Other·April 4, 2019

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 Entity Reported Incident (ERI) No: CA00625217. 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 28951, HFEN. THE DEPARTMENT SUBSTANTIATED THE ERI AND FINDINGS WERE CITED AT F689 FOR RESIDENT 1. GLOSSARY OF ABBREVIATIONS & DEFINITATIONS: DON - Director of Nursing LVN - Licensed Vocational Nurse mA - milliampere(s) ng - milligrams MDS - Minimum Data Set (a standardized assessment tool) NMES - Neuromuscular electrical stimulation or Electrical stimulation/E-stim (a device that transmits an electrical impulse to the skin for a selected muscle groups and used as a treatment modality; it helps to increase muscle strength, blood circulation, and lessen muscle spasms) P&P - policy and procedure PT - Physical Therapy/Therapist PTA - Physical Therapy Assistant

F689 SS=G Free of Accident Hazards/Supervision/Devices F689 CFR(s): 483.25(d)(1)(2) §483.25(d) Accidents. 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: XD6X11 Facility ID: CA060001154 If continuation sheet 1 of 10 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: _______________ 555515 (X3) DATE SURVEY COMPLETED 03/05/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PARK VISTA AT MORNINGSIDE 2525 Brea Blvd Fullerton, CA 92835 (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 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 observation, interview, medical record review, and facility P&P review, the facility failed to provide adequate supervision for one of two sampled residents (Resident 1) who received the electrical stimulation treatments. * Resident 1 had an electrical stimulation (estim) machine applied to him and set at "60 microamperes" when the usual setting was "30 microamperes." Then, Resident 1 was left alone while the e-stim treatment was ongoing and was not instructed on how to stop the stimulation when he experienced the intense pain to his left lower leg where the e-stim pad was placed. As as result, Resident 1 sustained burns to his left lower leg which developed into open wounds into the muscle, requiring prolonged wound care due to wound worsening, debridement procedures (removal of damaged tissues from a wound), and weekly visits by a surgical wound specialist. Findings: Review of the facility's P&P titled Modalities released date of 9/23/16, showed the electrical stimulation is one of the facility's rehabilitation therapy services. The P&P showed the safety of the resident is the responsibility of the clinician at all times during the course of the treatment. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: XD6X11 Facility ID: CA060001154 If continuation sheet 2 of 10 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: _______________ 555515 (X3) DATE SURVEY COMPLETED 03/05/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PARK VISTA AT MORNINGSIDE 2525 Brea Blvd Fullerton, CA 92835 (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 record review for Resident 1 was initiated on 2/22/19. Resident 1 was admitted to the facility on 12/20/18, with diagnoses including muscle weakness. Review of Resident 1's MDS dated 12/27/18, showed the resident had moderate cognitive impairment and required extensive assistance of two persons for bed mobility and transfers. Resident 1 was assessed to be able to understand others and make himself understood. Review of Resident 1's Order Recap Report dated 12/20/18 to 1/30/19, showed a physician's order dated 1/14/19, for skilled PT services every day, six times a week for four weeks with exercises and neuromuscular reeducation, wheelchair mobility training, gait training, and electrical stimulation for strengthening. Review of Resident 1's physician's orders showed the following orders dated 2/29/18, for Tramadol HCL (a controlled substance used to control moderate to severe pain) tablet 50 mg one tablet by mouth every 8 hours PRN for severe pain; dated 12/29/18, for Ultracet tablet 37.5-325 mg (Tramadol-Acetaminophen) (a controlled substance used to control moderate to severe pain) one tablet by mouth every 8 hours for pain management; and dated 12/30/18, Tylenol tablet 325 mg (Acetaminophen) two tablets by mouth every 8 hours PRN for mild pain. Review of Resident 1's PT - Therapist Progress and Plan of Care dated 1/14/19, showed Resident 1 would receive neuromuscular reeducation and electrical stimulation to increase lower extremity functional strength and flexibility. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: XD6X11 Facility ID: CA060001154 If continuation sheet 3 of 10 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: _______________ 555515 (X3) DATE SURVEY COMPLETED 03/05/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PARK VISTA AT MORNINGSIDE 2525 Brea Blvd Fullerton, CA 92835 (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 PT Daily Treatment Note dated 1/22/19, showed PTA 1 provided NMES treatment to the left inner thigh muscle and tibialis anterior (muscle on front of lower leg) of Resident 1 for muscle re-education and strengthening using bipolar electrode placement at 30 mA for 20 minutes. Resident 1 was positioned in a supine position, instructed on the purpose of NMES, and performed the heel slide during the current cycle. Review of the PT Daily Daily Treatment Note dated 1/23/19, showed the electrical stimulation treatment was held due to Resident 1's impaired skin integrity to his left anterior tibia proximal to the left lateral knee joint about 2 inches down. PTA 2 performed the skin assessment to Resident 1 prior to the therapy. The documentation showed Resident 1's skin was red with dark patches. Documentation showed the Director of Rehabilitation, DON, and treatment nurse were all notified about Resident 1's e-stim incident and care of the resident's burn which was the treatment nurse's responsibility. Review of Resident 1's Medication Administration Record (MAR) showed from 1/1 to 2/21/19, Resident 1 received Ultracet 37.5325 mg every 8 hours for pain management. Resident 1's MAR for January and February 2019 also showed Resident 1 received 24 PRN doses of Tramadol. Review of Resident 1's wound care physician's progress notes dated 2/13/19, showed Resident 1 had a traumatic wound to his left lateral lower leg, measuring 3.5 cm (length) by 4.5 cm (width) and the depth was unable to be determined. The wound had multiple punctate wounds (a wound with multiple holes in it) FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: XD6X11 Facility ID: CA060001154 If continuation sheet 4 of 10 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: _______________ 555515 (X3) DATE SURVEY COMPLETED 03/05/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PARK VISTA AT MORNINGSIDE 2525 Brea Blvd Fullerton, CA 92835 (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 separated by skin bridges. The progress notes showed the wound was caused by a electrical stimulation burn, which was the device used by the PT to stimulate the muscles. The progress notes showed the wound was down to the muscle level and required to be surgically debrided. On 2/22/19 at 0810 hours, an interview and concurrent medical record review for Resident 1 was conducted with LVN 1. LVN 1 stated Resident 1 was seen weekly by a wound care specialist for his left lower leg wound. LVN 1 stated a change of condition report was completed on 1/23/19, due to five dry brown spots noted on Resident 1's left lower leg where the e-stim pad was placed. LVN 1 stated on 1/30/19, four of the spots opened up and a wound care specialist surgically debrided the areas and started routine wound care. On 2/22/19 at 0900 hours, an interview with Resident 1 and concurrent wound treatment observation was conducted with LVN 1. Resident 1 was observed with four open wound sites, each approximately the size of a pencil eraser and in a pattern of a semi-circle on the resident's left lower leg. Resident 1 stated he had the e-stim therapy every day which contracted his muscles on his left shoulder and left lower leg. Resident 1 stated he usually received this treatment in the facility's rehab gym, but on 1/22/19, he sustained the burn and developed these wounds when he received the e-stim treatment in his room. Resident 1 stated he was not given the control button to stop the e-stim machine nor was he informed there was a "pause" button on the machine itself. Resident 1 stated the therapist who applied the e-stim machine to his skin left his room. Resident 1 stated he began to notice pain in his leg unlike any of his previous treatments. Resident 1 stated his family member who was FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: XD6X11 Facility ID: CA060001154 If continuation sheet 5 of 10 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: _______________ 555515 (X3) DATE SURVEY COMPLETED 03/05/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PARK VISTA AT MORNINGSIDE 2525 Brea Blvd Fullerton, CA 92835 (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 visiting at the time left his room to find someone who could turn the e-stim machine off. On 2/22/19 at 0930 hours, an interview was conducted with the Director of Rehabilitation. The Director of Rehabilitation stated the PTs and PTAs had received education on the use of e-stim during their school and hands-on experience during their clinical rotations while in school. The Director