Other·July 8, 2019

F000 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The following reflects the findings of the California Department of Public Health during an ABBREVIATED survey to investigate COMPLAINT Nos: CA00634745 and CA00635228. Inspection was limited to the specific complaint investigated and does not represent the findings of a full inspection of the facility. Representing the California Department of Public Health: Surveyors 39453, HFEN; 39670, HFEN; and 41701, HFEN. FOR COMPLAINT No. CA00634745, THE DEPARTMENT WAS NOT ABLE TO SUBSTANTIATE THE COMPLAINT ALLEGATIONS. FOR COMPLAINT No. CA00635228, THE DEPARTMENT WAS ABLE TO PARTIALLY SUBSTANTIATE THE COMPLAINT ALLEGATIONS. FINDINGS WERE CITED AT

F684. IN ADDITION, DURING THE INVESTIGATION, THE DEPARTMENT DETERMINED THERE WAS A VIOLATION OF THE REGULATIONS UNRELATED TO THE COMPLAINT ALLEGATIONS. FINDINGS WERE CITED AT F554 and F880. GLOSSARY OF ABBREVIATIONS AND BRIEF DEFINITIONS: Accucheck - blood sugar measuring system using capillary blood (finger stick) ADL - activities of daily living CNA - Certified Nursing Assistant LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE 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. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BY1311 Facility ID: CA060000039 If continuation sheet 1 of 13 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555688 (X3) DATE SURVEY COMPLETED 06/03/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ANAHEIM POINT 3415 W Ball Rd Anaheim, CA 92804 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE DON - Director of Nursing DSD - Director of Staff Development IDT - Interdisciplinary Team LVN - Licensed Vocational Nurse MAR - Medication Administration Record MDS - Minimum Data Set (a standardized assessment tool) mg/dL - milligram(s) per deciliter RN - Registered Nurse SQ - subcutaneous (between the skin and muscle)

F554 SS=D Resident Self-Admin Meds-Clinically Approp CFR(s): 483.10(c)(7)

