Anaheim Point
ANAHEIM POINT in ANAHEIM, CA — inspection on March 6, 2025.
Found 21 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
Nutraceuticals Rub On Relief fast acting all-natural topical cream (pain reliever), and Real Time Pain
acknowledged and verified the presence of two containers of the pain relieving creams at Resident 38's nightstand. LVN 4 told Resident 38 that he would speak to the nursing supervisor to check on her and discuss with the physician. LVN 4 further stated he would remove the creams for now because the resident could not keep the creams at the bedside.
Medical record review for Resident 38 was initiated on 3/4/25. Resident 38 was admitted to the facility on [DATE].
On 3/4/25 at 1244 hours, an interview was conducted with RN 1. RN 1 acknowledged and verified the findings of the two containers of the pain relieving creams at Resident 38's night stand. RN 1 stated, I was notified by LVN 4 and saw the creams.
Further review of Resident 38's medical record did not show the assessment, physician's order, care plan, and documentation in the MAR for Resident 38's self-administration of the pain relieving medications.
On 3/6/35 at 1415 hours, an interview was conducted with the DON.
The DON was made aware and acknowledged the above findings.
555688 03/06/2025
Anaheim Point 3415 W Ball Road Anaheim, CA 92804
Review of Resident 20's MDS dated [DATE], showed Resident 20 had a BIMS score of 14 (cognitively intact), and always incontinent with the bladder and bowel elimination.
The MDS further showed Resident 20 was 68 inches in height and weighed 405 lbs.
On 3/4/25 at 1130 hours, an observation and current interview was conducted with CNA 3 in Resident 20's room. CNA 3 stated he had been taking care of Resident 20 for more than a year. CNA 3 further stated Resident 20 had been wearing the size of 6x diaper and recently had been provided with the size of 4x or 5x diapers. Resident 20 showed her diaper, and CNA 3 verified Resident 20's diaper was small and did not cover the whole area.
On 3/4/25 at 1350 hours, an interview was conducted with the Central Supply In-charge.
The Central Supply In-charge stated the facility's diaper supplier did not carry the Prevail diaper brand a couple of weeks ago and was replaced with a comparable diaper size.
On 3/6/25 at 1415 hours, an interview was conducted with the DON.
The DON was made aware and acknowledged the above findings.
The DON further stated the Prevail diapers were not available from the facility's vendor, and the facility would purchase the Prevail diapers to accommodate Resident 20's preference.
555688 03/06/2025
Anaheim Point 3415 W Ball Road Anaheim, CA 92804
Review of Resident 142's H&P examination dated 12/3/24, showed Resident 142 had the capacity to understand and make decisions.
Review of Resident 142's Order Summary Report showed a physician's order dated 12/30/24, to discharge to home with hospice services, may discharge home on 1/3/25, as per the resident and POA's request.
Review of Resident 142's Discharge MDS dated [DATE], under section A of the MDS for the discharge status, showed Resident 142 was coded for the Short-Term General Hospital instead of hospice (to home/non-institutional).
On 3/6/25 at 1029 hours, an interview and concurrent medical record review for Resident 142 was conducted with the MDS Coordinator.
The MDS Coordinator verified the above findings and stated the MDS Assistant coded the Discharge MDS status incorrectly.
On 3/6/25 at 1430 hours, an interview was conducted with the DON.
The DON was informed and acknowledged the above findings.
555688 03/06/2025
Anaheim Point 3415 W Ball Road Anaheim, CA 92804
Review of Resident 82's Care Plan titled At Risk for Falls/Injuries initiated on 5/17/23, showed Resident 82 was at risk for falls related to dementia, impaired cognition, and poor safety awareness.
The care plan further showed Resident 82 had a long history of ongoing falls.
The interventions included to provide the bilateral floor mats.
On 3/3/25 at 0900 hours, an observation was conducted of Resident 82. Resident 82 was observed lying in bed. Resident 82's bed was observed with a floor mat in place on one side of Resident 82's bed.
The opposite side of Resident 82's bed was observed without a floor mat in place.
