Other·February 14, 2020

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: CA00666356. Inspection was limited to the specific complaint investigated and did 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 COMPLAINT ALLEGATION. FINDINGS WERE CITED AT

F686 FOR RESIDENT 1. Glossary of Abbreviations & Definitions: Clinitron bed - a special mattress to reduce pressure on areas of the body prone to developing pressure ulcers cm - centimeters DON - Director of Nursing LAL mattress - low air loss mattress, a mattress which provides pressure redistribution to a person's body. MDS - Minimum Data Set (a standardized assessment tool) MRSA - methicillin-resistant staphylococcus Aureus (infection caused by staph bacteria that is resistant to antibiotics) Pressure Ulcer - injury to the skin and underlying tissue resulting from prolonged pressure RN - Registered Nurse PRN - as needed Roho - seat cushion for preventing and treating pressure ulcers Sacrococcyx - tail bone area Wound VAC - vacuum assisted closure 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: 52Y611 Facility ID: CA060000089 If continuation sheet 1 of 18 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 01/07/2020 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 dressing (negative pressure wound therapy) used to control drainage of fluids, reduction of local edema, reduction of bacterial load, and aide in the development of granulation tissue

F686 Treatment/Svcs to Prevent/Heal Pressure Ulcer F686 01/25/2020 SS=G CFR(s): 483.25(b)(1)(i)(ii) §483.25(b) Skin Integrity §483.25(b)(1) Pressure ulcers. Based on the comprehensive assessment of a resident, the facility must ensure that(i) A resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable; and (ii) A resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and medical record review, the facility failed to ensure the necessary care and services were provided to prevent the development of pressure ulcers to one of two sampled residents (Resident 1). Resident 1 was admitted to the facility with an unstageable pressure ulcer. * The facility failed to assess, measure, obtain a wound treatment order, and implement the necessary interventions to prevent further skin breakdown of Resident 1's Stage 4 pressure ulcer on the sacrococcyx. This resulted in Resident 1's Stage 4 pressure ulcer on the sacrococcyx deteriorating. Resident 1 was transferred to the acute care hospital for FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 52Y611 Facility ID: CA060000089 If continuation sheet 2 of 18 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 01/07/2020 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 infection of the Stage 4 sacrococcyx pressure ulcer on 9/30/19. * Resident 1 was readmitted to the facility on 11/12/19. The peri-wound (skin around the wound) of Resident 1's Stage 4 pressure ulcer on the sacrococcyx had breakdown and was irritated starting 11/25/19. The facility failed to assess, measure, obtain wound treatment orders, and implement the necessary interventions to prevent further skin breakdown. This resulted in the peri-wound of the Stage 4 sacrococcyx pressure ulcer further deteriorating and developing deep tissue injury, which extended to the bilateral buttocks. Resident 1 was transferred to the acute care hospital with an infected Stage 4 pressure ulcer. In addition, the wound assessments by the licensed nurses did not match the assessments completed by the Wound Technician. * The physician's order for a Roho cushion for Resident 1 was not carried out. These failures resulted in worsening of Resident 1's pressure ulcer requiring another hospitalization. Findings: The National Pressure Ulcer Advisory Panel released definitions of pressure ulcers on April 13, 2016. They are as follows: - Stage 3: full-thickness loss of skin, in which adipose (fat tissue) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar (dead tissue) may be visible. - Stage 4: full thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon, or muscle are exposed. - Unstageable: full thickness skin and tissue loss in which the extent of tissue damage within FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 52Y611 Facility ID: CA060000089 If continuation sheet 3 of 18 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 01/07/2020 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 the ulcer, cannot be confirmed because it is obscured by slough or eschar. - Deep tissue injury (DTI): intact or non-intact skin with localized area of persistent nonblanchable, deep red, maroon, purple discoloration or epidermal separation revealing a dark wound bed or blood filled blister. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. Medical record review for Resident 1 was initiated on 12/9/19. Resident 1 was admitted to the facility on 7/29/19, and readmitted on 11/12 and 12/5/19. Review of the MDS dated 11/19/19, showed Resident 1 was cognitively intact. a. Review of the Admission/Readmission Nursing Data Tool dated 7/29/19, under section XIV - Pressure Ulcer Assessment showed Resident 1 was not at risk for developing a skin/pressure injury. Review of the Wound Evaluation Flow Sheet showed the date first observed was 7/30/19. The date of the first assessment was 7/31/19. This assessment showed Resident 1 had a Stage 4 sacrococcyx pressure ulcer with 5% granulation (new tissue), 5% yellow slough, and 90% necrotic tissue, measuring 8.5 cm (length) x 10 cm (width) x UTD (unable to determine) (depth). The depth was obstructed by necrosis, there was no undermining, there was a small amount of serosanguineous exudate (bloody serous fluid), and the skin color surrounding the wound was pink or normal. Review of Resident 1's Treatment Administration Record for July 2019 showed a physician's order dated 7/30/19 at 0940 hours, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 52Y611 Facility ID: CA060000089 If continuation sheet 4 of 18 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 01/07/2020 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 to apply Santyl ointment (a debridement agent) to the sacrococcyx pressure injury for 14 days, cleanse with normal saline, pat dry, apply calcium alginate (a highly absorbent, biodegradable alginate dressing), and cover with a bordered dressing. Review of the Wound Evaluation Flow Sheet dated 8/19/19, showed Resident 1's sacrococcyx pressure ulcer was a Stage 4 with 10% granulation tissue, 50% yellow slough, and 40% necrotic tissue, measuring 8.5 cm x 10 cm x UTD. Review of the Wound Technician's Visit Report dated 8/19/19 at 1759 hours, showed Resident 1's Stage 4 sacrococcyx pressure ulcer measured 8.5 cm x 10 cm x 0.1 cm. The Assessment Notes showed the wound was the same as the observation on 8/12/19, with 25% granulation tissue, 25% yellow slough, 25% eschar (necrotic tissue), and the Wound Technician would request a longer bed for Resident 1. Review of the Wound Technician's Visit Report dated 8/21/19 at 1908 hours, under Assessment Notes showed Resident 1's Stage 4 sacrococcyx pressure ulcer had a mild odor. The physician started an antibiotic and the wound was debrided (the dead tissue was cut away). The Assessment Notes showed Resident 1 required a Roho cushion (Roho cushion is a soft pressure relief cushion to sit on). Review of the Wound Evaluation Flow Sheet dated 9/16, 9/23, and 9/30/19, showed Resident 1 had a Stage 4 sacrococcyx pressure ulcer with 10-20% granular tissue, 3040% yellow slough, and 50-60% necrotic tissue, measuring 8.5 cm x 9 cm x UTD. The depth of the wound was obstructed by FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 52Y611 Facility ID: CA060000089 If continuation sheet 5 of 18 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 01/07/2020 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 necrosis, no undermining, there was a small amount of serosanguineous exudate, and the skin color surrounding the wound was pink or normal. Review of the Wound Technician's Visit Reports dated 9/16, 9/18, 9/23, and 9/30/19, showed Resident 1's Unstageable sacrococcyx pressure ulcer measured 8.5 cm x 9 cm x 0.1 cm with 1-25% granulation tissue, 1-25% yellow slough, and 76-100% eschar. The Assessment Notes showed the following treatment orders and recommendations for Resident 1's Unstageable sacrococcyx pressure ulcer: - On 9/9/19, Resident 1's wound had a foul odor. The Dakin's solution (treats skin/wound infections) was used and the gentamycin (antibiotic) topical would be added to the wound treatment; - On 9/11/19, the gentamycin topical would be added to the wound treatment. Resident 1 still had not received the Clinitron bed (a Clinitron bed is an air fluidized therapy bed which minimized pressure that cause tissue breakdown) and a Roho cushion; - On 9/16/19 at 1723 hours, Resident 1's wound culture was positive for MRSA, and Resident 1 was on Vancomycin (antibiotic). Resident 1's Unstageable sacrococcyx pressure ulcer had an odor, and the peri-wound had redness. Calmoseptine (treatment and prevention of skin irritation) would be added. The Treatment Notes for Stage III/IV pressure injury - Necrotic Tissues showed to apply appropriate primary cover dressing using gentamycin ointment, and Santyl ointment. The Wound Orders showed Resident 1 needed a wheelchair cushion (Roho cushion) and a long Clinitron bed for Resident 1's Unstageable FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 52Y611 Facility ID: CA060000089 If continuation sheet 6 of 18 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 01/07/2020 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 sacrococcyx pressure ulcer. Resident 1 was unable to off load the pressure due to the right shoulder bursitis (a painful inflammation); - On 9/23/19 at 1646 hours, the Notes showed Resident 1's peri-wound treatment with antifungal cream, and the Assessment Notes showed Resident 1 was still waiting for the Clinitron bed; - On 9/30/19 at 1706 hours, the Assessment Notes showed