of Rehabilitation stated the facility did not provide training on how to use the e-stim machine unless the staff asked for. The Director of Rehabilitation stated once an e-stim machine was connected to a resident and turned on, the PTA was to stay with the resident while instructing them in active muscle contraction. The Director of Rehabilitation went on to say if the staff needed to leave the resident, they would provide the resident with a safety measure and show the resident how to stop the machine in the event they were in pain. The Director of Rehabilitation stated pain was not an expected response to the e-stim treatment, and it would be stopped right away. The Director recalled on 1/23/19, she was called into Resident 1's room by another PTA and had observed four or five small blackish reddish marks in a semi-circle on Resident 1's left lateral lower leg. The Director of Rehabilitation stated she called PT 1 who was Resident 1's primary PT. She stated PT 1 told her Resident 1 usually tolerated the e-stim treatment very well. The Director of Rehabilitation was asked how Resident 1 had sustained the marks on his left leg. The Director of Rehabilitation stated on 1/22/19, PTA 1 applied the e-stim machine to Resident 1 left lower leg and left the resident's room. Resident 1 complained of high intensity pain and the resident's family member came to look for PTA 1 but was unable to find PTA 1. PT 1 went to Resident 1 and lowered the intensity, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: XD6X11 Facility ID: CA060001154 If continuation sheet 6 of 10 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: _______________ 555515 (X3) DATE SURVEY COMPLETED 03/05/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PARK VISTA AT MORNINGSIDE 2525 Brea Blvd Fullerton, CA 92835 (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 gave Resident 1 the safety switch, and instructed the resident on how to use it. When PTA 1 came back to the resident's room and stated he had gone to use the restroom and did not ask anyone to watch Resident 1 while he was gone. On 2/22/19 at 1020 hours, an interview was conducted with the Medical Director. The Medical Director stated the facility had investigated Resident 1's incident involving the e-stim machine and stated it was an event that should have never happened and it had never happened before. The Medical Director confirmed Resident 1 had been left alone while receiving the e-stim treatment without a means to stop or shut off the machine. On 2/22/19 at 1025 hours, an observation of the electrical stimulation machine was conducted with the Director of Rehabilitation. There was a long cord attached to the machine which had a red push button on the end of the cord. The Director of Rehabilitation stated the red push button was a safety button given to the resident receiving the treatment so they could stop the machine if needed. The Director of Rehabilitation also pointed out a button on the machine which showed to "stop" and another button which showed to "pause." The Director of Rehabilitation stated PTA 1 had an upset stomach, left Resident 1 alone, and was in the bathroom "a little longer." On 2/22/19 at 1415 hours, an interview was conducted with PT 1. PT 1 stated when the PT service was ordered for a resident, she was the therapist one who determined the resident's treatment plan regarding the use of NMES/estim. PT 1 stated the e-stim machine was automatically set for 15 to 20 minutes and left at 20 minutes unless the resident would not tolerate that long. PT 1 stated the resident FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: XD6X11 Facility ID: CA060001154 If continuation sheet 7 of 10 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: _______________ 555515 (X3) DATE SURVEY COMPLETED 03/05/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PARK VISTA AT MORNINGSIDE 2525 Brea Blvd Fullerton, CA 92835 (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 would not necessarily feel the electrical stimulation, but the therapist was to palpate manually for muscle contraction when the estim machine was on. When asked about Resident 1's incident on 1/22/19, PT 1 stated Resident 1's family member came to the gym looking for PTA 1, told PT 1 her dad needed help, and the resident felt uncomfortable with the e-stim machine. PT 1 stated when she ran to Resident 1's room and paused his e-stim machine. PT 1 stated the e-stim machine was set on "60 microamperes," which was a pretty high setting. PT 1 stated the usual setting was "30 microamperes." PT 1 stated she lowered the setting to "30 microamperes" on his quadriceps and "16 microamperes" on his tibialis anterior (lower