On 3/3/25 at 0937 hours, an observation was conducted of Resident 82. Resident 82 was observed lying in bed. Resident 82's bed was observed with a floor mat in place on one side of Resident 82's bed.
The opposite side of Resident 82's bed was observed without a floor mat in place.
On 3/3/25 at 1640 hours, an observation and concurrent interview was conducted with LVN 8. Resident 82 was observed lying in bed. Resident 82's bed was observed with a floor mat in place on one side of Resident 82's bed.
The opposite side of Resident 82's bed was observed without a floor mat in place. LVN 8 verified the findings and stated he would implement the second floor mat in accordance with Resident 82's At Risk for Falls care plan.
555688 03/06/2025
Anaheim Point 3415 W Ball Road Anaheim, CA 92804
Review of Resident 394's MDS dated [DATE], showed Resident 394 had severe cognitive impairment.
Review of Resident 394's POLST (in the hospice binder), showed it was blank.
Review of Resident 394's Order Summary Report failed to show a physician's order for Resident 394's code status.
Review of Resident 394's plan of care did not show Resident 394's code status was addressed.
On [DATE] at 1210 hours, an interview and concurrent medical record review for Resident 394 was conducted with LVN 1.
When asked what Resident 394's code status was, LVN 1 reviewed Resident 394's electronic health record and did not see any copy of Resident 394's POLST, the code status was not reflected in the physician's orders, and not addressed in the care plan. LVN 1 also reviewed Resident 394's hospice binder and verified the POLST form was blank. LVN 1 further reviewed Resident 394's physical chart and did not see any copy of Resident 394's POLST, but found a copy of Resident 394's Pre-admission Report.
Review of Resident 394's Pre-admission Report dated 2/1 showed Resident 394 had a full code status. LVN 1 stated Resident 394 was on hospice services, and one would assume that the family had come to terms and just to provide the comfort care, however, LVN 1 further stated, Resident 394 would be considered a full code because there was no POLST spelled out, so then I would provide the CPR.
Further review of Resident 394's medical record showed the POLST form was scanned and uploaded in the resident's electronic health record under the miscellenous documents.
Review of the POLST dated [DATE], showed Resident 394 code status was DNR. LVN 1 verified the above findings.
On [DATE] at 1250 hours, an interview and concurrent medical record review for Resident 394 was conducted with RN 1. RN 1 verified the POLST form in Resident 394's hospice binder was blank. RN 1 also verified the POLST form dated [DATE], scanned and uploaded in Resident 394's electronic health record, showed Resident 394's code status was DNR. RN 1 further verified Resident 394's DNR code status was not reflected in Resident 394's physician's orders and not addressed in his plan of care.
555688 03/06/2025
Anaheim Point 3415 W Ball Road Anaheim, CA 92804
Review of Resident 82's care plan titled At Risk for Falls/Injuries initiated 5/17/23, showed Resident 82 was at risk for falls related to dementia, impaired cognition, and poor safety awareness.
The care plan showed Resident 82 had a long history of ongoing falls.
Review of Resident 82's Order Summary Report showed a physician's order dated 7/27/23, for bilateral floor mats for safety.
On 3/3/25 at 0900 hours, an observation was conducted of Resident 82. Resident 82 was observed lying in bed. Resident 82's bed was observed with a floor mat in place on one side of Resident 82's bed.
The opposite side of Resident 82's bed was observed without a floor mat in place.
On 3/3/25 at 0937 hours, an observation was conducted of Resident 82. Resident 82 was observed lying in bed. Resident 82's bed was observed with a floor mat in place on one side of Resident 82's bed.
The opposite side of Resident 82's bed was observed without a floor mat in place.
On 3/3/25 at 1640 hours, an observation and concurrent interview was conducted with LVN 8. Resident 82 was observed lying in bed. Resident 82's bed was observed with a floor mat in place on one side of Resident 82's bed.
The opposite side of Resident 82's bed was observed without a floor mat in place. LVN 8 verified the findings and stated he would implement the second floor mat in accordance with the physician's order.
Cross reference to F-F656.
