Other·January 15, 2020

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 Facility Reported Incident (FRI) No: CA00663322. Inspection was limited to the specific FRI investigated and does not represent the findings of a full inspection of the facility. Representing the California Department of Public Health: Surveyor 33453, HFEN. THE DEPARTMENT WAS ABLE TO SUBSTANTIATE THE FACILITY REPORTED INCIDENT. FINDINGS WERE CITED AT F600 FOR RESIDENT 1. Glossary of Abbreviations & Definitions: ADL - activities of daily living CNA - Certified Nursing Assistant LVN - Licensed Vocational Nurse MDS - Minimum Data Set (a standardized assessment tool) RN - Registered Nurse

F600 SS=D Free from Abuse and Neglect CFR(s): 483.12(a)(1)

F600 12/29/2019 §483.12 Freedom from Abuse, Neglect, and Exploitation The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's 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: 6YM211 Facility ID: CA060000089 If continuation sheet 1 of 5 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 12/16/2019 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 medical symptoms. §483.12(a) The facility must§483.12(a)(1) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion; This REQUIREMENT is not met as evidenced by: Based on interview, medical record review, and facility document review, the facility failed to ensure one of two sampled residents (Resident 1) was free from abuse. Resident 1 had both wrists tied together with a sock. Being physically restrained caused Resident 1 the inability to move both hands freely and caused swelling of both hands and redness around both wrists. Findings: Review of the Report of Suspected Dependent Adult/Elder Abuse dated 11/11/19, showed on 11/11/19 at 0030 hours, Resident 1 was found with both hands tied together with a sock. Medical record review was initiated for Resident 1 on 11/13/19. Resident 1 was admitted to the facility on 7/20/17. Review of the MDS dated 7/13/19, showed Resident 1's cognition was severely impaired and had no speech. Resident 1 needed extensive assistance from the staff with her ADL care. Review of the facility's investigation report initiated on 11/11/19, showed at 0030 hours, Resident 1 was lying in bed fully dressed with her day clothes on. Resident 1 was also noted to have both hands tied together with a sock. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 6YM211 Facility ID: CA060000089 If continuation sheet 2 of 5 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 12/16/2019 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 Review of the facility's Summary Letter dated 11/15/19, showed in the early morning hours of 11/11/19, Resident 1 was found lying on her left side with her hands bound by a long bluish colored sock. Resident 1's hands were swollen and red on the wrist. On 11/13/19 at 1414 hours, an interview was conducted with LVN 1. LVN 1 stated Resident 1 required total assistance from the staff for eating and all care needs. LVN 1 stated Resident 1 had hand tremors and had not seen Resident 1 use her hands. LVN 1 stated Resident 1 did not have combative behaviors and did not speak. On 11/13/19 at 1425 hours, an interview was conducted with CNA 1. CNA 1 stated Resident 1 had been seen putting her hands in her pants. CNA 1 stated when Resident 1 put her hands in her pants, she checked Resident 1's brief and placed the resident's hands outside the pants. On 12/3/19 at 1242 hours, a telephone interview was conducted with LVN 4. LVN 4 stated on 11/11/19, CNA 5 informed her Resident 1 was still in her day clothes. LVN 4 stated when she entered the room Resident 1 was lying on her side with her back to the door and fully dressed. LVN 4 stated she then walked out the door and CNA 5 called her back into Resident 1's room and showed her Resident 1's hands were tied together at the wrist with a sock. LVN 4 stated she immediately removed the sock from Resident 1's wrist and noted redness on the wrists and swelling of both hands. During a telephone interview on 12/4/19, at 1250 hours with RN 1, RN 1 stated she recalled last seeing Resident 1 on 11/10/19 at FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 6YM211 Facility ID: CA060000089 If continuation sheet 3 of 5 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 12/16/2019 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 2200 hours, lying on the right side facing the door, and both hands were visible. RN 1 stated Resident 1 was non-verbal. RN 1 stated Resident 1 had behaviors of scratching inside the brief and sometimes got feces on her hands. RN 1 stated she did not see any of those behaviors during her shift on 11/10/19. During a telephone interview on 12/9/19 at 1248 hours, with CNA 3, CNA 3 stated on 11/10/19, she had worked a double shift, 07001500 hours and 1500-2300 hours. CNA 3 stated she had only been assigned to Resident 1 a few times in the past. CNA 3 stated Resident 1 required all care provided by staff. CNA 3 stated Resident 1 was bed ridden and did not speak. When was asked if Resident 1 was able to move both arms and hands, CNA 3 stated Resident 1 had a little bit of movement. CNA 3 stated Resident 1 had shaking of the hands. CNA 3 stated Resident 1 was in bed all shift and had changed Resident 1's briefs two times, the first time between 1700-1800 hours and again between 2220 -2230 hours. CNA 3 stated she repositioned Resident 1 on the left side facing the window. CNA 3 stated Resident 1 tried to put her hands in her brief, and that was why she left Resident 1's clothes on. CNA 3 was asked if Resident 1 was putting her hands in her brief on 11/10/19. CNA 3 stated no, but when left with just a gown and brief on, Resident 1 would put her hands in her brief. CNA 3 was asked if anyone went into the room after Resident 1 was changed and repositioned at 2230 hours. CNA 3 stated no. During a telephone interview on 12/13/19 at 1328 hours, with CNA 5, CNA 5 stated on 11/11/19 at 12 midnight, Resident 1 was in bed, covered with a sheet, and on her left side facing the window. CNA 5 stated Resident 1 had her clothes (pants and blouse) on, and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 6YM211 Facility ID: CA060000089 If continuation sheet 4 of 5 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 12/16/2019 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 CNA 5 immediately informed LVN 4. CNA 5 stated she then noticed Resident 1's hands were tied together. CNA 5 stated she immediately informed LVN 4 again. LVN 4 immediately removed the sock. CNA 5 stated when LVN 4 removed the sock, which was tied around Resident 1's wrist, she observed redness and swelling of both hands. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 6YM211 Facility ID: CA060000089 If continuation sheet 5 of 5