Park Anaheim Healthcare Center

F-F803, examples #1, #2, and #3.

d. Review of the facility's P&P titled Sanitizing Equipment and Surfaces undated, showed sanitizer levels will be checked and recorded at least once per shift to ensure equipment and surfaces are sanitized appropriately. Procedure: 3. Test strip should read 200-400 ppm refer to manufacturer's recommendations.

Review of the sanitizing test strip container showed: Dip paper in quat solution , for ten seconds, Don't shake.

Review of the facility's document titled In-service titled Manual dishwashing; Quat bucket dated 3/4/25, showed [NAME] 1 was in attendance.

On 3/12/25 at 0948 hours, an observation of the sanitizing solution and concurrent interview was conducted with [NAME] 1. [NAME] 1 was asked to test the ppm of the sanitizing solution. [NAME] 1 held the sanitizing test strip in the sanitizing solution for three seconds. The test strip read 100 ppm. [NAME] 1 obtained a second test strip and held it in the sanitizing solution for three seconds and stirred the test strip in the solution. [NAME] 1 was shown with the instructions on the sanitizing test strip container. [NAME] 1 was asked to test the strip a third time. Using the surveyor's phone stopwatch, the testing was monitored for ten seconds. [NAME] 1 held the sanitizing test strip in the sanitizing solution for ten seconds and the strip read 200 ppm.

On 3/13/25 at 0837 hours, a concurrent interview was conducted with the RD and DSS. The DSS confirmed

the kitchen employees should know how to test the sanitizing solution correctly.

e. Review of the facility's P&P Manual Dish Washing - 2 or 3 compartment sink undated showed, two-compartment sink procedures:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 37 of 77 555035 Department of Health & Human Services Printed: 09/04/2025 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 555035 B. Wing 03/14/2025

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)

F 0802 1. Fill sink 1 with warm water and soap to proper level to complete wash process. Scrub all surfaces to clean and remove food and other debris. Level of Harm - Minimal harm or potential for actual harm 2. Drain sink 1 and rinse walls with fresh water.

Residents Affected - Some 3. Refill sink 1 to proper level to freely rinse all items with fresh water only.

4. Fill sink 2 with fresh water to proper level with water from cold line and add Quaternary sanitizer.

5. Test to ensure paper solution of no less than 200 ppm to no more than 400 ppm is available with proper test strips.

6. Place all items in solution for no less than 1 minute.

7. Place on a clean surface and allow to dry clean.

Review of the facility's document titled In-service titled Manual dishwashing; Quat (sanitizing solution) bucket dated 3/4/25, showed [NAME] 1 was in attendance.

On 3/11/25 at 0756 hours, during initial tour of the facility's kitchen, an observation of [NAME] 1 and concurrent interview was conducted with the DSS. [NAME] 1 was asked to wash a dirty peeler. [NAME] 1 used the cleaning solution located in a green bucket by dipping the peeler in the bucket. [NAME] 1 then rinsed the peeler off with the faucet and dried the peeler using a paper towel. [NAME] 1 returned the peeler to the storage drawer. The DSS verified the findings and stated [NAME] 1 should have followed the manual dish washing procedure. Cross reference to

F-F812, example #2.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 39 of 77 555035 Department of Health & Human Services Printed: 09/04/2025 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 555035 B. Wing 03/14/2025

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)

F 0803 Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. Level of Harm - Minimal harm or potential for actual harm 50953

Residents Affected - Some Based on observation, interview, and facility document review, the facility failed to ensure the menus were followed when the recipes for puree meat, vegetables, and starch were not adhered to. This failure had the potential for the nutritional needs to not be met for 15 residents who received a puree diet.

Findings:

Review of the Order Listing Report dated 3/11/25, showed 15 residents had the physicians' orders for the pureed diet.

1. Review of the facility's document titled Recipe: Puree (IDDSI Level 4) Meats dated 2024 showed 12 servings mix 12 to 24 oz (1 1/2 to 3 cups) warm fluid such as gravy, or low sodium both. If the meat is moist, you can start with only a few ounces of liquid. These amounts are only an average and may vary. If needed: Stabilizer: for 12 serving to mix 6 to 12 Tbsp (3/8 - 3/4 cup) instant potato, non -fat dry milk, breadcrumbs, toast, instant cream of rice or farina, or commercial instant food thickener.

On 3/12/25 at 1002 hours, an observation of the puree meat preparation and concurrent interview was conducted with [NAME] 1. [NAME] 1 stated he was preparing 12 servings of puree sweet and sour chicken. [NAME] 1 added nine six-ounce servings of sweet and sour chicken to the Robot Coupe (RC, a device used to puree foods), then blended. The puree sweet and sour chicken had a runny consistency. [NAME] 1 stated

he could use thickener to reach the appropriate consistency. [NAME] 1 pour an unmeasured quantity of thickener into a metal pitcher that held one quart (equivalent to four cups). The metal pitcher was approximately half full (two cups) with thickener. [NAME] 1 added the unmeasured thickener to the puree sweet and sour chicken and stirred it with a wire whisk.

On 3/13/25 at 0837 hours, an interview was conducted with the RD and DSS. Both the RD and DSS agreed all recipes should be followed.

2. Review of the facility's document titled Recipe: Stir Fry Vegetables dated 2024 showed Ingredients: assorted vegetables, margarine, garlic powder, salt. Directions: 2. Pan fry vegetables with margarine or boil, steam vegetables until soft. Drain well. Add margarine, garlic and salt.

Review of the facility's document titled Recipe: Pureed Vegetable (undated) showed 12 serving puree vegetables: mix vegetable with 2 to 6 oz (1/4 cup to 3/4 cup) of warm fluid such as milk, or low sodium broth.

These are suggested amounts and may vary from vegetable to vegetable. Some vegetables may not require any fluids at all. If needed: Stabilizer: for 12 serving to mix 6 to 12 Tbsp (3/8 - 3/4 cup) instant potato, or commercial instant food thickener.

Review of the chicken flavored bouillon nutritional information showed 3/4 teaspoon chicken flavored bouillon mixed with one cup of water contained 620 mg sodium.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 40 of 77 555035 Department of Health & Human Services Printed: 09/04/2025 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 555035 B. Wing 03/14/2025

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)

F 0803 On 3/12/25 at 1016 hours, an observation of the puree vegetable preparation and concurrent interview was conducted with [NAME] 1. [NAME] 1 took a large pan out of the oven with vegetables cooked in liquid. Level of Harm - Minimal harm or [NAME] 1 stated he cooked the stir fry vegetables in chicken broth in the oven. [NAME] 1 placed 13 1/2 cup potential for actual harm servings of the stir fry vegetable mixture into the RC. The product was blended and placed in the oven at 500 degrees. Residents Affected - Some recipes should be followed. The stir fry vegetable recipe was reviewed with the RD. The RD confirmed the stir fry vegetable recipe did not specify what liquid to boil or steam the vegetables in. The RD stated she would prefer the vegetables to be boiled in water. The RD agreed using regular chicken broth with a high sodium content to cook the vegetables was not correct.

3. Review of the facility's document titled Recipe: Sesame Noodles dated 2024 showed Ingredients: Low sodium vegetable or chicken broth (200 mg or less per eight-ounce reconstituted broth).

Review of the facility's document titled Recipe: Pureed Starch (Rice, Pasta, Potatoes) (undated) showed 12 servings mix 12 to 24 oz (1 1/2 to 3 cups) warm milk, starting with the smaller amount and adding in more as needed to achieve the desired consistency. If needed: Stabilizer: for 12 serving to mix 6 to 12 Tbsp (3/8 - 3/4 cup) instant potato, non -fat dry milk, breadcrumbs, toast, instant cream of rice or farina, or commercial instant food thickener.

Review of the chicken flavored bouillon nutritional information showed 3/4 teaspoon chicken flavored bouillon mixed with one cup of water contained 620 mg sodium.

On 3/12/25 at 1021 hours, an observation of the puree noodle preparation and concurrent interview was conducted with [NAME] 1. [NAME] 1 pour an unmeasured quantity of chicken flavored bouillon into a metal pitcher that held one quart (equivalent to four cups). [NAME] 1 added water to the metal pitcher to equal approximately two cups (the metal pitcher was half full). [NAME] 1 added 13 1/2 cup servings of sesame noodles and the chicken flavored bouillon mixture to the RC. The noodles were blended until smooth then placed in a pan and put in the oven at 500 degrees F.

On 3/13/25 at 0837 hours, an interview was conducted with the RD and DSS. The RD confirmed all the recipes should be followed and the pureed starch should be pureed with milk per the recipe or low sodium broth.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 41 of 77 555035 Department of Health & Human Services Printed: 09/04/2025 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 555035 B. Wing 03/14/2025

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)

F 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Level of Harm - Minimal harm or 39856 potential for actual harm Based on observation, interview, and facility P&P review, the facility failed to ensure the nutrient content of Residents Affected - Few pureed vegetables was preserved when pureed vegetables were prepared more than one hour prior to meal service and held in an oven at 500 degrees F. This failure posed the risk of 15 residents on a puree diet to not meet their nutritional needs.

Findings:

Review of the Order Listing Report dated 3/11/25, showed 15 residents had physician's orders for a pureed diet.

During the review of the professional reference titled, https://www.healthline. com/nutrition/cooking-nutrient-content, dated 11/7/2019, the reference showed in part, . The following nutrients are often reduced during cooking: water-soluble vitamins: vitamin C and the B vitamins - thiamine (B1), riboflavin (B2), niacin (B3), pantothenic acid (B 5), pyridoxine (B6), folic acid (B9), and cobalamin (B12), fat-soluble vitamins: vitamins A, D, E, and K, and minerals: primarily potassium, magnesium, sodium, and calcium .

On 3/12/25 at 1011 hours, an observation of the puree preparation and concurrent interview was conducted with [NAME] 1. [NAME] 1 stated he was preparing 13 portions of the puree stir fry vegetables. [NAME] 1 had placed 13 1/2 cup servings of the stir fry vegetables previously cooked in chicken broth, into the Robot Coupe (RC, a device used to puree food). The stir fry vegetables were blended until a pudding consistency was obtained then placed in a pan and stored in the oven at 500 degrees fahrenheit (F) until the lunch meal tray line began at 1146 hours.

On 3/13/25 at 1041 hours, an interview was conducted with the RD. The RD agreed that storing the pureed vegetables in an oven at 500 degrees F for more than one hour prior to the meal service was not the ideal way to preserve the nutrients of the pureed vegetables.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 42 of 77 555035 Department of Health & Human Services Printed: 09/04/2025 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 555035 B. Wing 03/14/2025

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)

F 0805 Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 44175

Residents Affected - Few Based on observation, interview, and facility document review, the facility failed to ensure two of 10 final residents reviewed for dining (Residents 11 and 85) received food prepared in a form to meet their individual dietary needs.

