Health inspection·February 15, 2024

F 0842 Review of Resident 1's MDS dated [DATE], showed Resident 1 was cognitively intact. Level of Harm - Minimal harm or potential for actual harm a. Review of Resident 1's MAR for December 2023 showed the following medications were scheduled to be administered on 12/24/23: Residents Affected - Few * At 0800 hours: - metoprolol tartrate (use to lower blood pressure) oral tablet 100 mg one tablet by mouth two times a day for hypertension, and - pro-stat sugar free (use to increase protein needs) oral liquid (Amino Acids-Protein Hydrolysate) 30 ml by mouth two times a day for supplement. * At 0900 hours: - ascorbic acid (vitamin supplement) tablet 500 mg one tablet by mouth one time a day, - aspirin EC (enteric coated) tablet delayed release 81 mg one tablet by mouth one time a day for CVA (Cerebrovascular Accident) prophylaxis, - buproprion HCl ER (Extended Release) (antidepressant medication) 150 mg by mouth one time a day, - multivitamin oral tablet by mouth one time a day for supplement, - oxybutin chloride ER (use to treat symptoms of overactive bladder) oral tablet 5 mg give three tablets by mouth one time a day for neurogenic bladder (lack of bladder control due to a brain, spinal cord, or nerve problem), and - vitamin D3 (vitamin supplement) oral tablet 50 mcg one tablet by mouth one time a day. However, further review of Resident 1's MAR for December 2023 showed the spaces for licensed nurses' initials were left blank for the above medications on 12/24/23. On 2/14/24 at 1054 hours, a telephone interview was conducted with LVN 3. LVN 3 stated she worked on 12/24/23, and was Resident 1's assigned nurse for the 3-11 shift. LVN 3 further stated the scheduled 0900 hours medications on 12/24/23, were given to Resident 1 before leaving the facility. LVN 3 stated Resident 1 always asked for his medications before leaving the facility. When asked about how the LVN documented on the MAR when the medications were given, LVN 3 stated there was an option in the electronic MAR to click for additional documentation. LVN 3 verified Resident 1's MAR for December 2023 showed the documentation for 12/24/23 at 0800 and 0900 hours, for the above medications scheduled were missed. LVN 3 further stated if the MAR did not have documentation, the nurses should have documented in the resident's progress notes as late entry. On 2/14/23 at 1115 hours, an interview and concurrent medical record review was conducted with the DON. The DON stated the MAR should be signed by the nurses after giving the medications. The DON stated if the MAR was not signed, the nurse should document in the resident's progress notes. The DON verified the 0800 and 0900 hours medications were not signed by the nurse and there was no documentation in the resident's progress notes. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555688 If continuation sheet Page 2 of 4 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 555688 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Anaheim Point 3415 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)

F 0842 Level of Harm - Minimal harm or potential for actual harm b. Review of Resident 1's Order Summary Report showed a physician's order dated 9/19/23, to may go out on pass with supervision and medications. Review of Resident 1's plan of care showed a care plan problem dated 12/13/23, addressing the resident's non-compliant/goes out on pass for more than four hours. Residents Affected - Few Review of Resident 1's Nursing Progress Notes dated 12/29/23, showed Resident 1 returned from an acute care hospital with a physician's order for Macrobid (antibiotic) oral capsule 100 mg two times a day for UTI for 10 days. Review of Resident 1's MAR for December 2023 showed the Macrobid medication was not administered to Resident 1 on 12/29/23 at 1700 hours. Chart code 1 was documented on the MAR for the Macrobid medication, which meant the resident was absent from the facility without medications. Further review of the medical record showed no documented evidence when the resident went out on pass and returned to the facility on [DATE]. On 1/31/24 at 1527 hours, an interview and concurrent medical record review was conducted with RN 1. When asked if Macrobid was given on 12/29/23 at 1700 hours, RN 1 stated Macrobid was not given to Resident 1 because he was maybe out on pass. On 2/1/24 at 1125 hours, a follow-up interview was conducted with RN 1. RN 1 was asked for the facility's process for the residents who were out on pass. RN 1 stated the residents signed the logbook for out on pass, then the nurse should initial in the logbook when the resident left and returned. RN 1 stated if a resident missed the medication while out on pass, the nurse should administer the medication upon returning to the facility, depending on what the medication was for. Furthermore, RN 1 stated it should be documented in the resident's progress notes for the late administration of the medication. On 2/1/24 at 1140 hours, an interview and concurrent medical record review was conducted with the DON. The DON verified the above findings. The DON verified there was no documentation if Resident 1 was out on pass on 12/29/23 at 1700 hours. The DON further stated the December 2023 Out on Pass logbook could not be found. On 2/14/24 at 1327 hours, a follow-up interview was conducted with the DON. The DON stated the nurse from a registry company was working the 3-11 shift on 12/29/23. The DON was asked for the facility's process for the residents who were out on pass. The DON stated the resident should sign the out of pass logbook, then nurse should sign when the resident left the facility and when the resident came back from the outing. Furthermore, the DON stated the nurse should assess the resident coming back from the outing and if there were any medications that were missed, the medications should be given, if it could still be given. c. Review of Resident 1's plan of care showed a care plan problem dated 9/19/23, addressing Resident 1's sacrococcyx MASD and another care plan problem dated 12/20/23, addressing Resident 1's MASD to the right buttock. Review of Resident 1's TAR for December 2023 showed the following wound treatments: - dated 11/30/23, to cleanse MASD at the left buttock with NS (normal saline), pat dry, apply zinc (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555688 If continuation sheet Page 3 of 4 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 555688 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Anaheim Point 3415 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)

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few oxide, then cover with a dry dressing every day shift for two weeks, starting on 11/30/23, and ending on 12/13/23, and - dated 12/19/23, to cleanse sacrococcyx extending to the right and left buttocks MASD with NS, pat dry, then apply triad ointment (a topical corticosteroid), and cover with a foam dressing every day shift for 14 Days. However, review of Resident 1's Weekly Skin/Wound Assessment - V2 for December 2023 showed the skin assessments were completed only on 12/16 and 12/19/23, instead of weekly as per the facility's P&P. On 1/31/24 at 1527 hours, an interview and concurrent medical record review was conducted with RN 1. RN 1 confirmed the weekly skin assessments were not done weekly for Resident 1 for December 2023. On 1/31/24 at 1622 hours, an interview and concurrent medical record review was conducted with the DON. The DON stated the treatment nurse was to complete the weekly skin assessments for the residents with skin problems and verified Resident 1's wound assessments were not done weekly for December 2023. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555688 If continuation sheet Page 4 of 4