Affected - Some
Findings:
Review of the Long-Term Facility Resident Assessment Instrument 3.0 User's Manual v1.18.11 dated
October 2023 in Chapter 5: Submission and Correction of the MDS Assessments, Section 5.2, showed a
Quarterly (Non-Comprehensive) Review Assessment data submission must be no later than 14 days of the
assessment's completion date.
Medical record review for Resident 14 was initiated on 4/3/24. Resident 14 was admitted to the facility on
[DATE], and readmitted on [DATE].
Review of Resident 14's MDS Quarterly assessment dated [DATE], showed the assessment with a
completion date of 2/28/24.
Review of the MDS 3.0 Nursing Home (NH) Final Validation Report showed Resident 14's MDS Quarterly
assessment dated [DATE], with submission date and time of 3/28/24 at 1255 hours.
On 4/3/24 at 1630 hours, an interview and concurrent interview was conducted with the MDS Nurse. The
MDS Nurse stated she was not the person submitting the residents' assessments to CMS. The MDS Nurse
stated a person from the corporate submitted the residents' assessments to CMS. The MDS Nurse stated
Resident 14's MDS quarterly assessment dated [DATE], should had been submitted on 3/13/24.
On 4/4/24 at 0844 hours, the MDS Nurse provided documents to show Resident 14's MDS quarterly
assessment dated [DATE], was submitted on 3/28/24, and stated the assessment was submitted late.
On 4/5/24 at 1530 hours, the DON was informed and acknowledged the above finding.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055671
If continuation sheet
Page 19 of 87
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
055671
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/10/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Parkview Healthcare Center
1514 E. Lincoln Avenue
Anaheim, CA 92805
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 0641
Ensure each resident receives an accurate assessment.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Medical
Record Review for Resident 3 was initiated on 4/3/24. Resident 3 was admitted to the facility on [DATE],
and readmitted on [DATE].
Residents Affected - Some
Review of Resident 3's Immunization Administration Record showed Resident 3 received pneumococcal
vaccine on 3/6/20. The Immunization Administration Record for Resident 3 did not show the type of the
pneumococcal vaccine received.
Review of Resident 3's MAR dated March 2020 showed Resident 3 had received PPSV23 on 3/6/20.
Review of the Resident 3's General Nurses Note dated 4/8/24 at 1733 hours, showed the resident's
responsible party was called and offered PCV 20, educated on pneumococcal vaccination, and declined
the vaccination.
Further review of Resident 3's medical record did not show if Resident 3 was offered PCV 20 single dose or
PCV 15 followed by PPSV 23, until 4/8/24.
Review of Resident 3's MDS dated [DATE], showed Section O0300A with a question if the resident's
pneumococcal vaccination up to date, and was coded yes.
4. Medical record review for Resident 16 was initiated on 4/9/24. Resident 16 was admitted to the facility on
[DATE], and readmitted on [DATE].
Review of Resident 16's MAR dated June 2021 showed Resident 16 had received PPSV23 on 6/10/21.
Further review of the medical record for Resident 16 did not show if Resident 16 was offered PCV 20 single
dose or the PCV 15 followed by PPSV 23.
Review of Resident 16's MDS dated [DATE], showed Section O0300A with a question if the resident's
pneumococcal vaccination up to date, and was coded yes.
5. Record review for Resident 19 was initiated on 4/9/24. Resident 19 was admitted to the facility on [DATE].
Review of Resident 19's undated Immunization Administration Record showed Resident 19 had received
Pneumococcal vaccine on 6/11/21, and PCV 20 on 4/6/24. The Immunization Administration Record for
Resident 19 did not show the type of pneumococcal vaccine received on 6/11/21.
Review of Resident 19's MAR dated June 2021 showed Resident 19 received PPSV23 on 6/11/21.
Further review of Resident 19's medical record did not show if Resident 19 was offered PCV 20 single dose
or the PCV 15 followed by PPSV23, until 4/6/24.
Review of Resident 16's MDS dated [DATE], showed Section O0300A with a question if the resident's
pneumococcal vaccination up to date, and was coded yes.
6. Medical record review for Resident 23 was initiated on 4/9/24. Resident 23 was admitted to the
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055671
If continuation sheet
Page 20 of 87
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
055671
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/10/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Parkview Healthcare Center
1514 E. Lincoln Avenue
Anaheim, CA 92805
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 0641
facility on [DATE], and readmitted on [DATE].
Level of Harm - Minimal harm
or potential for actual harm
Review of Resident 23's undated Immunization Administration Record showed Resident 23 had received
pneumococcal vaccine on 5/10/22, and PCV 20 on 4/6/24. The Immunization Administration Record for
Resident 19 did not show the type of pneumococcal vaccine received on 5/10/22.
Residents Affected - Some
Review of Resident 23's MAR dated May 2022 showed Resident 23 received PPSV 23 on 5/10/22.
Further review of Resident 23's medical record did not show if Resident 23 was offered PCV 20 single dose
or the PCV 15 followed by PPSV 23, until 4/6/24.
Review of Resident 23's MDS dated [DATE], showed Section O0300A with a question if the resident's
pneumococcal vaccination up to date, and was coded yes.
7. Medical record review for Resident 27 was initiated on 4/9/24. Resident 27 was admitted to the facility on
[DATE].
Review of Resident 27's undated Resident Immunization Record did not show an entry for the
pneumococcal vaccination.
Review of Resident 27's General Nurses Note dated 2/14/24, showed the facility called the resident's
responsible party to inquire about the vaccination status and was awaiting for a call back from the
responsible party.
Further review of the medical record for Resident 27 did not show if the facility followed up with the
responsible party to inquire about Resident 27's pneumococcal vaccination status after 2/14/24, and if a
pneumococcal vaccination was offered to the Resident 27.
Review of Resident 27's MDS dated [DATE], showed Section 0300B showed with a question if
pneumococcal vaccine not received state reason, and was coded offered and declined.
On 4/9/24 at 1447 hours, a concurrent interview and medical record review for Residents 3, 16, 19, 23, and
27 was conducted with the IP. The IP verified the above findings. The IP stated Residents 3, 16, 19, and 23
did not receive the updated vaccination which was either PCV20 single dose, or PCV15 followed by PPSV
23 to be up to date with their pneumococcal immunization until 4/6/24. The IP stated she inquired about
Resident 27's vaccination status and received an email from the previous facility that Resident 27 declined
the pneumococcal vaccination; however, she did not offer the pneumococcal vaccination in the facility. The
IP further stated Residents 3 and 19 received the updated pneumococcal vaccine PCV20 on 4/6/24, and
Resident 3's responsible party had declined the offer for the pneumococcal vaccination on 4/8/24, and she
was working to provide the updated pneumococcal vaccination to the other residents.
On 4/10/24 at 1234 hours, a concurrent interview and medical record review for Residents 3, 16, 19, 23
and 27 was conducted with the DON and IP. The DON and IP verified the above findings and stated the
pneumococcal immunization was not up to date for Residents 3, 16, 19, and 23. In addition, the DON and
IP verified the updated pneumococcal vaccination was not offered to Resident 27 in the facility. The DON
and IP verified the MDS was not coded accurately for the above residents.
Cross reference to F883 for examples #12, #13, #14, #15 and #16.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055671
If continuation sheet
Page 21 of 87
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
055671
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/10/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Parkview Healthcare Center
1514 E. Lincoln Avenue
Anaheim, CA 92805
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 0641
Level of Harm - Minimal harm
or potential for actual harm
Based on interview and medical record review, the facility failed to ensure the MDSs for 11 of 17 reviewed
residents (Residents 3, 15, 16, 18, 19, 21, 23, 25, 27, 31, and 33) were accurate. This failure posed the risk
of the residents not receiving an individualized plan of care on the residents' specific needs.
Findings:
Residents Affected - Some
Review of the Long-Term Facility Resident Assessment Instrument 3.0 User's Manual v1.18.11 dated
October 2023 in Chapter 3 under Section O0300: Pneumococcal Vaccine, showed Up to date in item
O0300A means in accordance with current Advisory Committee on Immunization Practices (ACIP)
recommendations. For up-to-date information on timing and intervals between vaccines, please refer to
ACIP vaccine recommendations available at
- https://www.cdc.gov/vaccines/schedules/hcp/index.html
- http://www.cdc.gov/vaccines/hcp/acip-recs/index.html
- https://www.cdc.gov/pneumococcal/vaccination.html
Review of the new CDC guideline titled (MMWR) Morbidity and Mortality Weekly Report dated 1/28/22,
showed use of 15-Valent Pneumococcal Conjugate Vaccine and 20-Valent Pneumococcal Conjugate
Vaccine among U.S. Adults: Updated Recommendations of the Advisory Committee on Immunization
Practices (APIC) - United States, 2022.
Review of the CDC guidelines for pneumococcal vaccination reviewed 9/22/23, showed the following:
- for adults 65 years or older who had never received any pneumococcal vaccine regardless of risk
conditions, give one dose of PCV 15 or PCV 20. When PCV 15 is used, it should be followed by a dose of
PPSV 23 at least one year later. The minimum interval (eight weeks) can be considered in adults with an
immunocomprising condition, cochlear implant, or cerebrospinal fluid leak. Their vaccines will the be
complete. When PCV 20 is used, it does not need to be followed by a dose of PPSV 23. Their vaccines are
then completed.
- for adults 65 years or older who had only received PPSV 23 regardless of risk condition, give 1 dose of
PCV 15 or PCV 20 at least one year after the most recent PPSV 23 vaccination. Regardless of vaccine
given, an additional dose of PPSV 23 is not recommended since they already received it. Their vaccines
are then completed.
1. Medical record review for Resident 21 was initiated on 4/3/24. Resident 21 was admitted to the facility on
[DATE], and readmitted on [DATE].
Review of Resident 21's Resident Immunization Record form (undated), showed Resident 21 received the
Pneumococcal polysaccharide vaccine (PPV) on 9/10/20, prior to admission to the facility. Resident 21's
Pneumococcal Pneumonia Immunization Program Consent Form was not completed.
Review of Resident 21's MDS dated [DATE], showed Section O0300A with a question if the resident's
pneumococcal vaccination up to date and was coded yes.
On 4/9/24 at 1415 hours, an interview and concurrent medical record review was conducted with the
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055671
If continuation sheet
Page 22 of 87
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
055671
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/10/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Parkview Healthcare Center
1514 E. Lincoln Avenue
Anaheim, CA 92805
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 0641
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
IP. The IP stated she should have offered Resident 21 the option to receive the Pneumococcal Conjugate
Vaccine 20 (PCV 20) to be up to date with her pneumococcal immunization.
On 4/10/24 at 1236 hours, an interview and concurrent medical record review was conducted with the DON
and IP. The DON and IP verified the above findings, and they stated the MDS was not up to date regarding
Resident 21's pneumococcal immunization.
2. Medical record review for Resident 25 was initiated on 4/9/24. Resident 25 was admitted to the facility on
[DATE].
Review of Resident 25's Resident Immunization Record form (undated), showed Resident 25 received a
pneumonia vaccination on 5/10/22. However, the form did not show what type of pneumococcal vaccination
was administered to Resident 25.
Review of Resident 25's MDS dated [DATE], showed Section O0300A with a question if the resident's
pneumococcal vaccination up to date and was coded yes.
On 4/9/24 at 1348 hours, an interview and concurrent medical records was conducted with the IP. The IP
stated Resident 25's pneumococcal vaccination history information should had been unknown. The IP
stated she only offered the residents the option to receive the Pneumococcal polysaccharide vaccine 23
(PPV 23) because it was the only pneumococcal vaccination listed in the Pneumococcal Pneumonia
Immunization Program Consent Form. The IP stated she should had offered the PCV 20 for Resident 25 be
up to date with her pneumococcal immunization.
On 4/10/24 at 1233 hours, an interview and concurrent medical record review was conducted with the DON
and IP. The DON and IP verified the above findings, and they stated the MDS Nurse was not up to date
regarding Resident 21's pneumococcal immunization.
On 4/10/24 at 1253 hours, an interview was conducted with the MDS Nurse. The MDS Nurse stated the IP
told her if the resident did not have a pneumonia vaccine for the past five year, the MDS Nurse would notify
the IP to offer the pneumonia vaccine. The MDS Nurse further stated she received the most updated
information about immunization from the IP.
Cross reference to F883 for examples #9 and #10.
8. Medical record review for Resident 15 was initiated on 4/9/24. Resident 15 was admitted to the facility on
[DATE].
Review of Resident 15's Resident Immunization Record Form, (undated), showed Resident 15 declined the
pneumonia vaccine on 1/8/16. Further review of Resident 15's medical record showed no documented
evidence Resident 15 was educated on the risk and benefits of the pneumonia vaccine, provided a VIS
(Vaccine Information Statement) handout from the CDC, signed a consent acknowledging a declination of
the pneumonia vaccine.
Review of Resident 15's Annual MDS dated [DATE], Section O, showed pneumococcal vaccine was offered
and declined.
9. Medical record review for Resident 33 was initiated on 4/9/24. Resident 33 was admitted to the facility on
[DATE].
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055671
If continuation sheet
Page 23 of 87
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
055671
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/10/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Parkview Healthcare Center
1514 E. Lincoln Avenue
Anaheim, CA 92805
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 0641
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Review of Resident 33's Resident Immunization Record Form, (undated), showed Resident 33 received a
pneumonia vaccination on 2/10/23. However, the form did not show what type of pneumococcal vaccination
was administered to Resident 33. Review of Resident 33's Physician's Telephone Order form showed
Resident 33 had a physician's order to receive the Pneumovax 23 vaccine on 2/10/23.
Review of Resident 33's Quarterly MDS dated [DATE], Section O, showed a yes response to pneumococcal
vaccine was up to date.
10. Medical record review for Resident 18 was initiated on 4/9/24. Resident 18 was admitted to the facility
on [DATE], and readmitted on [DATE].
Review of Resident 18's Resident Immunization Record Form, (undated), showed Resident 18 received a
pneumonia vaccine on 6/10/21. However, the form did not show what type of pneumococcal vaccination
was administered to Resident 18. Review of Resident 18's physician Orders List showed Resident 18 had a
physician's order to receive the Pneumovax 23 vaccine on 6/10/21.
Review of Resident 18's Quarterly MDS dated [DATE], Section O, showed a yes response to pneumococcal
vaccine was up to date.
11. Medical record review for Resident 31 was initiated on 4/9/24. Resident 31 was admitted to the facility
on [DATE].
Review of Resident 31's Resident Immunization Record Form, (undated), showed Resident 31 received
PPV on 6/4/21, outside of the facility. However, the form did not indicate what type of pneumonia
vaccination was administered. Further review of Resident 31's Immunizations history form showed Resident
31 received the Pneumococcal conjugate PCV 13 on 6/4/21.
Review of Resident 31's Quarterly MDS dated [DATE], Section O, showed a yes response to pneumococcal
vaccine was up to date.
On 4/9/24 at 1517 hours, a concurrent interview and medical record review was conducted with the IP. The
IP verified the above findings for Residents 15, 18, 31, and 33. The IP also verified the MDS Section O
showed if the residents were up to date on their pneumococcal vaccine. The IP acknowledged Resident
15's MDS Section O was inaccurately documented since Resident 15 was not offered the pneumococcal
vaccine after declining the pneumococcal vaccine on 1/8/16. The IP also stated Residents 18, 31, and 33's
MDS Section O were also inaccurately documented and the response to the question should have been
marked with a no.
On 4/10/24 at 1241 hours, a telephone interview with the MDS Coordinator was conducted. The MDS
Coordinator verified the above findings. The MDS Coordinator stated she received the CDC updates for the
pneumococcal vaccines from the IP and stated she was not informed of the updated guidelines from
January 2022.
On 4/10/24 at 1302 hours, an interview with the DON and the Administrator was conducted. The DON and
the Administrator acknowledged above findings.
Cross reference to F883 for #17, #18, #19, and #20.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055671
If continuation sheet
Page 24 of 87
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
055671
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/10/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Parkview Healthcare Center
1514 E. Lincoln Avenue
Anaheim, CA 92805
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 0655
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being
admitted
**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 provide a summary of the
baseline care plan for one of one reviewed resident (Resident 441). This failure had the potential for
inappropriate interventions and care for Resident 441.
Findings:
Review of the facility's P&P titled Care Plans- Baseline revised December 2016 showed the resident and
their representative will be provided a summary of the baseline care plan that includes but is not limited to:
a. The initial goals of the resident;
b. A summary of the resident's medications and dietary instructions;
c. Any services and treatments to be administered by the facility and personnel acting on behalf of the
facility; and
d. Any updated information on the details of the comprehensive care plan, as necessary.
During the initial tour on 4/2/24 at 0845 hours, Resident 441 stated the SSD spoke to her about the
physical therapy for walking and returning home. Resident 441 stated she did not have a discussion of her
plan of care or received a copy of the documents for a summary of her baseline care plan.
Medical record review was initiated for Resident 441 on 4/3/24. Resident 441 was admitted to the facility on
[DATE].
Review of Resident 441's H&P examination dated 3/28/24, showed Resident 441 had the capacity to
understand and make decisions.
Further review of Resident 441's medical record did not show documented evidence Resident 441 was
informed or provided a summary of her baseline care plan.
On 4/3/24 at 1020 hours, an interview was conducted with the DSD. The DSD stated the RN completed the
care plan within 72 hours of the resident's admission. The DSD further stated if the RN was not able to
complete the care plan, the DON would complete the care plan and assessments of the newly admitted
residents. The DSD stated the IDT would conduct a care plan meeting with the newly admitted residents to
discuss their care.
On 4/3/24 at 1110 hours, an interview and concurrent medical record review was conducted with the DON.
The DON stated the care plan should be completed within 24 hours. The DON stated the initial care plans
included psychosocial concerns, risk safety, risk for falls, side rails, pain, nutrition, activities of daily living,
bowel and bladder elimination, risk for dehydration, rehabilitation services, active diagnoses, and active
medications. The DON stated a care plan meeting was completed within 72 hours of a resident's
admission. The IDT which included the SSD/Activities Director, RD, DON, and dietary supervisor will meet
with the resident to discuss the resident's care and concerns. The
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055671
If continuation sheet
Page 25 of 87
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
055671
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/10/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Parkview Healthcare Center
1514 E. Lincoln Avenue
Anaheim, CA 92805
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 0655
Level of Harm - Minimal harm
or potential for actual harm
DON stated the facility did not provide copies of a summary baseline care plan to the residents unless
requested by the resident but the residents were informed of their care. The DON verified there was no
documentation to show Resident 441 was provided a copy of a summary baseline care plan.
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055671
If continuation sheet
Page 26 of 87
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
055671
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/10/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Parkview Healthcare Center
1514 E. Lincoln Avenue
Anaheim, CA 92805
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 0656
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Develop and implement a complete care plan that meets all the resident's needs, with timetables and
actions that can be measured.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview, and medical record review, the facility failed to develop and implement the
comprehensive plan of care to reflect the individual care needs of one of 14 sampled residents (Resident
22). The facility failed to develop a care plan problem to address Resident 22's noncompliance with a
physician's order to apply her abduction pillow at all times while in bed. This failure posed the risk of not
providing appropriate, consistent, and individualized care to Resident 22.
Findings:
Medical record review for Resident 22 was initiated on 4/3/24. Resident 22 was readmitted to the facility on
[DATE].
Review of Resident 22's H&P examination dated 3/21/24, showed Resident 22 had the capacity to
understand and make decisions and had diagnosis for status post repeated surgery for infection open
reduction and internal fixation (ORIF, put pieces of a broken bone into place using surgery with screws,
plates, sutures, or rods to hold the broken bones together).
Review of Resident 22's Physician's Orders for April 2024 showed a physician's order dated 3/19/24, to
apply a hip abduction pillow while in bed at all times to Resident 22.