* The facility failed to ensure Resident 11 was provided with the minced and moist diet as per physician's diet order.

* The facility failed to ensure Resident 85 was provided with the mechanical soft snacks as per the resident's diet order.

These failures placed Residents 11 and 85 at risk for aspiration (accidental breathing in of food or fluid into

the lungs) or choking.

Findings:

1. Medical record review for Resident 11 was initiated on 3/11/25. Resident 11 was readmitted to the facility

on [DATE REDACTED].

Review of Resident 11's SLP Evaluation and Plan of Treatment dated 3/12/24, showed Resident 11 was currently edentulous (toothless) per dentist recommendation and was awaiting a procedure on her gums to improve the ability to wear dentures. Further review of the SLP Evaluation and Plan of Treatment showed Resident 11 had difficulty chewing tough/fibrous material but refused to be downgraded to a puree diet. The recommendation showed for minced and moist textures, thin liquid and puree vegetables only per the residents' request.

Review of Resident 11's Order Summary Report for March 2025 showed a physician order dated 3/12/25, for no added salt diet, minced and moist texture (foods must be soft, moist, and easily formed into a ball, with no hard lumps and pieces no larger than 4 mm), thin consistency, low purine diet, no beans, no nuts, oatmeal with breakfast lunch and dinner. Puree vegetables only.

Review of Resident 11's H&P examination dated 7/26/24, showed Resident 11 had the capacity to understand and make decisions.

On 3/11/25 at 0959 hours, an interview was conducted with Resident 11. Resident 11 stated she was in a process of getting an oral surgery and could not use her dentures. Resident 11 further stated the facility had been providing her with minced diet; however, sometimes she would get food in big pieces which was hard for her to swallow.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 43 of 77 555035 Department of Health & Human Services Printed: 09/04/2025 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 555035 B. Wing 03/14/2025

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)

F 0805 On 3/11/25 at 1224 hours, Resident 11 was observed eating her lunch in the dining room. Resident 11's food

on the tray was mashed potatoes, cooked green leaves, chicken in pieces, milk, dessert, puree salad, and a Level of Harm - Minimal harm or bowl of oatmeal. Resident 11's plate had dry pieces of chicken approximately more than 1 cm long and was potential for actual harm not finely minced and moist. Resident 11 was observed taking lumps of the chicken pieces out of her plate and putting it aside. Resident 11 stated the pieces of the chicken in her plate were big for her to swallow. Residents Affected - Few

On 3/11/25 at 1232 hours, an observation and concurrent interview was conducted with the DSD. The DSD verified the above observation and stated the chicken Resident 11 received was not moist and was not minced properly. The DSD was observed offering Resident 11 another tray of the meal.

On 3/11/25 at 1240 hours, an observation and concurrent interview was conducted with the DSS. The DSS verified the observation and stated the chicken in Resident 11's plate was not minced and moist. The DSS stated she would replace the meal for Resident 11.

On 3/11/25 at 1245 hours, Resident 11 was observed receiving another replacement tray for her lunch which included finely minced and moist chicken. Resident 11 stated she was finally able to easily swallow the food served.

On 3/11/25 at 1251 hours, an interview was conducted with the SLP. The SLP was informed and verified the above findings and stated the food Resident 11 receive should be finely minced and moist that required very little or no chewing.

On 3/14/25 at 0946 hours, the DON was informed and acknowledged the above findings.

47474

2. Medical record review for Resident 85 was initiated on 3/11/25. Resident 85 was admitted to the facility on [DATE REDACTED], and readmitted to the facility on [DATE REDACTED].

Review of Resident 85's Order Summary Report for March 2025 showed a physician order dated 12/23/24, for an oral great diet. Puree texture, nectar/mildly thick consistency. Patient may have occasional soft and bite sized snacks/mechanical soft snacks upon request for per resident request only.

Review of Resident 85's annual MDS dated [DATE REDACTED], showed Resident 85 had a BIMS score of 14 which meant the resident was cognitively intact.

On 3/11/25 at 0929 hours, during the initial tour observation, Resident 85 was in bed eating saltine crackers. There were three packets of saltine crackers on the resident's bedside table.

On 3/11/25 at 1222 hours, a concurrent observation and interview was conducted with Resident 85 in her room. When asked if the resident eats the saltine crackers via her cellphone to communicate, Resident 85 replied it takes forever to eat the saltine crackers.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 44 of 77 555035 Department of Health & Human Services Printed: 09/04/2025 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 555035 B. Wing 03/14/2025

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)

F 0805 On 3/11/25 at 1226 hours, a concurrent observation, interview, and medical record review was conducted with LVN 12. LVN 12 verified there were a total of eight saltine crackers at Resident 85's bedside table. LVN Level of Harm - Minimal harm or 12 stated Resident 85 was given saltine crackers; however, has a hard time eating them. LVN 12 further potential for actual harm verified Resident 85's diet order showed she was allowed for a soft and bite sized snacks and/or mechanical soft snacks. LVN 12 acknowledged the saltine crackers were not appropriate snacks and Resident 85 was at Residents Affected - Few risk for aspiration or choking.

On 3/11/25 at 1233 hours, an interview with the DSS was conducted. The DSS verified the saltine crackers were not considered a mechanical soft snack.

On 3/11/25 at 1235 hours, a concurrent interview and medical record review with the RD was conducted.

The RD verified Resident 85's diet orders. When the RD was asked if the saltine crackers were offered for

the residents on a mechanical soft snacks, the RD stated it was not.

On 3/11/25 at 1244 hours, a concurrent interview with the SLP was conducted. The SLP stated Resident 85 can have soft and bite size snacks. The SLP stated Resident 85 can have saltine crackers if it was dipped in water first; however, verified instructions were not on the diet order and stated not all the nurses were aware of her instructions regarding the saltine crackers should be dipped in water first prior to the resident eating it.

On 3/14/25 at 1320 hours, an interview was conducted with the Administrator and DON with the Regional Director of Operations present. The Administrator and DON was made aware and acknowledged the above findings.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 45 of 77 555035 Department of Health & Human Services Printed: 09/04/2025 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 555035 B. Wing 03/14/2025

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)

F 0806 Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 51352

Residents Affected - Few Based on interview, medical record review, facility document review and facility P&P review, the facility failed to ensure the food preferences were honored for one of 24 final sampled residents (Resident 10). This failure had the potential for decreased meal intake, weight loss, and a negative impact on the resident's psychosocial wellbeing.

Findings:

Review of the facility's P&P titled Resident Food Preferences (undated) showed the DSS will meet with the resident or representative to go over food preferences, allergies, likes and dislikes upon admission and as needed. The DSS will visit the resident periodically to ensure food preferences are being honored.

Medical record review for Resident 10 was initiated on 3/11/25. Resident 10 was admitted to the facility on [DATE REDACTED], and readmitted on [DATE REDACTED].

Review of the facility's Resident Council minutes dated 1/14/25, showed Resident 10 requested the collard greens with meals.

Review of the the Resident Council Response Form dated 1/14/25, showed the DSS would order the collard greens and have them in the facility for Resident 10.

Review of Resident 10's care plan dated 1/23/25, showed the resident had a risk for alteration in nutritional status and was at risk for weight loss and malnutrition. The care plan interventions included adhering to Resident 10's food preferences.

Review of Resident 10's H&P examination dated 2/21/25, showed Resident 10 had the capacity to understand and make decisions.

Review of Resident 10's Order Summary Report showed a physician's order dated 2/28/25, for CCHO, NAS diet, regular texture, thin liquids, no orange juice, no potatoes, and no banana.

On 3/12/25 at 1106 hours, an interview was conducted with Resident 10. Resident 10 stated they requested collard greens at the Resident Council meeting in January 2025. Resident 10 stated the facility had not informed her of the status of her request or if the facility was able to order the collard greens. Resident 10 stated the collard greens had not been served with any meals.

On 3/13/25 at 1101 hours, an interview and concurrent medical record review was conducted with the DSS for Resident 10. The DSS verified Resident 10's request for the collard greens was received by the facility.

The DSS stated the facility had not purchased the collard greens. The DSS verified the facility has not accommodated Resident 10's request for collard greens. The DSS verified Resident 10's medical record failed to show documentation of a follow-up with Resident 10 regarding the request for the collard greens.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 46 of 77 555035 Department of Health & Human Services Printed: 09/04/2025 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 555035 B. Wing 03/14/2025

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)

F 0806 On 3/14/25 at 1503 hours, an interview was conducted with the Administrator and DON. The Administrator and DON were informed of and acknowleged the above findings. Level of Harm - Minimal harm or potential for actual harm

Residents Affected - Few

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 47 of 77 555035 Department of Health & Human Services Printed: 09/04/2025 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 555035 B. Wing 03/14/2025

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)

F 0812 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food

in accordance with professional standards. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 50953

Residents Affected - Some Based on observation, interview, facility document and facility P&P review, the facility failed to ensure the food safety and sanitary requirements were met in the kitchen as evidenced by:

* The facility failed to ensure the egg served was fully cooked when there were no pasteurized eggs were available.

* The facility failed to ensure the proper hand hygiene was followed during the food preparation.

* The facility failed to ensure the fish thawing process was followed.

* The facility failed to the ensure the automatic dish washing water temperature reached the acceptable range.

* The facility failed to ensure the manual dishwashing process was followed.

* The facility failed to ensure the refrigerated food items were stored properly.

* The facility failed to ensure the ice storage was in sanitary condition.

* The facility failed to ensure the hair restraints were available and worn by staff in the kitchen.

* The facility failed to ensure the kitchen equipment were maintained in a sanitary condition.

* The facility failed to ensure the food item in the walk-in freezer was dated, label and not left open.

* The facility failed to ensure the dry food was properly stored.

* The facility failed to ensure the food preparation equipment was air dried.

* The facility failed to ensure Resident 7's personal refrigerator was maintained.

These failures had the potential to cause foodborne illnesses for Resident 7 and in the 62 residents who consumed food prepared in the kitchen.

