Other·August 1, 2018

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 ENTITY REPORTED INCIDENT (ERI) NO: CA00588207. Inspection was limited to the specific ERI investigated and does not represent the findings of a full inspection of the facility. Representing the California Department of Public Health: Surveyor 38489, HFEN and Surveyor 39453, HFEN. FOR ENTITY REPORTED INCIDENT No. CA00588207: THE DEPARTMENT WAS ABLE TO SUBSTANTIATE THE ERI AND FINDINGS WERE CITED AT F641, F656, AND F689. GLOSSARY OF ABBREVIATIONS AND BRIEF DEFINITIONS: ADL - activities of daily living ADON - Assistant Director of Nursing Bed mobility-how the resident moves to and from the lying position, turns side or side, and body positions while in bed or alternate sleep furniture CNA - Certified Nursing Assistant Craniotomy - surgical operation in which a bone flap is temporarily removed from the skull to access the brain DON - Director of Nursing GT - gastrostomy tube (a tube inserted into his stomach) Hematoma - localized collection of blood outside the blood vessels Intracranial Hemorrhage - occurs when a blood vessel ruptures within the brain or between the skull and your brain 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: CG0M11 Facility ID: CA060000147 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: _______________ 555035 (X3) DATE SURVEY COMPLETED 06/25/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PARK ANAHEIM HEALTHCARE CENTER 3435 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 LVN - Licensed Vocational Nurse MDS - Minimum Data Set (a standardized assessment tool) mg - milligram(s) ml - milliliter(s) Pathologic fractures - a bone fracture caused by disease that led to weakness of the bone structure. P&P - Policy and Procedure POP program - a facility's Protect Our Patient program to protect the residents from pathological fractures Respiratory Failure - inadequate gas exchange by the respiratory system Traumatic brain injury - result of a sudden, violent blow or jolt to the head

F641 SS=D Accuracy of Assessments CFR(s): 483.20(g)

F641 §483.20(g) Accuracy of Assessments. The assessment must accurately reflect the resident's status. This REQUIREMENT is not met as evidenced by: Based on interview and medical record review, the facility failed to ensure the MDS assessment did not accurately reflect the amount of assistance needed during ADL care for one of two sampled residents (Resident 1). Findings: Medical record review for Resident 1 was initiated on 5/30/18. Resident 1 was admitted to the facility on 1/17/13, with a history of traumatic brain injury and cognitive impairment. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CG0M11 Facility ID: CA060000147 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: _______________ 555035 (X3) DATE SURVEY COMPLETED 06/25/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PARK ANAHEIM HEALTHCARE CENTER 3435 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 On 5/22/18, Resident 1 sustained a fall from bed and was transferred to the acute care hospital emergency department. On 5/25/18, Resident 1 was readmitted to the facility with a new diagnoses of status post fall, intracranial bleed, and left femur fracture. Review of the MDSs dated 12/6/17 and 3/1/18, showed the Resident 1's bed mobility was coded a "4" (totally dependent on others) and "2" (needed one person for assistance). Review of the the Admission Rehabilitation Screening form dated 11/28/17, showed Resident 1 was totally dependent for bed mobility with a change from a one person assistance to a two or more persons' assistance. Review of the care plan problem dated 12/28/17, addressed self-care deficits showed Resident 1 was totally dependent with one person's assistance for bed mobility. The care plan did not reflect the amount of assistance for Resident 1 for bed mobility. Review of the Certified Nursing Assistant ADL Sheet from 11/30/17 to 12/6/17 and 4/23/18 to 3/1/18, did not show the amount of support Resident 1 needed for his ADL care, including bed mobility. Review of the Licensed Nurse Records dated 11/30/17 to 12/6/17 and 4/23 to 3/1/18, did not show the amount of support needed by Resident 1 in all of his ADL care. On 6/4/18 at 1020 hours, a concurrent interview and medical record review for Resident 1 was conducted with the Director of Rehabilitation. The Director of Rehabilitation verified the Admission Rehabilitation Screening dated 11/28/17, showed Resident 1 was totally FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CG0M11 Facility ID: CA060000147 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: _______________ 555035 (X3) DATE SURVEY COMPLETED 06/25/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PARK ANAHEIM HEALTHCARE CENTER 3435 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 dependent on others for bed mobility and needed assistance from two or more persons. The Director of Rehabilitation stated Resident 1 continued to be totally dependent and continued to require two or more persons with bed mobility. When asked why two or more persons were necessary, the Director stated Resident 1 was placed on the facility's POP program and the recommendation included to provide two persons' assistance for transfers and repositioning to prevent injuries such as pathologic fractures. The Director of Rehabilitation stated Resident 1 was heavy (weighed approximately 200 pounds) and needed a second and even a third person for support when repositioned and turned. On 6/4/18 at 1030 hours, a concurrent interview and medical record review for Resident 1 was