Other·January 24, 2018

F000 INITIAL COMMENTS

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 for COMPLAINT NO: CA00558690. 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: Surveyor 37689, HFEN and Surveyor 39210, HFEN. THE DEPARTMENT WAS ABLE TO SUBSTANTIATE THE COMPLAINT ALLEGATION(S). FINDINGS WERE CITED AT F309. GLOSSARY OF ABBREVIATIONS: ADON - Assistant Director of Nursing DON - Director of Nursing mg - milligram(s) OT - Occupational Therapy

F309 SS=G PROVIDE CARE/SERVICES FOR HIGHEST WELL BEING CFR(s): 483.24, 483.25(k)(l)

F309 483.24 Quality of life Quality of life is a fundamental principle that applies to all care and services provided to facility residents. Each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, consistent with the 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: SWYU11 Facility ID: CA060000089 If continuation sheet 1 of 8 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: _______________ 055459 (X3) DATE SURVEY COMPLETED 12/20/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BUENA VISTA CARE CENTER 1440 S Euclid St Anaheim, CA 92802 (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 resident’s comprehensive assessment and plan of care. 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, including but not limited to the following: (k) Pain Management. The facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents’ goals and preferences. (l) Dialysis. The facility must ensure that residents who require dialysis receive such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents’ goals and preferences. This REQUIREMENT is not met as evidenced by: Based on interview, medical record review, and facility document review, the facility failed to provide the necessary care and services after a hip surgery for one of two sampled residents (Resident 1). The facility failed to provide necessary hip precautions to Resident 1 when she was readmitted to the facility after a hip surgery, which resulted in a dislocation of her left hip prosthesis. This failure caused Resident 1 to be readmitted to the acute care hospital for close reduction of the left hip dislocation. In addition, the facility failed to FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: SWYU11 Facility ID: CA060000089 If continuation sheet 2 of 8 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: _______________ 055459 (X3) DATE SURVEY COMPLETED 12/20/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BUENA VISTA CARE CENTER 1440 S Euclid St Anaheim, CA 92802 (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 promptly carry out a physician's order for a STAT ((immediately) orthopedic appointment, resulting in a delay in treatment for the resident. Findings: According to the Foundations and Adult Health Nursing, fifth edition, nursing interventions after a surgery of a fractured hip included the following: - Avoid elevating the affected extremity when sitting. - The head of the patient's bed is to be elevated at maximum of 45 degrees to avoid flexion of the hip and strain on the fixation device. - Do not allow patient to cross their legs because this could adduct (cross body part over the midline) which can dislocate the hip. - Do not allow patient to abduct their legs by using an abductor pillow for 7 to 10 days following surgery to prevent dislocation of the prosthesis. Medical record review for Resident 1 was initiated on 11/8/17. Resident 1 was readmitted to the facility on 10/17/17, with diagnoses including dementia and left femoral neck fracture with status post left hip hemiarthroplasty. Review of the History and Physical Examination dated 10/18/17, showed Resident 1 did not have the capacity to understand and make decisions. Review of the Admission/Readmission Nursing Data Tool showed Resident 1 arrived at the facility on 10/17/17 at 1800 hours, via ambulance. The entry for Musculoskeletal assessment under the section for Musculoskeletal Limitations showed "none FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: SWYU11 Facility ID: CA060000089 If continuation sheet 3 of 8 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: _______________ 055459 (X3) DATE SURVEY COMPLETED 12/20/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BUENA VISTA CARE CENTER 1440 S Euclid St Anaheim, CA 92802 (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 identified" was checked off. The admission assessment showed Resident 1 was anxious and restless. Review of the Physician's Admitting Order form dated 10/17/17, showed an order for hydrocodone-acetaminophen (controlled pain medication) 10-325 mg one tablet every