Findings:

Review of the facility's document titled Order Listing Report dated 3/11/25, showed 62 of 109 residents received food prepared in the kitchen.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 48 of 77 555035 Department of Health & Human Services Printed: 09/04/2025 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 555035 B. Wing 03/14/2025

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)

F 0812 1. According to the Center for Disease Control (CDC) Salmonella are bacteria (germs) that can make people sick with an illness called salmonellosis. Anyone can get a Salmonella infection. But some groups of people Level of Harm - Minimal harm or have an increased chance of infection, and some people may become seriously ill. These groups include potential for actual harm Adults who are [AGE] years and older with underlying medical problems, such as heart disease, Adults who are 65 and older and People who have a weakened immune system. https://www.cdc. Residents Affected - Some gov/salmonella/about/index.html#:~:text=People%20at%20risk&text=These%20groups%20include%3A, who%20are%2065%20and%20older.

A reference review from California Department of Food and Agriculture (CDFA) dated 7/1/13, showed California Shell Egg Food Safety Compliant or the abbreviated CA SEFS Compliant statement means that

the eggs you're purchasing have gone through added measures to reduce the risk of Salmonella Enteritidis (SE) contamination, as specified in California Code of Regulation Title 3 Section 1350 (3 CCR 1350). SE is

the number one food borne illness associated to raw shell eggs.

Review of California Code, Health and Safety Code - HSC S 114091 showed in part, in a licensed health care facility the following shall apply . Pasteurized shell eggs or pasteurized liquid, frozen, or dry eggs or egg products shall be substituted for raw shell eggs in the preparation of foods.

https://www.cdfa.ca.gov/ahfss/mpes/pdfs/CA_SEFS_Compliant.pdf

On 3/11/25 at 0756 hours, during the initial tour of the facility's kitchen, observation and concurrent interview was conducted with the DSS. Three cases of CASEFS eggs were observed in the walk-in refrigerator. The DSS verified there were no pasteurized eggs and stated she was unable to purchase the pasteurized eggs from the provider.

On 3/11/25 at 1121 hours, an interview was conducted with the RD. The RD stated the eggs were safe because they were CASEFS approved.

On 3/12/25 at 0645 hours, a breakfast meal tray-line observation was conducted. The DSS was observed cooking the fried eggs for residents on the grill.

On 3/12/25 at 0720 hours, an observation of Resident 33's breakfast meal tray and concurrent interview was conducted with the RD. Resident 33's breakfast meal tray ticket showed a daily standing order for two fried eggs. The two fried eggs were observed on the plate; however, one of the egg yolks was observed runny and not fully cooked. The RD verified the findings and stated she would have the DSS cook the eggs until

the yolk was completely cooked.

2. Review of the facility's P&P titled Hand Washing (undated) showed to wash hands after handling the cart, soiled dishes and utensils, before and after handling foods, and wash hands when changing gloves. Change

the disposable gloves when:

- gloves get ripped or torn;

- beginning a different task;

- after coughing or sneezing into hands, use of handkerchief or tissue, smoking, touching hair or face, and using the toilet;

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 49 of 77 555035 Department of Health & Human Services Printed: 09/04/2025 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 555035 B. Wing 03/14/2025

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)

F 0812 - after handling waste and

Level of Harm - Minimal harm or - during food preparation, as often as necessary when it get soiled and when changing task to prevent cross potential for actual harm contamination.

Residents Affected - Some On 3/11/25 at 0756 hours, during the initial tour of the facility's kitchen, an observation and concurrent

interview was conducted with the DSS. [NAME] 1 was asked to discard the two rubber spatulas and wash a dirty peeler. [NAME] 1 touched the trash can lid to throw away the rubber spatulas, then proceeded to wash

the dirty peeler. [NAME] 1 did not change his gloves or wash his hands after touching the trash can. After washing the peeler, [NAME] 1 was observed wiping his wet gloved hands on his apron and returned to the food preparation.

On 3/12/25 at 0859 hours, a follow-up observation was conducted of [NAME] 1. [NAME] 1 was observed placing her gloved hands in the trash can to remove a sticker from her gloves. [NAME] 1 did not remove her gloves or wash her hands prior to returning to the food preparation.

On 3/12/25 between 1002 and 1025 hours, an observation of the puree meal preparation was conducted with [NAME] 1. The following was observed:

- [NAME] 1 was observed preparing the puree meat with gloved hands,

- [NAME] 1 removed his gloves to wash the Robot Coupe (RC) in the automatic dish machine,

- [NAME] 1 touched the dish machine tray and dish machine handle then donned a new pair of gloves without washing his hands,

- [NAME] 1 proceeded with the puree meal preparation. During the puree meal preparation, [NAME] 1 rested his gloved hands on the counter. Without changing his gloves or washing his hands, [NAME] 1 continued to touch multiple objects in the kitchen; a cooking pan, a blender, and oven handle while preparing the puree food for the residents, and

- [NAME] 1 washed the RC again in the automatic dish machine using the same gloved hands, then he prepared the chicken broth which he added to the noodles and continued to puree the food for the facility residents.

On 3/13/25 at 0837, an interview was conducted with the DSS and RD. Both the RD and DSS acknowledged

the cooks should wash their hands and change gloves prior to starting a new task such as the food preparation.

3. Review of the facility's P&P titled Refrigerator /Freezer Storage (undated) showed all the items should be properly covered, dated, and labeled. The food items should have the following appropriate dates:

- delivery date upon receipt,

- open date for opened containers of the PHF (potentially hazardous food), and

- thaw date of any frozen items.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 50 of 77 555035 Department of Health & Human Services Printed: 09/04/2025 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 555035 B. Wing 03/14/2025

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)

F 0812 Review of the chart from the US Food & Drug Administration (USFDA) posted outside of the walk-in refrigerator titled Refrigerator and Freezer Storage Chart dated March 2018 showed the lean and fatty fish Level of Harm - Minimal harm or may be stored in the refrigerator safely for one to two days. potential for actual harm

On 3/11/25 at 0800 hours, an observation of the walk-in refrigerator and concurrent interview was conducted Residents Affected - Some with the DSS. Two boxes of 10 pounds tilapia were observed in the walk-in refrigerator dated 3/5/25. The DSS was asked what the 3/5/25 date meant. The DSS verified the 3/5/25 was the delivery date and there was no date to indicate when the tilapia was removed from the freezer to thaw.

4. Review of the facility's P&P titled Dish Washing Procedures- Dish Machine (undated) showed to inform the DSS or Maintenance personnel if the dish machine is not reaching the proper temperature and chlorine levels. Manual dish washing or disposables will be used if the dish machine is not working properly. For the low temperature dish machine, the temperature should be between 120-135 degrees Fahrenheit (F), and Chlorine at 50 to 100 ppm.

Review of the facility' s document titled Dish Machine Temperature Log for 3/1-3/11/25, the breakfast through dinner showed the automatic dishwashing machine temperature was 120-123 degrees F on every entry.

On 3/11/25 at 0833 hours, an observation of the automatic dishwashing machine and concurrent interview was conducted with DA 1 using the DSS as a translator. As DA 1 was washing the dishes, she was asked where she checked the temperature for the automatic dish washing machine. DA 1 was unable to state where she obtained the dish washing machine temperature. DA 1 was shown where the dish machine temperature dial which was located at the bottom of the machine near the floor. DA 1 was unable to stoop down to read the dish machine temperature dial. DA 1 and the DSS was informed the temperature of the wash water was at 100 degrees F. DA 1 acknowledged the temperature of 100 degrees F was too low. Although the dish machine had been running for several cycles before DA 1 was interviewed, the DSS stated

the dish machine needed to be run a few times to get the water temperature to the correct range.

On 3/13/25 at 1134 hours, a follow-up observation of the automatic dish machine and concurrent interview was conducted with the RD. The RD stated the dish machine company had come out to check the machine and stated everything was fine. Upon the inspection of the dish machine temperature dial, the wash temperature was at 112 degrees F. The dish machine was then ran twice; however, the dish machine temperature remained at 112 degrees F. The RD stated she would notify the maintenance.

5. Review of the facility's P&P titled Manual Dish Washing - 2 or 3 Compartment Sink (undated) showed the two-compartment sink procedures as follows:

- Fill sink 1 with warm water and soap to proper level to complete wash process. Scrub all surfaces to clean and remove food and other debris.

- Drain sink 1 and rinse walls with fresh water.

- Refill sink 1 to proper level to freely rinse all items with fresh water only.

- Fill sink 2 with fresh water to proper level with water from cold line and add Quaternary sanitizer.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 51 of 77 555035 Department of Health & Human Services Printed: 09/04/2025 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 555035 B. Wing 03/14/2025

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)

F 0812 - Test to ensure paper solution of no less than 200 ppm to no more than 400 ppm is available with proper test strips. Level of Harm - Minimal harm or potential for actual harm - Place all items in solution for no less than 1 minute.

Residents Affected - Some - Place on a clean surface and allow to dry clean.

On 3/11/25 at 0756 hours, during the initial tour of the facility's kitchen, an observation of [NAME] 1 and concurrent interview was conducted with the DSS. [NAME] 1 was asked to wash a dirty peeler. [NAME] 1 was observed dipping the peeler in the solution in a green bucket. [NAME] 1 then rinsed the peeler off with

the water from the faucet and dried the peeler using a paper towel. [NAME] 1 returned the peeler to the storage drawer. The DSS verified the findings and stated [NAME] 1 should have followed the manual dish washing procedure.

6. Review of the facility's document titled Refrigerator and Freezer Storage Chart dated 3/2018 showed

these short but safe time limits will help keep the refrigerated food at 40-degree F from spoiling or becoming dangerous. The section for the Hot Dogs and Lunch Meats (in freezer wraps), the opened package of the lunch meat can be stored in refrigerator for 3-5 days and 1-2 months in the freezer.

Review of the facility's document Health Shake Nourishment Storage and Handling instruction: Store frozen showed to thaw under refrigeration (at 40 degree F or below), after thawing keep refrigerated, and use within 14 days after thawing.

On 3/11/25 at 0800 hours, an observation and concurrent interview was conducted with the DSS. An opened package of turkey lunch meat dated 3/3/25, and one box of the health shakes dated 2/12/25, were observed inside the walk-in refrigerator. The DSS verified the finding and stated the turkey lunch meat should be discarded after seven days. When asked regarding the process for thawing of the health shakes, the DSS stated the health shakes can be used for 30 days after thawing. Upon the inspection of the health shake guidelines located on the health shake carton, the DSS verified the health shakes can only be used for 14 days once thawed.

7. Review of the USDA Food Code 2022, Section 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils, (A) Equipment, food-contact surface and utensils shall be clean to sight and touch.

On 3/11/25 at 1102 hours, an observation and concurrent interview was conducted with the DSS. The DSS stated the ice cooler located near the kitchen door was used by the CNAs to get ice for the residents' water pitchers. The inside of the ice cooler was observed with a brown residue. The DSS was asked about the process on how to clean the ice cooler. The DSS stated the ice cooler was cleaned weekly with soap and water. The DSS verified the ice cooler was not clean and removed it to be cleaned.