conducted with the MDS Consultant. When asked how much support Resident 1 needed for bed mobility, the MDS Consultant stated she based it on the licensed nurses' notes, ADL flow sheets, and rehabilitation therapy assessment. The MDS Consultant verified there was no documented evidence to show Resident 1's level of support during ADL care on the Licensed Nurses Notes and ADL flow sheets. The MDS Consultant verified Resident 1 was assessed as totally dependent and needed two or more persons' assistance for bed mobility based on the Rehabilitation Screening forms dated 11/28/17 and 2/2/018. The MDS Consultant acknowledged the rehabilitation staff's recommendations should have been reflected in Resident 1's MDS and plan of care. The MDS Consultant acknowledged Resident 1's MDS did not reflect the amount of assistance he needed for bed mobility. On 6/19/18 at 1500 hours, an interview was conducted with the DON. The DON stated FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CG0M11 Facility ID: CA060000147 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: _______________ 555035 (X3) DATE SURVEY COMPLETED 06/25/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PARK ANAHEIM HEALTHCARE CENTER 3435 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 Resident 1 needed two or more persons' assistance when turned and repositioned to ensure the resident was safe and from sliding off his bed. The DON verified Resident 1's MDS dated 3/1/18, did not accurately reflect the amount of assistance Resident 1 needed during ADL care.

F656 SS=D Develop/Implement Comprehensive Care Plan F656 CFR(s): 483.21(b)(1) §483.21(b) Comprehensive Care Plans §483.21(b)(1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at §483.10(c)(2) and §483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following (i) The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under §483.24, §483.25 or §483.40; and (ii) Any services that would otherwise be required under §483.24, §483.25 or §483.40 but are not provided due to the resident's exercise of rights under §483.10, including the right to refuse treatment under §483.10(c)(6). (iii) Any specialized services or specialized rehabilitative services the nursing facility will provide as a result of PASARR recommendations. If a facility disagrees with the findings of the PASARR, it must indicate its rationale in the resident's medical record. (iv)In consultation with the resident and the resident's representative(s)(A) The resident's goals for admission and desired outcomes. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CG0M11 Facility ID: CA060000147 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: _______________ 555035 (X3) DATE SURVEY COMPLETED 06/25/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PARK ANAHEIM HEALTHCARE CENTER 3435 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 (B) The resident's preference and potential for future discharge. Facilities must document whether the resident's desire to return to the community was assessed and any referrals to local contact agencies and/or other appropriate entities, for this purpose. (C) Discharge plans in the comprehensive care plan, as appropriate, in accordance with the requirements set forth in paragraph (c) of this section. This REQUIREMENT is not met as evidenced by: Based on interview, medical record review, and facility record review, the facility failed to develop the care plan problems to address the necessary care and services needed for one of two sampled residents (Resident 1). This failure had the potential for Resident 1 to not receive adequate and individualized care to support safety and well-being. Findings: Review of the facility's P&P titled The Resident Care Plan showed a resident's plan of care shall be developed and implemented throughout the assessment process for each resident. Medical record review for Resident 1 was initiated on 5/30/18. Resident 1 was admitted to the facility on 1/17/13, with a history of traumatic brain injury and cognitive impairment. Review of Resident 11's plan of care showed various individual care plan problems with interventions that did not address the problem and/or was non-resident specific. For example: * A care plan problem dated 6/12/17 and last revised on 12/28/17, titled "Expected Behavior related to Movement to Floor Mat: History of FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CG0M11 Facility ID: CA060000147 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: _______________ 555035 (X3) DATE SURVEY COMPLETED 06/25/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PARK ANAHEIM HEALTHCARE CENTER 3435 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 falls / High risk for falls with interventions that include low bed and floor mat with expected episodes of behaviors of movement from bed to floor mat." The interventions addressed frequent visual checks, however, did not identify what "frequent" meant or identify what the resident's behaviors were. * A care plan problem dated 5/29/17, addressed Resident 1's risk for pathological fractures. The interventions included to assist with all transfers and ambulation as needed. However, there was no documentation to identify the number staff to be present to assist. * A care plan problem revised on 12/28/17, addressed Resident 1's alteration in nutritional status secondary to "poor oral intake". The interventions included to notify the physician of the resident's refusals of meals and provide the medication as ordered for appetite stimulation. Resident 1 was not able to eat orally and receiving all of his food and fluids via GT. On 6/19/18 at 1500 hours, a concurrent interview and medical record review for Resident 1 was conducted with the DON. The DON stated Resident 1 was not able to move out from his bed and was not able to ambulate. The DON acknowledged Resident 1's care plan problem addressing his poor oral intake was not appropriate since he had a GT and not receiving any food by mouth. The DON verified there were no care plans developed to address the use of a low air loss mattress or any interventions to address the safety precautions. The DON acknowledged Resident 1 needed assistance from two persons with his ADL care such as turning and repositioning in bed. The DON acknowledged Resident 1's plan of care did not reflect his individualized needs and interventions. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CG0M11 Facility ID: CA060000147 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: _______________ 555035 (X3) DATE SURVEY COMPLETED 06/25/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PARK ANAHEIM HEALTHCARE CENTER 3435 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)

F689 Free of Accident Hazards/Supervision/Devices F689 CFR(s): 483.25(d)(1)(2) SS=G ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE §483.25(d) Accidents. The facility must ensure that §483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and §483.25(d)(2)Each resident receives adequate supervision and assistance devices to prevent accidents. This REQUIREMENT is not met as evidenced by: Based on interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services to ensure adequate assistance was in place to prevent a fall, resulting in injuries to one of two sampled residents (Resident 1). * Resident 1 fell out of bed and onto the floor while a CNA (CNA 1) was providing incontinence care by himself. At the time of the fall, Resident 1 was laying on a low air loss mattress and the bed was in a high position. As a result, Resident 1 sustained a left femur fracture, left intracranial hemorrhage, skin tears to both left and right feet, and was admitted to the acute care hospital emergency department and intensive care unit. Findings: Review of the User Service Manual for the low air loss mattress dated 2015 showed the risk of gradual movement and/or sinking into hazardous position or inadvertent bed exit may be increased due to the nature of these products. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CG0M11 Facility ID: CA060000147 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: _______________ 555035 (X3) DATE SURVEY COMPLETED 06/25/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PARK ANAHEIM HEALTHCARE CENTER 3435 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 the facility's P&P titled Pathological/spontaneous Fractures-reducing Risk (POP) Reducing Risks showed resident will be provided two persons' assistance for transfers and repositioning. Medical record review for Resident 1 was initiated on 5/30/18. Resident 1 was admitted to the facility on 1/17/13, with diagnoses of traumatic brain injury, status post craniotomy, and chronic respiratory failure. Review of the Incident Report prepared by LVN 1 dated 5/22/18 at 0600 hours, showed while CNA 1 was providing incontinence care to Resident 1, Resident 1 rolled out of bed. LVN 1's documentation showed Resident 1 coughed, which made him move and rolled out of bed. Resident 1 landed on his left side. Resident 1 was assessed to have swelling on his left thigh, a hematoma on his left forehead, and skin tears to both of his left and right feet. Review Resident 1's Order Summary Report dated 3/29/18, showed a physician's order dated 7/18/16, for the use of a low air loss mattress. Review of the MDS dated 3/1/18, showed the Resident 1 had severe cognitive impairment and required total assistance from one person for bed mobility, toilet use, and personal hygiene. Resident 1 had functional limitation of both upper and lower extremities. Resident 1 weighed over 200 pounds. Review of the Admission Rehabilitation Screening dated 11/8/17, showed Resident 1 was totally dependent on staff for bed mobility and required assistance from two or more persons for safety. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CG0M11 Facility ID: CA060000147 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: _______________ 555035 (X3) DATE SURVEY COMPLETED 06/25/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PARK ANAHEIM HEALTHCARE CENTER 3435 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 the POP form showed Resident 1 needed assistance from two persons for ADL care. Review of the plan of care failed to find any care plan problem or intervention to identify Resident 1 had a low air loss mattress and the safety precautions related to its use. Review of the Fall Risk Assessment dated 3/23/18, showed Resident 1 was assessed to be a high risk for falls. Review of the Incident Report dated 5/22/18 at 0600 hours, showed CNA 1 had been providing incontinence care to Resident 1 when Resident 1 rolled out of bed. Documentation showed Resident 1 coughed, which made him move and roll out of bed landing on his left side. Resident 1 was assessed to have swelling on his left thigh, a hematoma on his left forehead, and skin tears to both of his left and right feet. Review of the physician's telephone order dated 5/22/18 at 0630 hours, showed a physician's order to transfer Resident 1 to an acute care hospital emergency department for further evaluation. Review of the acute care hospital's medical record for Resident 1 showed an x-ray