four hours as needed for pain. Review of the nurses' notes dated 10/17/17 at 1800 hours, failed to show any documentation of the hip precautions or interventions in place following the resident's left hip surgery. Review of the nurses' notes dated 10/17/17, for the night shift (2100 to 0700 hours) failed to show any hip precautions or interventions were implemented . Review of Resident 1's plan of care developed on admission failed to show any care plan problems or interventions to address any hip precautions following the resident's left hip surgery. On 11/8/17 at 1359 hours, an interview was conducted with CNA 1. CNA 1 stated she provided total assistance of one person (herself) to Resident 1 for bed mobility. CNA 1 stated Resident 1 could not understand or follow instructions. On 11/8/17 at 1417 hours, an interview was conducted with CNA 2. CNA 2 stated she did not receive any instructions regarding Resident 1 after care limitation for hip precautions. CNA 2 stated she would only turn Resident 1 to her right side. When asked how she would turn Resident 1, CNA 2 stated she would stand on Resident 1's left side and hold the resident left shoulder and lower thigh or knee area and turn the resident and then place a pillow behind her FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: SWYU11 Facility ID: CA060000089 If continuation sheet 4 of 8 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: _______________ 055459 (X3) DATE SURVEY COMPLETED 12/20/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BUENA VISTA CARE CENTER 1440 S Euclid St Anaheim, CA 92802 (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 back. On 11/8/17 at 1430 hours, an interview was conducted with the Director of Rehabilitation. The Director of Rehabilitation stated she evaluated Resident 1 on 10/18/17 (one day after admission), and noticed Resident 1's legs were uneven (one leg was shorter than the other), and Resident 1 was screaming in pain when she was touched. The Director of Rehabilitation stated the residents who underwent this type of hip surgery should have hip precautions in place. When asked what the hip precautions were, the Director of Rehab stated the resident's affected leg should not be externally rotated, the resident could not cross their affected leg over the other or bend their hips more than 90 degrees. In addition, for the residents with poor safety awareness like Resident 1, they needed to use an abductor pillow (a wedge that is placed between the resident's legs) to prevent the resident from crossing their leg over the other to maintain proper alignment. On 11/8/17 at 1504 hours, an interview was conducted with the OT Assistant. The OT Assistant stated he was approached by the ADON on 10/18/17, regarding Resident 1's leg discrepancy. The OT Assistant stated he provided Resident 1 with an abductor pillow because Resident 1 was not compliant with the hip precautions due to poor safety awareness. The OT was asked how the staff should have turned or positioned Resident 1 in bed. The OT Assistant stated when the staff needed to turn Resident 1, they should stand on the resident's right side of the bed and log roll her (turn her trunk and legs to maintain alignment to prevent her left leg crossing over). On 11/8/17 at 1532 hours, an interview was conducted with the ADON. The ADON stated FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: SWYU11 Facility ID: CA060000089 If continuation sheet 5 of 8 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: _______________ 055459 (X3) DATE SURVEY COMPLETED 12/20/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BUENA VISTA CARE CENTER 1440 S Euclid St Anaheim, CA 92802 (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 she did the admission assessment for Resident 1 on 10/17/17. The ADON stated she did not receive any instructions regarding the use of an abductor pillow and could not remember if Resident 1 had one on admission. The ADON also stated the morning of 10/18/17, when she went to administer the intravenous medication to Resident 1, she noticed the resident's leg discrepancy. The ADON stated she notified physical therapy staff right away. The ADON also stated there was no abductor pillow in between Resident 1's legs at that time. On 11/9/17 at 1134 hours, a follow-up telephone interview was conducted with the ADON. The ADON stated she was aware Resident 1 had a hip surgery; however, there were no instructions from the acute care hospital regarding hip precautions. The ADON stated the evening of 10/17/17, when Resident 1 was readmitted to the facility, she was not able to review all of the