Resident 1's sacrococcyx pressure ulcer with necrotic tissue and a foul odor that was much different than the previous odor, resident was non-compliant with turning every two hours, and Resident 1 now had a new bed. The wet necrotic tissue of Resident 1's sacrococcyx pressure ulcer was debrided, and the bone was exposed. The physician was notified, and Resident 1 was recommended to be transferred to the acute care hospital for surgical debridement and evaluation of the wound. Review of the Progress Notes showed a Skin/Wound Note entry dated 9/16/19 at 1306 hours, showing Resident 1 was seen and examined by the Wound Technician with no new order noted. Review of the Progress Notes showed a Skin/Wound Note entry dated 9/23/19 at 1137 hours, showing Resident 1 was seen and examined by the Wound Technician with no new order noted, and the peri-wound was slightly erythematous (reddened associated with irritation). Review of the Wound Technician's Visit Notes showed the date the facility received the Wound Technician's Visit Notes as follows: - The Wound Technician saw Resident 1 and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 52Y611 Facility ID: CA060000089 If continuation sheet 7 of 18 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 01/07/2020 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 signed the Visit Note on 9/16/19 at 1723 hours; the facility received the Visit Note on 9/28/19 at 1736 hours; - The Wound Technician saw Resident 1 on 9/23/19, and signed the Visit Note on 9/25/19 at 1646 hours. The facility received the Visit Note on 10/21/19 at 1658 hours; - The Wound Technician saw Resident 1 and signed the Visit Note on 9/30/19 at 1707 hours. The facility received the Visit Note on 10/16/19 at 0940 hours. Review of Resident 1's medical record failed to show Resident 1's pressure ulcer treatment was discussed between the Wound Technician and treatment nurses, and failed to show the above recommendations for Calmoseptine ointment, gentamycin ointment, and antifungal cream were ordered for Resident 1's Stage 4 sacrococcyx pressure ulcer and skin area around the wound (peri-wound). Review of Resident 1's care plan failed to show the facility addressed the resident's right shoulder bursitis and the inability to offload due to pain in the right shoulder. The care plan problems addressing the resident's pressure ulcers and pain concerns showed generic interventions to identify and treat existing conditions which might increase pain and discomfort, and turn and reposition every two hours or PRN. There were no specifics regarding how to turn and reposition Resident 1 in view of the right shoulder bursitis, or how frequently the turn schedule should be changed considering the resident's right shoulder pain. Review of the acute care hospital's medical record showed Resident 1 was transferred to the acute care hospital with an infected Stage 4 sacral decubitus ulcer on 9/30/19. b. Review of the medical record showed FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 52Y611 Facility ID: CA060000089 If continuation sheet 8 of 18 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 01/07/2020 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 1 was readmitted to the facility on 11/12/19. Review of the Wound Evaluation Flow Sheet dated 11/13/19, showed an initial examination of Resident 1's Stage 4 sacrococcyx pressure ulcer with 80% granulation, and 20% yellow slough, measuring 8 cm x 9 cm x 5 cm. The skin color surrounding the wound was bright red, and/or blanched to the touch. Review of the Wound Evaluation Flow Sheet dated 12/2/19, showed Resident 1's Stage 4 sacrococcyx pressure ulcer measured 8 cm x 9 cm x 5 cm, and the skin color surrounding the wound was bright red, and/or blanched to touch. Review of the Wound Technician's Visit Report dated 11/20/19 at 1901 hours, showed Resident 1's Stage 4 sacrococcyx pressure ulcer measured 8 cm x 9 cm x 3 cm. The Assessment Notes showed the wound had 80% granulation tissue, 20% slough, and the wound was treated with a wound vac. Under the Treatment Notes showed Sacral Peri-wound Impaired or Altered Skin Protocol included: - If red apply appropriate product using zinc ointment; - If macerate (soft, wet, or soggy skin often associated with improper wound care) apply appropriate product using zinc ointment; - If fungus/yeast apply antifungal agents using antifungal cream; - If denuded (surface area of skin is missing) apply appropriate product using skin prep; - If dry apply appropriate product using A&D ointment. The Notes showed a Roho and longer LAL (mattress) were ordered, and the Wound FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 52Y611 Facility ID: CA060000089 If continuation sheet 9 of 18 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 01/07/2020 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 Technician spoke with the case manager of the insurance company. Review of the Wound Technician's Visit Report dated 11/25/19 at 1757 