555688 03/06/2025
Anaheim Point 3415 W Ball Road Anaheim, CA 92804
referring to the bruit and thrill noted from the resident's access site. LVN 2 stated she did not know
the licensed staff should have notified the physician because it was an emergency case if the AV
On 3/6/25 at 1512 hours, an interview was conducted with the ADON.
The ADON stated the negative sign - meant no thrill and bruit, the zero 0 and X could be interpreted as no thrill and bruit as well.
The ADON stated the NA was meant for not applicable.
The ADON stated the dialysis access site should be assessed properly to make sure it was functioning well as what was expected and if there was no thrill and bruit, the physician should have been notified as soon as possible.
The ADON was notified and acknowledged the above findings.
555688 03/06/2025
Anaheim Point 3415 W Ball Road Anaheim, CA 92804
Review of the facility's P&P titled Bed Rails dated 6/12/24, showed the licensed nurse will complete the Bed Rail Evaluation prior to the use and/or installation of any bed rail, upon admission, readmission, change in bed or mattress, and a change in mobility status.
On 3/4/25 at 1405 hours, Resident 394 was observed awake, lying in bed with the bilateral upper side rails elevated.
Medical record review for Resident 394 was initiated on 3/3/25. Resident 394 was admitted to the facility on [DATE].
Review of Resident 394's Order Summary Report showed a physician's order dated 2/14/25, for a bilateral ½ side rails as enablers.
Review of Resident 394's Bed Rail assessment dated [DATE], showed the side rails were not indicated for Resident 394.
Review of Resident 394's plan of care showed a care plan problem dated 2/17/25, addressing the use of the grab bars.
Review of Resident 394's MDS dated [DATE], showed Resident 394 had severe cognitive impairment and dependent to the facility staff member for bed mobility.
On 3/5/25 at 1017 hours, an observation for Resident 394 and concurrent interview and medical record review was conducted with RN 1. Resident 394 was observed in bed with the bilateral upper side rails elevated. RN 1 verified the above findings. RN 1 stated Resident 394 was under the hospice services, and Resident 394's bed was brought into the facility with the bilateral side rails already installed. RN 1 verified Resident 394's Bed Rail Assessment showed the side rails were not indicated for Resident 394. RN 1 also verified the physician's order was for the bilateral side rails; however, a care plan problem was developed to address the use of the grab bars.
Cross reference to F-F909.
555688 03/06/2025
Anaheim Point 3415 W Ball Road Anaheim, CA 92804
Review of the facility's P&P titled Medication Administration revised 1/1/12, showed the licensed nurse will chart the drug, time administered and initial his/her name with each medication administration.
The time and dose of the drug administered to the patient will be record in the patient's individual medication record by the person who administers the drug.
Medical record review for Resident 34 was initiated on 3/4/25. Resident 34 was admitted to the facility on [DATE], and readmitted on [DATE].
Review of Resident 34's H&P examination dated 2/10/25, showed Resident 34 had the capacity to understand and make decisions.
Review of Resident 34's Order Summary Report showed a physician's order dated 2/10/25, to administer hydrocodone-acetaminophen (controlled pain medication) 10-325 mg one tablet by mouth every six hours as needed for severe pain (pain level of 7-10, using the 0-10 pain scale; zero meaning no pain and 10 meaning worst pain).
Review of Resident 34's Individual Narcotic Record for the hydrocodone-acetaminophen 10-325 mg tablet showed one hydrocodone-acetaminophen 10-325 mg oral tablet was dispensed and signed out on 2/25/25 at 1808 hours, and 3/1/25 at 2000 hours.
Review of Resident 34's MARs for February and March 2025, failed to show the documentation of the administration for the hydrocodone-acetaminophen 10-325 mg oral tablet dispensed on 2/25/25 at 1808 hours, and 3/1/25 at 2000 hours.
On 3/4/25 at 1403 hours, an interview and concurrent medical record review was conducted with LVN
- LVN 6 verified the above findings.
On 3/4/25 at 1410 hours, an interview and concurrent medical record review was conducted with the DON.
The DON was informed and verified the above findings.
The DON stated the licensed nurse must document on the MAR when the medication was administered to the resident.
