Health inspection·June 20, 2025

F 0842 Level of Harm - Potential for minimal harm Residents Affected - Some 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** Based on interview, medical record review, and facility P&P review, the facility failed to ensure the medical record was accurate and complete for one of five sampled residents (Resident 1). * Resident 1's informed consent for a bolster pillow was not signed by the provider who had obtained the informed consent. In additon, there was no physician's order for the use of the bolster pillow. This failure had the potential for the resident's care needs not being met as their medical information was inaccurate and incomplete. Findings: Review of the facility's P&P titled Informed Consent revised on 3/25/24, showed it is the responsibility of the healthcare professional who proposes any medical intervention or treatment that requires informed consent to provide information to the resident/resident representative regarding the resident's condition and circumstances that are pertinent to a decision to accept or refuse the proposed intervention or treatment. Medical record review for Resident 1 was initiated on 6/18/25. Resident 1 was admitted to the facility on [DATE], and was readmitted on [DATE]. Review of Resident 1's H&P examination dated 5/27/25, showed Resident 1 could make needs known but could not make medical decisions. Review of Resident 1's care plan dated 6/8/25, showed Resident 1 had an unwitnessed fall from the bed. The interventions included to have the bilateral bolster pillows to maintain proper body alignment when in bed. Review of Resident 1's Physician Document of Informed Consent dated 6/9/25, failed to show the signature of the provider who had obtained the informed consent. Review of Resident 1's Medication Review Report for June 2025 failed to show a physician's order for the use of the bilateral bolster pillow. On 6/18/25 at 0951 hours, an observation for Resident 1 was conducted. Resident 1's bed had a bilateral bolster pillow. On 6/20/25 at 1038 hours, an interview and concurrent medical record review was conducted with LVN (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 06/20/2025 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)