hours, showed Resident 1's Stage 4 sacrococcyx pressure ulcer was granulating well, some peri-wound skin irritation, would treat with skin prep and antifungal powder. The Notes showed to continue with wound vac and apply skin prep and antifungal powder to peri-wound. Review of the Wound Technician's Visit Report dated 11/27/19 at 1757 hours, showed Resident 1's Stage 4 sacrococcyx pressure ulcer was debrided and the wound vac was reapplied. The Notes showed to apply appropriate primary of filler dressing using Medihoney gel (promotes a moisture-balanced environment conducive to wound healing). Review of the Wound Tech Multi Wound Chart Details dated 12/2/19 at 1835 hours, showed Resident 1's Stage 4 sacrococcyx pressure ulcer measured 12 cm x 15 cm x 3.2 cm. The wound had 1-25% granulation, 1-25 % yellow slough, and 51-75% moist black eschar. The Assessment Notes showed the wound was worse with necrosis, increase in size and a foul odor. The resident was reported to have been in bed and had not been offloaded for two days. The bone in the wound bed was exposed, and Resident 1 was to be transferred to the acute care hospital due to wound worsening and resident was non-compliant. The Treatment Notes - Stage III/IV Pressure Injury/Moderate Drainage showed to apply appropriate primary or filler dressing using Medihoney gel. Review of the Wound Technician's Visit Notes showed the date the facility received the Wound Technician's Visit Notes as follows: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 52Y611 Facility ID: CA060000089 If continuation sheet 10 of 18 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 01/07/2020 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 - The Wound Technician saw Resident 1 and signed the Visit Note on 11/20/19 at 1901 hours. The facility received the Visit Note on 11/28/19 at 0925 hours; - The Wound Technician saw Resident 1 and signed the Visit Note on 11/25/19 at 1757 hours. The facility received the Visit Note on 12/2/19 at 0626 hours; - The Wound Technician saw Resident 1 on 11/27/19, and signed the Visit Note on 11/27/19 at 1846 hours. The facility received the Visit Note on 12/2/19 at 0815 hours. Review of the Progress Notes showed Skin/Wound Note entries dated 11/25 at 1837 hours, and 11/27/19 at 1615 hours, showing Resident 1 was seen and examined by the Wound Technician with no new orders. Review of the Progress Notes showed a Discharge Summary dated 12/2/19 at 1210 hours, showing Resident 1's Stage 4 sacrococcyx pressure injury's peri-wound had eschar and erythema. Resident 1 was admitted to the hospital for a recurrent infected Stage 4 sacrococcyx pressure ulcer on 12/2/19. Review of the acute care hospital's Emergency Department Record, under Assessment dated 12/2/19 at 1445 hours, showed a large sacral pressure ulcer with a foul smell, surrounding erythema, and a large amount of necrotic tissue. Review of the acute care hospital's Daily Assessment Inquiry dated 12/2/19 at 1657 hours, showed Resident 1 had a sacrum pressure ulcer Stage 4, measuring 7 cm x 6 cm FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 52Y611 Facility ID: CA060000089 If continuation sheet 11 of 18 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 01/07/2020 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 x 4 cm, a right ischium (bottom of the buttock) DTI measuring 7 cm x 6 cm x UTD, and a left ischium DTI measuring 7 cm x 5 cm x UTD. Review of the acute care hospital's Daily Assessment Inquiry dated 12/5/19 at 1630 hours, showed Resident 1's Stage 4 sacrum pressure ulcer measured 7 cm x 6 cm x 4 cm, the right ischium DTI measured 7 cm x 6 cm x UTD, and the left ischium DTI measured 7 cm x 5 cm x UTD. On 12/5/19, Resident 1 was readmitted to the facility. Review of the Wound Evaluation Flow Sheet dated 12/5/19, showing an initial examination of Resident 1's Stage 4 sacrococcyx pressure ulcer showed 10% granulation, 40% yellow slough, and 50% necrotic tissue, and measuring 15 cm x 16 cm x 5.5 cm. Review of the Wound Technician's Visit Report dated 12/9/19 at 1835 hours, showed Resident 1's Stage 4 sacrococcyx pressure ulcer had 2650% granulation, 1-25 % yellow slough, and 125% necrotic tissue, measuring 12 cm x 15 cm x 3.2 cm. Under Treatment Notes - Stage III/IV Pressure Injury/Moderate Drainage showed to apply appropriate primary or filler dressing using Calcium Alginate, foam dressing and Medihoney gel. On 12/11/19 at 1135 hours, an observation and concurrent interview concerning Resident 1's sacrococcyx pressure ulcer was conducted with the Treatment Nurse. Resident 1 was observed laying on his left side. No Roho cushion was observed on Resident 1's wheelchair. The Treatment nurse was asked how she measured the wounds. The Treatment Nurse stated she measured the sacrococcyx pressure ulcer, left and right buttock skin breakdown area as one big FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 52Y611 Facility ID: CA060000089 If continuation sheet 12 of 18 