F554 07/03/2019 §483.10(c)(7) The right to self-administer medications if the interdisciplinary team, as defined by §483.21(b)(2)(ii), has determined that this practice is clinically appropriate. This REQUIREMENT is not met as evidenced by: Based on observation, interview, medical record review, and facility P&P review, the facility failed to determine if it was safe for one of three sampled residents (Resident 2) and one nonsampled resident (Residents A) to selfadminister the medications. * Resident A had a Ventolin inhaler (a bronchodilator medication, used to relax the muscles in the airways and increases air flow to the lungs) at the bedside. Resident A was not mentally and physically able to administer the medications and did not have a physician's order, or a care plan problem addressing the self-administration of medications. In addition, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BY1311 Facility ID: CA060000039 If continuation sheet 2 of 13 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555688 (X3) DATE SURVEY COMPLETED 06/03/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ANAHEIM POINT 3415 W Ball Rd Anaheim, CA 92804 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE there was no physician's order to administer the Ventolin inhaler. * Resident 2 had her medications at the bedside. Resident 2 did not have a physician's order to keep medications at her bedside. The resident was not assessed or have a care plan problem to address the self-administration of the medications. These failures had the potential for Residents A and 2 to administer the medications inaccurately. Findings: Review of the facility's P&P titled MedicationSelf Administration revised 1/1/12, showed the residents requesting to self-administer hand held nebulizers will be required to demonstrate their ability to safely and effectively use the hand-held nebulizers without the assistance of a licensed nurse. The resident may not begin self-administration of medications prior to the approval of the IDT and attending physician. The attending physician must provide a written order permitting the resident to self-administer medication. 1. On 4/30/19 at 1025 hours, a concurrent observation and interview was conducted with Resident A. A Ventolin inhaler was observed at Resident A's bedside. Resident A stated she had been administering the inhaler by herself since she came to the facility. Medical record review for Resident A was initiated on 4/30/19. Resident A was admitted to the facility on 4/23/19. Review of the MDS dated 4/30/19, showed Resident A had the capacity to understand and make decisions. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BY1311 Facility ID: CA060000039 If continuation sheet 3 of 13 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555688 (X3) DATE SURVEY COMPLETED 06/03/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ANAHEIM POINT 3415 W Ball Rd Anaheim, CA 92804 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Review of Resident A's Self-Administration of Medication Assessment dated 4/24/19, showed Resident A did not express a desire to selfadminister the medications. The assessment showed Resident A was not mentally and physically able to administer the medications. Review of Resident A's Order Summary Report failed to show a physician's order for the administration of the Ventolin inhaler. Review of Resident A's care plan failed to show a care plan problem was developed to address the resident's self-administration of the Ventolin inhaler. On 4/30/19 at 1050 hours, and 1120 hours, Resident A was observed in bed. The Ventolin inhaler was observed on Resident A's bedside table. On 4/30/19 at 1120 hours, LVN 1 verified Resident A had a Ventolin inhaler at the bedside. On 4/30/19 at 1350 and 1356 hours Resident A was observed in bed. The Ventolin inhaler was observed on Resident A's bedside table. On 4/30/19 at 1356 hours, an interview and concurrent medical record review was conducted with RN 1. RN 1 verified Resident A had a Ventolin inhaler at the bedside. RN 1 verified Resident A's Self-Administration of Medication Assessment showed Resident A was not mentally and physically able to selfadminister medications. RN 1 could not locate a physician's order for the administration of the Ventolin inhaler. RN 1 verified Resident A did not have a physician's order or a care plan problem addressing the self-administration of medications. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BY1311 Facility ID: CA060000039 If continuation sheet 4 of 13 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555688 (X3) DATE SURVEY COMPLETED 06/03/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ANAHEIM POINT 3415 W Ball Rd Anaheim, CA 92804 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 2. On 4/30/19 at 1020 hours, an observation and concurrent interview was conducted with Resident 2. Two round white tablets and one medicine cup full of a brown color liquid was observed on Resident 2's bedside table. Resident 2 stated it was her medications. Medical record review for Resident 2 was initiated on 4/30/19. Resident 2 was admitted to the facility on 4/18/19. Review of the History and Physical form dated 4/21/19, showed Resident 2 was able to make decisions. Review of Resident 2's Order Summary Report failed to show a physician's order to allow Resident 2 to self-administer medication. Review of the Self Administration of Medication Assessment form dated 4/18/19, failed to show Resident 2 was assessed by the IDT for the ability to self-administer her medications. Review of Resident 2's plan of care failed to show a care plan problem was developed to address the resident's self-administration of medications. On 4/30/19 at 1040 hours, an interview was conducted with LVN 5. LVN 5 acknowledged she had left Resident 2's medications on the resident's bedside table. LVN 5 stated she should not have left the medications at the bedside. On 4/30/19 at 1050 hours, an interview was conducted with the DSD. The DSD stated any resident who are alert, oriented and want to self-administer medications should be assessed properly by the IDT. The DSD verified the above findings. The DSD stated the licensed nurses should not leave FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BY1311 Facility ID: CA060000039 If continuation sheet 5 of 13 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555688 (X3) DATE SURVEY COMPLETED 06/03/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ANAHEIM POINT 3415 W Ball Rd Anaheim, CA 92804 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE medications at bedside.