Review of Resident 22's General Nurses' Notes dated 4/2/24, showed, Res noted with episodes of
removing Abductor pillow. Risk and benefits explained, res. got upset, stated It's my right. Frequent visual
checks done to ensure safety and comfort.
Review of Resident 22's Comprehensive Plan of Care did not show a care plan problem was developed to
address Resident 22's noncompliance with the use of abduction pillow.
During the wound treatment observation for Resident 22 on 4/3/24 at 1524 hours, Resident 22's abduction
pillow was removed and at the right side of her bed.
On 4/3/24 at 1550 hours, an observation, interview, and concurrent medical record review was conducted
with LVN 1. LVN 1 verified the above findings. LVN 1 stated the abduction pillow should not be removed
while Resident 22 was in bed if the physician's order was to apply the abduction pillow at all times while
Resident 22 was in bed.
On 4/4/24 at 0851 hours, an interview and concurrent medical record review was conducted with the DON.
The DON stated Resident 22's abduction pillow should be in place at all times while in bed per the
physician's order. The DON stated Resident 22 had episodes of noncompliance for removing her abduction
pillow. The DON verified the above findings. The DON verified there was no care plan problem to address
Resident 22's noncompliance for removing the abduction pillow.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055671
If continuation sheet
Page 27 of 87
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
055671
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/10/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Parkview Healthcare Center
1514 E. Lincoln Avenue
Anaheim, CA 92805
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 0679
Provide activities to meet all resident's needs.
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 an
individualized and ongoing activity program to meet the needs and interests of one of one resident
reviewed for activity (Resident 11). The facility failed to provide activities for Resident 11 which met his
identified interests. This failure had the potential for Resident 11 to experience feelings of social isolation
and frustration.
Residents Affected - Few
Findings:
Review of the facility's P&P titled Activity Program revised June 2018 showed the activity program are
designed to meet the interest of and support the physical mental and psychosocial well being of each
resident. Further review of the P&P showed the activities offered are based on the comprehensive resident
centered assessment and the preferences of each resident.
On 4/2/24 at 0942 hours, and 4/3/24 at 0801 and 1308 hours, Resident 11 was observed lying awake in
bed staring at the wall.
On 4/2/24 at 1024 hours, an interview was conducted with Resident Representative 1. Resident
Representative 1 stated she visited Resident 11 almost every day in the evening and had not seen the
facility providing activities to Resident 11.
On 4/4/24 at 1008 hours, an observation and a concurrent interview was conducted with CNA 2. Resident
11 was observed in bed awake and the television was observed to be turned off. CNA 2 verified the
observation. CNA 2 was asked if the facility provided any activities to Resident 11, she stated she had not
seen the facility provided activities to Resident 11; however, when the resident's family member came in to
visit Resident 11 in the evening, they provided music and turned on the television for Resident 11.
Medical record review for Resident 11 was initiated on 4/2/24. Resident 11 was admitted to the facility on
[DATE].
Review of Resident 1's H&P examination dated 10/7/23, showed Resident 11 had no capacity to
understand and make decisions.
Review of Resident 11's MDS dated [DATE], showed Resident 11 had severe cognitive impairment.
Review of Resident 1's Activity assessment dated [DATE], showed Resident 11's current activity preference
which required 1:1 staff assistance (one resident to one staff) with cards and other games, exercise/sports,
reading writing, spiritual religious, and talking conversing. Resident 11 was able to independently
participate in listening to music and watching television. Further review of the activity assessment showed
Resident 11 required prompts and cues to increase participation.
Review of Resident 11's Care Plan dated 10/5/23, showed a problem addressing little or no involvement in
the activities. The interventions included activities department to provide room visit with the resident's
activity of interest and to provide sensory stimulation three times a week. The care plan interventions
included activities to provide materials to assist with independent activities.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055671
If continuation sheet
Page 28 of 87
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
055671
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/10/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Parkview Healthcare Center
1514 E. Lincoln Avenue
Anaheim, CA 92805
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 0679
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Review of Resident 11's Activity Attendance Record for March and April 2024 showed there was no activity
provided from 4/1to 4/4/24; and in March 2024, Resident 1 was mostly provided with beauty social,
educational/current events, hand massage/manicure, and movie on the television on 3/7, 3/9, 3/11, 3/12,
3/19, 3/21, and 3/25/24. Review of the Activity Attendance Record for March 2024 showed Resident 11
were provided with room visits and mostly provided sensory stimulation and spiritual/religious/hymns on
3/4, 3/5, 3/8, 3/14, 3/15, 3/18, 3/23, and 3/26/24. Further review of the Activity Attendance Record for
March 2024 did not show if Resident 11 was provided with any activity on 3/1, 3/2, 3/3, 3/6, 3/10, 3/13,
3/16, 3/17, 3/20, 3/22, 3/24, 3/27, 3/28, 3/29, 3/30, and 3/31/24.
On 4/4/24 at 1440 hours, an observation and concurrent interview was conducted with the Activity Director.
Resident 11 was observed lying in bed awake and staring at the wall, television was not observed to be on,
or any in-room sensory stimulation was observed. The Activity Director verified the observation and above
findings. The Activity Director stated Resident 11 required daily activities and the preferred activity should
have been provided to Resident 11 as identified in activity assessment and care plan.
On 4/4/24 at 1626 hours, an interview was conducted with the DON. The DON was informed and
acknowledged the above findings.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055671
If continuation sheet
Page 29 of 87
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
055671
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/10/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Parkview Healthcare Center
1514 E. Lincoln Avenue
Anaheim, CA 92805
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 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, and medical record review, the facility failed to ensure to provide the necessary
services to attain or maintain the highest practicable well-being for three of three reviewed residents
(Residents 20, 22, and 36).
Residents Affected - Some
* The facility failed to ensure Resident 22's abduction pillow and bilateral heel protectors were in place while
in bed per the physician's orders. In addition, the facility failed to ensure Resident 22 did not wear the left
knee immobilizer while Resident 22 was in bed per the physician's order. The facility failed to ensure
Resident 22 had other bowel management medication intervention as needed.
* The facility failed to ensure the hospice and facility collaborated in the hospice care for Residents 20 and
36.
* The facility failed to ensure a hospice care member participated in Resident 36's Quarterly IDT meeting.
Findings:
1.a. Medical record review for Resident 22 was initiated on 4/3/24. Resident 22 was readmitted to the facility
on [DATE].
Review of Resident 22's H&P examination dated 3/21/24, showed Resident 22 had the capacity to
understand and make decisions and had diagnosis for status post repeated surgery for infection open
reduction and internal fixation (ORIF).
Review of Resident 22's Physician's Orders for April 2024 showed the following physician's orders:
- dated 3/19/24, to apply a hip abduction pillow while in bed at all times to Resident 22.
- dated 3/19/24, to apply a knee immobilizer on LLE while ambulating to Resident 22.
- dated 3/19/24, to apply the bilateral heel protectors every shift as ordered for skin management to
Resident 22.
During the wound treatment observation for Resident 22 on 4/3/24 at 1524 hours, Resident 22's abduction
pillow was removed and placed at the right side of her bed. Resident 22 was observed wearing a left knee
immobilizer while she was in bed. Resident 22 was not observed wearing the bilateral heel protectors.
On 4/3/24 at 1550 hours, an observation, interview, and concurrent medical record review was conducted
with LVN 1. LVN 1 verified the above findings. LVN 1 stated the abduction pillow should not be removed
while Resident 22 was in bed if the physician's order was to apply the abduction pillow at all times while
Resident 22 was in bed. LVN 1 stated Resident 22 should not be wearing the left knee immobilizer while
Resident 22 was in bed if the physician's order was to apply the left knee immobilizer while ambulating. LVN
1 verified Resident 22 did not have the bilateral heel protectors.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055671
If continuation sheet
Page 30 of 87
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
055671
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/10/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Parkview Healthcare Center
1514 E. Lincoln Avenue
Anaheim, CA 92805
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 0684
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
On 4/4/24 at 0851 hours, an interview and concurrent medical record review was conducted with the DON.
The DON verified and acknowledged the above findings.
b. Review of Resident 22's Physician's Orders for April 2024, showed the following physician's orders:
- dated 3/19/24, to administer Norco (pain medication) 5/325 mg one tablet by mouth every six hours as
needed for severe pain.
- dated 3/19/24, to administer Sertraline (an antidepressant medication) 50 mg one tablet by mouth for
depression manifested by sad facial expression.
- dated 3/20/24, to administer senna (a stool softener medication) 8.6 mg one tablet by mouth twice a day
for bowel management.
Review of Resident 22's Resident Care Details for March 2023, under the question of bowel management
size, did not show Resident 22 had an episode of bowel movement from 3/10 to 3/15/24.
Review of Resident 22's MAR for March 2024 did not show Resident 22 was administered any medication
for bowel management.
On 4/5/24 at 0804 hours, an interview and concurrent medical records review was conducted with RN 1.
RN 1 verified the above findings. RN 1 stated Resident 22 was on Norco medication as needed and at risk
for constipation. RN 1 stated the licensed nurses should notify the physician if Resident 22 did not have an
episode of a bowel movement for more than three days and should ask for bowel management medication.
On 4/5/24 at 1530 hours, the DON was informed and acknowledged the above findings.
2. Medical record review for Resident 20 was initiated on 4/2/24. Resident 20 was admitted to the facility on
[DATE], under Hospice A.
Review of Resident 20's H&P examination dated 11/7/23, showed Resident 20 had no capacity to
understand and make decisions and goals for comfort care.
On 4/4/24 at 0919 hours, a concurrent interview and medical record review was conducted with the IP.
Review of Resident 20's care plan showed no documented evidence the hospice care team reviewed or
acknowledged Resident 20's care plans. The IP stated the hospice care team should also be updated and
informed of the resident's care plans to ensure they were in agreement with Resident 20's plan of care.
3. Medical record review for Resident 36 was initiated on 4/2/24. Resident 36 was admitted to the facility on
[DATE], under Hospice B.
Review of Resident 36's H&P examination dated 11/7/23, showed Resident 36 had no capacity to
understand and make decisions.
Review of Resident 36's Quarterly IDT dated 1/23/24, showed no documented evidence the hospice care
member participated in the meeting.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055671
If continuation sheet
Page 31 of 87
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
055671
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/10/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Parkview Healthcare Center
1514 E. Lincoln Avenue
Anaheim, CA 92805
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 0684
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
On 4/4/24 at 0919 hours, a concurrent interview and medical record review with the IP was conducted. The
IP verified the care plans for Resident 36 was not signed by the hospice care team and could not show
documented evidence the hospice care team were aware of the new or updated care plans for Resident 36.
Moreover, the IP verified no documented evidence a hospice care member participated in the Quarterly IDT
meeting dated 1/23/24. The IP stated the hospice care team should be part of the IDT meeting and review
care plans to ensure the hospice and facility were in agreeance of the resident's plan of care.
On 4/4/24 at 1455 hours, an interview with the DON was conducted. The DON verified the hospice staff did
not sign the care plans or have documented evidence the care plans were reviewed for Resident 20 or
Resident 36. The DON stated by signing the care plans, the hospice care team (Hospices A and B)
acknowledged and agreed with the facility's plan of care rendered to the residents.
On 4/5/24 at 1550 hours, an interview with the DON was conducted. The DON acknowledged above
findings.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055671
If continuation sheet
Page 32 of 87
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
055671
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/10/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Parkview Healthcare Center
1514 E. Lincoln Avenue
Anaheim, CA 92805
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 0690
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate
catheter care, and appropriate care to prevent urinary tract infections.
**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 ensure two of two
residents reviewed for the use of indwelling urinary catheter (Residents 20 and 35) were provided with the
necessary indwelling urinary catheter care to prevent UTI. The facility failed to ensure Resident 20's
indwelling urinary catheter orders followed the CDC's guidelines. These failures had the potential to put
Residents 20 and 35 at risk for UTI.
Findings:
Review of the facility's P&P titled Catheter Care, Urinary revised September 2014 showed the following
information should be recorded in the resident's medical record:
- The date and time that catheter care was given.
- The name and title of the individual(s) giving the catheter care.
- All assessment data obtained when giving catheter care.
- Character of urine such as color (straw-colored, dark or red), clarity (cloudy, solid particles, or blood), and
odor.
- Any problems noted at the catheter-urethral junction during perineal care such as drainage, redness,
bleeding, irritation, crusting, or pain.
- Any problems or complaints made by the resident related to the procedure.
- How the resident tolerated the procedure.
- If the resident refused the procedure, the reason(s) why and the intervention taken.
- The signature and title of the person recording the data.
1. During initial tour of the facility on 4/2/24 at 0844 hours, Resident 35 was observed with an indwelling
urinary catheter hanging on the right side of her bed with a blue privacy bag. The indwelling urinary
catheter tubing was observed with urine which appeared cloudy and had while particles.
Medical record review for Resident 35 was initiated on 4/3/24. Resident 35 was readmitted to the facility on
[DATE].
Review of Resident 35's H&P examination dated 5/10/23, showed Resident 35 had the capacity to
understand and make decisions.
Review of Resident 35's Physician's Orders for April 2024, showed the following physician's orders:
- dated 2/22/24, Foley catheter 18 Fr/10 ml to gravity drainage for wound healing. Change monthly
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055671
If continuation sheet
Page 33 of 87
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
055671
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/10/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Parkview Healthcare Center
1514 E. Lincoln Avenue
Anaheim, CA 92805
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 0690
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
and as needed if removed or blockage. May irrigate the Foley catheter with 100 ml of sterile water as
needed if clogged.
- dated 3/17/24, may flush the Foley catheter with normal saline 250 ml three times a day as needed.
Review of Resident 35's TAR (Treatment Administration Record) for March and April 2024 did not show
documentation of the indwelling urinary catheter care.
Review of Resident 35's Comprehensive Plan of Care showed a problem care area for the Foley catheter
dated 2/22/24, with an intervention for catheter care every shift and as needed.
Review of Resident 35's General Nurses Notes from 3/31-4/2/24, did not show documented evidence an
indwelling urinary catheter care was provided every shift to the resident.
Review of Resident 35's Resident Care Details showed the following:
- dated 3/27, 3/29, 3/30, and 4/2/24, an indwelling catheter care was provided at 0700 hours and 2300
hours.
- dated 3/28/24, an indwelling catheter care was provided at 0700 hours.
On 4/3/24 at 0828 hours, an observation and concurrent interview was conducted with CNA 2. CNA 2
verified Resident 35 had an indwelling urinary catheter with yellow and clear urine in the tubing.
On 4/3/24 at 1051 hours, an interview and concurrent medical record review was conducted with LVN 1.
LVN 1 stated an indwelling urinary catheter care included peri-care, monitoring the fluid intake and urine
output, and urine drainage every shift or as needed. LVN 1 stated the CNAs reported the urine output to the
charge nurse at the end of the shift and the LNs (licensed nurses) recorded the amount of urine output.
LVN 1 stated Resident 35's indwelling urinary catheter was used for wound management. LVN 1 verified
there was no order for an indwelling urinary catheter care for Resident 35. LVN 1 further verified Resident
35's MAR for March and April did not show documentation an indwelling urinary catheter care was provided
every shift for Resident 35.
On 4/3/24 at 1150 hours, an interview and concurrent medical record review was conducted with the DON.
The DON verified and acknowledged the above findings. The DON stated there should be a standing order
for an indwelling urinary catheter care every shift or as needed to show the documentation indwelling
urinary catheter care was provided every shift and as needed.
2. Review of the CDC's Infection Control - Catheter-Associated Urinary Tract Infections (CAUTI) 2009
showed Proper Techniques for Urinary Catheter Maintenance included changing indwelling catheters or
drainage bags at routine, fixed intervals is not recommended. Rather, it is suggested to change catheters
and drainage bags based on clinical indications such as infection, obstruction, or when the closed system
is compromised.
Review of the facility's P&P titled Catheter Care, Urinary revised on 9/2014 showed the purpose of the
procedure is to prevent catheter-associated urinary tract infections. The P&P showed changing the
indwelling catheters or drainage bags at routine, fixed intervals is not recommended. Rather, it is suggested
to change catheters and drainage bags based on clinical indications such as infection,
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055671
If continuation sheet
Page 34 of 87
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
055671
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/10/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Parkview Healthcare Center
1514 E. Lincoln Avenue
Anaheim, CA 92805
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 0690
obstruction, or when the closed system is compromised.
Level of Harm - Minimal harm
or potential for actual harm
Medical record review for Resident 20 was initiated on 4/2/24. Resident 20 was admitted to the facility on
[DATE].
Residents Affected - Few
Review of Resident 20's medical record showed a physician's order dated 11/7/23, for Resident 20 to have
an indwelling urinary catheter with a size 20 Fr/10 ml and to change the Foley catheter as needed if
removed or blocked, and may irrigate the Foley catheter with 80 ml sterile water as needed if clogged.
Further review of Resident 20's medical record showed a physician's order dated 11/7/23, to change the
Foley catheter bag every week on Sunday.
Review of Resident 20's March 2024 eTAR showed the Foley catheter bag was changed weekly on
Sundays for the following dates:
- 3/3/24
- 3/10/24
- 3/17/24
- 3/24/24
- 3/31/24
On 4/4/24 at 0943 hours, a concurrent interview and medial record review was conducted with the IP. The
IP verified Resident 20 had routine orders to change the Foley catheter bag weekly on Sunday. The IP
denied Resident 20 was assigned to a urologist and was following the physician's orders to change the
Foley catheter bag weekly on Sunday. The IP acknowledged the weekly Foley catheter bag changes
increased the risk for infection.
On 4/4/24 at 1109 hours, a concurrent interview and medical record review was conducted with the DON.
The DON verified Resident 20 had an indwelling urinary catheter size 20 Fr/10 ml. The DON stated the
indwelling catheter bags and indwelling catheters should be changed out as needed to help reduce the risk
for infection.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055671
If continuation sheet
Page 35 of 87
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
055671
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/10/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Parkview Healthcare Center
1514 E. Lincoln Avenue
Anaheim, CA 92805
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 0692
Provide enough food/fluids to maintain a resident's health.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview, and medical record review, the facility failed to ensure the nutrition needs were met
for one of two residents reviewed for nutrition (Resident 32).
Residents Affected - Few
* The facility failed to ensure Resident 32 was offered alternative when Resident 32 consumed less than
50% of his meal tray. This failure had the potential to compromise Resident 32's nutritional status.
Findings.
On 4/2/24 at 0802 hours, an interview was conducted with Resident 32. Resident 32 stated he had been
losing weight; however, he thought the current weight was his ideal weight.
Medical record review for the Resident 32 was initiated on 4/2/24. Resident 32 was admitted to the facility
on [DATE], and readmitted to the facility on [DATE].
Review of Resident 32's Vital Signs Grid dated 4/5/24, showed following weights:
- 3/4/24, 174 lbs (pounds);
- 2/26/24, 174 lbs;
- 2/19/24, 168 lbs;
- 2/12/24, 168 lbs;
- 2/5/24, 168 lbs; and,
- 1/5/24, 180 lbs.
Review of Resident 32's MDS dated [DATE], showed Resident 32 was cognitively intact.
Review of Resident 32's Physician Order dated 2/29/24, showed a physician's order for the resident's diet
to liberalize diet to regular with large protein portion.
On 4/2/24 at 1233 hours during the dinning observation, Resident 32 was observed eating his lunch in his
room. The meal tray was observed with white bread with herbs, zesty lasagna, green beans, one banana, 8
oz (eight ounces) of boost, a cup of chicken noodle soup, a cookie, a cup of grape juice, and a cup of water.
Resident 32 was observed eating one cup of chicken noodle soup, 8 oz of boost, a bite of cookie, and half
banana. Resident 32 was not observed eating the main portion of the meal bread with herbs, zesty
lasagna, green beans, a cup of grape juice and water.