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 01/07/2020 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 wound. Resident 1's pressure ulcer measured 15 cm x 16 cm x 5.2 cm. Resident 1's lower sacrococcyx and left and right ischium wounds were observed with three separate wounds with three clearly distinct wound edges. The Treatment Nurse was asked to measure the three separate wounds. Resident 1's sacrococcyx Stage 4 measured 10 cm x 8 cm x 5.2 cm. The wound bed was observed with 40% granulation, 20% eschar and 40% slough. The skin area surrounding the wound was observed with erythema. Resident 1's left ischium wound measured 7 cm x 5 cm with 20% eschar, and 80% yellow and red tissue. The skin area surrounding the wound was observed macerated, with erythema, and denuded. The right ischium wound measured 9 cm x 5 cm, the wound bed was observed with 100% red and yellow tissue with a small amount of yellow drainage. On 12/11/19 at 1200 hours, an interview and concurrent medical record review was conducted with the Treatment Nurse regarding Resident 1's sacrococcyx pressure ulcer and the left and right ischium DTIs. The Treatment Nurse stated she measured the wound area including the sacrococcyx, and the left and right ischium wounds together to get the total wound measurement of 15 cm x 16 cm x 5.5 cm after Resident 1's readmission from the acute care hospital on 12/5/19. When the Treatment Nurse was asked about the wound assessment when Resident 1 was transferred to the hospital on 12/2/19, with the Stage 4 sacrococcyx measuring 8 cm x 8 cm x 5 cm, the Treatment Nurse stated she measured the sacrococcyx wound only; she did not see or might have overlooked the right and the left ischium wounds. The Treatment Nurse stated she thought the area on the right and left ischium wounds were just macerated skin, and the wound vac was on top of the wound. The FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 52Y611 Facility ID: CA060000089 If continuation sheet 13 of 18 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 01/07/2020 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 Treatment Nurse was asked when she observed the skin area surrounding the wound was deteriorated. The Treatment Nurse stated she observed the peri-wound was deteriorated on Monday 12/2/19, when Resident 1 was transferred to the hospital. The Treatment Nurse stated the Wound Technician was with her when they assessed Resident 1's pressure ulcer. On 12/11/19 at 1518 hours, an interview and concurrent medical record review was conducted with RN 1 regarding Resident 1's sacrococcyx pressure ulcer. RN 1 stated she assessed Resident 1 before transferring the resident to the hospital. RN 1 stated Resident 1's Stage 4 sacrococcyx pressure ulcer with the skin area surrounding the wound extended to both buttocks, and the skin had erythema with eschar. RN 1 stated she did not measure the wound. On 12/12/19 at 1330 hours, a telephone interview and concurrent medical record review was conducted with the DON regarding the wound assessment and documentation. The DON stated the wound assessment should include the wound measurement, appearance, correct classification of the wound, accurate description of the wound, signs or symptoms of infection, whether the wound improved, physician notification of the wound, any discharge, any smell from the wound, and pain. The DON was asked how she measured the wound. The DON stated the peri-wound measurement was not included in the measurement of the wound; the peri-wound description should be under the comment section. After reviewing the Wound Technician's Visit Report and the Treatment Nurse's Wound Evaluation Flow Sheets for the months of August, September, November, and December 2019, the DON verified the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 52Y611 Facility ID: CA060000089 If continuation sheet 14 of 18 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 01/07/2020 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 discrepancies in the wound assessments by the Wound Technician and the Treatment Nurse. The DON verified Resident 1's Wound Evaluation Flow Sheets for the months of August, September, November, and December 2019 failed to show the peri-wound was deteriorated and when it occurred. The DON was asked how the Wound Technician ordered the wound treatment after assessing the resident. The DON stated the Wound Technician should have given the wound treatment orders after she saw the resident, and sent the Visit Report. On 12/12/19 at 1405 hours, a telephone interview and concurrent medical record review was conducted with the DON and the Treatment Nurse. The DON verified the recommendations for gentamycin ointment on 9/6/19, Calmoseptine on 9/11, and the antifungal on 9/25/19, had not been ordered for the resident. The Treatment Nurse was asked about the recommendations for wound treatment in the Visit Reports dated 11/25/19, and 11/27/19. The Treatment Nurse stated the Wound Technician