F684 SS=D Quality of Care CFR(s): 483.25

F684 07/03/2019 § 483.25 Quality of care Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive personcentered care plan, and the residents' choices. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and medical record review, the facility failed to provide services to attain or maintain the highest practicable well-being for one of two final sampled residents (Resident 1). Resident 1 had a physician's order to administer insulin lispro (rapid acting insulin used to lower blood sugar levels) and blood sugar monitoring. However, these orders were omitted during the admission process to the facility. Seven days later after being admitted to the facility Resident 1 was transferred to the acute care hospital with diagnoses including elevated blood sugar level. On readmission from the acute care hospital, Resident 1's regular insulin with sliding scale and blood sugar monitoring was again omitted. As a result, three days later, Resident 1 was transferred back to the acute care hospital emergency department with diagnoses including elevated blood sugar level. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BY1311 Facility ID: CA060000039 If continuation sheet 6 of 13 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555688 (X3) DATE SURVEY COMPLETED 06/03/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ANAHEIM POINT 3415 W Ball Rd Anaheim, CA 92804 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Findings: Medical record review for Resident 1 was initiated on 4/30/19. Resident 1 was initially admitted to the facility on 4/3/19, and was readmitted on 4/15/19. a. Review of the Resident 1's acute care hospital's transfer medication list titled Final Active Medication List dated 4/3/19, showed the following insulin orders: - "lispro x unit(s)" SQ every morning - Lantus (long acting insulin) 15 units SQ nightly at bedtime. Review of Resident 1's physician's order dated 4/3/19, showed to administer Lantus insulin 15 units SQ at bedtime. The physician's orders failed to show an order for lispro insulin or blood sugar monitoring. Review of the Admission Summary Progress Notes dated 4/3/19, showed the admission order was relayed to the primary physician who agreed. New order was noted, carried out, and communicated. There was no documentation the licensed nursing staff had clarified with the physician about the lispro insulin administration and blood sugar monitoring. Review of Resident 1's Medication Administration Record for April 2019 showed Lantus insulin 15 units were administered at bedtime. There was no documentation to show Resident 1's blood sugar levels were monitored and the lispro insulin were administered. On 5/21/19 at 1610 hours, a telephone interview and concurrent medical record review for Resident 1 review was conducted with LVN 4. LVN 4 stated for Resident 1's initial admission on 4/3/19, and he used the Final Active Medication List dated 4/3/19, from the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BY1311 Facility ID: CA060000039 If continuation sheet 7 of 13 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555688 (X3) DATE SURVEY COMPLETED 06/03/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ANAHEIM POINT 3415 W Ball Rd Anaheim, CA 92804 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE acute care hospital to verify the orders with the attending physician. LVN 4 verified the Final Active Medication List included Lantus and lispro insulins. LVN 4 stated the physician did not discontinue the order for lispro insulin and could not explain why the insulin lispro was not added to the MAR. Review of the Progress Notes dated 4/10/19 at 0855 hours, showed Resident 1 was transferred to the acute care hospital emergency department for hyperglycemia (high blood sugar level), fever, and low oxygen levels. Review of Resident 1's Transfer Record dated 4/10/19, showed the reasons for transfer to the acute care hospital were "low oxygen, high temperature, and high blood sugar." Review of the acute care hospital's Discharge Summary dated 4/15/19, showed Resident 1 was admitted to the acute care hospital on 4/10/19, with a blood sugar level of 669 mg/dL (normal range: 70-99 mg/dL). b. Resident 1 was readmitted to the facility on 4/15/19. Review of the acute care hospital's transfer medication list titled Current FacilityAdministered Medications list dated 4/15/19, showed the following insulin orders: - Lantus insulin 13 units SQ every 12 hours - regular insulin with sliding scale SQ every six hours Review of Resident 1's physician's order dated 4/15/19, showed to administer Lantus insulin 15 units SQ at bedtime. The physician's orders failed to show an order for Lantus insulin 13 units SQ every 12 hours, regular insulin with sliding scale, and blood sugar monitoring. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BY1311 Facility ID: CA060000039 If continuation sheet 8 of 13 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555688 (X3) DATE SURVEY COMPLETED 06/03/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ANAHEIM POINT 3415 W Ball Rd Anaheim, CA 92804 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE There was no documentation the licensed nursing staff had clarified with the physician about the Lantus insulin, regular insulin with sliding scale, and blood sugar monitoring. Review of Resident 1's MAR for April 2019 failed to show documentation Resident 1's blood sugar levels were monitored and the regular insulin utilizing a sliding scale was administered. The MAR only showed documentation Resident 1 was administered 15 units of regular insulin on 4/18/19. On 5/21/19 at 1610 hours, an interview and concurrent medical record review was conducted with LVN 4. LVN 4 stated he was the nurse who readmitted Resident 1 on 4/15/19. LVN 4 stated he used the Current Facility-Administered Medications list from the acute care hospital to verify the orders with the physician. LVN 4 verified the Final Active Medication List included a physician's order for Lantus insulin 13 units every 12 hours and regular insulin with sliding scale every six hours. LVN 4 acknowledged he did not include the physician's order for regular insulin with sliding scale on to the resident's MAR. LVN 4 stated he did not remember the physician changing the order for Lantus insulin. LVN 4 stated the physician did not discontinue the order for regular insulin with sliding scale and could not explain why the regular insulin was not included on the MAR. Review of the Progress Notes dated 4/18/19 at 1401 hours, showed Resident 1 was transferred back to the acute care hospital emergency department (three days after being readmitted to the facility) for elevated blood sugar level and elevated BUN (blood urea nitrogen, a blood test to determine how well the kidneys function). FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BY1311 Facility ID: CA060000039 If continuation sheet 9 of 13 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555688 (X3) DATE SURVEY COMPLETED 06/03/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ANAHEIM POINT 3415 W Ball Rd Anaheim, CA 92804 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Review of Resident Transfer Record dated 4/18/19, showed the reason for transfer was elevated BUN and blood sugar level of more than 400 mg/dL. Review of the acute care hospital's laboratory report dated 4/18/19, showed a critical lab result for Resident 1's glucose level at 678 mg/dL (normal range: 70-99 mg/dL). On 5/22/19 at 1615 hours, an interview and concurrent medical record review for Resident 1 was conducted with LVN 5. LVN 5 stated she was assigned to care for Resident 1 when Resident 1 was transferred to the acute care hospital on 4/18/19. LVN 5 stated Resident 1's blood sugar levels were not monitored while he was at the facility. LVN 5 stated she had noted on 4/18/19, Resident 1 had a fever and was weak. LVN 5 stated they notified the nurse practitioner who ordered a stat (immediately) laboratory test. LVN 5 stated the results of the laboratory tests showed Resident 1 had a high blood glucose. LVN 5 stated the nurse practitioner was notified and ordered 15 units of regular insulin to be administered one time to Resident 1 on 4/18/19. LVN 5 verified Resident 1 was then transferred to the acute care hospital emergency department because of high blood sugar and elevated BUN. On 5/28/19 at 1345 hours, a telephone interview was conducted with Resident 1's primary physician. Resident 1's primary physician stated if there were orders from the acute care hospital for insulin and accuchecks he expected the nurses to continue those orders, especially if the patient was diabetic. Review of the acute care hospital's Discharge Summary dated 4/29/19, showed Resident 1's diagnosis included diabetes mellitus with hyperglycemia (elevated blood sugar). FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BY1311 Facility ID: CA060000039 If continuation sheet 10 of 13 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555688 (X3) DATE SURVEY COMPLETED 06/03/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ANAHEIM POINT 3415 W Ball Rd Anaheim, CA 92804 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG

F880 Infection Prevention & Control CFR(s): 483.80(a)(1)(2)(4)(e)(f)

F880 SS=D PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 07/03/2019 §483.80 Infection Control The facility must establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. §483.80(a) Infection prevention and control program. The facility must establish an infection prevention and control program (IPCP) that must include, at a minimum, the following elements: §483.80(a)(1) A system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon the facility assessment conducted according to §483.70(e) and following accepted national standards; §483.80(a)(2) Written standards, policies, and procedures for the program, which must include, but are not limited to: (i) A system of surveillance designed to identify possible communicable diseases or infections before they can spread to other persons in the facility; (ii) When and to whom possible incidents of communicable disease or infections should be reported; (iii) Standard and transmission-based FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BY1311 Facility ID: CA060000039 If continuation sheet 11 of 13 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555688 (X3) DATE SURVEY COMPLETED 06/03/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ANAHEIM POINT 3415 W Ball Rd Anaheim, CA 92804 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE precautions to be followed to prevent spread of infections; (iv)When and how isolation should be used for a resident; including but not limited to: (A) The type and duration of the isolation, depending upon the infectious agent or organism involved, and (B) A requirement that the isolation should be the least restrictive possible for the resident under the circumstances. (v) The circumstances under which the facility must prohibit employees with a communicable disease or infected skin lesions from direct contact with residents or their food, if direct contact will transmit the disease; and (vi)The hand hygiene procedures to be followed by staff involved in direct resident contact. §483.80(a)(4) A system for recording incidents identified under the facility's IPCP and the corrective actions taken by the facility. §483.80(e) Linens. Personnel must handle, store, process, and transport linens so as to prevent the spread of infection. §483.80(f) Annual review. The facility will conduct an annual review of its IPCP and update their program, as necessary. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and medical record review, the facility failed to implement the infection control practices for one nonsampled resident (Resident B). The facility failed to ensure Resident B's wound dressing was secure and not touching the floor. This posed the risk of spreading an infection to Resident B's wound. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BY1311 Facility ID: CA060000039 If continuation sheet 12 of 13 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555688 (X3) DATE SURVEY COMPLETED 06/03/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ANAHEIM POINT 3415 W Ball Rd Anaheim, CA 92804 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Findings: On 4/30/19 at 1030 hours, Resident B was observed in his wheelchair. A wound dressing on Resident B's left foot was unraveled and the wound dressing was touching the floor. The dressing was noted to be dirty. When asked about his wound dressing, Resident B stated he walked to the bathroom and the dressing was unraveled. Resident B stated he asked for the wound dressing to be changed earlier in the morning at 0800 hours. Resident B stated he remembered what time he asked because he looked at the clock on the wall. On 4/30/19 at 1040 hours, an observation and concurrent interview was conducted with RN 1. RN 1 verified Resident B's wound dressing was unraveled, dirty, and touching the floor. RN 1 stated Resident B had a daily wound dressing to the left foot. RN 1 stated she would call the wound treatment nurse to change the dressing right away. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BY1311 Facility ID: CA060000039 If continuation sheet 13 of 13