555688 03/06/2025
Anaheim Point 3415 W Ball Road Anaheim, CA 92804
Review of Resident 104's Physician Progress notes dated [DATE], showed Resident 104 was able to understand and make treatment decisions.
Review of Resident 104's MDS dated [DATE], showed a BIMS score of 12 (moderately impaired cognition).
Review of Resident 104's Order Summary Report did not show a physician's order for the eyedrops for dry eyes.
On [DATE] at 1415 hours, an interview was conducted with the DON.
The DON was made aware and acknowledged the above findings.
555688 03/06/2025
Anaheim Point 3415 W Ball Road Anaheim, CA 92804
Review of the facility's Diet Count dated 3/6/25, showed 123 of 140 residents residing in the facility received food prepared in the kitchen.
On 3/3/25 at 0907 hours, an observation and concurrent interview was conducted with Resident 88. Resident 88 was sitting up in bed watching TV. Resident 88 stated she was ordering more salads for her meals because she was trying to lose weight to qualify for her knee surgery. Resident 88 stated she was not receiving enough protein on her salads and did not feel like with enough food.
Medical record review for Resident 88 was initiated on 3/3/25. Resident 88 was admitted to the facility on [DATE].
Review of Resident 88's Order Summary Report showed a diet order dated 11/15/25, for NAS (no added salt) diet, regular texture, regular/thin consistency.
Review of Resident 88's Care Plan Report dated 11/18/25, showed the resident was admitted with NAS diet, regular texture, regular/thin consistency with the goal of maintaining weight status.
The interventions included to give diet as ordered and accommodate food reasonably.
On 3/3/25 at 1233 hours, a follow-up observation and concurrent interview was conducted with Resident 88. Resident 88 was sitting up in bed with her lunch tray.
The lunch tray included a plate of lettuce with shredded carrots and purple cabbage.
There were also a side of ranch dressing, a cup of pears, and a four oz (ounce) cup of orange juice. Resident 88 stated she was disappointed that she did not receive any protein with her salad.
Review of Resident 88's lunch meal card dated 3/3/25, showed the resident's diet as NAS, lactose free, consistency regular; beverages: four oz juice; allergies: lactose, fruit, peanuts; dislikes: tomato products, watermelon; and likes: chef salad with ranch only.
Review of the facility's recipe for chef salad showed the ingredients included lettuce, turkey, lean ham, cheese, tomatoes, hard cooked eggs, salad dressing, and optional beets and shredded carrots.
On 3/3/25 at 1524 hours, an interview was conducted with the Dietary Supervisor and Administrator.
The Dietary Supervisor reviewed the recipe card for the chef salad and verified it was incorrectly made for Resident 88.
555688 03/06/2025
Anaheim Point 3415 W Ball Road Anaheim, CA 92804
Review of the facility's P&P titled Restorative Dining Program revised January 2012 showed the residents will be provided a tray with their respected diet.
The special adaptive equipment may be recommended by the OT and will be provided by the facility.
The equipment may include, but may not be limited to built-up handled utensils, weight utensils, large handled utensils, and angled utensils.
The facility staff should consistently place the adaptive equipment in the same position on the tray and encourage use of the adaptive equipment by the resident during the meal.
On 3/3/25 at 1315 hours, during the dining observation of the facility, Resident 8 was observed having lunch in the bed. Resident 8 was observed using a regular silver spoon and a light gray colored built-up fork. Resident 8's meal tab showed to have a built-up utensils and lip plate.
Medical record review for Resident 8 was initiated on 3/4/25. Resident 8 was readmitted to the facility on [DATE].
Review of Resident 8's H&P examination dated 2/21/24, showed Resident 8 had no capacity to make medical decisions.
Review of Resident 8's Care Plan revised 11/6/24, showed a care plan focus problem addressing Resident 8's nutritional problem.
The interventions included the use of the built-up utensils and lip plate.
Review of Resident 8's Order Summary Report showed a physician's order dated 1/22/25, for the built-up utensils and lip plate with all meals.