On 4/2/24 at 1255 hours, an observation and concurrent interview was conducted with the IP. The IP was
observed asking Resident 32 if he was done with his meal, Resident 32 stated yes. The IP then was
observed taking out the tray of Resident 32's meal. The IP verified Resident 32 ate less than 50% of his
meal tray. The IP was not observed offering an alternative meal to Resident 32.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055671
If continuation sheet
Page 36 of 87
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
055671
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/10/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Parkview Healthcare Center
1514 E. Lincoln Avenue
Anaheim, CA 92805
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 0692
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
On 4/2/24 at 1259 hours, a follow-up interview was conducted with the IP. The IP verified Resident 32 ate
less than 50% of his meal tray and she did not offer alternatives to the Resident 32. The IP further stated
she should have offered the alternatives to the Resident 32 when he ate less 50% of his meal tray. The IP
then was observed going back to Resident 32's room and offering alternative meal to Resident 32.
On 4/4/24 at 0808 hours, an interview was conducted with the DON. The DON was informed of the above
findings. The DON stated when taking the meal tray out and if the staff noticed the resident eating less than
50% of their meal tray, then the staff should offer an alternatives to the resident to maintain their nutritional
status. The DON stated the IP should have offered the alternative meal to the Resident 32 when he ate less
than 50% of his tray.
On 4/5/24 at 1440 hours, a telephone interview was conducted with the RD. The RD was informed of the
above findings and stated the staff in the facility should offer alternative meal when the resident ate less
than 50% of any specific meal.
Cross reference to F842 example #2
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055671
If continuation sheet
Page 37 of 87
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
055671
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/10/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Parkview Healthcare Center
1514 E. Lincoln Avenue
Anaheim, CA 92805
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 - Minimal harm
or potential for actual harm
Residents Affected - Few
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and
provide appropriate care for a resident with a feeding tube.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview, facility P&P review, and facility document review, the facility failed to ensure three of
four sampled residents with GT (Residents 2, 9, and 36) were provided care as evidence by:
* The facility failed to ensure CNA 6 worked within their scope of practice as shown on the facility's
document titled Patient Care Assistant - CNA Job Description.
* The facility failed to ensure Residents 2, 9, and 36's GT tubing were properly labeled.
These failures posed the risk for negative outcomes for the residents with GT.
Findings:
Review of the facility's P&P titled Enteral Feedings - Safety Precautions revised 12/2011 showed all
personnel responsible for preparing, storing and administering enteral nutrition formulas will be trained,
qualified and competent in his or her responsibilities. The facility will remain current in and follow accepted
best practices in enteral nutrition. The P&P further showed administration set changes include:
a. Change administration sets for open-system enteral feedings at least every 24 hours
b. Change administration sets for closed-system enteral feedings according to manufacture's instructions.
Review of the facility's document titled Patient Care Assistant - CNA Job Description, undated, showed the
Nursing Assistant assists the resident in performing activities of daily living, provides a clean and safe living
environment, gathers data on the resident's physical and emotional state, and reports observations to the
nurse in charge. The facility document further showed the standard of performance for CNA include
performing routine patient care in accordance with Company and Center policies and nursing procedures.
1. Medical record review for Resident 9 was initiated on 4/2/24. Resident 9 was admitted to the facility on
[DATE], and readmitted back to the facility on 5/20/23.
Review of Resident 9's medical record showed a physician's order dated 5/20/23, showed the resident had
a GT. Further review of Resident 9's medical record showed the resident was on GT feeding formula, Jevity
1.5 at 40 ml/hr via GT for 20 hours.
On 4/2/24 at 0842 hours, a concurrent observation and interview was conducted with CNA 6. CNA 6 was
observed turning off Resident 9's GT feeding machine. CNA 6 verified the finding and stated he turned off
the GT feeding machine so that he could clean the resident. When asked if turning off GT feeding machines
was within a CNA's scope of practice, CNA 6 stated no; however, he sometimes turned the GT feeding
machine on and off to help the charge nurse when they were not available to turn on or off the GT feeding
machine.
On 4/4/24 at 0918 hours, an interview with the DSD was conducted. The DSD verified the CNA could
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055671
If continuation sheet
Page 38 of 87
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
055671
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/10/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Parkview Healthcare Center
1514 E. Lincoln Avenue
Anaheim, CA 92805
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 - Minimal harm
or potential for actual harm
Residents Affected - Few
not turn on or off the GT feeding machine and stated it was not within their scope of practice. The DSD
stated the CNA needed to notify the charge nurses since the charge nurses monitored the residents on GT
feeding to ensure they were receiving the complete dose of their feeding.
On 4/4/24 at 1455 hours, an interview with the DON was conducted. The DON stated it was not within the
CNA's scope of practice to turn on or off the GT feeding machine. The DON further stated only the license
nurses were able to turn on or off the GT feeding machine.
2.a. Medical record review for Resident 2 was initiated on 4/2/24. Resident 2 was admitted to the facility on
[DATE], and readmitted back to the facility on [DATE].
Review of Resident 2's medical record showed a physician's order dated 12/5/23, showed the resident had
a GT. Further review of Resident 2's medical record showed the resident was on GT feeding formula,
Fibersource HN 1.2 at 40 ml/hr via GT for 20 hours.
On 4/2/24 at 0913 hours, an initial tour of the facility was conducted. Resident 2's GT tubing was observed
with no label showing when it was changed.
b. Medical record review for Resident 9 was initiated on 4/2/24. Resident 9 was admitted to the facility on
[DATE], and readmitted back to the facility on 5/20/23.
Review of Resident 9's medical record showed a physician's order dated 5/20/23, showed the resident had
a GT. Further review of Resident 9's medical record showed the resident was on GT feeding formula, Jevity
1.5 at 40 ml/hr via GT for 20 hours.
On 4/2/24 at 0918 hours, an initial tour of the facility was conducted. Resident 9's GT tubing was observed
with no label showing when it was changed.
c. Medical record review for Resident 36 was initiated on 4/2/24. Resident 36 was admitted to the facility on
[DATE].
Review of Resident 36's medical record showed a physician's order dated 9/18/23, showed the resident
had a GT. Further review of Resident 36's medical record showed the resident was on GT feeding formula,
Jevity 1.5 at 50 ml/hr via GT for 20 hours.
On 4/2/24 0936 hours, an initial tour of the facility was conducted. Resident 36's GT tubing was observed
with no label showing when it was changed.
On 4/2/24 at 0950 hours, a concurrent observation and interview was conducted with LVN 2. LVN 2 verified
Residents 2, 9, and 36 had GT. LVN 2 further verified Residents 2, 9, and 36's GT tubing were not labeled.
LVN 2 stated GT tubing should be labeled to ensure the tubing was changed daily.
On 4/4/24 at 1455 hours, an interview with the DON was conducted. The DON stated her expectation for
the charge nurses caring for the residents on GT was to change out the GT feeding, syringe, and tubing
every 24 hours; and label and date the feeding, syringe, and tubing.
On 4/5/24 at 1550 hours, an interview with the DON was conducted. The DON acknowledged above
findings.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055671
If continuation sheet
Page 39 of 87
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
055671
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/10/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Parkview Healthcare Center
1514 E. Lincoln Avenue
Anaheim, CA 92805
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 0695
Provide safe and appropriate respiratory care for a resident when needed.
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 respiratory care services for two of three residents reviewed for respiratory care (Residents 2
and 17).
Residents Affected - Few
* The facility failed to provide oxygen therapy as per the physician's order for Resident 17.
* The facility failed to ensure Resident 2's suction machine canister was discarded after use and failed to
ensure an oxygen bag was available and suction machine bag was dated.
These failure posed the risk for residents' safety and respiratory related complications including infection.
Findings:
Review of the facility's P&P titled Oxygen Administration revised October 2010 showed to verify that there
was a physician order for the procedure and to review the physician's orders or facility protocol for oxygen
administration.
Medical record review for Resident 17 was initiated on 4/2/24. Resident 17 was admitted to the facility on
[DATE], and readmitted on [DATE].
On 4/2/24 at 0910 hours, an observation, interview, and concurrent medical record review for Resident 17
was conducted with LVN 2. Resident 17 was observed lying in bed and receiving oxygen at 3 LPM (liters
per minute)via nasal cannula. LVN 2 verified the observation and acknowledged Resident 17 was receiving
oxygen at 3 LPM. LVN 2 acknowledged Resident 17 was receiving oxygen at 3 LPM instead of 2 LPM as
ordered by the physician.
Review of the Resident 17's Physician Order List dated 1/19/24, showed an order to administer oxygen at 2
LPM via nasal cannula continuously. However, during the above observation, Resident 17 was on oxygen at
3 LPM via nasal canula.
On 4/4/24 at 0808 hours, an interview was conducted with the DON. The DON verified and acknowledged
the above findings.
2. Review of the facility's P&P titled Oxygen Administration revised on 10/2010 showed to discard used
supplies into designated containers.
Medical record review for Resident 2 was initiated on 4/2/24. Resident 2 was admitted to the facility on
[DATE], and readmitted back to the facility on [DATE].
Review of Resident 2's medical record showed a physician's order dated 12/5/23, to administer oxygen at 2
LPM continuously via nasal cannula and may suction as needed.
On 4/2/24 at 0913 hours, an initial observation of the facility was conducted. Resident 2 was observed with
2 LPM oxygen via nasal cannula with no oxygen bag noted. Further observation showed a suction machine
canister with white liquid secretion and suction machine bag not dated.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055671
If continuation sheet
Page 40 of 87
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
055671
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/10/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Parkview Healthcare Center
1514 E. Lincoln Avenue
Anaheim, CA 92805
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 0695
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
On 4/2/24 at 0931 hours, a concurrent observation and interview was conducted with LVN 2. LVN 2 stated
Resident 2 was on continuous oxygen at 2 LPM via nasal cannula. LVN 2 verified Resident 2 did not have
an oxygen bag to store the nasal cannula if Resident 2 went to an appointment using a portable oxygen
tank. LVN 2 further verified Resident 2's suction machine bag was not dated and the suction machine
canister was observed with white liquid secretions. LVN 2 stated Resident 2 should have an oxygen bag
and a suction machine bag properly dated and labeled to ensure respiratory materials were changed out
on a weekly basis. LNV 2 also stated the suction machine canister should have been replaced once it was
used to ensure infection control was maintained.
On 4/4/24 at 1455 hours, an interview with the DON was conducted. The DON stated oxygen bags should
be labeled with a date and changed out weekly on Fridays. The DON stated the suction machine canisters
were discarded after every use to prevent bacterial from growing and for infection control.
On 4/5/24 at 1550 hours, an interview was conducted with the DON. The DON acknowledged above
findings.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055671
If continuation sheet
Page 41 of 87
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
055671
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/10/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Parkview Healthcare Center
1514 E. Lincoln Avenue
Anaheim, CA 92805
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 0698
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview, facility document review, and facility P&P review, the facility failed to ensure the
ongoing assessment before, during, and after dialysis treatments for one of one resident reviewed for
dialysis services (Resident 10) was conducted as evidenced by:
Residents Affected - Few
* Resident 10's dialysis communication forms dated 4/2 and 4/4/24, were incomplete. This failure had the
potential of not identifying negative outcomes for the dialysis resident (Resident 10).
Findings:
Review of the facility's P&P titled Hemodialysis Access Care revised on 9/2010 showed documentation
included:
1. Location of the catheter
2. Condition of the dressing (interventions if needed)
3. If dialysis was done during the shift
4. Any part of the report from dialysis nurse post-dialysis being given
5. Observations post-dialysis
Medical record review for Resident 10 was initiated on 4/5/24. Resident 10 was admitted to the facility on
[DATE].
Review of Resident 10's physician's order dated 2/1/24, showed Resident 10 had dialysis on Tuesdays,
Thursdays, and Saturdays.
Review of Resident 10's dialysis care plan dated 2/2/24, showed an intervention to check the resident's
shunt for bruit and thrill on the LUA QS (left upper arm every shift). Further review of Resident 10's medical
record showed the dialysis communication forms dated 4/2 and 4/4/24, were incomplete.
On 4/5/24 at 1119 hours, a concurrent interview and medical record review with the IP was conducted. The
IP stated Resident 10 had an AV shunt to the left upper arm. The IP verified Resident 10's dialysis
communication form dated 4/2/24, under the section titled Dialysis Unit on the Access Site Assessment
was left blank. The IP further verified Resident 10's dialysis communication form dated 4/4/24, under the
section titled Post Dialysis Assessment #2 showed the assessments of the bruit and thrill were blank. The
IP stated the Dialysis Unit completed the section titled Dialysis Unit while the resident was at the dialysis
center and should have answered the Access Site Assessment question. The IP stated the nurses would
contact the dialysis center to complete. The IP further stated the nurses assessed the dialysis residents
upon return from the dialysis center every four hours for a total of three assessments. The IP verified the
nurses did not show documented evidence the bruit and thrill were assessed on the second assessment
post dialysis dated on 4/4/24. The IP stated assessing the bruit and thrill were important to ensure the
resident's dialysis site was still working and accessible.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055671
If continuation sheet
Page 42 of 87
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
055671
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/10/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Parkview Healthcare Center
1514 E. Lincoln Avenue
Anaheim, CA 92805
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 0698
On 4/5/24 at 1550 hours, an interview with the DON was conducted. The DON acknowledged the above
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:
055671
If continuation sheet
Page 43 of 87
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
055671
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/10/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Parkview Healthcare Center
1514 E. Lincoln Avenue
Anaheim, CA 92805
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
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, and facility P&P review, the facility failed to provide the
necessary pharmaceutical services to meet the needs of residents. The emergency kit for the facility's oral
medications was not replaced in a timely manner. This failure had the potential for to contribute to a
decreased availability of medications in an emergency.
Findings.
Review of the facility's P&P titled Availability and Use of Emergency Medication Kits revised January 2020
showed the facility must notify pharmacy when an emergency kit was opened and needs replacement.
Further review of the P&P showed the pharmacy will then replace the open kit on the next working day.
On 4/3/24 at 1518 hours, during the inspection of Medication Storage room [ROOM NUMBER] with the IP,
the emergency kit for the oral medications was observed to be locked with a white zip tie. The IP stated the
emergency kit locked with white zip tie was once opened and meant to alert staff it needed to be replace.
The Emergency kit dose slip inside the emergency kit showed the medication levofloxacin 250 mg
(antibiotic) was removed on 3/30/24.
The IP verified the observation and stated the emergency kit was opened since 3/30/24. The IP stated the
staff who opened the emergency kit should have notified the pharmacy immediately after opening and the
pharmacy should replace the emergency kit within 72 hours.
On 4/3/24 at 1615 hours, a telephone interview was conducted with the Pharmacy Technician. The
Pharmacy Technician stated the staff in the facility should inform the pharmacy immediately after opening
the emergency kit and the pharmacy to replace the emergency kit the next day. The Pharmacy Technician
verified the pharmacy did not receive the notification for the oral emergency kit to be replaced in the facility
when it was opened on 3/30/24, he stated he received the call from the facility for the oral emergency kit
replacement on 4/3/24 around 1500 hours (four days after opening the emergency kit).
On 4/4/24 at 0808 hours, an interview was conducted with the DON. The DON was informed and
acknowledged the above findings.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055671
If continuation sheet
Page 44 of 87
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
055671
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/10/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Parkview Healthcare Center
1514 E. Lincoln Avenue
Anaheim, CA 92805
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 0756
Level of Harm - Minimal harm
or potential for actual harm
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart,
following irregularity reporting guidelines in developed policies and procedures.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of
the facility's P&P titled Medication Regimen Review revised May 2019 showed the following:
Residents Affected - Few
- The consultant pharmacist preforms a medication regimen review (MRR) for every resident in the facility
receiving medication upon admission and at least monthly thereafter, or more frequently if indicated.
- The irregularity referred to the use of medication that was inconsistent with accepted pharmaceutical
services standard of practice was not supported by medical evidence and or impedes or interferes with
achieving the intended outcomes of pharmaceutical services. It may also include the use of medication
without indication, without adequate monitoring, in excessive doses, and are in the presence of adverse
consequences.
- The attending physician to document in the medical record that irregularity have been reviewed and what
(if any) action was taken to address it.
- Consultant pharmacist provides the director of nursing services and medical director with a written signed
and dated copy of all medication regimen report.
- Copies of medication regimen review reports, including physician responses, are maintained as part of
the permanent medical record.
Medical record review for the Resident 32 was initiated on 4/2/24. Resident 32 was admitted to the facility
on [DATE].
Review of Resident 32's Order Summary Report showed a physician's order dated 2/1/24, to administer
Lovenox 40 mg per 0.4 ml, 0.4 ml subcutaneously (given into the subcutaneous fat under the skin) every
day.
Review of the Consultant Pharmacist's Medication Regimen Review for Resident 32 dated 3/1/24, showed
if clinically feasible, to provide a duration of therapy for the prescribed lovenox medication for Resident 32.
The document further showed a handwritten note continue as per MD.
On 4/5/24 at 0819 hours, an interview and concurrent medical record review for Resident 32 was
conducted with the DON. When the DON was asked how the facility informed the prescribing physician
about the pharmacy consultant's recommendations, the DON stated she faxed the prescribing physician to
inform of the pharmacy consultant's recommendation. The DON stated when she received the response
back, she would follow up, then she would mark the medication regimen review form to indicate that it was
done or verified. When asked about the pharmacy consultation's recommendation to provide a duration of
therapy for the prescribed lovenox medication for Resident 32, the DON verified the handwritten note
continue as per MD. The DON stated for Resident 32, she received response back from the resident's
physician stating to continue same order on the same day of the medication regimen review date which
was 3/1/24. The DON was asked if the physician provided the documented rational for not acting upon the
pharmacy consultant's recommendations and continued the medication order as it was; the DON stated no,
the MD did not provide the rational.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055671
If continuation sheet
Page 45 of 87
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
055671
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/10/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Parkview Healthcare Center
1514 E. Lincoln Avenue
Anaheim, CA 92805
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 0756
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Based on interview, medical record review, facility document review, and facility P&P review, the facility
failed to ensure the Pharmacy Consultant's recommendations were acted upon for two of five residents
reviewed for unnecessary medications (Residents 22 and 32).
* The facility failed to ensure the Pharmacy Consultant's recommendation to provide duration of the therapy
for enoxaparin (its brand name, Lovenox, an anticoagulant used to decrease the clotting ability of the blood)
for Resident 22 was acted upon. This failure had the potential to put Resident 22 at risk for adverse
consequences related to the medication.
* The failed to ensure the physician provided a rational when no action was taken for the Pharmacy
Consultant's recommendation if clinically feasible to provide a duration of therapy for Lovenox for Resident
32.
These failures had the potential to put Residents 22 and 32 at risk for adverse consequences related to the
medication.
Findings:
1. Medical record review for Resident 22 was initiated on 4/3/24. Resident 22 was readmitted to the facility
on [DATE].
Review of Resident 22's H&P examination dated 3/21/24, showed Resident 22 had the capacity to
understand and make decisions.
Review of Resident 22's Physician's Orders for April 2024 showed a physician's order dated 3/19/24, to
administer enoxaparin (Lovenox) 40 mg/0.4 ml syringe injection subcutaneously (injections given into the
fat under the skin) daily for deep vein thrombosis (DVT, a condition that occurs when a blood clot forms in a
deep vein) prophylaxis.
Review of Resident 22's MAR for April 2024 showed enoxaparin (Lovenox) was administered daily at 0900
hours.
Review of Resident 22's Consultant Pharmacist's Medication Regimen Review for the month of February
2024 showed a recommendation dated 2/13/24, for Resident 22 if clinically feasible to provide a duration of
therapy for Lovenox.
