Health inspection·October 1, 2024

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 interview, medical record review, and facility P&P review, the facility failed to develop the comprehensive plan of care to address the IV hydration and clogged nephrostomy tube for one of two sampled residents (Resident 1). This failure posed the risk of not providing appropriate individualized care to Resident 1. Findings: Review of the facility's P&P titled Hydration dated 12/19/22, showed the facility will utilize a systematic approach to optimize the resident's hydration status: developing and consistently implementing pertinent approaches, and monitoring the effectiveness of interventions and revising them as necessary. The resident's goals and preferences regarding hydration will be reflected in the resident's plan of care, and the interventions will be individualized to address the specific needs of the resident. Review of the facility's P&P titled Nephrostomy and Cystostomy Tube Care and Maintenance dated 12/19/22, showed the resident's goals and preferences for care and treatment of the tube(s) will be used to formulate a plan of care. Interventions will include but are not limited to: Monitoring for symptoms of blockage or dislodgement. Review of Resident 1's medical record was initiated on 9/27/24. Resident 1 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 1's Order Summary Report dated 9/27/24, showed a physician's order dated 7/8/24, for the right flank area, nephrostomy site. Review of Resident 1's Order Listing Report showed a physician's order dated 9/19/24, for sodium chloride 0.45% IV solution 50 ml/hr intravenously every shift for dehydration for 1 liter until 9/20/24. Review of Resident 1's progress notes dated 9/20/24 at 0919 hours, showed Resident 1's nephrostomy tube was not flushing and clogged. Review of Resident 1's SBAR Communication Form dated 9/20/24, showed Resident 1's nephrostomy tube was clogged, unable to flush. Review of Resident 1's Plan of Care failed to show any documented evidence a care plan problem was developed to address administration of IV solution for dehydration on 9/19/24, and clogged (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 2 Event ID: 055984 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 055984 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/01/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Anaheim Healthcare Center, LLC 501 South Beach Blvd. Anaheim, CA 92804 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)