of the left knee dated 5/22/18, identifying Resident 1 had sustained a left femur fracture. A CT scan of the head dated 5/22/18, showed Resident 1 sustained a brain hemorrhage. Review of the Neurosurgery consult dated 5/22/18, showed Resident 1 had an acute brain hemorrhage secondary to a cerebral contusion (bruise of the brain from trauma). Review of a Trauma History and Physical Examination dated 5/23/18, showed Resident 1 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CG0M11 Facility ID: CA060000147 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: _______________ 555035 (X3) DATE SURVEY COMPLETED 06/25/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PARK ANAHEIM HEALTHCARE CENTER 3435 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 presented to the emergency department with a left femur fracture and left intracranial hemorrhage. Resident 1 was admitted to the acute care hospital's intensive care unit. On 6/1/18 at 1419 hours, an interview was conducted with CNA 1. CNA 1 stated she worked the night shift (1900 to 0700 hours) and was assigned to care for Resident 1 the night Resident 1 fell out of bed. CNA 1 stated she was familiar with Resident 1 and had taken care of him before. She stated Resident 1 was total care and did not usually move. CNA 1 explained before she provided incontinence care, she had raised Resident 1's bed to her waist level. She stated she then turned Resident 1 onto to his left side in order to clean him properly. CNA 1 stated Resident 1 suddenly coughed causing his body to move, slide off the bed (away from her), and fell onto the floor. CNA 1 verified Resident 1 was laying on a low air loss mattress. CNA 1 acknowledged the low air loss mattress was soft and slippery, which increased the risk of Resident 1 sliding off the bed. When asked how many persons Resident 1 needed to assist with repositioning, CNA 1 stated she had provided care to Resident 1 by herself in the past, and since Resident 1 did not move, she thought it was okay. CNA 1 stated Resident 1 was on the facility's POP program which identified Resident 1 was to have two persons' assistance with his ADL care. CNA 1 acknowledged she was by herself when she repositioned the resident on 5/22/18, and was providing incontinent care at the time he fell out of bed. CNA 1 acknowledged she should have asked for additional staff assistance. On 6/4/18 at 0650 hours, an interview was conducted with CNA 2. CNA 2 stated she always asked for help when taking care of Resident 1. CNA 2 stated Resident 1 was FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CG0M11 Facility ID: CA060000147 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: _______________ 555035 (X3) DATE SURVEY COMPLETED 06/25/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PARK ANAHEIM HEALTHCARE CENTER 3435 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 heavy, was difficult to turn, and had episodes of jerky movements when he coughed. CNA 2 stated Resident 1 was lying on a low air loss mattress which was soft and made of a slippery material. CNA 2 stated Resident 1 needed a second person to hold onto him when he was repositioned during care as he could slip off the mattress. CNA 2 stated Resident 1 was to have two persons in attendance during repositioning. On 6/4/18 at 0700 hours, an interview was conducted with LVN 1. LVN 1 stated he was working the night Resident 1 fell out of bed. LVN 1 stated he was assigned to Resident 1 and acknowledged the low air loss mattress and the sides of the bed could collapse when a resident was near the edge. LVN 1 verified he was present immediately after Resident 1's fall on 5/22/18. LVN 1 stated Resident 1's bed was in the high position when he found him on the floor. LVN 1 verified CNA 1 was by herself when she repositioned Resident 1. LVN 1 stated Resident 1 had a history of pathological fractures, and for safety, he needed two persons' assistance during repositioning and transfers. LVN 1 added Resident 1 needed a second person to hold onto him when repositioned to prevent him from sliding from the side of the bed which had no rails. On 6/4/18 at 0715 hours, an interview was conducted with RN 1. RN 1 he was working the night Resident 1 fell. RN 1 stated he was called to assess Resident 1's condition after the fall. RN 1 stated he found Resident 1 lying on the floor on his left side. RN 1 stated Resident 1 was identified to have swelling on the left side of his forehead and left thigh. RN 1 stated Resident 1's bed was in a high position to about CNA 1's waist level. RN 1 stated Resident 1 slid off the bed down to the floor. RN 1 stated Resident 1 was to have two FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CG0M11 Facility ID: CA060000147 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: _______________ 555035 (X3) DATE SURVEY COMPLETED 06/25/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PARK ANAHEIM HEALTHCARE CENTER 3435 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 persons' assistance when repositioned. On 6/19/18 at 1500 hours, a concurrent interview and review of the product information for the low air loss mattress was conducted with the DON. The DON acknowledged the use of the low air loss mattress placed Resident 1 at risk for sliding off the side of the bed. The DON stated Resident 1 was totally dependent and needed assistance from two persons for repositioning to prevent him from sliding off the bed due to his inability to steady himself. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CG0M11 Facility ID: CA060000147 If continuation sheet 13 of 13