Further review of Resident 22's medical record did not show documented evidence Resident 22's physician
was notified or if the Pharmacy Consultant's recommendation for Lovenox was acted upon.
On 4/5/24 at 0921 hours, an interview and concurrent medical record review was conducted with the DON.
The DON verified and acknowledged the above findings. The DON stated she did not find documentation
the Pharmacy Consultant's recommendation for Lovenox was followed up and if Resident 22's physician
was notified by the recommendation and if he/she agreed or disagreed with the Pharmacy Consultant's
recommendation to provided duration of therapy for Lovenox.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055671
If continuation sheet
Page 46 of 87
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
055671
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/10/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Parkview Healthcare Center
1514 E. Lincoln Avenue
Anaheim, CA 92805
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 0758
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated,
prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic
medications are only used when the medication is necessary and PRN use is limited.
**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 residents were free
from the unnecessary psychotropic medications (any drug that affects brain activity associated with mental
processes and behavior) for two of two residents reviewed for antipsychotic medications (Residents 20 and
35).
* Resident 35 had an order for olanzapine (its brand name, Zyprexa, an antipsychotic medication). The
facility failed to ensure Resident 35 was assessed for Abnormal Involuntary Scale (AIMS, a rating scale that
was designed in the 1970s to measure involuntary movements known as tardive dyskinesia (TD) for the
use of olanzapine (Zyrexa).
* Resident 20 had an order for bupropion (Wellbutrin) (antidepressant medication) and quetiapine
(Seroquel) (antipsychotic medication). The facility failed to ensure Resident 20 was assessed for abnormal
involuntary movement using the AIMS (The Abnormal Involuntary Movement Scale) test for the use of
bupropion and quetiapine medications.
These failures had the potential for the residents to have adverse complications from the medications and
the potential of not providing the correct data to the prescriber in order to adjust the dose of the
psychotropic medications for the residents.
Findings:
Review of the facility's P&P titled Psychotropic Medication Use revised 7/2022 showed the use of any
psychotropic medication is based on comprehensive review of the resident. This includes evaluation of the
resident's signs and symptoms in order to identify underlying causes.
Review of the facility's P&P titled Antipsychotic Medication Use revised July 2022 showed the nursing staff
shall monitor for and report any of the following side effects and adverse consequences of antipsychotic
medications to the attending physicians: d. Neurologic: akathisia, dystonia, extrapyramidal effects, akinesia,
or tardive dyskinesia, stroke, or TIA.
1. Medical record review for Resident 35 was initiated on 4/3/24. Resident 35 was readmitted to the facility
on [DATE].
Review of Resident 35's H&P examination dated 5/10/23, showed Resident 35 had the capacity to
understand and make decisions.
Review of Resident 35's Physician's Orders for April 2024 showed the following physician's orders:
- dated 2/16/24, to administer Resident 35 olanzapine 5 mg tablet, one tablet by mouth at bedtime for
schizoaffective disorder and depression.
- dated 2/16/24, to document episodes of schizoaffective disorder as manifested by constantly yelling or
calling for help and calling different people like her children and parents every shift for olanzapine use.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055671
If continuation sheet
Page 47 of 87
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
055671
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/10/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Parkview Healthcare Center
1514 E. Lincoln Avenue
Anaheim, CA 92805
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 0758
- dated 2/26/24, to monitor for antipsychotic drug side effects every shift for the use of olanzapine.
Level of Harm - Minimal harm
or potential for actual harm
Review of Resident 35's MAR for the month of April 2024 showed Resident 35 was administered
olanzapine 5 mg at 2100 hours daily.
Residents Affected - Few
Further review of Resident 35's medical record did not show documented evidence the AIMS assessment
was completed for the use of antipsychotic medication such as olanzapine.
On 4/5/24 at 0752 hours, an interview and concurrent medical record review was conducted with RN 1. RN
1 verified the above findings. RN 1 stated AIMS was an assessment completed if there were side-effects of
hypotension or Parkinsonism (a brain disorder that causes unintended or uncontrollable movements, such
as shaking, stiffness, and difficulty with balance and coordination). RN 1 verified there was no
documentation the AIMS assessment was completed for Resident 35's use of olanzapine medication.
On 4/5/24 at 0838 hours, an interview and concurrent medical record review was conducted with the DON.
The DON verified the above findings. The DON stated the facility did not have a form to assess for AIMS.
The DON stated moving forward, the facility would implement the assessment of AIMS in the residents with
the use of antipsychotic medications.
2. Medical record review for Resident 20 was initiated on 4/2/24. Resident 20 was admitted to the facility on
[DATE].
Review of Resident 20's H&P examination dated 11/7/23, showed Resident 20 had no capacity to
understand and make decisions.
Review of Resident 20's Physician's Orders for April 2024 showed the following physician's orders:
- To administer quetiapine fumarate 25 mg one tablet by mouth twice daily for mood disorder M/B
(manifested by)hallucinations dated 11/8/23.
- To administer bupropion HCL SR 150 mg one tablet by mouth twice daily for depression M/B verbalization
of feeling sad dated 11/7/23.
- To monitor episodes of verbalization of hallucinations every shift dated 11/8/23.
- To monitor episodes of verbalization of feeling sad every shift dated 11/7/23.
Further review of Resident 20's medical record showed no documented evidence the AIMS assessment
was completed for Resident 20's use of quetiapine and bupropion medications.
On 4/4/24 at 1445 hours, a concurrent interview and medical record review was conducted with LVN 2. LVN
2 verified the above findings and stated the facility did not perform the AIMS assessment. LVN 2 further
stated the AIMS assessment was to assess for the side effects of the antipsychotic medications.
On 4/4/24 at 1455 hours, a concurrent interview and medical record review was conducted with the DON.
The DON verified Resident 20 was receiving quetiapine and bupropion medications. The DON further
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055671
If continuation sheet
Page 48 of 87
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
055671
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/10/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Parkview Healthcare Center
1514 E. Lincoln Avenue
Anaheim, CA 92805
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 0758
Level of Harm - Minimal harm
or potential for actual harm
verified the facility did not perform the AIMS assessment for Resident 20 and any of the residents with
antipsychotic medications. The DON stated the facility would implement the AIMS assessment moving
forward.
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055671
If continuation sheet
Page 49 of 87
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
055671
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/10/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Parkview Healthcare Center
1514 E. Lincoln Avenue
Anaheim, CA 92805
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 0761
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted
professional principles; and all drugs and biologicals must be stored in locked compartments, separately
locked, compartments for controlled drugs.
Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure
the medications were not left unattended on the medication cart for one of two residents reviewed for
medication administration (Resident 3). This failure had the potential for medication diversion.
Findings:
Review of the facility's P&P titled Storage of Medication revised April 2019 showed the drugs and
biologicals used in the facility are stored in locked compartments under proper temperature, light and
humidity controls. Further review of the P&P showed to not leave medications unattended on the
medication cart.
On 4/3/24 at 0845 hours, a medication pass observation was conducted with LVN 2. LVN 2 was observed
preparing the following medications for Resident 3:
- Amantadine (medication to treat Parkinson's disease) 50 mg/ml 5 ml;
- Decousate sodium (stool softer) two tablets;.
- Rivastigiminie 9.5 mg (medicine to treat dementia) transdermal system (a technique that provides drug
absorption via the skin);
- Oxybutynin 50 mg (a medicine used to treat symptoms of an overactive bladder) one tablet;
- Carbidopa levodepa (medication to treat Parkinson disease) 10-100 mg one tablet;
- Vitamin D3 25 mcg two tablets;
- Vitamin C- 500 mg two tablets;
- Multivitamin with minerals one tablet; and
- Potassium Chloride 20 meq/15 ml, mixed with 120 ml of water.
LVN 2 crushed the tablets separately, mixed each crushed medications with 5 mls of water in a medication
cup and put it in a tray. LVN 2 then left the tray with prepared medications unattended on the medication
cart to look for overbed table. LVN 2's medication cart was parked in the hallway where the staff, visitors,
and residents passed through. LVN 2 went back to the medication cart and took the tray with the
medications to the bedside.
On 4/4/24 at 0935 hours, an interview was conducted with LVN 2. When asked about the medications left
on top of the medication cart, LVN 2 acknowledged her actions and stated she should not have left the
medications unattended.
On 4/4/24 at 0808 hours, an interview was conducted with the DON. The DON was informed and
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055671
If continuation sheet
Page 50 of 87
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
055671
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/10/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Parkview Healthcare Center
1514 E. Lincoln Avenue
Anaheim, CA 92805
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 0761
acknowledged above 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:
055671
If continuation sheet
Page 51 of 87
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
055671
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/10/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Parkview Healthcare Center
1514 E. Lincoln Avenue
Anaheim, CA 92805
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 0803
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be
updated, be reviewed by dietician, and meet the needs of the resident.
Based on observation, interview, facility P&P review, and facility document review, the facility failed to
ensure the puree recipes and renal and CCHO menus were followed for three residents (Residents 11, 18,
and 35) with puree diet, two of four residents (Residents 11 and 18) with a puree renal diet, and 10 of 32
residents (Residents 5, 10, 11, 13, 16, 17, 18, 28, 29, and 35) on CCHO diet as evidenced by:
* The facility failed to ensure the puree recipes were followed.
* The facility failed to ensure two residents (Residents 11 and 18) on a renal pureed diet did not receive
roasted red potatoes.
* The facility failed to ensure the residents with a CCHO diet (Residents 5, 10, 11, 13, 16, 17, 18, 28, 29,
and 35)received plain ice cream as shown on the Spring Cycle Menu Week 1 dated for 4/3/24.
These findings had the potential for the residents on special diets to not receive the adequate nutritional
and caloric intake as recommended on the recipes and menus.
Findings:
1. Review of the facility's P&P titled Standardized Recipes revised 4/2007 showed standardized recipes
shall be developed and used in the preparation of foods. The P&P further showed only tested, standardized
recipes will be used to prepare food and the Food Services Manager will maintain the recipe file and make
it available to Food Services staff as necessary.
Review of the undated Healthcare menus Direct, L.L.C.'s Recipe: Pureed Meats, showed step number two
was to puree on low speed to a paste consistency before adding any liquid. The recipe also showed meat
per recipe for servings for six, 12, and 24.
a. Review of the Spring Cycle Menu Week 1 dated 4/3/24, showed the Regular menu included roast turkey
with Bernaise sauce, herb roasted red potatoes, rosemary cauliflower and peas, parsley sprig, fresh green
salad, dressing, sherbet, and milk.
Review of the facility's Physician Orders List dated 4/2/24, showed Residents 11, 18, and 35 were on a
pureed diet.
On 4/3/24 at 1102 hours, a concurrent observation and interview was conducted with the DSS. During the
puree procedure observation, the DSS stated he was preparing the puree foods for four residents on
pureed diets and was following the Recipe: Pureed Meats for six servings. The DSS was observed adding
300 ml turkey broth into a blender and four three-ounce turkey slices prior to blending together. Review of
the Recipe: Pureed Meats showed for six servings required six slices of meat. The recipe further showed to
puree meat on low speed to a paste consistency before adding any liquids. The DSS verified the above
findings.
On 4/4/24 at 1317 hours, an interview with the RD was conducted. The RD stated the recipe for pureed
meat for a six servings and directions were not followed. The RD further stated she expected the DSS to
follow the recipe.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055671
If continuation sheet
Page 52 of 87
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
055671
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/10/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Parkview Healthcare Center
1514 E. Lincoln Avenue
Anaheim, CA 92805
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 0803
Level of Harm - Minimal harm
or potential for actual harm
b. On 4/3/24 at 1102 hours, a concurrent observation and interview was conducted with the DSS. During
the puree food preparation observation, the DSS stated he was preparing the pureed roasted red potatoes.
The DSS was observed using the Recipe: Pureed Vegetables instead of the Recipe: Pureed Starch (Rice,
Pasta, Potatoes). The DSS verified the findings and stated he used the recipe for pureed vegetables for the
red potatoes.
Residents Affected - Few
On 4/4/24 at 1317 hours, an interview with the RD was conducted. The RD stated the roasted red potatoes
should follow under pureed starch. The RD stated the DSS should have followed the recipe for pureed
starch instead of pureed vegetables when making the pureed roasted red potatoes.
2. Review of the facility's P&P titled Menus revised 10/2017 showed menus meet the nutritional needs of
residents in accordance with the recommended dietary allowances of the Food and Nutrition Board
(National Research Council and National Academy of Sciences). The P&P further showed menus provide a
variety of foods from the basic daily food groups and indicate standard portions at each meal.
Review of the Spring Cycle Menu Week 1 dated 4/3/24, showed the renal diet should receive brown rice
with margarine and wheat bread.
Review of the Recipe: Herb Roasted Red Potatoes for Week 1 Wednesday showed for renal diet, do not
give.
On 4/3/24 at 1255 hours, a concurrent observation and interview was conducted with the DSS. During the
tray line observation, the DSS stated two of four residents had pureed renal diet orders. The DSS was
observed plating pureed roasted red potatoes for Residents 11 and 18 on pureed renal diet. The DSS
verified the menu for renal diet showed brown rice with margarine and wheat bread. The DSS further
verified Residents 11 and 18 did not receive brown rice with margarine and wheat bread on their meal tray.
The DSS stated the facility did not have brown rice and substituted with white rice instead; however, they
should have followed the recipe.
On 4/4/24 at 1317 hours, an interview with the RD was conducted. The RD stated the potatoes had higher
potassium content. The RD stated the spreadsheet for renal diet should have been followed and Residents
11 and 18 should have received brown rice and wheat bread as shown.
3. Review of the Spring Cycle Menu Week 1 dated 4/3/24, showed the regular CCHO menu included roast
turkey with Bernaise sauce, herb roasted red potatoes, rosemary cauliflower and peas, parsley sprig, fresh
green salad, dressing, plain ice cream, and milk.
Review of the facility's Physician Orders List dated 4/2/24, showed Residents 5, 10, 11, 13, 16, 17, 18, 28,
29, and 35 had the physician's orders for CCHO diets.
On 4/3/24 at 1102 hours, during the trayline observation, the Dietary Aide verified she served all of the
residents with CCHO diets with sherbert, instead of the plain ice cream listed on the Spring Cycle Menu
Week 1. The Dietary Aide stated she should have followed the menu.
On 4/4/24 at 1317 hours, an interview with the RD was conducted. The RD stated the DSS should have
followed the menu for CCHO diets.
On 4/5/24 at 1550 hours, an interview with the DON was conducted. The DON acknowledged all of the
above findings.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055671
If continuation sheet
Page 53 of 87
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
055671
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/10/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Parkview Healthcare Center
1514 E. Lincoln Avenue
Anaheim, CA 92805
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 0804
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Level of Harm - Minimal harm
or potential for actual harm
Based on observation, interview, facility P&P review, and facility document review, the facility failed to
ensure the food test tray was prepared in an appetizing temperature as evidenced by:
Residents Affected - Few
* Test tray temperatures were below the recommended temperature for hot meats, vegetables, and
potatoes.
* Three of 38 residents (Residents 12, 26, and 32) had complained the food was cold
These failures posed the risk for not providing palatable and appetizing food for the residents receiving a
meal tray from the kitchen.
Findings:
Review of the facility's P&P titled Food Preparation and Service dated 4/2019 showed fresh, frozen, or
canned fruits and vegetables are cooked to a holding temperature of 135 degrees Fahrenheit. The P&P
showed the danger zone for food temperatures is between 41 degrees Fahrenheit and 135 degrees
Fahrenheit and the longer foods remain in the danger zone the greater the risk for growth of harmful
pathogens. Therefore, PHF must be maintained below 41 degrees Fahrenheit or above 135 degrees
Fahrenheit.
1. Review of the Spring Cycle Menu Week 1 dated for 4/3/24, showed the regular menu included roast
turkey with Bernaise sauce, herb roasted red potatoes, rosemary cauliflower and peas, parsley sprig, fresh
green salad, dressing, sherbet, and milk.
On 4/3/24 at 1358 hours, a concurrent interview and test tray of the regular menu was conducted with the
DSS, CNA 5, and four surveyors were present. The DSS checked and verified the following temperatures:
* Roast Turkey with Bernaise sauce - 102 degrees Fahrenheit
* [NAME] cauliflower and peas - 102 degrees Fahrenheit
* Herb roasted red potatoes - 103 degrees Fahrenheit
* Coffee - 136 degrees Fahrenheit
* Sherbet - 14 degrees Fahrenheit
The DSS and CNA 5 verified the temperature of the turkey, cauliflower and peas, and herb roasted red
potatoes were not hot.
On 4/4/24 at 1317 hours, an interview with the RD was conducted. The RD stated holding temperatures for
hot foods including meats, vegetables, and potatoes should be over 140 degrees Fahrenheit. The RD
verified the test tray temperatures of 102 and 103 degrees Fahrenheit was below the recommended
temperatures for a hot meal tray. The RD stated residents may not like the food if it's cold and not palatable.
Furthermore, the RD stated potential weight loss could occur if the residents do not eat, which can lead to
potential weight loss.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055671
If continuation sheet
Page 54 of 87
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
055671
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/10/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Parkview Healthcare Center
1514 E. Lincoln Avenue
Anaheim, CA 92805
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 0804
Level of Harm - Minimal harm
or potential for actual harm
2. On 4/2/24 at 0802 hours, an interview with Resident 32 was conducted. Resident 32 stated he received a
french fries that was still frozen inside.
On 4/2/24 at 0836 hours, an interview with Resident 12 was conducted. Resident 12 stated with concerns
with the food temperature and variety.
Residents Affected - Few
On 4/2/24 at 1040 hours, an interview with Resident 26 was conducted. Resident 26 stated with concerns
with the food being cold when the meal trays were delivered late.
On 4/4/24 at 1317 hours, an interview with the RD was conducted. The RD acknowledged three of 38
residents had complaints of their food being cold. The RD stated the hot foods should be kept hot and cold
foods kept cold.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055671
If continuation sheet
Page 55 of 87
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
055671
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/10/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Parkview Healthcare Center
1514 E. Lincoln Avenue
Anaheim, CA 92805
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 0812
Level of Harm - Minimal harm
or potential for actual harm
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve
food in accordance with professional standards.
Based on observation, interview, facility P&P review, and facility document review, the facility failed to
ensure the food safety and sanitary requirements were met in the kitchen.
Residents Affected - Some
* The facility failed to ensure the cutting boards and kitchen equipment were in sanitary conditions
* The facility failed to ensure the food items were discarded on or before the best by date
* The facility failed to ensure the temperature of the food items were checked prior to preparing or
distributing to residents
* The facility failed to ensure the staff's personal belonging was not stored in the kitchen's clean utility room
* The facility failed to ensure the kitchen staff maintained proper hand hygiene
* The facility failed to ensure the staff covered food during transportation through the outdoor dry storage
room and back inside facility
* The facility failed to ensure Resident 4 received the correct diet texture as ordered
These failures had the potential to cause foodborne illnesses to the medically vulnerable resident
population who consumed food prepared in the kitchen
Findings:
Review of the facility census on 4/2/24 showed there were 38 residents at the facility. The facility document
titled Residents on GT Feeding provided on 4/2/24, showed the facility had six residents on G-tube feeding,
resulting in the kitchen providing the diets to 32 residents in the facility.
1. According to the USDA Food Code 2022 4-501.12, Cutting Surfaces, cutting surfaces such as cutting
boards and blocks that become scratched and scored may be difficult to clean and sanitize. As a result,
pathogenic microorganisms transmissible through food may build up or accumulate. These microorganisms
may be transferred to foods that are prepared on such surfaces.
On 4/2/24 at 0805 hours, a concurrent observation and interview was conducted with the DSS. One green,
one yellow, one brown, one blue, and one red cutting board were observed heavily marred with dark
discoloration knife marks. The DSS verified the findings and stated he would replace the set of the cutting
boards.