8. According to the USDA Food Code 2022, Section 2-402.11 Hair Restraints, Effectiveness, Food employees shall wear hair restraints such as hats, hair covering or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed food, clean equipment, and utensils.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 52 of 77 555035 Department of Health & Human Services Printed: 09/04/2025 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 555035 B. Wing 03/14/2025

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)

F 0812 Review of the facility's P&P titled Sanitation and Infection control (undated) showed the beard and/or moustache should be closely trimmed or must be covered at all times. Level of Harm - Minimal harm or potential for actual harm On 3/12/25 at 1355 hours, an observation in the kitchen and concurrent interview was conducted with DA 2 and [NAME] 2. DA 2 and [NAME] 2 was observed with uncovered facial hair. When asked if their facial hair Residents Affected - Some should be covered, [NAME] 2 stated the kitchen used to have beard restraints but not any longer.

On 3/12/25 at 1359 hours, an interview was conducted with the DSS. The DSS was informed of DA 2 and [NAME] 2's uncovered facial hair. The DSS verified the findings and stated any kitchen staff with facial hair or beard need to use the hair restraints and she would need to order some hair restraint.

9. Review of the USDA Food Code 2022, Section 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils, (A) Equipment, food-contact surface and utensils shall be clean to sight and touch.

a. On 3/11/25 at 0800 hours, during the initial tour of the facility's kitchen, an observation and concurrent

interview was conducted with the DSS. The following was observed and verified by the DSS:

- one peeler was not clean,

- a plastic container used to store the silverware was not clean and observed with food debris,

- two rubber spatula were chipped and no longer in a cleanable condition,

- one can opener blade with excessive wear, and

- one nonstick pan was unclean and the coating was coming off.

b. On 3/12/25 at 0955 hours, a lunch meal puree preparation observation and concurrent interview was conducted with [NAME] 1 and the DSS. The Robot Coupe was observed with hard brown residue on the blade assembly. The DSS stated the Robot Coupe was old and the residue did not come off with cleaning.

The DSS further stated she would order a new blade assembly.

10. Review of the facility's P&P titled Refrigerator /Freezer Storage (undated) showed all the items should be properly covered, dated and labeled. The food items should have the following appropriate dates:

- delivery date upon receipt,

- open date for opened containers of the PHF (potentially hazardous food), and

- thaw date of any frozen items.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 53 of 77 555035 Department of Health & Human Services Printed: 09/04/2025 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 555035 B. Wing 03/14/2025

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)

F 0812 On 3/11/25 at 0800 hours, during the initial tour of the facility's kitchen, an observation and concurrent

interview was conducted with the DSS. One 20 pounds bag of peas was observed open with no date label in Level of Harm - Minimal harm or the walk-in freezer. The DSS verified the finding and stated all the food items should be dated and sealed potential for actual harm once opened.

Residents Affected - Some 11. Review of the facility's P&P titled Storage of Canned and Dry Goods (undated) showed the plastic or metal containers (with tight fitting lids and NSF approved), or re-sealable plastic bags will be used for staples and opened packages (like pasta, rice, cereal, flour, etc.). The food items will be dated and labeled when placed in the containers. The scoops should not be left in the container and will be cleaned after each use.

On 3/12/25 at 0649 hours, during the breakfast tray line observation, a scoop was observed inside the thickener container.

On 3/12/25 at 0804 hours, an observation and concurrent interview was conducted with the DSS. The DSS verified the finding, and stated the scoop should not be kept in the thickener container.

12. According to the USDA Food Code 2017, Section 4-901.11, Equipment and Utensils, Air-Drying Required, items must be allowed to drain and to air-dry before being stacked or stored. Stacking of the wet items prevents them from drying and may allow an environment where microorganism can begin to grow.

On 3/11/25 at 0800 hours, during the initial tour of the facility's kitchen, an observation and concurrent

interview was conducted with the DSS. A clean blender was observed stored with the top lid on and wet inside. The DSS verified the blender was not air-dried.

On 3/14/25 at 0947 hours, an interview was conducted with the Administrator, RD, and DSS. The Administrator, RD, and DSS were informed and acknowledged the above findings

51352

13. Review of the facility's P&P titled Resident's Refrigerator/Freezer Storage (undated), showed the nursing staff or a designee to check and record temperatures of all refrigerators and freezers daily to ensure the equipment is within the appropriate temperature for food. The section for Procedure showed the following:

1. Nursing staff or designee will check the inside temperature of refrigerators and freezers.

2. Nursing staff or designee will record and initial the temperature log twice a day.

3. If the temperatures are not within appropriate range, nursing staff or designee will notify the Maintenance Supervisor and Administrator.

- Refrigerator Temperature: 40 degrees F (Fahrenheit) or lower

- Freezer Temperature: 0 degrees F or lower

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 54 of 77 555035 Department of Health & Human Services Printed: 09/04/2025 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 555035 B. Wing 03/14/2025

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)

F 0812 Medical record review for Resident 7 was initiated on 3/11/24. Resident 7 was admitted to the facility on [DATE REDACTED], and readmitted on [DATE REDACTED]. Level of Harm - Minimal harm or potential for actual harm Review of Resident 7's H&P examination dated 8/9/24, showed Resident 7 had the capacity to understand and make decisions. Residents Affected - Some

On 3/11/25 at 0930 hours, an observation and concurrent interview was conducted with Resident 7. Resident 7's room was observed with a personal refrigerator and the log titled Refrigerator Log March 2025 was posted on the outside of the refrigerator. Resident 7 verified the refrigerator inside the room was his personal refrigerator.

Review of the Refrigerator Log for March 2025 showed the columns for the date, nurse's initials, and refrigerator temperatures for 0600 and 1800 hours. The daily refrigerator temperature log for Resident 7's personal refrigerator showed the following temperature at 0600 hours:

- 48 degrees F on 3/2, and 3/3/25;

- 49 degrees F on 3/8/25;

- 50 degrees F on 3/1, 3/4, 3/5, 3/6, 3/7, 3/9, 3/11, and 3/12/25, and

- 52 degrees F on 3/13/25.

Further review of the refrigerator log failed to show the documentation of Resident 7's personal refrigerator temperature for the 1800 hours or documentation of the freezer temperature.

On 3/13/25 at 0847 hours, an observation, interview, and concurrent facility document review for Resident 7's personal refrigerator was conducted with RN 3. RN 3 verified the refrigerator log showed the temperature for the refrigerator must be between 36 and 46 degrees F and the RN Supervisor and/or Maintenance Supervisor should be notified immediately for the temperatures not within range. RN 3 verified the refrigerator log showed the temperature for Resident 7's personal fridge was outside of the acceptable temperature range every day for March 2025. RN 3 verified the log showed no documentation if the RN Supervisor and/or Maintenance Supervisor was contacted when Resident 7's personal refrigerator temperature was outside of the acceptable range. RN 3 stated the RN Supervisor and/or Maintenance Supervisor should have been notified. RN 3 also verified the refrigerator log showed no documentation the temperature of Resident 7's personal refrigerator was checked daily at 1800 hours. Furthermore, RN 3 acknowledged the facility's policy for maintaining the personal refrigerator temperatures of less than 40 degrees F should be followed. RN 3 verified the refrigerator log showed an unacceptable temperature range that was inconsistent with the facility's policy for personal refrigerators.

On 3/13/25 at 0912 hours, a follow-up observation and concurrent interview was conducted with RN 3. RN 3 verified the refrigerator log for Resident 7's personal refrigerator showed no documentation of the freezer temperatures for March 2025. The temperature of the freezer in Resident 7's personal refrigerator was observed at 10 degrees F. RN 3 verified and acknowledged the temperature of Resident 7's freezer was at 10 degrees F, and was out of the recommended range of zero degrees or lower per the facility's policy.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 55 of 77 555035 Department of Health & Human Services Printed: 09/04/2025 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 555035 B. Wing 03/14/2025

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)

F 0812 On 3/13/25 at 0948 hours, an interview and concurrent facility document review was conducted with the Maintenance Director. The facility's P&P titled Resident's Refrigerator/Freezer Storage (undated) and Level of Harm - Minimal harm or maintenance department's Refrigerator Log for Resident 7's personal fridge for March 2025 was reviewed potential for actual harm with the Maintenance Director. The Maintenance Director verified the Refrigerator Log posted outside Resident 7's personal refrigerator showed the refrigerator temperatures were outside of the acceptable range Residents Affected - Some of 40 degrees F or less every day for March 2025. The Maintenance Director stated he was unaware the temperature of Resident 7's personal refrigerator was outside of the acceptable range every day in March 2025. The Maintenance Director verified he should have been notified when Resident 7's refrigerator temperature was outside of the acceptable range so the refrigerator temperature could have been adjusted.

Review of the maintenance department's Refrigerator Log for Resident 7's personal refrigerator for March 2025 showed the following temperatures:

- 39 degrees F on 3/5, and 3/11/25;

- 40 degrees F on 3/1, 3/2, and 3/6/25;

- 41 degrees F on 3/3, 3/4, 3/7, 3/8, 3/9, and 3/10/25, and

- no entry on 3/12/25.

The Maintenance Director verified the maintenance department checks the temperatures of all the personal refrigerators daily. The Maintenance Director verified the maintenance department's Refrigerator Log for Resident 7's personal refrigerator was incomplete and showed no documentation if the refrigerator's temperature was checked on 3/12/25. The Maintenance Director verified the facility's policy for maintaining

the personal refrigerator temperatures of less than 40 degrees F should be followed and the refrigerator logs showed an unacceptable temperature range that was inconsistent with the facility's policy for personal refrigerators. The Maintenance Director verified the maintenance department's refrigerator log for Resident 7's personal refrigerator showed the temperature was outside of the acceptable range on 3/3, 3/4, and 3/7 to 3/10/25, and the log showed no documentation the refrigerator temperature was adjusted to ensure the refrigerator's temperature remained within the acceptable range.

On 3/14/25 at 1503 hours, an interview was conducted with the Administrator and DON. The Administrator and the DON were informed and acknowledged the above findings.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 56 of 77 555035 Department of Health & Human Services Printed: 09/04/2025 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 555035 B. Wing 03/14/2025

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)

F 0813 Have a policy regarding use and storage of foods brought to residents by family and other visitors.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 39856 potential for actual harm Based on observation, interview, and facility P&P review, the facility failed to ensure food brought from the Residents Affected - Few outside was stored for three nonsampled residents (Residents 57, 65, and 70). Additionally, the facility failed to ensure the visitors and staff were educated on safe food handling guidelines. These failures had the potential to expose residents who received food brought from the outside to food borne illnesses.