On 3/4/25 at 0815 hours, an observation and concurrent interview was conducted with Resident 8. Resident 8 was observed having breakfast in the bed. Resident 8 was observed using a regular silver spoon, fork, and knife. Resident 8 stated it was hard to eat and grab the spoon and fork. Resident 8 was observed with contracted left hand. Resident 8 further stated her left hand was weak. Resident 8's meal tab showed for devices, to use the built-up utensils and lip plate.
On 3/4/25 at 0824 hours, an interview and concurrent medical record review was conducted with LVN
- LVN 6 stated Resident 8 had a history of stroke and Resident 8's left hand was contracted. LVN 6
stated the built-up utensils would help Resident 8 to have a better grip and control of the utensils since Resident 8 had a limited hand strength. LVN 6 verified Resident 8 required the use of the built-up utensil as per the physician's order.
On 3/6/25 at 1615 hours, an interview was conducted with the DON.
The DON was notified and acknowledged the above findings.
555688 03/06/2025
Anaheim Point 3415 W Ball Road Anaheim, CA 92804
Review of the facility's Diet Count dated 3/6/25, showed 123 of 140 residents residing in the facility received food prepared in the kitchen.
Review of the facility's P&P titled Dietary Department - Infection Control for Dietary Employees revised on 11/9/16, showed personal are required to have clean hair covered with an effective hair restraint while in all kitchen and food storage areas, and beard/mustache covering when applicable.
On 3/3/25 at 0745 hours, during the initial tour of the kitchen, the kitchen staff was observed preparing breakfast for the residents.
The DSS was inside the kitchen and observed with a beard and mustache, however, the DSS was not wearing a hair restraint.
The DSS verified the findings and stated he should have donned a hair restraint in accordance with the facility's P&P.
Review of the facility's P&P titled Food Storage revised 11/1/14, showed any opened (dry storage) products should be placed in a storage containers with tight fitting lids.
The dry storage guidelines include monitoring dry storage areas routinely for pest activity.
On 3/5/25 at 0958 hours, an observation of the kitchen dry storage room was conducted. A canister containing the brown rice was observed without a lid, inside of the dry storage room.
On 3/5/25 at 1009 hours, an observation and concurrent interview was conducted with the Cook.
The [NAME] verified a canister containing the brown rice, in the dry storage room, did not have a lid in place.
The [NAME] stated the canister of the brown rice should have had a lid in place to ensure the rice remained clean.
On 3/5/25 at 1015 hours, an interview was conducted with the DSS.
The DSS stated the canister of the brown rice, located in the dry storage room, required a lid to be in place for infection control.
555688 03/06/2025
Anaheim Point 3415 W Ball Road Anaheim, CA 92804
According to the 2022 FDA Food Code, outside garbage receptacles must be constructed with tight-fitting lids or covers to prevent the scattering of the garbage or refuse by birds, the breeding of flies, or the entry of rodents.
On 3/3/25 at 1132 hours, an observation of the facility's garbage dumpsters was conducted.
Two of six dumpsters were observed with the lids open and garbage inside.
The dumpsters were observed with the lids propped open by garbage, preventing the lids from fully closing.
On 3/4/25 at 1601 hours, an interview was conducted with the Administrator.
The Administrator verified the findings (via a photograph taken of the findings).
The Administrator stated the garbage company was scheduled to pick up the garbage at the facility six times a week.
555688 03/06/2025
Anaheim Point 3415 W Ball Road Anaheim, CA 92804
Review of Resident 79's POLST, Section D (advance directive), dated 11/12/24, failed to show documentation as to whether Resident 79 had formulated an advance directive. LVN 2 verified the findings and stated the information specific to the advance directive would be added to Resident 79's POLST.
- Medical record review for Resident 84 was initiated on 3/3/25. Resident 84 was admitted to the
facility on [DATE].
On 3/6/25 at 1049 hours, an interview and concurrent medical record review was conducted with LVN
- Review of Resident 84's POLST, Section D (advance directive), dated 9/5/23, failed to show
- On 3/4/25 at 0953 hours, an interview and concurrent medical record review was conducted with
documentation as to whether Resident 84 had formulated an advance directive. LVN 2 verified the findings and stated the information specific to the advance directive would be added to Resident 84's POLST.