2. According to the USDA Food Code 2022, Section 4-601.11, Equipment, Food-Contact Surfaces,
Nonfood-Contact Surfaces, and Utensils:
(A) Equipment food-contact surfaces and utensils shall be clean to sight and touch.
(B) The food-contact surfaces of cooking equipment and pans shall be kept free of encrusted grease
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055671
If continuation sheet
Page 56 of 87
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
055671
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/10/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Parkview Healthcare Center
1514 E. Lincoln Avenue
Anaheim, CA 92805
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 0812
deposits and other soil accumulations.
Level of Harm - Minimal harm
or potential for actual harm
(C) Nonfood-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue,
and other debris.
Residents Affected - Some
On 4/2/24 at 0805 hours, a concurrent observation and interview was conducted with the DSS. The
following was observed and verified by the DSS:
* One medium-sized frying pan was observed heavily married on the inside surface
* One slotted spoon was noted with a melted handle
* One ice cream scooper noted with dried brown food particle
* One lime squeezer noted with dried brown food particle
The DSS stated the kitchen equipment should be thoroughly cleaned and maintained.
3. On 4/2/24 at 0745 hours, a concurrent observation and interview was conducted with the DSS. Three
honeydew with the best by date of 4/1/24, and one orange juice pitcher dated 3/29/24, were observed in
Refrigerator 1. The DSS verified the findings and stated the food items should be discarded by the best by
date to limit the growth of bacteria.
On 4/4/24 at 1317 hours, the above findings were verified with the RD. The RD stated the expired food
items should not be served to the residents and should be discarded on or prior to the best by date.
4. Review of the facility's P&P titled Food Preparation and Service dated 4/2019 showed the danger zone
for food temperatures is between 41 degrees Fahrenheit and 135 degrees Fahrenheit. This temperature
range promotes the rapid growth of pathogenic microorganisms that cause foodborne illness.
According to the USDA Food Code 2022, one of the epidemiological outbreak risk factors related to
employee behaviors and preparation practices in retail and food service establishments as contributing to
food borne illness include the improper holding temperatures.
On 4/3/24 at 1255 hours, a concurrent observation and interview was conducted with the DSS during the
tray line observation. During the observation, the temperature was not checked for the shredded cheddar
cheese prior to preparing two cheese quesadillas. Furthermore, the temperature check was not observed
for the fresh green salad placed on the food trays stored in Food Cart 1. The DSS verified the temperature
of the shredded cheddar cheese was not checked. The temperature of the shredded cheddar cheese read
37 degree Fahrenheit. The DSS also verified the temperature of the fresh green salad was not checked
prior to placing on the food trays. The temperature reading for the salad was verified by the DSS with a
temperature of 45 degrees Fahrenheit. The DSS stated the temperature of the salad should be below 41
degrees Fahrenheit and stated the facility could not serve the fresh green salad since the temperature was
within the danger zone.
On 4/4/24 at 1317 hours, an interview with the RD was conducted. The RD stated the hot foods should be
kept hot and cold foods kept cold to ensure the foods were outside the danger zone and prevent the growth
of bacteria.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055671
If continuation sheet
Page 57 of 87
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
055671
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/10/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Parkview Healthcare Center
1514 E. Lincoln Avenue
Anaheim, CA 92805
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 0812
Level of Harm - Minimal harm
or potential for actual harm
5. On 4/2/24 at 0805 hours, a concurrent observation and interview was conducted with the DSS. One pair
of Croc clogs (one type of shoes that is produced by Crocs) was observed in the kitchen's clean utility
room. The DSS stated the utility room stored supply items including napkins, plastic utensils, zip bags, and
lids. The DSS further stated the personal belongings should not be kept in the kitchen due to potential cross
contamination and infection control.
Residents Affected - Some
On 4/4/24 at 1317 hours, an interview with the RD was conducted. The RD stated the Croc clogs should
not be kept in the kitchen utility room and stated it could bring in dirt from outside.
6. According to the USDA Food Code 2022 2-301.14, When to Wash, showed food employees shall clean
their hands and exposed portions of their arms after engaging in other activities that contaminate the
hands. In addition, according to the USDA Food Code 2022 2-301.11, Clean Condition, the hands are
particularly important in transmitting foodborne pathogens. Food employees with dirty hands and/or
fingernails may contaminate the food being prepared. Therefore, any activity which may contaminate the
hands must be followed by thorough handwashing in accordance with the procedures outlined in the USDA
Code.
On 4/3/24 at 1102 hours, a concurrent observation and interview was conducted with the DSS. The DSS
was observed sanitizing the preparation table with gloves and cleaning towel and then retrieved one stick of
margarine from Refrigerator 1 to the stove without performing proper hand hygiene. The DSS verified the
findings.
On 4/4/24 at 1317 hours, an interview was conducted with the RD. The RD stated hand hygiene needs to
be performed between sanitizing preparation table and handling of the food. The RD further stated hand
hygiene was essential to help prevent cross contamination from cleaning the supply and food.
7. On 4/3/24 at 1255 hours, a concurrent observation and interview was conducted with the DSS. The meal
ticket for Resident 4 showed a regular NAS (no added salt) diet; however, the plate on the tray showed the
resident had mechanical soft turkey. The DSS verified the findings and redid a regular plate for Resident 4.
On 4/4/24 at 1317 hours, an interview with the RD was conducted. The RD stated the residents were
expected to receive the right diet texture as noted on their meal ticket. The RD further stated the
consistency between the regular and mechanical soft were different and may affect the resident's appetite.
8. On 4/3/24 at 1102 hours, a concurrent observation and interview was conducted with the DSS. The DSS
was observed transferring the wheat flour in an open container without a lid from the dry storage room
located at the back of the facility and back into the kitchen. The DSS verified the wheat flour was exposed
during the transportation and stated the container should be covered since the flies could go inside and for
infection control.
On 4/4/24 at 1317 hours, an interview with the RD was conducted. The RD stated the protocol when
transporting opened food items was to have it covered especially when coming from outside, there was a
risk for a fly to land on the food.
On 4/5/24 at 1550 hours, an interview with the DON was conducted. The DON acknowledged all of the
above findings.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055671
If continuation sheet
Page 58 of 87
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
055671
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/10/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Parkview Healthcare Center
1514 E. Lincoln Avenue
Anaheim, CA 92805
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 0842
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in
accordance with accepted professional standards.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Medical
record review for the Resident 32 was initiated on 4/2/24. Resident 32 was admitted to the facility on
[DATE], and readmitted on [DATE].
On 4/2/24 at 1233 hours, during dinning observation, Resident 32 was observed eating his lunch in his
room. The meal tray was observed with white bread with herbs, zesty lasagna, green beans, one banana, 8
oz of boost, a cup of chicken noodle soup, a cookie, a cup of grape juice and a cup of water. Resident 32
was observed eating one cup of chicken noodle soup, 8 oz of boost, a bite of cookie and half banana.
Resident 32 was not observed eating main portion of the meal bread with herbs, zesty lasagna, green
beans, a cup of grape juice and water.
On 4/2/24 at 1255 hours, an observation and a concurrent interview was conducted with the IP. The IP was
observed asking Resident 32 if he was done with his meal, Resident 32 stated yes. The IP then was
observed taking out the tray of Resident 32's meal. The IP verified Resident 32 ate less than 50% of his
meal tray. The IP was not observed offering alternative meal to Resident 32.
Review of Resident 32's Completed Care Details showed on 4/2/24 at 1332 hours, the percentage of lunch
eaten by Resident 32 was documented as 100%.
On 4/5/24 at 1456 hours, an interview and concurrent medical record review for Resident 32 was
conducted with the IP. The IP verified the above findings and stated the CNA should not documented
Resident 32 ate 100% of their lunch, when they did not observe the amount of the lunch eaten by Resident
32 on 4/2/24. The IP stated she should have documented lunch amount eaten by Resident 32 on 4/2/24.
On 4/5/24 at 1510 hours, an interview was conducted with the DON. The DON was informed and
acknowledged the above findings.
Cross reference to F692.
Based on interview, medical record review, and facility P&P review, the facility failed to ensure the medical
record for three of 14 final sampled residents (Residents 26, 32, and 35) was complete and accurate.
* The facility failed to ensure an active physician's orders for Resident 26 to continue no weight bearing
status to the left upper extremity and to continue to use a left arm sling for support were discontinued.
* The facility failed to ensure Resident 35's physician's order for Dulcolax (laxative) medication was
accurate.
These failures had the potential for the resident's accurate clinical status not being available and
communicated to care team.
Findings:
Review of the facility's P&P titled Charting and Documentation revised July 2017 showed all
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055671
If continuation sheet
Page 59 of 87
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
055671
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/10/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Parkview Healthcare Center
1514 E. Lincoln Avenue
Anaheim, CA 92805
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 0842
Level of Harm - Minimal harm
or potential for actual harm
services provided to the resident, progress toward the care plan goals, or any changes in the resident's
medical, physical, functional, or psychosocial condition, shall be documented in the resident's medical
record. The medical record should facilitate communication between the interdisciplinary team regarding
the resident's condition and response to care. Documentation in the medical record will be objective (not
opinionated or speculative), complete, and accurate.
Residents Affected - Few
1. Medical record review for Resident 26 was initiated on 4/2/24. Resident 26 was readmitted to the facility
on [DATE].
Review of Resident 26's H&P examination dated 10/7/23, showed Resident 26 had the capacity to
understand and make decisions.
Review of Resident 26's Physician's Orders for April 2024 showed a physician's order dated 12/21/23, to
continue the status of no weight bearing on Resident 26's left upper extremity, and to continue to use left
arm sling for support. In addition, Resident 26 had a diagnosis for two-part displaced fracture of the surgical
neck of the left humerus.
On 4/4/24 at 0911 hours, Resident 26 was observed without a sling support to his left upper extremity. CNA
3 verified Resident 26 was not wearing a left upper extremity sling support. Resident 26 stated his
orthopedic physician told him that he did not have to use the sling support eight days after his fall last
December 10th. Resident 26 stated he had not worn his sling support since then.
On 4/4/24 at 0918 hours, an interview and concurrent medical record review was conducted with the DON.
The DON verified and acknowledged the above findings. The DON stated the active orders for Resident
26's no weight bearing status and sling support to the left upper extremities should had been discontinued.
The DON stated she remembered the orders should be discontinued and the license nurses forgot to
remove the orders.
2. Medical record review for Resident 35 was initiated on 4/3/24. Resident 35 was readmitted to the facility
on [DATE].
Review of Resident 35's H&P examination dated 5/10/23, showed Resident 35 had the capacity to
understand and make decisions.
Review of Resident 35's Physician's Orders for April 2024, showed the following physician's orders:
-dated 2/13/24, to administer bisacodyl (Dulcolax, a laxative stimulant medication) 10 mg suppository daily
as needed if Milk of Magnesia (MOM, a laxative stimulant medication) was not effective for constipation.
-dated 2/13/24, to administer Fleet Enema (a laxative stimulant medication) one bottle daily as need for
constipation if Dulcolax suppository was ineffective.
-dated 2/13/24, to administer docusate sodium (a stool softener medication) 100 mg tablet and give one
tablet by mouth twice a day as needed for constipation.
However, further review of Resident 35's Physician's Orders for April 2024 did not show an order for MOM.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055671
If continuation sheet
Page 60 of 87
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
055671
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/10/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Parkview Healthcare Center
1514 E. Lincoln Avenue
Anaheim, CA 92805
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 0842
Level of Harm - Minimal harm
or potential for actual harm
On 4/5/24 at 0752 hours, an interview and concurrent medical record review was conducted with RN 1. RN
1 verified the above findings. RN 1 stated the order was inaccurate. RN 1 stated the order should had been
to administer MOM daily as needed and not the docusate sodium medication.
On 4/5/24 at 1530 hours, the DON was informed and acknowledged the above findings.
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055671
If continuation sheet
Page 61 of 87
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
055671
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/10/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Parkview Healthcare Center
1514 E. Lincoln Avenue
Anaheim, CA 92805
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 0849
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will
arrange for the provision of hospice services.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview, facility document review, and facility P&P review, the facility failed to ensure the
hospice and facility staff worked collaboratively together in the plan of care for two of three hospice
residents (Residents 20 and 36) as per the hospice contract agreement. This failure had the potential of
Residents 20 and 36 to not receive hospice care as per the hospice agreement.
Findings:
1. Medical record review for Resident 20 was initiated on 4/2/24. Resident 20 was admitted to the facility on
[DATE].
Review of Resident 20's H&P examination dated 11/7/23 showed Resident 20 had nocapacity to
understand and make decisions and goals for comfort care.
Review of Resident 20's Physician's Orders for April 2024 showed an order dated 11/7/23, to admit the
resident to the facility under Hospice A.
Review of Hospice A Contract Agreement dated 11/6/23, showed if providers schedule service specific IDT
meetings, they will allow the agency personnel to participate in these and notify the agency of the
scheduled dates of these meetings. All participants will be subject to patient confidentiality policy per this
agreement. The agreement further showed both the plan of care and the nursing care plan developed by
the agency will be part of the patients record in the facility. Both of these will be developed in collaboration
with the agency and facility staff. The facility staff will notify the agency if there are any changes in the plan
of care or the nursing care plan and make copies of these changes available to the agency personnel.
On 4/4/24 at 0919 hours, a concurrent interview and medical record review with the IP was conducted. The
IP verified Resident 20 was under Hospice A services. Review of Resident 20's care plans showed no
documented evidence the hospice care team reviewed or acknowledged Resident 20's care plans. The IP
stated since the hospice care team was also providing care to the hospice residents, they would also need
to be updated and informed of the resident's care plans.
On 4/5/24 at 1550 hours, an interview with the DON was conducted. The DON acknowledged above
findings.
2. Medical record review for Resident 36 was initiated on 4/2/24. Resident 36 was admitted to the facility on
[DATE].
Review of Resident 36's H&P examination dated 11/7/23, showed Resident 36 had no capacity to
understand and make decisions.
Review of Resident 36's Physician's Orders for April 2024, showed an order dated 9/1/23, to admit the
resident to the facility under Hospice B.
Review of Hospice B Certification of Terminal Illness dated 3/13/24, showed to continue to provide comfort
measures per the hospice protocol.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055671
If continuation sheet
Page 62 of 87
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
055671
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/10/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Parkview Healthcare Center
1514 E. Lincoln Avenue
Anaheim, CA 92805
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 0849
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
On 4/4/24 at 0919 hours, a concurrent interview and medical record review with the IP was conducted. The
IP verified Resident 36 was under Hospice B services. The IP also verified the care plans for Resident 36
was not signed off by the hospice care team. The IP could not show documented evidence the hospice care
team was aware of new and updated care plans for Resident 36. Further review of Resident 36's medical
record showed the Quarterly IDT note dated 1/23/24, showed no documented evidence the hospice staff
had participated in the IDT. The IP stated the hospice care team should be part of the IDT meetings and
review of the care plans to ensure they and the facility were in agreeance of the resident's plan of care.
On 4/4/24 at 1455 hours, an interview with the DON was conducted. The DON stated her expectation for
hospice was for the hospice care team to participate in the IDT meetings during admission, quarterly,
annually, and PRN (as needed) upon request by the resident's family member. The DON also verified the
hospice care team did not sign the care plans after reviewed and agreed upon.
On 4/5/24 at 1550 hours, an interview with the DON was conducted. The DON acknowledged the above
findings.
Cross reference to F684.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055671
If continuation sheet
Page 63 of 87
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
055671
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/10/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Parkview Healthcare Center
1514 E. Lincoln Avenue
Anaheim, CA 92805
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
Provide and implement an infection prevention and control program.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. On 4/3/24
at 0845 hours, a medication pass observation was conducted with LVN 2. LVN 2 was observed preparing
the following medications for Resident 3:
Residents Affected - Some
- Amantadine (medication to treat Parkinson's disease) 50 mg/ml 5 ml.
- Decousate sodium (stool softer) two tablets.
- Rivastigiminie 9.5 mg (medicine to treat dementia) transdermal system (a technique that provides drug
absorption via the skin).
-Oxybutynin 50 mg ( a medicine used to treat symptoms of an overactive bladder) one tablet.
-Carbidopa levodepa (medication to treat Parkinson disease) 10-100 mg one tablet.
-Vitamin D3 25 mcg two tablets.
- Vitamin C 500 mg two tablets.
- Multivitamin with minerals one tablet.
- Potassium Chloride 20 meq/15 ml, mixed with 120 ml of water.
- Multivitamin minerals one tablet.
LVN 2 crushed the tablets separately mixed each crushed medications with 5 mls of water in a medication
cup and put it in a tray. LVN 2 entered the room with the medications on tray and closed the curtain for
Resident 3's privacy. LVN 2 then performed hand hygiene, donned a clean pair of gloves, confirmed g-tube
placement and administered medications through the GT each medication separately with 5 ml of flush in
between each medications.
LVN 2 was observed not wearing gown before administering medication through the GT.
On 4/4/24 at 0745 hours, an interview was conducted with LVN 2. LVN 2 verified the above observation and
stated she did not wear gown before she administered the medications through the GT. LVN 2 stated she
wore gloves as a standard precaution and Resident 3 was not on any isolation precautions. When asked
LVN 2 if Resident 3 required enhanced barrier precaution, she stated she was not aware about the
enhanced barrier precaution required for the residents with a GT.
On 4/4/24 at 0801 hours, an interview was conducted with the DON. The DON was informed of the above
findings. The DON acknowledged the above findings and stated she was aware about the enhanced barrier
precaution; however, she thought that was a recommendation not the requirement, so the facility did not put
the residents with a GT on the enhanced barrier precautions. The DON stated she would review the new
QSO for enhanced barrier precaution for nursing home.
On 4/4/24 at 1331 hours, a follow-up interview was conducted with the DON. The DON stated she reviewed
QSO on enhanced barrier precaution. The DON stated Resident 3 had a GT and required enhanced
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055671
If continuation sheet
Page 64 of 87
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
055671
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/10/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Parkview Healthcare Center
1514 E. Lincoln Avenue
Anaheim, CA 92805
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
barrier precautions. The DON further stated the LVN should have worn gown in addition to the gloves
before administering medication through a GT for Resident 3.
Medical record review for Resident 3 was initiated on 4/3/24. Resident 3 was admitted to the facility on
[DATE], with diagnoses which included gastrotomy status ( an artificial external opening into the stomach).
Residents Affected - Some
4. On 4/2/24 at 0917 hours, during the observation at Resident 11's left side of the bed, the opened
yankauer suction connected to the tubing attached to the suction machine was observed. The yankauer
suction was observed stored in a bag with miscellaneous items with no label.
On 4/2/24 at 0939 hours, a concurrent observation and interview was conducted with the IP. The IP verified
the observation and stated the yankuer suction was being used for the Resident 11 and should have been
stored in a separate bag with a label. The IP further stated not labeling yankuer suction and storing it with
miscellaneous items could create a source of infection for Resident 11.
On 4/4/24 at 0808 hours, an interview was conducted with the DON. The DON acknowledged the above
findings and stated the yankuer suctioning should be one time use, if it was not visibly dirty then it should
be changed every shift. The DON further stated the Licensed Nurses should have labeled the yankuer
suctioning with the date opened and stored in a separate bag.
2. Review of the facility's P&P titled Handwashing/Hand Hygiene revised August 2019 showed all personnel
shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other
personnel, residents, and visitors. Use an alcohol-based hand rub containing at least 62% alcohol; or,
alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: m. after
removing gloves.
According to the QSO-24-08-NH with subject of Barrier Precautions in Nursing Home dated 3/20/24,
showed the resident who has wound or indwelling medical device, without secretions or excretions that are
unable to be covered or contained and are not known to be infected or colonized with any MDROs should
use Enhanced Barrier Precautions.