Findings:

Review of the facility's P&P titled Food from Outside Sources (undated) showed the food from outside sources is discouraged due to concerns with food safety and infection control and maintaining control of therapeutic diet orders.

1. While it is preferred that families and/or friends do not bring foods or beverages into the facility, it is within

the resident's right to allow the resident to eat outside food, especially if an individual is eating poorly. If outside food is brought in, the facility is not liable for safety and infection control concerns.

a. Review of Resident 70's medical record showed Resident 70 was admitted to the facility on [DATE REDACTED], with diagnoses which included cardiomegaly (enlargement of the heart), old myocardial infarction (heart attack) and acute kidney failure. A No Added Salt diet was ordered by the physician on 1/3/25.

On 3/11/25 at 1158 hours, an observation of the lunch meal in the dining room and concurrent interview was conducted with Resident 70's family member. Resident 70's family member brought a piece of cake for Resident 70. Resident 70's family member stated the facility did not like the family member to bring food from

the outside because Resident 70 was on a special diet. When Resident 70's family member asked if she had received information from the facility regarding safe food handling guidelines, she stated she was not sure.

b. Review of Resident 65's medical record showed Resident 65 was admitted to the facility on [DATE REDACTED], with diagnoses which included diabetes mellitus (a disease that results with too much sugar in the blood), alcoholic liver disease (liver damage caused by long term excessive alcohol consumption), and hepatic failure (liver failure).

On 3/11/25 at 1201 hours, an observation of the lunch meal in the dining room and concurrent interview was conducted with Resident 65 using CNA 3 as a translator. Resident 65 was observed eating BBQ ribs and macaroni salad. Resident 65 stated his friend brought the food from the outside for him. When asked if his friend received information from the facility regarding safe food handling guidelines, Resident 65 stated he told his friends what foods they were allowed to bring to the facility.

c. Review of Resident 57's medical record showed Resident 57 was admitted to the facility on [DATE REDACTED], with diagnoses which included hemiplegia (paralysis on one side of the body) and hemiparesis (weakness on one side of the body) following cerebrovascular disease (medical emergency that encompasses a range of conditions affecting the brain's blood vessels and blood flow), and diabetes mellitus.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 57 of 77 555035 Department of Health & Human Services Printed: 09/04/2025 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 555035 B. Wing 03/14/2025

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)

F 0813 On 3/11/25 at 1206 hours, an observation of the lunch meal in the dining room and concurrent interview was conducted with Resident 57's family member using the Activities Director as a translator. Resident 57's Level of Harm - Minimal harm or family member had brought in pureed chicken and rice in a plastic container. When asked if Resident 57's potential for actual harm family member had received information from the facility regarding safe food handling guidelines, Resident 57's family member stated she had received information regarding Resident 57's diet. Residents Affected - Few

On 3/12/25 at 8:26 hours, an interview was conducted with RN 1. RN 1 was asked to explain the facility process for food brought to the facility from the outside. RN 1 stated they made sure the food was appropriate for the resident. When asked where the food from the outside was stored, RN 1 stated storage of

the food was not allowed; the food must be eaten in one sitting. RN 1 confirmed there was no refrigeration available for storage of outside food. RN 1 was asked how the food from the outside was heated. RN 1 showed two microwave ovens located in the dining room. One microwave oven was observed with excess food debris inside. RN 1 stated the housekeeping was responsible to clean the microwave.

On 3/12/25 at 0929 hours, an interview was conducted with the DSD. The DSD confirmed there was no staff training given regarding safe food handling guidelines.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 58 of 77 555035 Department of Health & Human Services Printed: 09/04/2025 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 555035 B. Wing 03/14/2025

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)

F 0814 Dispose of garbage and refuse properly.

Level of Harm - Minimal harm or 50953 potential for actual harm Based on observation, interview, and facility P&P review, the facility failed to ensure the facility's garbage Residents Affected - Few and refuse was properly disposed as evidence by:

* The facility failed to ensure the waste dumpsters were properly closed.

* The facility failed to ensure the organic waste and recycling refuse were handled as per state mandate SB1383.

* The facility failed to ensure trash was placed in the appropriate containers and not stored in the trash bags placed on the ground or stacked on hand carts.

These failures had the potential to cause unsafe sanitary conditions and potential to harbor pests and rodents.

Findings:

1. According to the USDA Food Code 2022, Section 5-501.113 Covering Receptacles:

Receptacles and waste handling units for refuse, recyclables, and returnables shall be kept covered. (B) With tight-fitting or doors if kept outside the food establishment,

Review of the facility's P&P titled Waste Control and Disposal (undated) showed outside garbage bin should be keep closed at all times and surrounding area must be kept clean.

On 3/11/25 at 0733 hours, during the initial tour of the facility, an observation of the facility's garbage dumpsters was conducted. One of the four dumpsters was observed with the lid open and garbage inside. Another dumpster was observed with the lid propped open by garbage, preventing the lid from fully closing.

On 3/11/25 at 1122 hours, an interview was conducted with Maintenance Director. The Maintenance Director verified the findings (via a photograph taken of the findings).

On 3/12/25 at 0638 hours, an observation of the facility's outside dumpster located in front of the facility was conducted. One of four dumpsters was observed with the lid open and garbage inside.

On 3/12/25 at 0849 hours, an interview was conducted with Maintenance Director. The Maintenance Director verified the findings (via a photograph taken of the findings).

2. Review of the Senate [NAME] (SB) 1383 regulation dated 1/1/22, showed every jurisdiction was to provide organic waste collection services to all residents and businesses. Jurisdiction includes city, county, a city and county, or a special district that provides solid waste collection services. Organic waste includes food, green material, landscape and pruning waste, organic textiles and carpets, lumber, wood, paper products, printing and writing paper, manure, biosolids, digestate, and sludges.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 59 of 77 555035 Department of Health & Human Services Printed: 09/04/2025 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 555035 B. Wing 03/14/2025

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)

F 0814 On 3/11/25 at 1122 hours, an observation and concurrent interview was conducted with Maintenance Director. One organic waste barrel was observed in the dumpster storage area with the regular trash inside. Level of Harm - Minimal harm or The Maintenance Director verified the findings. potential for actual harm

On 3/11/25 at 1146 hours, an interview was conducted with the Administrator. The Administrator verified the Residents Affected - Few facility was not collecting the organic trash.

On 3/12/25 at 0804 hours, an interview was conducted with the DSS. The DSS verified the kitchen was not collecting the organic trash.

3. Review of California State [NAME] AB 341, also called the Mandatory Commercial Recycling Regulation, requires businesses and multi-family residential dwellings of five units or more, that generate four or more cubic yards of commercial solid waste per week to implement recycling programs, on or after 7/1/12. https://calrecycle.ca.gov/recycle/commercial/

According to the USDA Food Code 2022, Section 5-501.11 Storing Refuse, Recyclables, and Returnables showed refuse, recyclables, and returnables shall be stored in receptacles or waste handling units so that

they are inaccessible to insects and rodents.

On 3/11/25 at 1146 hours, an interview was conducted with the Administrator. The Administrator verified the facility was not collecting the recycle trash.

On 3/14/25 at 0947 hours, an interview was conducted with the Administrator, RD, and DSS. The Administrator, RD, and DSS were informed and acknowledged the above findings.

39683

4. According to the USDA Food Code 2022, Section 5-501.113 Covering Receptacles:

Receptacles and waste handling units for refuse, recyclables, and returnables shall be kept covered. (B) With tight-fitting or doors if kept outside the food establishment.

On 3/13/25 at 0924 hours, an observation and interview were conducted with the Maintenance Director outside by the side of the building. The following was observed:

- More than 10 large plastic trash bags piled on the ground along the block wall; and two empty cardboard boxes (one flattened) laying on top of the bags in the rain.

- A gray wheeled trash bin with clear plastic bunched up in the bin, with a portion hanging over the top of the bin, there was no lid.

- A black plastic trash bag filled with trash next to the building, with an empty cardboard box on top of it, and

a broom propped against it.

- Two hand carts with stacked cardboard boxes. Most of the boxes were flattened.

The Maintenance Director verified the above findings were all trash/refuse, and stated the dumpsters were already full.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 60 of 77 555035 Department of Health & Human Services Printed: 09/04/2025 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 555035 B. Wing 03/14/2025

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)

F 0814 On 3/13/25 at 1054 hours, during a follow-up observation with the Maintenance Director, a pile of more than 20 large trash bags full and closed with a knot, was observed along the block wall next to a storage unit in Level of Harm - Minimal harm or the back corner of the facility. The Maintenance Director stated that was also trash. potential for actual harm

Residents Affected - Few

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 61 of 77 555035 Department of Health & Human Services Printed: 09/04/2025 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 555035 B. Wing 03/14/2025

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)

F 0842 Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 47474

Residents Affected - Few Based on interview, medical record review, document review, and facility P&P review, the facility failed to ensure the medical records were accurately maintained for eight of 24 final sampled residents (Residents 9, 40, 45, 47, 51, 52, 72, 89, and 99).

* The facility failed to ensure the respiratory care documentation for Resident 72 were accurate.

* The facility failed to ensure the side rails assessment for the risk for entrapment for Residents 9, 40, 45, 47, 51, 52, 89, and 99 were accurate.

These failures posed the risk for residents not to receive the necessary care and services as their medical records were not accurate.

Findings:

1. Review of the facility's P&P titled Charting and Documentation revised on 7/2017 showed all services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. The documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate.

Medical record review for Resident 72 was initiated on 3/11/25. Resident 72 as admitted to the facility on [DATE REDACTED], and readmitted to the facility on [DATE REDACTED].

Review of Resident 72's annual MDS dated [DATE REDACTED], showed Resident 72's cognitive skills for daily decision making was severely impaired.

Review of Resident 72's Order Summary Report for March 2025 showed the following physician orders:

- dated 11/17/24, for Trach tube type: Portex 8 uncuffed

- dated 11/17/24, to change trach tube: Portex 8 uncuffed as needed

Further review of Resident 72's Order Summary Report showed no documented evidence the resident was

on a ventilator.

Review of the Progress Notes showed the license nurses documented Resident 72 was on a ventilator on

the following dates:

- 3/7/25 at 1929 hours,

- 3/6/25 at 1714 hours,

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 62 of 77 555035 Department of Health & Human Services Printed: 09/04/2025 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 555035 B. Wing 03/14/2025

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)

F 0842 - 3/5/25 at 1725 hours,

Level of Harm - Minimal harm or - 3/4/25 at 1733 hours, potential for actual harm - 3/3/25 at 1704 hours, and Residents Affected - Few - 2/28/25 at 1711 hours.