sent the Visit Reports late, and the Wound Technician's orders or recommendations were not communicated to her; therefore, she was not aware the recommendations and the treatment orders were not changed. The DON verified the findings and stated the treatment nurse was supposed to read and verify the recommendations in the Visit Report completed by the Wound Technician, and call the physician to get the orders for wound treatment. On 12/16/19 at 0935 hours, a telephone interview and concurrent medical record review was conducted with the Wound Technician. The Wound Technician was asked about her orders and recommendations in her Visit Notes FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 52Y611 Facility ID: CA060000089 If continuation sheet 15 of 18 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 01/07/2020 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 dated 8/19 and 9/19/19. The Wound Technician stated she discussed with the treatment nurse on the day she saw the resident, and put the orders in her visit notes. The Wound Technician stated the treatment nurse was supposed to call the physician to get the treatment orders, and the treatment nurse could read the visit notes and request the treatment orders for the resident. After review of Resident 1's Visit Notes dated 11/25, 11/27, and 12/2/19, and the wound photos taken by the Wound Technician on 11/25 and 12/2/19, the Wound Technician verified the skin area surrounding the wound was not measured and specifically described. The Wound Technician confirmed the wound assessments dated 11/25 and 12/2/19, had a discrepancy when it showed Resident 1 had three separate wounds, the sacrococcyx, and the left and right ischiums; however, she measured the whole skin break down area as one wound. The Wound Technician was asked if the peri-wound treatment recommendations in November 2019 were discussed with the facility's treatment nurses. The Wound Technician stated it was the PRN order, it was not written in the physician's order for wound treatment. The Wound Technician stated she did not remember if she discussed the recommendations or gave the wound treatment orders to the treatment nurse. Review of all wound technician Visit Notes showed the facility did not receive the Visit Notes via fax for a week or more. The Wound Technician verified the findings and stated she dictated her Visit Note the same day she saw the resident, and her company was supposed to fax the visit notes to the facility. The Wound Technician stated he did not know why the visit notes took a long time to reach the facility. c. Review of Resident 1's Order Summary Report dated 9/27/19, showed a physician's FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 52Y611 Facility ID: CA060000089 If continuation sheet 16 of 18 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 01/07/2020 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 order for a Roho cushion while up in the wheelchair when available. Review of the medical record failed to show the order for a Roho cushion was carried out by the facility staff. On 12/19/19 at 1136 hours, a telephone interview was conducted with Resident 1. When asked about turning and repositioning in bed, Resident 1 stated he had pain to his right shoulder and could not lay long on the right side; however, he was able to stay on the left side for one hour. Resident 1 stated that was the reason he refused to turn sometimes, but he did his best to reposition. Resident 1 stated he wanted his wounds healed, he did not want to return to the acute care hospital. Resident 1 stated he got up one hour a day and had a special mattress but had a regular cushion for the wheelchair, not a gel cushion or Roho cushion. On 12/19/19 at 1323 hours, a telephone interview and concurrent medical record review was conducted with the DON. When asked about the recommendation and order for the Roho cushion, the DON stated the Wound Technician had a contract with the insurance company. The Wound Technician contacted the insurance company to get the approval for the Roho cushion for Resident 1. On 12/23/19 at 1126 hours, a telephone interview was conducted with the Wound Technician. When asked about the order and recommendation for the Roho cushion, the Wound Technician stated the Roho cushion was pending approval. The Wound Technician was asked if there was any other cushion to replace the Roho cushion. The Wound Technician stated the Roho cushion was an ultimate treatment device for the resident. The FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 52Y611 Facility ID: CA060000089 If continuation sheet 17 of 18 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 01/07/2020 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 Wound Technician stated the facility did not have a case manager to follow up, and she called the insurance company herself. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 52Y611 Facility ID: CA060000089 If continuation sheet 18 of 18