RN 1.
During the record review, medical records for two residents were found to be filed in Resident 86's medical record. RN 1 verified the records should not be filed in Resident 86's medical record. RN 1 removed the records of the other residents from Resident 86's medical record.
3/22/25.
The DON stated she would have to verify with Hospice 2 if the calendar was the actual or projected visits.
The DON verified there was a missing skilled nursing visit on the week of 2/16 to 2/22/25, and there was no documented evidence to show the certified hospice aide visited Resident 394 for February and March 2025.
555688 03/06/2025
Anaheim Point 3415 W Ball Road Anaheim, CA 92804
Review of facility's P&P titled Laundry Services revised dated 1/1/12, showed a clean and safe environment is always maintained.
On 3/6/25 at 1530 hours, a laundry room inspection was conducted with the Housekeeping Supervisor.
The following was observed in the laundry room: - the outside of Washing Machine 1's door had large amounts of brown stains and white mineral-like residue; - the pipes on the back of Washing Machine 1 had brown stain and hard white substance, mineral-like residue; and - the wall next to Washing Machine 1 showed signs of damage with cracks and gap between the wall and baseboard.
The Housekeeping Supervisor verified the above findings and stated she would try to scrape the yellow stains and white mineral-like residue.
The Housekeeping Supervisor further stated she would let the maintenance know to repair the damaged wall.
555688 03/06/2025
Anaheim Point 3415 W Ball Road Anaheim, CA 92804
Review of the facility's Infection Prevention and Control Surveillance Log for February 2025 showed Resident 54 had signs and symptoms of diarrhea with an onset date of 2/17/25.
The surveillance log showed Resident 54 was prescribed with Ampicillin and did not meet the McGeer's criteria.
Review of Resident 54's Infection Screening Evaluation dated 2/17/25, showed the resident had symptoms (new or marked increase) of diarrhea (within the last 24 hours) and the resident met the McGeer's Criteria for gastroenteritis.
Review of Resident 54's medical record showed a physician's order dated 2/22/25, for Ampicillin oral capsule 500 mg one capsule by mouth every six hours for exposure to possible contaminated milk products for seven days; and to start after blood culture collected.
Review of Resident 54's Late Entry Note dated 2/25/25 at 1523 hours, showed the NP was made aware regarding the resident not meeting the McGeer's criteria and per the NP, to continue the antibiotic as ordered. Resident 54's information documented in the facility's Infection Prevention and Control Surveillance Log and progress notes about not meeting the McGeer's criteria did not match the assessment on the Infection Screening Evaluation showing Resident 54 met the McGeer's criteria for gastroenteritis.
On 3/6/25 at 1445 hours, an interview and concurrent medical record review for Resident 54 was conducted with the DON.
The DON acknowledged and verified the above findings.
555688 03/06/2025
Anaheim Point 3415 W Ball Road Anaheim, CA 92804
Review of Resident 394's plan of care showed a care plan problem dated 2/17/25, to address the use of the grab bars.
Review of Resident 394's MDS dated [DATE], showed Resident 394 had severe cognitive impairment, and dependent to the facility staff member for bed mobility.
Further review of Resident 394's medical record failed to show documented evidence an entrapment assessment was completed prior to the installation of the bilateral upper side rails.
On 3/5/25 at 1017 hours, an observation for Resident 394 and concurrent interview and medical record review was conducted with RN 1. Resident 394 was observed in bed with the bilateral upper side rails elevated. RN 1 verified the above findings. RN 1 stated Resident 394 was under the hospice services, and Resident 394's bed was brought into the facility with the bilateral side rails already installed.
When asked about the entrapment assessment, RN 1 stated the maintenance department installed the side rails and measured the bed and side rails to assess for entrapment.
On 1/24/25 at 1225 hours, a concurrent interview and facility document review for Resident 394 was conducted with the Maintenance Director and the Maintenance Assistant.
The Maintenance Director stated the maintenance department was responsible for the monthly bed inspection of all the beds in the facility, where they checked the whole bed, bed functionality, frame, bed control and the side rails which could be halos, U-bars, and the half or quarter side rails.