On 3/14/25 at 1000 hours, a concurrent observation and interview was conducted with LVN 8 in Resident 72's room. LVN 8 verified Resident 72 was not on a ventilator and stated the resident had not been on a ventilator since he started working at the facility.

On 3/14/25 at 1036 hours, a concurrent interview and medical record review was conducted with RT 2. RT 2 reviewed Resident 72's discontinued orders and verified the resident's ventilator orders were discontinued on 10/16/24. RT 2 acknowledged Resident 72's progress notes showed the resident was still on a ventilator and verified the above findings. RT 2 stated Resident 72 was not on a ventilator; however, the progress notes showed the resident was on a ventilator and could be confusing. RT 2 further stated it was important to assess and document accurately.

On 3/14/25 at 1300 hours, a concurrent interview and medical record review was conducted with the DON.

The DON verified Resident 72 was not on a ventilator; however, the nurses' progress notes documentation showed the resident was still on a ventilator. The DON stated she expected the licensed nurses to have proper documentation and to assess their residents rather than assuming the subacute residents were on a ventilator.

On 3/14/25 at 1320 hours, an interview with the Administrator and DON was conducted with the Regional Director of Operations present. The Administrator and DON acknowledged and verified the above findings.

50967

2. The FDA issued a Safety Alert entitled Entrapment Hazards with Hospital Bed Side Rails (1995). Residents most at risk for entrapment are those who are frail or elderly or those who have conditions such as agitation, delirium, confusion, pain, uncontrolled body movement, hypoxia, fecal impaction, acute urinary retention, etc., that may cause them to move about the bed or try to exit from the bed. Entrapment may occur when a resident is caught between the mattress and bed rail or in the bed rail itself. Inappropriate positioning or other care related activities could contribute to the risk of entrapment.

According to the Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment, the term entrapment describes an event in which a patient/resident is caught, trapped, or entangled in the space

in or about the bed rail, mattress, or hospital bed frame. Patient entrapments may result in deaths and serious injuries. These entrapment events have occurred in openings within the bed rails, between the bed rails and mattresses, under bed rails, between split rails, and between the bed rails and head or foot boards.

The population most vulnerable to entrapment are elderly patients and residents, especially those who are frail, confused, restless, or who have uncontrolled body movement. The seven areas in the bed system where there is a potential for entrapment are:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 63 of 77 555035 Department of Health & Human Services Printed: 09/04/2025 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 555035 B. Wing 03/14/2025

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)

F 0842 - Zone 1: within the rail;

Level of Harm - Minimal harm or - Zone 2: under the rail, between the rail supports or next to a single rail support; potential for actual harm - Zone 3: between the rail and the mattress; Residents Affected - Few - Zone 4: under the rail, at the ends of the rail;

- Zone 5: between split bed rails;

- Zone 6: between the end of the rail and the side edge of the head or foot board; and

- Zone 7: between the head or foot board and the mattress end.

Review of the facility's P&P titled Bed Safety and Bed Rails dated March 2023 showed regardless of the mattress type, width, length, and/or depth, the bed frame, bed rail and mattress will leave no gap wide enough to entrap a resident ' s head or body. Any gaps in the bed system are within the safety dimensions established by the FDA, and the Maintenance Staff routinely inspects all beds and related equipment to identify the risk and problems including potential entrapment risks.

a. On 3/12/25 at 0952 hours, an observation was conducted for Resident 51. Resident 51 was observed lying in bed, awake, and alert with the bilateral half upper side rails elevated.

Medical record review for Resident 51 was initiated on 3/14/25. Resident 51 was admitted to the facility on [DATE REDACTED].

Review of Resident 51's Order Summary Report dated 3/12/25, showed the physician's order dated 10/4/23, for the bilateral upper half side rails up and locked when in bed as an enabler for positioning and ease of mobility.

On 3/14/25 at 1025 hours, a concurrent observation and interview was conducted with LVN 1. LVN 1 observed and verified the bilateral half upper side rails were elevated.

Review of Resident 51's NC - Side Rail/Entrapment/Care Plan dated 1/6/25, showed Zones 1-7 were assessed and marked as they were within the measurement guidelines of less than four and 3/4 (three quarters) of an inch.

On 3/14/25 at 1029 hours, a concurrent interview and medical record review was conducted with RN 2. RN 2 verified the entrapment assessment was inaccurate, and Zone 5 should have not been assessed since it was not applicable when there were no split bed rails.

b. On 3/11/25 at 0943 hours, during the initial tour of the facility, a concurrent observation and interview was conducted with CNA 2. Resident 52 was observed lying in bed asleep with the bilateral upper half side rails elevated. CNA 2 stated Resident 52's bilateral arms and hands were contracted and unable to grab or use

the side rails.

Medical record review for Resident 52 was initiated on 3/11/25. Resident 52 was readmitted to the facility on [DATE REDACTED].

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 64 of 77 555035 Department of Health & Human Services Printed: 09/04/2025 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 555035 B. Wing 03/14/2025

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)

F 0842 Review of Resident 52's Order Summary Report showed a physician's order dated 5/13/24, for the bilateral upper half side rails up and locked when in bed as an enabler for positioning and ease of mobility. Level of Harm - Minimal harm or potential for actual harm On 3/12/25 at 1029 hours, a concurrent observation and interview was conducted with LVN 1. LVN 1 verified Resident 52's bilateral upper half side rails were elevated. Residents Affected - Few

Review of Resident 52's NC - Side Rail/Entrapment/Care Plan dated 8/6/24, showed Zones 1-7 were assessed and marked as they were within the measurement guideline of less than four and 3/4 (three quarters) of an inch.

On 3/14/25 at 1044 hours, a concurrent interview and medical record review was conducted with RN 2. RN 2 reviewed and verified Resident 52's Entrapment assessment was inaccurate and stated Zone 5 should have not been assessed since it was not applicable when there were no split bed rails.

On 3/14/25 at 1400 hours, an interview was conducted with the DON. The DON was informed and acknowledged the above findings.

51539

e. Medical record review for Resident 47 was initiated on 3/11/25. Resident 47 was admitted to the facility on [DATE REDACTED], and readmitted on [DATE REDACTED].

Review of Resident 47's Order Summary Report 3/14/25, showed a physician's order dated 1/12/25, for the bilateral upper half side rails up and locked when in bed as enabler for positioning and ease of mobility.

Review of Resident 47's NC-Side Rail/ Entrapment Assessment/Care Plan dated 4/13/24 and 1/11/25, showed the side rails for Zones 1-7 were assessed for the entrapment and marked as they were within the guidelines of less than four and 3/4 (three quarters) of an inch.

On 3/14/25 at 1308 hours, an interview and concurrent medical record review was conducted with RN 2. RN 2 was asked if all the seven zones should have the check marks on the side rail entrapment assessment. RN 2 verified all the seven zones should not have the check marks for Resident 47 who had an order for only the bilateral upper half side rails and not the split bed rails.

On 3/14/25 at 1335 hours, an interview and concurrent medical record review was conducted with the MDS RN. The MDS RN was asked about Resident 47's NC-Side Rail/ Entrapment Assessment/Care Plan dated 4/13/24, and 1/11/25. When asked if all the zones should have been assessed for entrapment for Resident 47, the MDS RN stated no and only the zones that were applicable to the physician's order should have the check marks.

f. Medical record review for Resident 9 was initiated on 3/11/25. Resident 9 was admitted to the facility on [DATE REDACTED], and readmitted on [DATE REDACTED].

Review of Resident 9's Order Summary Report dated 3/13/25, showed a physician's order dated 1/30/25, for

the bilateral upper half side rails up and locked when in bed as an enabler for positioning and ease of mobility.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 65 of 77 555035 Department of Health & Human Services Printed: 09/04/2025 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 555035 B. Wing 03/14/2025

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)

F 0842 Review of Resident 9's NC-Side Rail/ Entrapment Assessment/ Care Plan dated 1/29/25, showed the side rails for Zones 1-7 were assessed for entrapment and marked as they were within the guidelines of less than Level of Harm - Minimal harm or four and 3/4 (three quarters) of an inch. potential for actual harm

On 3/14/25 at 1314 hours, an interview and concurrent medical record review was conducted with RN 2. RN Residents Affected - Few 2 was asked if all the seven zones should have the check marks on the NC-Side Rail/Entrapment Assessment/Care Plan dated 1/29/25. RN 2 verified all seven zones should not have the check marks for Resident 9 who had an order only for the bilateral upper half side rails and not the split bed rails.

On 3/14/25 at 1407 hours, an interview and concurrent medical record review was conducted with the MDS RN. The MDS RN was asked if all the seven zones for Resident 9 should have been assessed for entrapment on the NC-Side Rail/Entrapment Assessment/Care Plan dated 1/29/25. The MDS RN verified all

the seven zones should not have the check marks for Resident 9.

g. Medical record review for Resident 99 was initiated on 3/11/25. Resident 89 was admitted to the facility on [DATE REDACTED], and readmitted on [DATE REDACTED].

Review of Resident 99's Order Summary Report 3/13/25, showed a physician's order dated 02/24/25, for the bilateral upper half side rails up and locked when in bed as an enabler for positioning and ease of mobility.

Review of Resident 99's NC-Side Rail/ Entrapment Assessment/Care Plan dated 2/24/25, showed the side rails ' Zones 1-7 were assessed for entrapment and marked as they were within the guidelines of less than four and 3/4 (three quarters) of an inch.

On 3/14/25 at 1316 hours, an interview and concurrent medical record review was conducted with RN 2. RN 2 was asked if all the seven zones for Resident 99 should have the check marks on the NC-Side Rail/Entrapment Assessment/Care Plan dated 2/4/25. RN 2 verified all seven zones should not have the check marks for Resident 99 who had an order only for the bilateral upper half side rails and not the split bed rails.

On 3/14/25 at 1350 hours, an interview and concurrent medial review was conducted with the MDS RN. The MDS RN was asked if all the seven zones for Resident 99 should have the check marks on the NC-Side Rail/Entrapment Assessment/Care Plan dated 2/24/25. The MDS RN verified all seven zones should not have the check marked for Resident 99.

h. Medical record review for Resident 89 was initiated on 3/11/25. Resident 89 was admitted to the facility on [DATE REDACTED], and readmitted on [DATE REDACTED].