Review of the facility's signage for the Enhanced Standard Precaution showed for the six groups of care
activities (morning and evening care; toileting and changing incontinence briefs; caring for devices and
giving medical treatments; wound care; mobility assistance and preparing to leave room; and cleaning the
environment), to use hand hygiene, gloves, and gowns.
a. During a wound treatment observation of Resident 22's infected left surgical hip wound on 4/3/24 at 1524
hours, LVN 1 was observed removing soiled gloves after patting the left hip surgical wound. LVN 1 was
observed donning new gloves without performing any form of hand hygiene. LVN 1 was then observed
reaching in her pocket with the same gloves to grab a pen and she wrote the date in the dry dressing. LVN
1 then applied the dated dry dressing on Resident 22's left hip surgical wound. LVN 1 was once again
observed removing her gloves and donned new gloves without performing any type of hand hygiene. Then,
LVN 1 was observed removing her gloves after cleaning Resident 22's Stage 4 pressure ulcer to her
midback and donned new gloves without performing any type of hand hygiene prior to applying the Santyl
(ointment medication used to removed damaged tissue from chronic skin ulcers or severely burned areas)
to wound.
Medical record review for Resident 22 was initiated on 4/3/24. Resident 22 was readmitted to the
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055671
If continuation sheet
Page 65 of 87
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
055671
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/10/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Parkview Healthcare Center
1514 E. Lincoln Avenue
Anaheim, CA 92805
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
facility on [DATE].
Level of Harm - Minimal harm
or potential for actual harm
Review of Resident 22's H&P examination dated 3/21/24, showed Resident 22 had the capacity to
understand and make decisions.
Residents Affected - Some
Review of Resident 22's Physician's Orders for April 2024, showed the following physician's orders:
- dated 3/19/24, to cleanse midback Stage 4 with normal saline, pat dry, apply Santyl ointment, and apply
dry dressing daily for 30 days and reevaluate on 4/11/24.
- dated 4/2/24, to cleanse left hip surgical incision with 21 staples with normal saline, pat dry and apply dry
dressing for 14 days, and reevaluate for 14 days on 4/16/24.
On 4/3/24 at 1545 hours, an interview was conducted with LVN 1. LVN 1 verified the above findings. LVN 1
stated she was supposed to wash her hands when she changed her old gloves to a new gloves.
On 4/4/24 at 0756 hours, an interview was conducted with the IP. The IP stated the staff was expected to at
least perform an alcohol-based hand rub or wash their hands any time the staff changes gloves and don
new gloves.
b. During a wound treatment observation of Resident 22's Stage 4 pressure ulcer to midback and infected
left surgical hip wound on 4/3/24 at 1524, Resident 22 was observed not placed on enhanced barrier
precaution.
On 4/4/24 at 1043 hours, an observation and concurrent interview was conducted with the IP. The IP
verified the above findings. The IP stated the residents with wounds, GTs, or any opening that can cause
splashes should be placed on enhanced standard precautions. The IP stated Resident 22 should be placed
on an enhanced standard precautions due to her Stage 4 pressure ulcer and infected left hip surgical
incision wounds. The IP stated there should be a signage outside Resident 22's room and an isolation cart
with gloves and gowns. The IP further stated staff should be performing hand hygiene before and after
direct care, don gloves, and gown. The IP stated she did not have any residents on enhanced standard
precautions, and she was aware of the Quality Safety and Oversight (QSO, a memoranda, guidance,
clarification, and instructions to State Survey Agencies and CMS locations) for enhanced barrier
precautions.
On 4/5/24 at 1530 hours, the DON was informed and acknowledged the above findings.
Cross reference to F882, example #2.
Based on observation, interview, facility P&P review, and facility document review, the facility failed to
establish and maintain the infection control program and practices designed to help prevent the
development and transmission of diseases and infections as evidenced by:
* The facility failed to ensure the EBP (Enhanced Barrier Precautions) was practiced for the residents with
an indwelling urinary catheter (Resident 20) and GT (Residents 2, 9, and 36).
* The facility failed to ensure LVN 2 wore proper PPE when administering medication through a GT for
Resident 3.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055671
If continuation sheet
Page 66 of 87
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
055671
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/10/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Parkview Healthcare Center
1514 E. Lincoln Avenue
Anaheim, CA 92805
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 - Some
* The facility failed to ensure the Yankuer Suctioning (oral suctioning tool) was stored separately with
opened date for Resident 11.
* The facility failed to ensure LVN 1 performed hand hygiene in between changing gloves when providing
wound treatment to Resident 22. In addition, the facility failed to ensure staff practiced the enhanced based
precaution for Resident 22 who had a Stage 4 pressure ulcer (full thickness tissue loss with exposed bone,
tendon, or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes
undermining and tunneling) wound and an infected left hip surgical wound.
These failures posed the risk for transmission of disease-causing microorganisms and infections to the
residents.
Findings:
Review of the CMS's QSO-24-08-NH Enhanced Barrier Precautions in Nursing Homes dated 3/20/24 and
effective 4/1/24, showed Enhanced Barrier Precautions (EBP) refer to an infection control intervention
designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove
use during high contact resident care activities. The QSO further showed EBP recommendations now
include use of EBP for the residents with chronic wounds or indwelling medical devices during high-contact
resident care activities regardless of their multidrug-resistant organism status. Indwelling medical device
examples include central lines, urinary catheters, feeding tubes, and tracheostomies.
1a. Medical record review for Resident 20 was initiated on 4/2/24. Resident 20 was admitted to the facility
on [DATE].
Review of Resident 20's medical record showed a physician's order dated 11/7/23, showed Resident 20
had an indwelling urinary catheter with a size 20 Fr/10 ml.
On 4/2/24 at 0849 hours, an initial observation of the facility was conducted. Resident 20 was observed
with an indwelling urinary catheter. Observation of Resident 20's room showed no evidence of EBP signage
or PPE availability.
b. Medical record review for Resident 2 was initiated on 4/2/24. Resident 2 was admitted to the facility on
[DATE], and readmitted back to the facility on [DATE].
Review of Resident 2's medical record showed a physician's order dated 12/5/23, showed the resident had
a GT. Further review of Resident 2's medical record showed the resident was on GT feeding formula,
Fibersource HN 1.2 at 40 ml/hr for 20 hours.
On 4/2/24 at 0913 hours, an initial observation of the facility was conducted. Resident 2 was observed with
a GT. Observation of Resident 2's room showed no evidence of EBP signage or PPE availability.
c. Medical record review for Resident 9 was initiated on 4/2/24. Resident 9 was admitted to the facility on
[DATE], and readmitted to the facility on [DATE].
Review of Resident 9's medical record showed a physician's order dated 5/20/23, showed the resident had
a GT. Further review of Resident 9's medical record showed the resident was on GT feeding formula, Jevity
1.5 at 40 ml/hr via GT for 20 hours.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055671
If continuation sheet
Page 67 of 87
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
055671
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/10/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Parkview Healthcare Center
1514 E. Lincoln Avenue
Anaheim, CA 92805
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
On 4/2/24 at 0842 hours, an initial observation of the facility was conducted. Resident 9 was observed with
a GT. Observation of Resident 9's room showed no evidence of EBP signage or PPE accessibility.
d. Medical record review for Resident 36 was initiated on 4/2/24. Resident 36 was admitted to the facility on
[DATE].
Residents Affected - Some
Review of Resident 36's medical record showed a physician's order dated 9/1/23, showed the resident had
a GT. Further review of Resident 36's medical record showed the resident was on GT feeding formula,
Jevity 1.5 at 50 ml/hr via GT for 20 hours.
On 4/2/24 at 0936 hours, an initial observation of the facility was conducted. Resident 36 was observed
with GT. Observation of Resident 36's room showed no evidence of EBP signage or PPE availability.
On 4/4/24 at 0807 hours, an interview with CNA 5 was conducted. CNA 5 stated the facility did not observe
EBP and the facility did not have any residents on isolation precautions. CNA 5 verified during care for his
residents with indwelling urinary catheters or GT, including changing the residents and emptying out the
indwelling urinary catheter bag, CNA 5 stated he did not don on gown; however, only wore gloves.
On 4/4/24 at 0918 hours, an interview with the IP was conducted. The IP verified the facility had the
residents with the indwelling urinary catheter, GT, and wounds. The IP verified the facility did not have any
residents on EBP. The IP further stated the residents with an indwelling urinary catheters and GT were at
risk for bodily fluids to splash onto staff during care and stated EBP should be used. The IP stated she
would set up isolation carts to have gown and gloves availability more accessible to staff and EBP signage
outside the residents' rooms to identify the residents on EBP. The IP acknowledged it was important for the
staff to be informed of EBP to protect themselves, the residents, other staff members, and visitors against
transmission-based infections.
On 4/4/24 at 1109 hours, a concurrent observation and interview with the DON was conducted outside of
Resident 20's room. The DON verified Resident 20 had an indwelling urinary catheter and there were no
EBP signage or isolation cart to provide PPE including gowns. The DON stated EBP was not practiced at
the facility; however, she was aware the residents with an indwelling urinary catheters, GT, central lines,
colostomy, wounds needed standard EBP precautions, including the use of gown and gloves during
treatment, medication administration for the residents with GT, and changing the residents or emptying out
the indwelling urinary catheters. The DON further stated use of the EBP help prevent transmission of
diseases and ensures infection control would be maintained.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055671
If continuation sheet
Page 68 of 87
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
055671
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/10/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Parkview Healthcare Center
1514 E. Lincoln Avenue
Anaheim, CA 92805
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 0882
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Many
Designate a qualified infection preventionist to be responsible for the infection prevent and control program
in the nursing home.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interview, medical record review, facility document review, and facility P&P review, the facility failed to
ensure the IP had the knowledge of the Pneumococcal immunization update per the CDC's guidelines. In
addition, the facility failed to ensure the IP had the appropriate knowledge to implement the enhanced
barrier precautions with the facility's residents needed to be placed on a special precautions. These failures
had the potential for the residents not to receive timely the appropriate type of pneumonia immunization
placing the residents at risk for developing pneumonia (infection of the lungs that causes inflammation of air
sacs in one or both lungs which may fill with fluid), and potential for spread of infection.
Findings:
Review of the facility's P&P titled Pneumococcal Vaccine dated October 2019 showed all the residents will
be offered pneumococcal vaccines to aid in preventing pneumonia/pneumococcal infections. Prior to or
upon admission, residents will be offered the vaccine series within thirty (30) days of admission to the
facility unless medically contraindicated or the resident has already been vaccinated. Assessment of
pneumococcal vaccination status will be conducted within five (5) working days of the resident's admission
if not conducted prior to admission. Before receiving a pneumococcal vaccine, the resident or legal
representative shall receive information and education regrading the benefits and potential side effects of
the pneumococcal vaccine. Provision of such education shall be documented in the resident's medical
record. Administration of the pneumococcal vaccines or revaccinations will be made in accordance with
current Centers for Disease Control and Prevention ( CDC) recommendations at the time of the
vaccination.
Review of the IP's training showed the IP was certified on the Nursing Home Infection Preventionist Training
Course on 8/30/20, and another Certificate of Completion on Healthcare-Associated Infections on 2/10/24.
Review of the IP's Job Description and Evaluation form dated July 2016 conducted and signed by the
Supervisor/Administrator on date of hire 8/20/20, showed the primary purpose of this position is to plan,
organize, develop, coordinate, and direct the infection prevention and control program and its activities in
accordance with current federal, state, and local standards, guidelines, and regulations that govern such
programs, and as maybe directed by the administrator and the infection Prevention and Control Committee
to ensure that an effective infection prevention and control program is maintained at all times. Specific
requirements included the IP must be knowledgeable of nursing and medical practices and procedures, as
well as laws, regulations and guidelines that pertain to nursing care facilities and infection prevention and
control practices, to include standard/universal precautions.
Review of the new CDC guideline titled (MMWR) Morbidity and Mortality Weekly Report dated 1/28/22,
showed use of 15-Valent Pneumococcal Conjugate Vaccine and 20- Valent Pneumococcal Conjugate
Vaccine among U.S. Adults: Updated Recommendations of the Advisory Committee on Immunization
Practices ( APIC) - United States , 2022.
Review of the CMS's QSO-24-08-NH Enhanced Barrier Precautions in Nursing Homes dated 3/20/24, and
effective 4/1/24, showed, Enhanced Barrier Precautions (EBP) refer to an infection control
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055671
If continuation sheet
Page 69 of 87
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
055671
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/10/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Parkview Healthcare Center
1514 E. Lincoln Avenue
Anaheim, CA 92805
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 0882
Level of Harm - Minimal harm
or potential for actual harm
intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown
and glove use during high contact resident care activities. The QSO further showed EBP recommendations
now include use of EBP for residents with chronic wounds or indwelling medical devices during
high-contact resident care activities regardless of their multidrug-resistant organism status. Indwelling
medical device examples include central lines, urinary catheters, feeding tubes, and tracheostomies.
Residents Affected - Many
1. On 4/05/24 at 1033 hours, an interview and concurrent document review was conducted with the IP. The
IP was asked about the type of (PNA) Pneumonia vaccine given to the residents. The IP had given PPSV
23 Pneumococcal Polysaccharide Vaccine) did not offer the PCV 15 or 20 ( Pneumococcal Conjugate
Vaccine). The IP stated she has no awareness of the current PNA vaccine per the CDC guideline and was
not tracking the type of vaccine the residents need based on the new CDC guidelines. The IP was asked if
facility offered anything else for pneumonia such as PCV 13, 15, or 20. The IP stated the facility did not offer
PCV 13,15, or 20; and offered only PPSV 23 to all the residents. Review the CDC Pneumococcal website
about Pneumococcal vaccine was conducted with the IP. When asked, the IP stated the CDC
recommended PCV 15 or 20 and they were not doing this.
3. On 4/4/24 at 0918 hours, an interview was conducted with the IP. The IP verified the facility did not have
any residents on EBP; however, the IP stated the facility had the residents with the indwelling urinary
catheters and GT. The IP further stated the residents with the indwelling urinary catheters and GT had a
risk for bodily fluids to splash onto staff during care and stated the EBP should have been used. The IP
denied the charge nurses using the proper PPE with use of gown and glove when doing the GT medication
administration. Moreover, the IP acknowledged it was important for the staff to be informed of the EBP to
protect themselves, the residents, other staff members, and visitors against transmission-based infections
and to help minimize the spread of infection.
On 4/4/24 at 1109 hours, an interview with the DON was conducted. The DON verified the facility had the
residents with indwelling urinary catheters, GT, and wounds; however, they did not have the residents on
EBP. The DON stated she received the current infection control guidelines from the IP. The DON stated she
relied on the IP for the current infectious control guidelines and protocols prior to initiating in the facility.
However, the DON stated the IP did not notify her of the current CMS guidelines for EBP effective on
4/1/24. The DON further stated the use of EBP would help prevent the transmission of diseases and
ensures infection control would be maintained.
Cross reference to F880 example #1.
2. Medical record review for Resident 22 was initiated on 4/3/24. Resident 22 was readmitted to the facility
on [DATE].
Review of Resident 22's H&P examination dated 3/21/24, showed Resident 22 had the capacity to
understand and make decisions.
Review of Resident 22's Physician's Orders for April 2024 showed the following physician's orders:
- dated 3/19/24, to cleanse the midback Stage 4 with normal saline, pat dry, apply Santyl (wound
debridement agent)ointment, and apply a dry dressing daily for 30 days and re-evaluate on 4/11/24.
- dated 4/2/24, to cleanse the left hip surgical incision with 21 staples with normal saline, pat dry and apply
a dry dressing for 14 days, and re-evaluate for 14 days on 4/16/24.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055671
If continuation sheet
Page 70 of 87
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
055671
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/10/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Parkview Healthcare Center
1514 E. Lincoln Avenue
Anaheim, CA 92805
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 0882
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Many
During the wound treatment observation of Resident 22's Stage 4 pressure ulcer to the midback and
infected left surgical hip wound on 4/3/24 at 1524 hours, Resident 22 was observed not placed on the
enhanced barrier precaution.
On 4/4/24 at 1043 hours, an observation and concurrent interview was conducted with the IP. The IP
verified the above findings. The IP stated the residents with wounds, GTs, or any opening that can cause
splashes should be placed on the enhanced standard precautions. The IP stated Resident 22 should be
placed in an enhanced standard precautions due to her Stage 4 pressure ulcer and infected left hip surgical
incision wounds. The IP stated there should be a signage outside Resident 22's room and an isolation cart
with gloves and gowns. The IP further stated the staff should be performing hand hygiene before and after
direct care, don gloves and gown. The IP stated she did not have any residents on enhanced standard
precautions, and she was aware of the Quality Safety and Oversight (QSO, a memoranda, guidance,
clarification, and instructions to State Survey Agencies and CMS locations) for enhanced barrier
precautions.
On 4/5/24 at 1530 hours, the DON was informed and acknowledged the above findings.
On 4/10/24 at 1012 hours, an interview was conducted with the Administrator. The Administrator stated he
expected the IP to report in the quarterly assurance meeting the antibiotic stewardship program, any use
and discontinuation of antibiotic medications, any patterns of infection, COVID 19 cases in the facility,
vaccination information, and any new infection prevention and control updates that affects the facility and
the residents. The Administrator stated he knew there were six moments to follow the enhanced barrier
precautions. The Administrator further stated the IDT was not aware of the enhanced barrier precaution not
being implemented for appropriate residents in the facility. The Administrator stated he expected the IP to
report this information in the QA meeting so the facility could prevent issues of spreading infections.
Cross reference to F880, example #2.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055671
If continuation sheet
Page 71 of 87
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
055671
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/10/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Parkview Healthcare Center
1514 E. Lincoln Avenue
Anaheim, CA 92805
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 0883
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interview, medical record review, facility document review, and facility P&P review, the facility failed to offer
PCV 15/PCV 20 (PCV 15 protects against two additional serotypes and PCV 20 protects against seven
additional serotypes involved in cases of invasive pneumococcal disease (IPD) and pneumonia)
immunizations for 20 of 20 nonsampled residents (Residents 1, 3, 4, 5, 6, 8, 13, 15, 16, 18, 19, 21, 23, 24,
25, 27, 29, 30, 31, and 33) reviewed for pneumococcal vaccination (a vaccine given to protect the resident
from pneumococcal disease) in accordance with the CDC's recommendations. No tracking system was in
place for pneumococcal vaccine history. These failures increased the residents' risk for being inadequately
vaccinated for the pneumococcal disease and its associated complications.
Residents Affected - Many
Findings:
Review of the new CDC guideline titled (MMWR) Morbidity and Mortality Weekly Report dated 1/28/22,
showed use of 15-Valent Pneumococcal Conjugate Vaccine and 20-Valent Pneumococcal Conjugate
Vaccine among U.S. Adults: Updated Recommendations of the Advisory Committee on Immunization
Practices (APIC) - United States, 2022.
Review of the CDC Morbidity and Mortality Weekly Report titled Use of 15-Valent Pneumococcal Conjugate
Vaccine (PCV 15) and 20-Valent Pneumococcal Conjugate Vaccine (PCV 20) Among U.S. Adults: Updated
Recommendations of the Advisory Committee on Immunization Practices (ACIP) dated 1/28/22, showed
the ACIP recommended PCV15 or PCV20 for adults who are either aged 65 years and older or aged 19-64
years with certain underlying conditions. When PCV15 is used, it should be followed by a dose of 23-valent
pneumococcal polysaccharide vaccine (PPSV23), typically one year later.
The previous CDC's pneumococcal vaccine guidelines, prior to 1/2022 update, was recommendations for
pneumococcal vaccination (PCV13 or Prevnar13®, and PPSV23 or Pneumovax23®) for all adults
65 years or older. For adults 65 years or older who have not previously received PCV13, should receive a
dose of PCV13 first, followed 1 year later by a dose of PPSV23.
