Anaheim Terrace Care Center

F-F656.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 6 of 8 056076 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056076 B. Wing 06/13/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Anaheim Terrace Care Center 141 South Knott Avenue 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 0698 Provide safe, appropriate dialysis care/services for a resident who requires such services.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 35346 potential for actual harm Based on interview and medical record review, the facility failed to ensure one sampled residents (Resident Residents Affected - Few 35) reviewed for dialysis treatment received the dialysis treatment at the prescribed time.

* Resident 35's transportation issues were not followed up on with the resident's insurance carrier. This failure had the potential for negative health outcomes for the resident.

Findings:

On 6/11/24 at 0813 hours, an interview was conducted with Resident 35. Resident 35 stated on 6/11/24, Resident 35 had an appointment to change his dialysis access site to a shunt. Resident 35 further stated his appointment was at 0800 hours on 6/11/24, and the transportation did not arrive to the facility until 0750 hours. Resident 35 stated he cancelled the appointment because the transportation was too late since his appointment was at 0800 hours and there was not enough time to get Resident 35 to his appointment location by 0800 hours. Resident 35 further stated last Friday, he did not get his dialysis until 1300 hours, which was late, and he was scheduled to receive his dialysis on Mondays and Fridays at 0415 hours and was supposed to be picked up between 0300 and 0330 hours, in order to ensure he would arrive on time to receive his dialysis treatments. Resident 35 stated he did not eat last Friday because he was prepared to be picked up on time for his dialysis appointment scheduled at 0415 hours. Resident 35 stated by the time he got back to the facility from his dialysis treatment last Friday, he was exhausted and not hungry. Resident 35 stated his body was already used to getting his dialysis treatments at 0415 hours, and it took a lot from his body to try to adjust to getting dialysis at different times. Resident 35 further stated these transportation issues happened multiple times.

On 6/11/24, at 1608 hours, an interview was conducted with the Social Services Director. The Social Services Director verified there had been issues with Resident 35's transportation. When asked about following up to resolve the transportation issues, the Social Services Director stated staff called the transportation drivers about the issues related to the transportation not showing up on time to take Resident 35 to his dialysis and other appointments.

On 6/11/24, medical record review was initiated for Resident 35. Resident 35 was admitted to the facility on [DATE REDACTED].

Review of Resident 35's H&P examination dated 2/11/24, showed Resident 35's diagnoses included renal failure, diabetes, and high blood pressure.

Review of Resident 35's June 2024 Order Summary Report showed an order dated 5/27/24, for Resident 35 to receive dialysis on Mondays and Fridays with pickup time of 0315 hours, and chair time 0415 hours.

Review of the facility's email correspondence dated 4/19/24, showed to get urgent solutions for Resident 35's transportation problems. The facility was to call the customer service line for Resident 35's insurance carrier.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 7 of 8 056076 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056076 B. Wing 06/13/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Anaheim Terrace Care Center 141 South Knott Avenue 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 0698 Review of Resident 35's progress notes showed the following issues related to Resident 35's transportation:

Level of Harm - Minimal harm or - On 6/11/24, transportation was late. potential for actual harm - On 6/7/24, transportation was a no show. Residents Affected - Few - On 6/3/24, transportation from the resident's appointment location had to be rescheduled.

- On 5/27/24, transportation was a no show.

On 06/12/24, at 0843 hours, a telephone interview was conducted with Resident 35's customer service insurance carrier. When asked if any staff member from the facility had called to file a grievance in relation to Resident 35's transportation, the customer service agent verbalized nobody had called to file any grievances.

On 6/12/24, at 1426 hours, an interview was conducted with the DON. When asked about the plan for ensuring Resident 35 had transportation to pick the resident up on time, the DON verbalized their plan was to have a back up transportation.

On 6/18/24, at 1018 hours, a telephone interview was conducted with Resident 35. Per Resident 35, transportation for his scheduled dialysis appointment on 6/17/24 at 0415 hours, did not show up. Resident 35 verbalized again that he ended up getting his dialysis treatment at 1300 hours, instead of his schedule at 0415 hours. Resident 35 stated when he got back from dialysis yesterday he was not very hungry because dialysis treatments had physically exhausted him. Resident 35 stated he did not have breakfast or lunch yesterday 6/17/24. Resident 35 verbalized wanting reliable transportation that arrived on time so he could receive his dialysis treatments at 0415 hours, as his body was already used to this time. Resident 35 stated

he needed transportation staff that would escort him into his appointment locations as he was not able to ambulate.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 8 of 8 056076