Review of Resident 89's Order Summary Report dated 3/13/25, showed a physician's order dated 8/27/24, for the bilateral upper half side rails up and locked when in bed as an enabler for positioning and ease of mobility.

Review of Resident 89's NC-Side Rail/Entrapment Assessment/Care Plan dated 8/27/24, showed the side rails for Zones 1-7 were assessed for entrapment and marked as they were within the guidelines of less than four and 3/4 (three quarters) of an inch.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 66 of 77 555035 Department of Health & Human Services Printed: 09/04/2025 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 555035 B. Wing 03/14/2025

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)

F 0842 On 3/14/25 at 1321 hours, an interview and concurrent medical record review was conducted with RN 2. RN 2 was asked if all the seven zones for Resident 89 should have the check marks on the NC-Side Level of Harm - Minimal harm or Rail/Entrapment Assessment/Care Plan dated 8/27/24. RN 2 verified all the seven zones should not have the potential for actual harm check marks for Resident 89 who had an order only for the bilateral upper half side rails and for the split bed rails. Residents Affected - Few

On 3/14/25 at 1405 hours, an interview and concurrent medial review was conducted with the MDS RN. The MDS RN was asked if all the seven zones for Resident 89 should have the check marks on the NC-Side Rail/ Entrapment Assessment/Care Plan dated 8/27/24. The MDS RN verified all the seven zones should have not the check marks for Resident 89 who had an order only for the bilateral upper half side rails and not

the split bed rails.

51352

c. On 3/11/25 at 0844 hours, an observation was conducted for Resident 45. Resident 45 was observed lying

in bed on his back with the bilateral upper half side rails elevated.

Medical record review for Resident 45 was initiated on 3/11/25. Resident 45 was admitted to the facility on [DATE REDACTED], and readmitted to the facility on [DATE REDACTED].

Review of Resident 45's Order Summary Report dated 3/14/25, showed a physician's order dated 3/1/25, for

the bilateral upper half side rails up when in bed for positioning and ease of mobility.

Review of Resident 45's NC - Side Rail/Entrapment Assessment/Care Plan dated 10/31/24, showed the recommendation for the bilateral upper half side rails was due to Resident 45's generalized muscle weakness. Additionally, the Side Rail/Entrapment Assessment showed Resident 45's bed was assessed for entrapment on Zones 1-7 and all the zones were within the measurement guidelines of less than four and 3/4 (three quarters) of an inch.

On 3/12/25 at 1411 hours, a concurrent observation and interview was conducted with LVN 1. LVN 1 verified Resident 45's bed had the bilateral upper half side rails elevated.

On 3/14/25 at 1308 hours, an interview and concurrent medical record review for Resident 45 was conducted with RN 2. RN 2 verified Resident 45's NC - Side Rail/Entrapment Assessment/Care Plan dated 10/31/24, showed the entrapment assessment was conducted for Zones 1-7. RN 2 verified the assessment was inaccurate and stated the entrapment assessment for Zone 5 should have not been assessed as it was not applicable when there were no split bed rails.

d. Medical record review for Resident 40 was initiated on 3/11/25. Resident 40 was admitted to the facility on [DATE REDACTED], and readmitted on [DATE REDACTED].

Review of Resident 40's Order Summary Report dated 3/14/25, showed a physician's order dated 2/10/25, for the bilateral upper side rails for positioning due to gravity related to involuntary movements.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 67 of 77 555035 Department of Health & Human Services Printed: 09/04/2025 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 555035 B. Wing 03/14/2025

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)

F 0842 On 3/14/25 at 1308 hours, an interview and concurrent medical record review for Resident 40 was conducted with RN 2. RN 2 verified Resident 40's NC - Side Rail/Entrapment Assessment/Care Plan dated 2/10/25, Level of Harm - Minimal harm or showed the entrapment assessment was conducted for Zones 1-7. RN 2 verified the entrapment assessment potential for actual harm was inaccurate, and stated the entrapment assessment for Zone 5 should have not been assessed as it was not applicable when there were no split bed rails. Residents Affected - Few

On 3/14/25 at 1503 hours, an interview was conducted with the Administrator and DON. The Administrator and DON were informed and acknowledged the above findings.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 68 of 77 555035 Department of Health & Human Services Printed: 09/04/2025 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 555035 B. Wing 03/14/2025

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)

F 0880 Provide and implement an infection prevention and control program.

Level of Harm - Minimal harm or 39683 potential for actual harm Based on observation, interview, medical record review, facility document review, and facility P&P review, Residents Affected - Few the facility failed to maintain the infection control program and practices to help prevent the development and transmission of diseases and infections.

* Two used mugs and a utensil were sitting on the laundry room's clean sink, and the clean linen shelf had staffs' personal belongings, hand sanitizers and lotion bottles next to the clean linen.

* The facility was not cleaning and maintaining their decorative water feature, as well as maintaining logs per

the facility's water management program.

* Residents 28, 77, 88, and 98's (nonsampled residents) infections were incorrectly listed as meeting McGeer's Criteria on the facility's monthly infection control report.

* The LVN failed to maintain infection control practices when initiating Resident 100's GT feeding.

* Hand hygiene was not performed prior to the medication administration for Resident 6.

* Basins were found in Rooms A, B and C's shared restrooms and were not labeled.

These failures resulted in inaccurate infection surveillance and/or prevention which had the potential for spread of infection in the facility.

Findings:

1. Review of the facility's P&P titled Work Practices revised 8/2008 showed the staff's belongings should not be stored in clean areas.

a. On 3/13/25 at 0924 hours, a laundry room inspection and concurrent interview was conducted with the Maintenance Director and the Laundry Staff. Two stacked mugs and one metal utensil were observed on the sink located in the laundry room. The Laundry Staff stated the dishes were used and from the staff's break.

The Maintenance Director stated the sink was considered a clean sink, and used dishes should not be placed in or on the sink.

b. During the inspection, the following was observed on the clean linen shelves located in the clean linen area:

- An umbrella was on top of the linen shelf, touching a clean blanket.

- A tote bag, water bottle and drink tumbler were on top of the clean linen shelf.

- Two hand-pump bottles of hand sanitizer and two bottles of skin moisturizer were on a shelf with clean linen. Two of the bottles were touching the clean linen.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 69 of 77 555035 Department of Health & Human Services Printed: 09/04/2025 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 555035 B. Wing 03/14/2025

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)

F 0880 The Laundry Staff stated the umbrella, tote bag, water bottle, and drink tumbler were staff's personal belongings. The Maintenance Director stated the personal belongings and hand sanitizer, and skin Level of Harm - Minimal harm or moisturizers should not be stored with the clean linen. potential for actual harm 2. Review of the facility's Water Management Program dated 2025 showed the program is designed to Residents Affected - Few reduce the risk for Legionnaires' disease and other opportunistic pathogens associated with the facility's water systems and devices. The program showed the following control point areas to be monitored and tested :

- HVAC vents will be checked monthly to ensure there is no water leaking from the vents, which could be aerosolized and inhaled by the residents.

- The decorative water fountain will be monitored and cleaned monthly.

- Water heaters and the HVAC will be checked quarterly to ensure there are no leaks, stagnant water, or biofilm collecting of fitting, in drip trays, and any other area where water can collect and stagnate.

Review of the Water Management Program showed each time a control point was checked, the date and time should be entered on a log sheet, which must be kept in a central location.

On 3/13/25 at 1054 hours, an observation, interview, and concurrent facility document review was conducted with the Maintenance Director. A water fountain feature was observed outside by the facility's front entrance.

The feature was a raised rectangular pond lined with smooth rocks at the bottom, a decorative pot with rocks spilling out, and two additional decorative pots. [NAME] residue was observed on two of the pots, and on some of the rocks spilling out of a pot. The Maintenance Director stated he did not test the water fountain, but adds a disinfectant tablet to the water monthly. The Maintenance Director stated he did not perform any other cleaning of the water fountain. When reviewing the disinfectant container used, the Maintenance Director verified the container showed to use an automatic feeder, a float, or a skimmer designed for the product. The directions showed to add the disinfectant to reach a free available chlorine level between 1-4 ppm. The Maintenance Director stated he did not test the chlorine level. When asked to review the control logs for the cleaning, inspection and maintenance of the HVAC unit, vents, and the water fountain, the Maintenance Director was unable to locate any.

3. Review of the facility's P&P titled Surveillance for Infection revised 4/2023 showed the purpose of infection surveillance is to identify cases and trends of infection, to guide appropriate interventions, and prevent future infections. The IP will gather data to determine if the resident has a healthcare-associated infection, analyze

the data trends and present the findings to the infection control committee.

On 3/13/25 at 1536 hours, a concurrent interview, medical record review, and facility document review was conducted with the IP. The IP stated the facility used McGeer's criteria to identify true infections and the data was presented to the infection control committee.

Review of the facility's Monthly Infection Surveillance Report for February 2025 showed there were 34 resident infections, with four of them not meeting criteria. The report showed Residents 28, 77, 88, and 98 had infections that not met criteria.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 70 of 77 555035 Department of Health & Human Services Printed: 09/04/2025 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 555035 B. Wing 03/14/2025

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)

F 0880 a. Resident 28's NI - Surveillance Data Collection Form (Respiratory Tract Infections) effective 2/3/25, inaccurately showed the resident's condition met McGeer's criteria for a true infection. Level of Harm - Minimal harm or potential for actual harm b. Resident 77's NI - Surveillance Data Collection Form (Respiratory Tract Infections) effective 2/25/25, inaccurately showed the resident's condition met McGeer's criteria for a true infection. Residents Affected - Few c. Resident 88's NI - Surveillance Data Collection Form (Respiratory Tract Infections) effective 2/4/25, inaccurately showed the resident's condition met McGeer's criteria for a true infection.

d. Resident 98's NI - Surveillance Data Collection Form (Respiratory Tract Infections) effective 2/6/25, inaccurately showed the resident's condition met McGeer's criteria for a true infection.

The IP verified the above residents' (Residents 28, 77, 88, and 98) dates were inaccurately reported to the infection control committee as meeting criteria when their infections did not meet criteria.

4. On 3/11/25 at 1252 hours, an observation of Resident 100's enteral tubing (connected to the enteral formula and water flush hanging on the enteral pump pole) and concurrent interview was conducted with LVN 5. Resident 100's enteral tubing was observed lying on the floor until LVN 5 entered and came to the resident's bedside at 1302 hours. LVN 5 was observed retrieving the tubing from the floor, and proceeded to connect it to the resident's GT. LVN 5 verified the tubing tip was on the floor and they should have discarded

the enteral set-up, and retrieved a new set-up before connecting it to the resident's GT.