Review of the CDC's guidelines for pneumococcal vaccination reviewed 9/22/23, showed the following:
- for adults 65 years or older who had never received any pneumococcal vaccine regardless of risk
conditions, give one dose of PCV 15 or PCV 20 (PCV 15 protects against two additional serotypes and
PCV 20 protects against seven additional serotypes involved in cases of invasive pneumococcal disease
(IPD) and pneumonia). When PCV 15 is used, it should be followed by a dose of PPSV 23 (pneumococcal
polysaccharide vaccine, use for protected adults and children older than 2 years of age against invasive
disease caused by the 23 capsular serotypes contained in the vaccine) at least one year later. The
minimum interval (eight weeks) can be considered in adults with an immunocomprising condition, cochlear
implant, or cerebrospinal fluid leak. Their vaccines will then be complete. When PCV 20 is used, it does not
need to be followed by a dose of PPSV 23. Their vaccines are then completed.
- for adults 65 years or older who had only received PPSV 23 regardless of risk condition, give one dose of
PCV 15 or PCV 20 at least one year after the most recent PPSV 23 vaccination. Regardless of vaccine
given, an additional dose of PPSV 23 is not recommended since they already received it. Their vaccines
are then completed.
Review of the facility's P&P titled Pneumococcal Vaccine revised October 2019 showed all residents
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055671
If continuation sheet
Page 72 of 87
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
055671
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/10/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Parkview Healthcare Center
1514 E. Lincoln Avenue
Anaheim, CA 92805
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 0883
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Many
will be offered pneumococcal vaccines to aid in preventing pneumonia/pneumococcal infections. Prior to or
upon admission, the residents will be offered the vaccine series within thirty (30) days of admission to the
facility unless medically contraindicated or the resident has already been vaccinated. Assessment of
pneumococcal vaccination status will be conducted within five (5) working days of the resident's admission
if not conducted prior to admission. Before receiving a pneumococcal vaccine, the resident or legal
representative shall receive information and education regarding the benefits and potential side effects of
the pneumococcal vaccine. Provision of such education shall be documented in the resident's medical
record. Administration of the pneumococcal vaccines or revaccinations will be made in accordance with
current Centers for Disease Control and Prevention ( CDC) recommendations at the time of the
vaccination.
Review of Residents 1, 4, 3, 5, 6, 8, 13, 16, 18, 19, 21, 23, 24, 25, 29, 30, and 33 for pneumococcal
immunization records were conducted on 4/9/24. Review of the Pneumococcal informed consents showed
all of these residents received the information on pneumococcal infections and education on the risks and
benefits associated with PPSV 23. There was no information about PCV 15 and PCV 20. The immunization
records showed the residents received PPSV 23 vaccine as follows:
- Resident 1 received PPSV 23 on 6/14/21.
- Resident 3 received PPSV 23 on 3/6/20.
- Resident 4 received PPSV 23 on 6/14/21.
- Resident 5 received PPSV 23 on 6/10/21.
- Resident 6 received PPSV 23 on 3/20/24.
- Resident 8 received PPSV 23 on 11/28/23.
- Resident 13 received PPSV 23 on 01/27/23.
- Resident 16 received PPSV 23 on 6/10/21.
- Resident 18 received PPSV 23 on 6/10/21.
- Resident 19 received PPSV 23 on 6/11/21.
- Resident 21 received PPSV 23 on 9/1/20.
- Resident 23 received PPSV 23 on 5/1/22.
- Resident 24 received PPSV 23 on 6/11/21.
- Resident 25 received PPSV 23 on 5/1/22.
- Resident 29 received PPSV 23 on 02/10/23.
- Resident 30 received PPSV 23 on 1/1/23.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055671
If continuation sheet
Page 73 of 87
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
055671
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/10/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Parkview Healthcare Center
1514 E. Lincoln Avenue
Anaheim, CA 92805
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 0883
- Resident 33 received PPSV 23 on 2/1/23.
Level of Harm - Minimal harm
or potential for actual harm
1. Medical record review for Resident 5 was initiated on 4/9/24. Resident 5 was admitted to the facility on
[DATE].
Residents Affected - Many
Review of Resident 5's Physician order dated 6/8/21, showed the facility may give the Pneumococcal
Polysaccharide Vaccine 23 (PPSV 23).
Review of Resident 5's Resident Immunization Record form (undated) showed Resident 5 received the
Pneumococcal Polysaccharide Vaccine 23 (PPSV 23) at the facility on 6/10/21.
Further review of Resident 5's medical record failed to show Resident 5 was offered the PCV 15 or PCV 20
vaccines after receiving the PPSV 23 as per the CDC's guidelines.
2. Medical record review for Resident 13 was initiated on 4/9/24. Resident 13 was admitted to the facility on
[DATE], and readmitted to the facility on [DATE].
Review of Resident 13's Physician order dated 1/15/23, showed the facility may give Resident 13 the
Pneumococcal Polysaccharide Vaccine 23 (PPSV 23).
Review of Resident 13's Pneumococcal Pneumonia Immunization Program Consent Form dated 1/26/23,
showed the signed consent for Resident 13 to receive the pneumococcal vaccine.
Review of Resident 13's Resident Immunization record form (undated), showed Resident 13 received the
Pneumococcal Polysaccharide Vaccine 23 (PPSV 23) at the facility on 1/27/23.
Further review of Resident 13's medical record failed to show Resident 13 was offered the PCV 15 or PCV
20 vaccines after receiving the PPSV 23 as per the CDC guidelines.
3. Medical record review for Resident 4 was initiated on 4/9/24. Resident 4 was admitted to the facility on
[DATE].
Review of Resident 4's Physician order dated 6/8/21, showed the facility may give Resident 4 the
Pneumococcal Polysaccharide Vaccine 23 (PPSV 23).
Review of Resident 4's Pneumococcal Pneumonia Immunization Program Consent Form dated 6/12/21,
showed a verbal consent was received from Resident 4's responsible party to give Resident 4 the
Pneumococcal Polysaccharide Vaccine 23 ( PPSV 23).
Review of Resident 4's Resident Immunization record form (undated) showed Resident 4 received the
Pneumococcal Polysaccharide Vaccine 23 (PPSV 23) in the facility on 6/14/21.
Further review of Resident 4's medical record failed to show Resident 4 was offered the PCV 15 or PCV 20
vaccines after receiving the PPSV 23 as per the CDC's guidelines.
4. Medical record review for Resident 29 was initiated on 4/9/24. Resident 29 was admitted to the facility on
[DATE].
Review of Resident 29's Physician order dated 2/18/23, showed the facility may give Resident 29 the
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055671
If continuation sheet
Page 74 of 87
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
055671
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/10/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Parkview Healthcare Center
1514 E. Lincoln Avenue
Anaheim, CA 92805
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 0883
Pneumococcal Polysaccharide Vaccine 23 (PPSV 23).
Level of Harm - Minimal harm
or potential for actual harm
Review of Resident 29's Resident Immunization record form (undated) showed Resident 29 received the
Pneumococcal Polysaccharide Vaccine 23 ( PPSV 23) in the facility on 2/20/23.
Residents Affected - Many
Further review of Resident 29's medical record failed to show Resident 29 was offered the PCV 15 or PCV
20 vaccines after receiving the PPSV 23 as per the CDC's guidelines.
5. Medical record review for Resident 24 was initiated on 4/9/24. Resident 24 was admitted to the facility on
[DATE].
Review of Resident 24's Physician order dated 6/8/21, showed the facility may give Resident 24 the
Pneumococcal Polysaccharide Vaccine 23 (PPSV 23).
Review of Resident 24's Pneumococcal Pneumonia Immunization Program Consent Form dated 6/10/21,
showed the signed consent for Resident 24 to receive the pneumococcal vaccine.
Review of Resident 24's Resident Immunization record form (undated) showed Resident 24 received the
Pneumococcal Polysaccharide Vaccine 23 ( PPSV 23) in the facility on 6/11/21.
Further review of Resident 24's medical record failed to show Resident 24 was offered the PCV 15 or PCV
20 vaccines after receiving the PPSV 23 as per the CDC's guidelines.
6. Medical record review for Resident 1 was initiated on 4/9/24. Resident 1 was admitted to the facility on
[DATE].
Review of Resident 1's Physician order dated 6/14/21, showed the facility may administer Resident 1 the
Pneumovax 23 (Pneumococcal Polysaccharide Vaccine 23).
Review of Resident 1's Pneumococcal Pneumonia Immunization Program Consent Form dated 6/14/21,
showed the signed consent for Resident 1 to receive the pneumococcal vaccine.
Review of Resident 1's Resident Immunization record form (undated) showed Resident 1 received the
Pneumococcal Polysaccharide Vaccine 23 ( PPSV 23) in the facility on 6/14/21.
Further review of Resident 1's medical record failed to show Resident 1 was offered the PCV 15 or PCV 20
vaccines after receiving the PPSV 23 as per the CDC's guidelines.
On 4/05/24 at 1033 hours, an interview was conducted with the IP (Infection Preventionist). The IP was
asked what are the types of (PNA) Pneumonia vaccine was given to the residents. The IP stated she had
only given the PPSV 23 ( Pneumococcal Polysaccharide Vaccine) to the above residents (Residents 1, 4, 5,
13, 24, and 29), and did not offer the PCV 15 or PCV 20 ( Pneumococcal Conjugate Vaccine). The IP
stated she had no awareness of the current PNA vaccine as per the CDC's guidelines and was not tracking
the type of vaccine the residents need based on the new CDC's guidelines. The IP stated she offered the
PPSV 23 only because the consent for PNA vaccine offered only PPSV 23 to all the residents. The facility
Pneumococcal Pneumonia Immunization Program Consent Form showed the Pneumococcal
Polysaccharide Vaccine was effective against 23 pneumococcal types which caused 90 percent of all
pneumococcal pneumonia and was effective for approximately six years. Anyone [AGE] years of age or
older or having chronic health problems were considered as high risk for exposure to and
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055671
If continuation sheet
Page 75 of 87
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
055671
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/10/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Parkview Healthcare Center
1514 E. Lincoln Avenue
Anaheim, CA 92805
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 0883
complications from pneumococcal pneumonia.
Level of Harm - Minimal harm
or potential for actual harm
On 4/09/24 at 0829 hours, further interview, concurrent medical record review, and document review was
conducted with the IP and DON (Director of Nursing). The IP was asked about the facility tracking system
for PNA vaccine and the list of the residents' pneumonia vaccine status. The IP provided the list, but the
document did not show the specific type of pneumonia vaccine given, it just showed, Pneumonia; which
was similar to what was written in the medical record. The IP and the DON verified and acknowledged the
findings. The IP stated the facility was not listing the specific pneumonia vaccine administered, and the
facility should.
Residents Affected - Many
17. Medical record review for Resident 15 was initiated on 4/9/24. Resident 15 was admitted to the facility
on [DATE].
Review of Resident 15's annual MDS dated [DATE], showed Resident 15 had a BIMS score of 15 which
meant the resident was cognitively intact.
Review of Resident 15's Resident Immunization Record Form, (undated), showed Resident 15 declined the
pneumonia vaccine on 1/8/16. Further review of Resident 15's medical record showed no documented
evidence Resident 15 was educated on the risk and benefits of the pneumonia vaccine, provided a VIS
(Vaccine Information Statement) handout from the CDC, or signed a consent acknowledging a declination
of the pneumonia vaccine.
On 4/9/24 at 1517 hours, a concurrent interview and medical record review was conducted with the IP. The
IP verified the above findings. The IP stated when the residents declined a vaccine, the staff would explain
the risk and benefits; however, the IP could not show the documented evidence the risk and benefits of
declining the pneumococcal vaccine or a VIS handout was provided to Resident 15. The IP further stated
the pneumococcal consent form showed if a resident agreed or declined to receive the vaccine and should
have been completed for Resident 15 after Resident 15 declined the pneumococcal vaccine. When asked if
Resident 15 was offered the pneumococcal vaccine after the resident initially declined, the IP stated no.
Moreover, the IP stated the residents who declined the pneumococcal vaccine should be offered yearly to
keep the residents up to date and if the residents decided to receive, the pneumococcal vaccine could be
provided.
18. Medical record review for Resident 33 was initiated on 4/9/24. Resident 33 was admitted to the facility
on [DATE].
Review of Resident 33's Quarterly MDS dated [DATE], showed Resident 33 has a BIMS score of 12
(moderately impaired).
Review of Resident 33's Resident Immunization Record Form (undated) showed Resident 33 received a
pneumonia vaccination on 2/10/23. However, the form did not show what type of pneumococcal vaccination
was administered to Resident 33. Review of Resident 33's Physician's Telephone Order form showed
Resident 33 had a physician's order to receive the Pneumovax 23 vaccine on 2/10/23.
Review of Resident 33's Pneumococcal Pneumonia Immunization Program Consent form dated 2/8/23,
showed Resident 33 agreed to receive the PPSV23 vaccine.
On 4/9/24 at 1517 hours, a concurrent interview and medical record review was conducted with the IP. The
IP verified the above findings. The IP stated she did not offer Resident 33 the PCV 20 or PCV
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055671
If continuation sheet
Page 76 of 87
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
055671
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/10/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Parkview Healthcare Center
1514 E. Lincoln Avenue
Anaheim, CA 92805
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 0883
Level of Harm - Minimal harm
or potential for actual harm
15; however, the IP stated she should have ensured Resident 33's pneumococcal immunization was
current.
19. Medical record review for Resident 18 was initiated on 4/9/24. Resident 18 was admitted to the facility
on [DATE], and readmitted to the facility on [DATE].
Residents Affected - Many
Review of Resident 18's Quarterly MDS dated [DATE], showed Resident 18 had a BIMS score of 11
(moderately impaired).
Review of Resident 18's Resident Immunization Record Form (undated) showed Resident 18 received a
pneumonia vaccine on 6/10/21. However, the form did not show what type of pneumococcal vaccination
was administered to Resident 18. Review of Resident 18's physician Orders List showed Resident 18 had a
physician's order to receive the PPV23 vaccine on 6/10/21.
Review of Resident 18's Pneumococcal Pneumonia Immunization Program Consent form dated 6/8/21,
showed Resident 18 agreed to receive the PPV23 vaccine.
On 4/9/24 at 1517 hours, a concurrent interview and medical record review was conducted with the IP. The
IP verified the above findings. The IP stated Resident 18 was only offered the PPSV23; however, the IP
stated she should have offered Resident 18 the PCV20 to ensure pneumococcal vaccination was current.
The IP stated as of 4/6/24, Resident 18 was offered and provided the PCV20.
20. Medical record review for Resident 31 was initiated on 4/9/24. Resident 31 was admitted to the facility
on [DATE].
Review of Resident 31's Quarterly MDS dated [DATE], showed Resident 31's cognitive skills for daily
decision making was assessed to be severely impaired (who never or rarely made decisions).
Review of Resident 31's Resident Immunization Record Form (undated) showed Resident 31 received PPV
on 6/4/21, outside of the facility. However, the form did not indicate what type of pneumonia vaccination was
administered. Further review of Resident 31's Immunizations history form showed Resident 31 received the
Pneumococcal conjugate PCV 13 on 6/4/21.
On 4/9/24 at 1517 hours, a concurrent interview and medical record review was conducted with the IP. The
IP verified the above findings. The IP stated Resident 31 was not up to date on her pneumococcal
vaccination. The IP further stated Resident 31 was not offered the PCV20 or PPSV23 as per the CDC's
recommendations after Resident 31 received the PCV13.
On 4/10/24 at 1302 hours, an interview with the DON and Administrator was conducted. The DON and
Administrator acknowledged the above findings.
Cross reference to F641, examples #8, #9, #10, and #11.
7. Medical record review for Resident 6 was initiated on 4/9/24. Resident 6 was admitted to the facility on
[DATE].
Review of Resident 6's H&P (History and Physical) examination dated 2/24/24, showed Resident 6 could
make needs known but could not make medical decisions.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055671
If continuation sheet
Page 77 of 87
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
055671
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/10/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Parkview Healthcare Center
1514 E. Lincoln Avenue
Anaheim, CA 92805
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 0883
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Many
Review of Resident 6's Resident Immunization Record Form (undated) showed Resident 6 had received a
pneumonia vaccination on 3/20/24. However, the form did not show what type of pneumonia vaccination
was administered.
Review of Resident 6's Pneumococcal Pneumonia Immunization Program Consent dated 2/14/24, showed
Resident 6 agreed to receive the PPV 23 vaccination.
Review of an email sent from a Veterans employee dated 2/20/24, showed a message that Resident 6
refused and needed his influenza and pneumonia vaccination.
On 4/9/24 at 1333 hours, an interview and concurrent medical record review was conducted with the IP. The
IP verified the above findings. The IP stated she should had offered the PCV 20 per the CDC's guidelines
so Resident 6 could had been updated with his pneumonia vaccination. However, the IP stated the
pneumonia consent form only offered the PPV 23.
8. Medical record review for Resident 8 was initiated on 4/2/24. Resident 8 was readmitted to the facility on
[DATE].
Review of Resident 8's H&P examination dated 10/3/23, showed Resident 8 could make needs known but
could not make medical decisions.
Review of Resident 8's Resident Immunization Record Form (undated) showed Resident 8 received a
pneumonia vaccination on 3/20/24. However, the form did not show what type of pneumonia vaccination
was administered.
Review of Resident 8's Pneumococcal Pneumonia Immunization Program Consent dated 3/22/24, showed
Resident 8 signed the consent form. However, the consent form did not show if Resident 8 wanted or did
not want to receive the pneumonia vaccination.
Review of Resident 8's General Nurses Note dated 3/20/24, showed Resident 8 was given PPV
(Pneumococcal Polysaccharide Vaccine) on his right deltoid as ordered by the resident's physician. A
verbal consent was received from Resident 8's responsible party.
On 4/9/24 at 1406 hours, an interview and concurrent medical record review was conducted with the IP. The
IP verified the above findings. The IP stated Resident 8 was updated with her pneumonia vaccination based
on the consent which only presented the PPV 23.
9. Medical record review for Resident 21 was initiated on 4/3/24. Resident 21 was admitted to the facility on
[DATE], and readmitted on [DATE].
Review of Resident 21's Resident Immunization Record form (undated), showed Resident 21 received
Pneumococcal polysaccharide vaccine (PPV) on 9/10/20, prior to admission to the facility.
Review of Resident 21's Pneumococcal Pneumonia Immunization Program Consent Form was not
completed.
On 4/9/24 at 1415 hours, an interview and concurrent medical record review was conducted with the IP. The
IP stated she should have had offered Resident 21 the option to receive the Pneumococcal Conjugate
Vaccine 20 (PCV 20) to be up to date with her pneumococcal immunization.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055671
If continuation sheet
Page 78 of 87
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
055671
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/10/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Parkview Healthcare Center
1514 E. Lincoln Avenue
Anaheim, CA 92805
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 0883
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Many
10. Medical record review for Resident 25 was initiated on 4/9/24. Resident 25 was admitted to the facility
on [DATE].
Review of Resident 25's Resident Immunization Record form (undated) showed Resident 25 received a
pneumonia vaccination on 5/10/22. However, the form did not show what type of pneumococcal vaccination
was administered to Resident 25.
Review of Resident 25's General Nurses Notes dated 5/9/22, showed pneumonia vaccination was offered
to Resident 25 and he agreed to receive the pneumonia vaccine. Resident 25 could not recall if he had the
pneumonia vaccine in the past. Resident 25's daughter did not have an idea if Resident 25 received the
PPV vaccine before.