resident's discharge instructions from the acute care hospital because she was working on two admissions. The ADON stated she could not remember if she gave the instructions to the CNA to keep a pillow in between Resident 1's legs. The ADON verified there was no care plan or interventions developed to address the hip precautions. When asked if she contacted the physician to clarify or obtain an order for hip precautions, the ADON stated she called Resident 1's primary care physician (PCP) to verify the medication orders but did not ask the physician about any precautions or interventions for a hip surgery. Review of the Physical Therapy Plan of Care dated 10/18/17, showed a discrepancy of a half an inch in length for Resident 1's left leg. The interventions included strict hip precautions. There was an entry showing a nurse to call the physician for recommended hip x-ray to rule FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: SWYU11 Facility ID: CA060000089 If continuation sheet 6 of 8 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: _______________ 055459 (X3) DATE SURVEY COMPLETED 12/20/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BUENA VISTA CARE CENTER 1440 S Euclid St Anaheim, CA 92802 (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 out dislocation. Review of the Pain Assessment Flow Sheets showed Resident 1 was given hydrocodoneacetaminophen as needed on the following dates: - On 10/18/17 at 1600 hours, for a pain level of 7 out of 10 on the left hip. - On 10/18/17 at 2100 hours, for a pain level of 7 out of 10 on the left hip. - On 10/19/17 at 1000 hours, for a pain level of 6 out of 10 on the left hip. - On 10/20/17 at 0930 hours, for a pain level of 6 out of 10 on the left hip. - On 10/23/17 at 0000 hours, for a pain level of 6 out of 10 on the left hip. - On 10/23/17 at 1600 hours, for a pain level of 7 out of 10 on the left hip. Additional review of Resident 1's plan of care showed a care plan problem dated 10/20/17, to address a dislocation of the left hip arthroplasty. The approaches included to perform the x-ray as ordered, monitor for increased pain, log roll the resident to prevent any further dislocation and provide an appointment STAT with the orthopedic surgeon. Review of the Physician and Telephone Orders dated 10/18/17, showed an order to have a follow up appointment with the orthopedic surgeon in one week and perform the x-ray of the left hip prior to the orthopedic appointment. Review of the nurses' notes dated 10/18/17 at 1900 hours, showed x-ray of the left hip was scheduled to be done on 10/20/17 (two days later). Review of the left hip x-ray result dated 10/20/17, showed Resident 1's left hip FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: SWYU11 Facility ID: CA060000089 If continuation sheet 7 of 8 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: _______________ 055459 (X3) DATE SURVEY COMPLETED 12/20/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BUENA VISTA CARE CENTER 1440 S Euclid St Anaheim, CA 92802 (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 arthroplasty was dislocated. Review of the Change of Condition form dated 10/20/17, showed the result of the x-ray taken on 10/20/17 was relayed to Resident 1's PCP; and the staff had received an order to get a STAT appointment with the orthopedic surgeon to see what kind of interventions would be necessary to repair Resident 1's left hip dislocation. Review of the Physician and Telephone Orders dated 10/20/17, showed an order for STAT appointment with the orthopedic surgeon. On 12/20/17 at 1422 hours, a telephone interview was conducted with the DON. The DON verified the physician's order on 10/20/17, for Resident 1 to see the orthopedic surgeon was to be done immediately (STAT). When asked what a STAT order meant, the DON stated it should be done right away, and if the licensed nurse could not get a STAT appointment, the resident should have been sent to the acute care hospital emergency department. The DON verified Resident 1 was not seen by the orthopedic surgeon until 10/24/17 (four days after), and from the orthopedic surgeon's office, Resident 1 was sent straight to the acute care hospital for surgical repair. Review of the acute care hospital Discharge Summary dated 11/9/17, showed Resident 1 was admitted to the acute care hospital on 10/24/17, and discharged back to the facility to 10/27/17, with diagnoses including dislocation of left hip prosthesis and status post closed reduction of the dislocation. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: SWYU11 Facility ID: CA060000089 If continuation sheet 8 of 8