The Maintenance Director stated after the nurses obtained a physician's order for the side rails, the DON or ADON would notify the maintenance department to install the side rails.
The Maintenance Assistant further stated if the maintenance department was not notified and he saw a resident bed had side rails, he would measure the bed and the entrapment zones, record in his notebook, and would document later in the log.
When asked about the entrapment assessment, the Maintenance Assistant stated he used a measuring tape to measure the entrapment zones on each bed.
When asked to show the documentation of the results of the bed inspection including the entrapment assessment, the Maintenance Assistant showed the Bed Side Rail Inspection Log and the Bed Entrapment Risk Checklist.
Review of the Bed Side Rails Inspection Log for February 2025 showed the information included the bed make, bed serial, location/ retighten, in good repair, if the mattress size was appropriate and the date of installation of the side rails.
The log did not show Resident 394's bed was inspected.
Review of the Bed Entrapment Risk Checklist for February 2025 which included the seven zones of entrapment, did not show Resident 394's bed was inspected.
The Maintenance Director and the Maintenance Assistant verified the above findings.
The Maintenance Director and the Maintenance Assistant stated they were not informed about Resident 394's bed with side rails.
On 3/6/25 at 1400 hours, an observation for Resident 394 and concurrent interview was conducted with the Maintenance Director. Resident 394 was lying in bed with the bilateral upper side rails.
The Maintenance Director verified the above findings.
555688 03/06/2025
Anaheim Point 3415 W Ball Road Anaheim, CA 92804
Review of Resident 4's Order Summary Report showed the following physician's orders:
- dated 1/30/24, Dialysis on Monday, Wednesday, and Friday at 1230 hours; and
- dated 2/8/24, to monitor the AV shunt in the right arm for bruit and thrill every shift.
Review of Resident 4's Care Plan revised 3/13/24, showed a care plan focus problem addressing Resident 4's potential for complications of ESRD/dialysis.
The interventions included to auscultate shunt site for bruit and palpate for thrill per protocol or every shift.
Document the presence or absence.
Notify the physician and dialysis center of absent thrill/bruit as soon as possible.
Review of Resident 4's MAR for December 2024, January, February, and March 2025 showed the licensed staff documented Resident 4's AV shunt was - (negative) for thrill and bruit on 12/1/24 and 1/18/25; 0 (zero) on 12/12/24; X on 12/13/24 and 1/29/25; and NA on 2/23 and 3/4/25.
Further review of Resident 4's medical record failed to show the physician was notified when the AV shunt was assessed without or negative for thrill and bruit.
555688
Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 555688 B.
Wing 03/06/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Anaheim Point 3415 W Ball Road Anaheim, CA 92804
Review of Resident 34's H&P examination dated 2/10/25, showed Resident 34 had the capacity to understand and make decisions.
Review of Resident 34's Order Summary Report showed a physician's order dated 2/10/25, to administer hydrocodone-acetaminophen (controlled pain medication) 10-325 mg one tablet by mouth every six hours as needed for severe pain (pain level of 7-10, using the 0-10 pain scale; zero meaning no pain and 10 meaning worst pain).
Review of Resident 34's Individual Narcotic Record for the hydrocodone-acetaminophen 10-325 mg tablet showed one hydrocodone-acetaminophen 10-325 mg oral tablet was dispensed and signed out on 2/25/25 at 1808 hours, and 3/1/25 at 2000 hours.
Review of Resident 34's MARs for February and March 2025, failed to show the documentation of the administration for the hydrocodone-acetaminophen 10-325 mg oral tablet dispensed on 2/25/25 at 1808 hours, and 3/1/25 at 2000 hours.
On 3/4/25 at 1403 hours, an interview and concurrent medical record review was conducted with LVN 6. LVN 6 verified the above findings.
On 3/4/25 at 1410 hours, an interview and concurrent medical record review was conducted with the DON.
The DON was informed and verified the above findings.
The DON stated the licensed nurse must document on the MAR when the medication was administered to the resident.
555688
Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 555688 B.
Wing 03/06/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Anaheim Point 3415 W Ball Road Anaheim, CA 92804
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.