On 4/9/24 at 1348 hours, an interview and concurrent medical records was conducted with the IP. The IP
stated Resident 25's pneumococcal vaccination history information should had been unknown. The IP
stated she only offered the residents the option to receive the PPV 23 because it was the only
pneumococcal vaccination listed in the Pneumococcal Pneumonia Immunization Program Consent Form.
The IP stated she should had offered the PCV 20 for Resident 25 be up to date with her pneumococcal
immunization.
11. Medical record review for Resident 30 was initiated on 4/9/24. Resident 30 was admitted to the facility
on [DATE], and readmitted on [DATE].
Review of Resident 30's H&P examination dated 11/13/22, showed Resident 30 had no capacity to
understand and make decisions.
Review of Resident 30's Resident Immunization Record form (undated) showed Resident 30 received a
pneumonia vaccination on 1/27/23. However, the form did not show what type of pneumococcal vaccination
was administered to Resident 30.
Review of Resident 30's General Nurses Note dated 1/25/23, showed a new order from the physician for
Resident 30 to receive a pneumonia vaccine. Resident 30 was made aware and signed the consent.
Review of Resident 30's Pneumococcal Pneumonia Immunization Program Consent Form, (undated),
showed both options for yes and no to receive the pneumococcal vaccine were checked off, the reason
showed the resident had it.
On 4/9/24 at 1423 hours, an interview and concurrent medical record review was conducted with the IP. The
IP verified the above findings. The IP stated she should have had offered the PCV 20 because it was more
than a year ago that Resident 30 received the PPV 23 if she followed the updated CDC's guidelines. The IP
stated she offered the PPV 23 to Resident 30 because that was the only pneumonia vaccine offered in the
pneumonia consent the facility had provided.
On 4/10/24 at 1310 hours, the DON was informed and acknowledged all the above findings.
Cross reference to F641 for examples #1 and #2.
12. Medical record review for Resident 3 was initiated on 4/3/24. Resident 3 was admitted to the facility on
[DATE], and readmitted on [DATE].
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055671
If continuation sheet
Page 79 of 87
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
055671
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/10/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Parkview Healthcare Center
1514 E. Lincoln Avenue
Anaheim, CA 92805
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 0883
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Many
Review of Resident 3's H&P examination dated 11/22/23, showed Resident 3 did not have the capacity to
understand and make medical decisions.
Review of Resident 3's Immunization Administration Record showed Resident 3 received pneumococcal
vaccine on 3/6/20. The Immunization Administration Record for Resident 3 did not show the type of
pneumococcal vaccine administered.
Review of Resident 3's MAR (Medication Administration Record) dated March 2020 showed Resident 3
was administered PPSV23 on 3/6/20.
Review of the Resident 3's General Nurses Notes dated 4/8/24 at 1733 hours, showed Resident 3's
responsible party was called and offered PCV 20, educated on the pneumococcal vaccination, and
declined the vaccination.
Further review of Resident 3's medical record did not show if Resident 3 was offered PCV 20 single dose or
PCV 15 followed by PPSV23, until 4/8/24.
13. Medical record review for Resident 16 was initiated on 4/9/24. Resident 16 was admitted to the facility
on [DATE], and readmitted on [DATE].
Review of Resident 3's H&P examination dated 7/29/23, showed Resident 16 had the capacity to
understand and make decisions.
Review of Resident 16's MAR dated June 2021 showed Resident 16 was administered with PPSV23 on
6/10/21.
Further review of the medical record for Resident 16 did not show if Resident 16 was offered PCV 20 single
dose or PCV 15 followed by PPSV23.
14. Record review for Resident 19 was initiated on 4/9/24. Resident 19 was admitted to the facility on
[DATE].
Review of Resident 19's H&P examination dated 8/27/23, showed Resident 19 did not have the capacity to
understand and make decisions.
Review of Resident 19's undated Immunization Administration Record showed Resident 19 received
Pneumococcal vaccine on 6/11/21, and PCV 20 on 4/6/24. The Immunization Administration Record for
Resident 19 did not show the type of the pneumococcal vaccine administered on 6/11/21.
Review of Resident 19's MAR dated June 2021 showed Resident 19 received PPSV23 on 6/11/21.
Further review of Resident 19's medical record did not show if Resident 16 was offered PCV 20 single dose
or PCV 15 followed by PPSV23, until 4/6/24.
15. Medical record review for Resident 23 was initiated on 4/9/24. Resident 23 was admitted to the facility
on [DATE], and was readmitted on [DATE].
Review of Resident 23 H&P examination dated 3/13/24, showed Resident 23 had the capacity to
understand and make decisions.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055671
If continuation sheet
Page 80 of 87
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
055671
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/10/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Parkview Healthcare Center
1514 E. Lincoln Avenue
Anaheim, CA 92805
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 0883
Level of Harm - Minimal harm
or potential for actual harm
Review of Resident 23's undated Immunization Administration Record showed Resident 23 received
pneumococcal vaccine on 5/10/22, and PCV 20 on 4/6/24. The Immunization Administration Record for
Resident 19 did not show the type of the pneumococcal vaccine administered on 5/10/22.
Review of Resident 23's MAR dated May 2022 showed Resident 23 received PPSV23 on 5/10/22.
Residents Affected - Many
Further review of Resident 23's record did not show if Resident 23 was offered PCV 20 single dose or PCV
15 followed by PPSV23, until 4/6/24.
16. Medical record review for Resident 27 was initiated on 4/9/24. Resident 27 was admitted to the facility
on [DATE].
Review of Resident 27's H&P examination dated 1/15/24, showed Resident 27 could make needs known
but could not make medical decisions.
Review of Resident 27's undated Resident Immunization Record did not show an entry for the
pneumococcal vaccination.
Review of Resident 27's General Nurses Note dated 2/14/24, showed the facility called Resident 27's
responsible party to inquire about the resident's vaccination status and was awaiting to call back from the
responsible party.
Review of an email sent from a veterans employee dated 2/20/24, showed a message Resident 27 refused
his influenza and pneumonia vaccination on 9/2023.
Further review of the medical record for Resident 27 did not show if the facility followed up with responsible
party to inquire about the Resident 27's pneumococcal vaccination status after 2/20/24, and if
pneumococcal vaccination was offered to Resident 27.
On 4/9/24 at 1447 hours, a concurrent interview, medical record review, and document review for Residents
3, 16, 19, 23, and 27 was conducted with the IP. The IP verified the above findings. The IP stated Residents
3, 16, 19, and 23 did not receive updated vaccination which was either PCV20 single dose, or PCV15
followed by PPSV 23 as recommended by APIC to be up to date with their pneumococcal immunization
until 4/6/24. In addition, the IP stated she inquired about Resident 27's vaccination status and received an
email from the previous facility Resident 27 declined the pneumococcal vaccination; however, she did not
offer the pneumococcal vaccination in the facility. The IP stated she should have followed up with Resident
27's responsible party and offered Resident 27 the updated pneumococcal vaccine.
The IP further stated Residents 19 and 23 received the updated pneumococcal vaccine PCV20 on 4/6/24.
Furthermore, Resident 3's responsible party declined the offer for pneumococcal vaccination on 4/8/24, and
she was working to provide the updated pneumococcal vaccination to other residents in the facility.
On 4/10/24 at 0939 hours, an interview was conducted with the DON. The DON was informed and
acknowledged the above findings.
Cross reference to F641 for examples #3, #4, #5, #6 and #7.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055671
If continuation sheet
Page 81 of 87
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
055671
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/10/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Parkview Healthcare Center
1514 E. Lincoln Avenue
Anaheim, CA 92805
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 0909
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and
mattresses must attach safely to the bed frame.
**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 follow up when the residents' beds failed on the entrapment assessments zone for two of three
residents reviewed for bed rails (Residents 9 and 32).
* The facility failed to ensure Residents 9 and 32's side rails were reassessed after failed Zone 6
measurement was noted. This failure had the potential to negatively impact the residents resulting in
possible entrapment, serious injury, and death.
Findings:
According to the Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment, the
term entrapment describes an event in which a patient/resident is caught, trapped, or entangled in the
space in or about the bed rail, mattress, or hospital bed frame. Patient entrapments may result in deaths
and serious injuries. These entrapment events have occurred in openings within the bed rails, between the
bed rails and mattresses, under bed rails, between split rails, and between the bed rails and head or foot
boards. The population most vulnerable to entrapment are elderly patients and residents, especially those
who are frail, confused, restless, or who have uncontrolled body movement. The seven areas in the bed
system where there is a potential for entrapment are:
- Zone 1: within the rail;
- Zone 2: under the rail, between the rail supports or next to a single rail support;
- Zone 3: between the rail and the mattress;
- Zone 4: under the rail, at the ends of the rail;
- Zone 5: between split bed rails;
- Zone 6: between the end of the rail and the side edge of the head or foot board; and
- Zone 7: between the head or foot board and the mattress end.
Review of the facility's P&P titled Bed Safety revised on 12/2007, showed to prevent deaths/injuries from
the beds and related equipment (including the frame, mattress, side rails, headboard, footboard, and bed
accessories), the facility shall promote the following approaches:
a. Inspection by maintenance staff of all beds and related equipment as part of the regular bed safety
program to identify risks and problems including potential entrapment risks.
Review of the facility's P&P titled Proper Use of Side Rails revised December 2016 showed an assessment
will be made to determine the resident's symptoms, risk of entrapment and reason for using the siderails.
When used for mobility or transfer, an assessment will include a review of the resident's:
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055671
If continuation sheet
Page 82 of 87
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
055671
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/10/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Parkview Healthcare Center
1514 E. Lincoln Avenue
Anaheim, CA 92805
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 0909
- Bed mobility;
Level of Harm - Minimal harm
or potential for actual harm
- Ability to change positions, transfer to and from bed or chair, and to stand and toilet;
- Risk of entrapment from the use of side rails; and,
Residents Affected - Few
- That the bed's dimensions are appropriate for the resident's size and weight.
The P&P further showed when side rail usage is appropriate, the facility will assess the space between the
mattress and side rails to reduce the risk for entrapment (the amount of safe space may vary, depending on
the type of bed and mattress being used) and the resident will be checked periodically for safety relative to
side rail use.
Review of the facility's document titled Safety Assessment for Siderail Usage showed Zone 6
measurements was between the end of the rail and the side edge of the head or foot board or any
V-shaped opening between the end of the rail and the head or foot board (risk of entrapment due to
wedging).
Review of the facility's undated document titled Side Rail Order showed the facility had 17 residents with
the use of side rails, including Residents 9, and 32.
1. On 4/2/24 at 0824 hours, a concurrent observation and interview was conducted with Resident 32.
Resident 32 was observed lying in bed, alert and awake, and bilateral half siderails was elevated. Resident
32 stated he did not use the siderails and was attached to the bed since he got admitted in the facility.
On 4/4/24 at 0723 hours, a concurrent observation and interview was conducted with LVN 1. Resident 32
was observed alert, awake in bed with the bilateral half siderails was observed elevated. LVN 1 verified the
observation.
Medical record review for the Resident 32 was initiated on 4/2/24. Resident 32 was admitted to the facility
on [DATE].
Review of Resident 32's Physician Orders showed an order dated 4/2/24, for bilateral 1/2 (half) side rails for
mobility and repositioning.
Review of the Resident 32's MDS dated [DATE], showed Resident 32 was cognitively intact.
On 4/4/24 at 0833 hours, an interview and concurrent medical record review for Resident 32 was
conducted with the IP. When asked about the bed inspection process, the IP stated she and the
Administrator checked if there was a gap between the mattress and side rails, using the bed system
measurement device annually. When asked if she and the Administrator inspected the bed when the side
rails were initially ordered and installed, the IP stated facility only conducted the bed inspection annually.
The IP stated when new resident gets admitted in the bed with siderails attached and if the resident request
siderails to be elevated, then she looked back to the measurements and determine possible entrapment
risk for the resident.
Review of Bed Inspection (Measurements) dated 1/3/24 showed Bed #15. The IP verified Bed #15
corresponded to the bed Resident 32 was currently using, to which she and the Administrator checked the
bedframe length, mattress length, mattress height, zone passed, and zone failed for the use of the
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055671
If continuation sheet
Page 83 of 87
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
055671
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/10/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Parkview Healthcare Center
1514 E. Lincoln Avenue
Anaheim, CA 92805
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 0909
Level of Harm - Minimal harm
or potential for actual harm
siderails. Further review of the document showed Bed #15 failed Zone 6. In addition, the document did not
show if the facility followed up to re-adjust the entrapment Zone 6 to reduce the risk of entrapment.
Further review of Resident 32's medical record did not show if the facility followed up to re-adjust the
entrapment Zone 6 to reduce the risk of entrapment for Resident 32.
Residents Affected - Few
On 4/4/24 at 1346 hours, an interview and concurrent medical record review for Resident 32 was
conducted with the Administrator. The Administrator verified Resident 32's bed (Bed#15) failed on the
entrapment Zone 6. The Administrator stated Resident 32's bed failing Zone 6 meant there was a risk
Resident 32's head might get entrapped in that zone.
On 4/4/24 at 1604 hours, a follow up interview was conducted with the Administrator. The Administrator
verified he did not follow up when Bed #15 failed in the entrapment Zone 6. The Administrator added he did
not think the siderails could be re-adjusted and he had to buy a new bed. The Administrator further stated
he would have the maintenance check the bed to see if he could readjust the Bed #15.
On 4/4/24 at 1626 hours, an interview was conducted with the DON. The DON was informed and
acknowledged the above findings.
Cross reference to F552, example #2
2. Review of facility's document titled Side Rail Order undated, showed Resident 9 with left 1/2 (half) SR
(Side Rail) Padded.
Review of facility's document titled Bed Inspection (Measurement) dated 1/3/24 showed Bed Number 27
was assigned to Resident 9 and showed failed on Zone 6 measurement. Further review of Resident 9's
medical record showed the resident had consent for padded left side rail dated 9/14/23.
On 4/2/24 at 0842 hours, an initial tour of the facility was conducted. Resident 9 was observed in bed with
padded left side rail. Resident 9 was observed able to move the upper extremities.
Medical record review for Resident 9 was initiated on 4/2/24. Resident 9 was admitted to the facility on
[DATE] and readmitted back to the facility on 5/20/23.
On 4/4/24 at 1602 hours, a concurrent interview and facility document review with the Administrator was
conducted. The Administrator verified Resident 9's side rail had failed Zone 6 measurement as documented
on the facility document titled Bed Inspection (Measurement) dated 1/3/24. When asked if an intervention
was conducted on the failed Zone 6 measurement, the Administrator stated the facility did not perform
further interventions after a failed Zone 6 measurement for Resident 9's side rails was observed. The
Administrator further stated he did not notify the maintenance staff or ask maintenance to reassess the
failed Zone 6 measurement and side rails. Moreover, the Administrator stated the facility would have to
replace Resident 9's bed frame to ensure Zone 6 measurement did not fail.
On 4/5/24 at 1550 hours, an interview with the DON was conducted. The DON acknowledged the above
findings.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055671
If continuation sheet
Page 84 of 87
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
055671
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/10/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Parkview Healthcare Center
1514 E. Lincoln Avenue
Anaheim, CA 92805
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 0909
Cross reference to F552 for example #1.
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:
055671
If continuation sheet
Page 85 of 87
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
055671
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/10/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Parkview Healthcare Center
1514 E. Lincoln Avenue
Anaheim, CA 92805
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 0911
Level of Harm - Potential for
minimal harm
Residents Affected - Some
Ensure resident rooms hold no more than 4 residents; for new construction after November 28, 2016,
rooms hold no more than 2 residents.
Based on observation and interview, the facility failed to ensure Room A did not accommodate more than
four residents. At the time of survey, there were five occupied beds in the room, which posed the risk of five
residents sharing one room.
Findings:
On 4/2/24 at 0904 hours, an initial tour of the Room A was conducted. Observation of Room A showed a
five-bed room occupied by five residents.
On 4/4/24 at 1542 hours, an interview was conducted with the Administrator. The Administrator verified
there were five residents occupied in Room A. The Administrator acknowledged Room A had less square
footage than required. The Administrator further stated the facility would like to continue with the room
variance waiver for Room A.
Cross reference to F912.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055671
If continuation sheet
Page 86 of 87
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
055671
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/10/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Parkview Healthcare Center
1514 E. Lincoln Avenue
Anaheim, CA 92805
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 0912
Level of Harm - Potential for
minimal harm
Residents Affected - Some
Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single
resident rooms.
Based on observation and interview, the facility failed to ensure Room A measured at least 80 square feet
per resident. Room A was a five-bed room, which measured 78.4 feet per resident if all the beds were filled.
At the time of the survey, the room was occupied by five residents. This failure to have the designated
square footage created the potential to negatively impact the residents' quality of life.
Findings:
On 4/2/24 at 0904 hours, an initial tour of the Room A was conducted. Observation of Room A showed a
five-bed room occupied by five residents.
On 4/4/24 at 1542 hours, an interview was conducted with the Administrator. The Administrator stated
Room A had a total of 392 square feet and when occupied by five residents, each resident would have 78.4
square foot of space. The Administrator acknowledged the residents should have 80 square foot of space
and verified the residents in Room A did not. The Administrator verbalized the facility would like to continue
with the room variance waiver for Room A.
Cross reference to F911.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055671
If continuation sheet
Page 87 of 87
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Back to topCitations
34 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F679 - Activities
Provide activities to meet all resident's needs.
F550 - Resident Rights
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
F552 - Planning and Implementing Care
Ensure that residents are fully informed and understand their health status, care and treatments.
F558 - The right to reside and receive services in the facility with reasonable
Reasonably accommodate the needs and preferences of each resident.
F561 - Self-determination
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
F578 - The right to request, refuse, and/or discontinue treatment, to participate in or
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
F623 - Transfer and discharge-
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
F625 - Transfer and discharge-
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
F638 - Quarterly Review Assessment
Assure that each resident’s assessment is updated at least once every 3 months.
F640 - Automated data processing requirement-
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
F641 - Accuracy of Assessments
Ensure each resident receives an accurate assessment.
F655 - Comprehensive Person-Centered Care Planning
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
F656 - Comprehensive Care Plans
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
F684 - Quality of care
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
F690 - Incontinence
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
F692 - Assisted nutrition and hydration
Provide enough food/fluids to maintain a resident's health.
F693 - Assisted nutrition and hydration
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
F695 - Respiratory care, including tracheostomy care and tracheal suctioning
Provide safe and appropriate respiratory care for a resident when needed.
F698 - Dialysis
Provide safe, appropriate dialysis care/services for a resident who requires such services.
F755 - Pharmacy Services
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
F756 - Drug Regimen Review
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
F758 - Medication Errors
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
F761 - Labeling of Drugs and Biologicals
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
F803 - Menus and nutritional adequacy
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
F804 - Food and drink
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
F812 - Food safety requirements
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
F842 - Resident-identifiable information
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
F849 - Hospice services
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
F882 - Infection preventionist
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
F909 - Conduct Regular inspection of all bed frames, mattresses, and bed
Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame.
F911 - Accommodate no more than four residents
Ensure resident rooms hold no more than 4 residents; for new construction after November 28, 2016, rooms hold no more than 2 residents.
F912 - Measure at least 80 square feet per resident in multiple resident
Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
F880 - Infection Control
Provide and implement an infection prevention and control program.
F883 - Influenza and pneumococcal immunizations
Develop and implement policies and procedures for flu and pneumonia vaccinations.
FAQ · About this visit
Common questions about this visit
What happened during the April 10, 2024 survey of PARKVIEW HEALTHCARE CENTER?
This was a inspection survey of PARKVIEW HEALTHCARE CENTER on April 10, 2024. The surveyor cited 34 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at PARKVIEW HEALTHCARE CENTER on April 10, 2024?
Yes, 34 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Provide activities to meet all resident's needs."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.
Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.