Health inspection·March 26, 2025

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm Based on interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services to ensure one of three sampled residents (Resident 1) attained and maintained the highest practicable physical well-being. Residents Affected - Few * The facility failed to ensure the proper documentation was completed as per the facility's protocol for Resident 1 who had a change in condition. This failure had the potential for Resident 1 to not be provided with the appropriate care and monitoring. Findings: Review of the facility's P&P titled Change of Condition, under Section E, showed the documentation of the change in condition shall be performed by the Licensed Nurse accordingly: 1. Documenting for at least 72 hours, or longer if condition change warrants 2. Using appropriate form for daily charting 3. Documenting vital signs each shift 4. Care plan evident 5. Reassessing MDS (if change is significant) 6. IDT conference if indicated 7. Reassess resident condition as needed 8. COC/SBAR will be completed as indicated Medical Record review for Resident 1 was initiated on 3/25/25. Resident 1 was admitted to facility on 11/26/24. Review of Resident 1's physician's telephone orders dated 3/20/25, showed for the following orders: Levofloxacin (antibiotic)tablet 500 mg, one tablet by mouth one time a day for fever and cough for five days, and for the first dose to be taken from E-kit. - Chest x-ray one time only on 3/20/25 - STAT CBC and BMP testson 3/20/25 - STAT Flu rapid test Review of Resident 1's Medication Administration Report for March 2025 showed Levofloxacin was (continued on next page) 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. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 4 Event ID: 555035 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555035 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/26/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Park Anaheim Healthcare Center 3435 W Ball Road Anaheim, CA 92804 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)