leg). PT 1 stated Resident 1 then felt comfortable, and he finished his treatment at the lower setting. PT 1 stated she gave Resident 1 the stop button and told him about the pause button on the machine. PT 1 stated the residents were never to be left alone with the e-stim machine on as they need one-to-one supervision while doing their exercises. PT 1 stated she was not sure but did not think Resident 1 had been educated on the stop and pause buttons of the e-stim machine prior to her instructing him. PT 1 stated PTA 1 told PT 1 he had gone to the bathroom when he left Resident 1 alone. On 2/25/19 at 1410 hours, a telephone interview was conducted with PTA 1. PTA 1 stated he had worked with Resident 1 since Resident 1 was admitted to the facility. PTA 1 stated Resident 1 had a stroke and had limited sensation to his left leg. PTA 1 explained on 1/22/19, he had placed the e-stim electrode pads on Resident 1's left thigh and lower leg and then turned up the e-stim setting to Resident 1's tolerance, although this resident had no feeling on his left side. PTA 1 stated if the intensity was too high, he would have FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: XD6X11 Facility ID: CA060001154 If continuation sheet 8 of 10 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: _______________ 555515 (X3) DATE SURVEY COMPLETED 03/05/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PARK VISTA AT MORNINGSIDE 2525 Brea Blvd Fullerton, CA 92835 (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 lowered the intensity, but Resident 1 did not feel the e-stim at all. When asked if the staff was to remain with a resident while they were having the e-stim treatment ongoing, PTA 1 stated Resident 1's family member was visiting the resident that day. PTA 1 stated he left Resident 1's room because he needed to go to the bathroom and was gone for "ten minutes, five to ten minutes." PTA 1 stated he did not remember instructing Resident 1 on how to turn off the e-stim machine, and the resident was immobile and would not have been able to push the pause button on the machine. PTA 1 stated Resident 1's family member was there and could have turned off the e-stim machine. On 3/5/19 at 0910 hours, a telephone interview was conducted with Resident 1's FM 1. FM 1 stated she was visiting Resident 1 for a number of weeks and had been present for approximately 10 or 11 other e-stim treatments prior to the burn incident on 1/22/19, caused by the e-still equipment. FM 1 stated on 1/22/19, Resident 1 was complaining of nausea, dizziness, and not feeling well, so the e-stim session was done while Resident 1 was lying in his bed instead of going to the rehab gym. FM 1 stated PTA 1 set up the e-stim equipment on Resident 1, then PTA 1 sat down in a chair for a few minutes, and worked on his tablet. PTA 1 then got up and stated the electrical stimulation would run for about 15 more minutes and he would be back; PTA 1 then left the room. FM 1 stated after approximately six or seven minutes, Resident 1 told FM 1 the estim really hurt him a lot, so FM 1 left the room and went to look for PT 1. FM 1 stated Resident 1 was grimacing, moving his leg some, and looked like the pain was "close to a 10." FM 1 stated instead of finding PTA 1, she found PT 1, and told her, "Hey, it's really hurting him." PT 1 then came to the room, looked at the e-stim, and stated she wondered FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: XD6X11 Facility ID: CA060001154 If continuation sheet 9 of 10 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: _______________ 555515 (X3) DATE SURVEY COMPLETED 03/05/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PARK VISTA AT MORNINGSIDE 2525 Brea Blvd Fullerton, CA 92835 (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 why it was set so high. PT 1, then lowered the intensity, and Resident 1 finished the e-stim session. FM 1 stated when PTA 1 removed the electrodes, the lights were off in the room and PTA 1 did not look at Resident 1's leg. FM 1 stated no one had explained to her or Resident 1 how to turn off the e-stim machine if needed until PT 1 came to the room and turned the estim intensity down on 1/22/19. On 3/5/19 at 1005 hours, an interview was conducted with the Director of Rehabilitation. The Director of Rehabilitation stated for neuromuscular re-education, they adjusted the intensity of e-stim unit and felt for muscle contraction or when the resident felt the e-stim. The Director of Rehabilitation stated one-to-one supervision during an e-stim session was the rehabilitation unit's policy. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: XD6X11 Facility ID: CA060001154 If continuation sheet 10 of 10