47474

5. Review of the facility's P&P titled Handwashing/Hand Hygiene revised 5/2023 showed the facility considers hand hygiene the primary means to prevent the spread of infections. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. The P&P further showed to use an alcohol-based hand rub containing at least 62% alcohol or soap and water for the following situation including before preparing or handling medications.

On 3/12/25 at 0939 hours, a concurrent medication administration observation and interview was conducted with LVN 1 in Resident 6's room. During the medication administration, LVN 1 did not perform hand hygiene prior to administering the oral medications to Resident 6. LVN 1 verified she did not perform hand hygiene prior to administering the medications to Resident 6. LVN 1 stated she should have performed hand hygiene. LVN 1 further stated hand hygiene would prevent contamination and ensures the cleanliness.

On 3/14/25 at 1320 hours, an interview with the Administrator and DON was conducted with the Regional Director of Operations present. The Administrator and DON acknowledged and verified the above findings.

49324

6. Review of the facility's P&P titled Personal Property dated 8/2022 showed the residents' belongings are treated with respect by facility staff, regardless of perceived value.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 71 of 77 555035 Department of Health & Human Services Printed: 09/04/2025 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 555035 B. Wing 03/14/2025

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)

F 0880 On 3/11/25 at 0822 hours, an observation of Rooms A and B's shared restroom and concurrent interview was conducted with CNA 3. Residents 49 and 53 shared the restroom in Room A, while Residents 50 and 87 Level of Harm - Minimal harm or shared the restroom in Room B. In Room B's restroom, there was an unlabeled basin found on the shower potential for actual harm floor. In Room A's restroom, there was an unlabeled basin on top of the sink. CNA 3 was asked what the basins were used for. CNA 3 stated the basins were used to clean up the residents. CNA 3 verified the Residents Affected - Few basins should have been stored properly and labeled for infection prevention and control.

On 3/11/25 at 0934 hours, an observation of Room C's shared restroom and concurrent interview was conducted with CNA 4. Residents 35, 75, and 101 shared the restroom in Room C. There were three unlabeled basins piled on top of each other on a bedside commode in Room C's shared restroom. CNA 4 verified all of the basins should be stored properly and labeled for infection prevention and control.

On 3/14/25 at 1045 hours, an interview was conducted with the DON. The DON verified the basins should be labeled and stored properly.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 72 of 77 555035 Department of Health & Human Services Printed: 09/04/2025 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 555035 B. Wing 03/14/2025

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)

F 0881 Implement a program that monitors antibiotic use.

Level of Harm - Minimal harm or 39683 potential for actual harm Based on interview, medical record review, facility document review, and facility P&P review, the facility Residents Affected - Few failed to implement the antibiotic stewardship program to reduce the risk of unnecessary or inappropriate antibiotic use when one closed record sampled resident (Resident 1) and four nonsampled residents (Residents 28, 77, 88, and 98) were being treated for conditions which did not meet the McGeer's criteria.

These failures had the potential of not accurately identifying true infections and exposing the residents to unnecessary antibiotic use.

Findings:

Review of the facility's P&P titled Antibiotic Stewardship - Review and Surveillance of Antibiotic Use and Outcomes revised 4/2023 showed the IP, or designee will review all antibiotic utilization and identify specific situations that are not consistent with the appropriate use of antibiotics, and the physician will be notified of

the review findings.

Review of the facility's P&P titled Infections - Clinical Protocol revised 3/2018 showed based on clinical review, the physician and staff will identify whether antibiotics are warranted or whether antibiotics that have already been started should continue or change.

On 3/13/25 at 1536 hours, a review of the facility's documents on antibiotic stewardship, medical record review, and concurrent interview was conducted with the IP. The IP stated the facility used the McGeer's criteria to identify for the true infections. The IP stated the process was to notify the physician to evaluate the antibiotic usage for suspected infections that did not meet the McGeer's criteria and were treated with the antibiotics.

a. Review of Resident 1's NI - Surveillance Data Collection Form (UTI) with Indwelling Catheter - V1.1 effective 1/26/25, had UTI-DNMC handwritten on the printed form. The form showed the resident was started

on Levaquin (an antibiotic) medication for a UTI. The additional notes section showed the results were relayed to the physician with no antibiotics for UTI. The IP stated DNMC meant it did not meet criteria for an infection.

Review of Resident 1's medical record showed the urine culture results received on 1/29/25 at 1236 hours, showed organisms were present, with no clinical significance.

Review of Resident 1's MAR for January 2025, showed the resident completed the ordered five days of Levaquin 250 mg by mouth four times a day for UTI.

The IP verified Resident 1's medical record failed to show the physician was notified when the resident's condition did not meet the McGeer's criteria and to reevaluate the need for the use of the antibiotic medication.

b. Review of Resident 28's NI - Surveillance Data Collection Form (Respiratory Tract Infections) effective 2/3/25, showed the resident's condition met McGeer's criteria for a true infection. The form failed to show the constitutional criteria needed to meet the McGeer's criteria. The form showed Resident 28 was treated with

the cefepime (an antibiotic) medication.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 73 of 77 555035 Department of Health & Human Services Printed: 09/04/2025 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 555035 B. Wing 03/14/2025

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)

F 0881 When the IP was asked to find where they had at least one of the constitutional criteria in Resident 28's medical records, the IP verified the resident's condition did not show at least one of the constitutional criteria, Level of Harm - Minimal harm or therefore, did not meet McGeer's criteria. The IP verified they incorrectly identified it as meeting the criteria. potential for actual harm The IP stated the physician was not notified of Resident 28's condition not meeting the McGeer's criteria and would need to reevaluate the need for the use of the antibiotic medication. Residents Affected - Few c. Review of Resident 77's NI - Surveillance Data Collection Form (Respiratory Tract Infections) effective 2/25/25, showed the resident's condition met McGeer's criteria for a true infection. The form showed the constitutional criteria needed to meet the McGeer's criteria. The form showed Resident 77 was treated with

the Zosyn (an antibiotic) medication.

When the IP was asked to find where they had at least one of the constitutional criteria in Resident 77's medical records, the IP verified the resident's condition did not show at least one of the constitutional criteria, therefore, did not meet the McGeer's criteria. The IP verified they incorrectly identified it as meeting the criteria. The IP stated the physician was not notified of Resident 77's condition not meeting the McGeer's criteria and would need to reevaluate the need for the use of the antibiotic medication.

d. Review of Resident 88's NI - Surveillance Data Collection Form (Respiratory Tract Infections) effective 2/4/25, showed the resident's condition met the McGeer's criteria for a true infection. The form failed to show

the constitutional criteria needed to meet the McGeer's criteria. The form showed Resident 88 was treated with the Zosyn (an antibiotic) medication.

When the IP was asked to find where they had at least one of the constitutional criteria in Resident 88's medical records, the IP verified the resident's condition did not show at least one of the constitutional criteria, therefore, did not meet the McGeer's criteria. The IP verified they incorrectly identified it as meeting criteria.

The IP stated the physician was not notified of Resident 88's condition not meeting the McGeer's criteria and would need to reevaluate the need for the use of the antibiotic medication.

e. Review of Resident 98's NI - Surveillance Data Collection Form (Respiratory Tract Infections) effective 2/6/25, showed the resident's condition met the McGeer's criteria for a true infection. The form failed to show

the constitutional criteria needed to meet the McGeer's criteria. The form showed Resident 98 was treated with the ciprofloxacin (an antibiotic) medication.

When the IP was asked to find where they had at least one of the constitutional criteria in Resident 98's medical records, the IP verified the resident's condition did not show at least one of the constitutional criteria, therefore, did not meet the McGeer's criteria. The IP verified they incorrectly identified it as meeting the criteria. The IP stated the physician was not notified of Resident 98's condition not meeting the McGeer's criteria and would need to reevaluate the need for the use of the antibiotic medication.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 74 of 77 555035 Department of Health & Human Services Printed: 09/04/2025 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 555035 B. Wing 03/14/2025

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)

F 0908 Keep all essential equipment working safely.

Level of Harm - Minimal harm or 50953 potential for actual harm Based on observation, interview, facility document review, and facility P&P review, the facility failed to Residents Affected - Few maintain the essential equipment in a clean and safe operating condition when:

* The ice machine located in the kitchen was not clean and the manufacturer's guidelines for cleaning and sanitizing were not followed.

* The walk-in refrigerator floor was not maintained in a clean/sanitary condition.

* The microwave used to heat the resident's food was not maintained in a clean condition.

These failures had the potential for the essential equipment to not function in the way it was intended and expose residents to unsafe practices, which could lead to food borne illnesses for the residents.

Findings:

1. Review of the facility's P&P titled Ice Machine cleaning (undated) showed the ice machine bin will be cleaned and sanitized once a month. The maintenance staff will clean and sanitize the motor (evaporator) every three to six months, depending on manufacturer's recommendation.

Review of the ice machine manufacturer guidelines titled [Hoshizaki] Model KML -325/500 Instruction Manual revised date 5/13/21, showed the following instructions for Cleaning:

- Move the mode switch to the CLEAN position, then move the control switch to the ON position (one short beeps occurs, then three seconds later one long beep occur).

- When the control board starts beeping (two beeps sequence), remove the front panel. Move the control switch to the OFF position.

- Remove the front insulation panel, then pour [Hoshizaki] Scale away into the water tank.

[Model KML -325/500 - 9 fluid ounces(266 ml) Scale away]

- Move the control switch to the ON position (one short beep occurs, then three seconds later one long beep occurs). Replace the front panel. To avoid excessive foaming in the water tank, there is a one minute delay

before circulation begins. After approximately 30 minutes of circulation, the ice maker performs three rinse cycle.

- When the control board start beeping (five beep sequence), remove the front panel. Move the control switch to the OFF position.

Sanitizing:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 75 of 77 555035 Department of Health & Human Services Printed: 09/04/2025 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 555035 B. Wing 03/14/2025

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)

F 0908 - Confirm the mode switch is in the CLEAN position, then move the control switch to the ON position (one short beeps occurs, then three seconds later one long beep occur). Replace the front panel. The water tank Level of Harm - Minimal harm or drains and then fills. potential for actual harm - When the control board starts beeping (two beeps sequence), remove the front panel. Move the control Residents Affected - Few switch to the OFF position.

- Remove the front insulation panel then pour 7.5% Sodium Hypochlorite solution (chlorine bleach) into the water tank.

- Move the control switch to the ON position (one short beep occurs, then three seconds later one long beep occurs). Replace the front panel. To avoid excessive foaming in the water tank, there is a one minute delay

before circulation begins. After approximately 30 minutes of circulation, the ice maker performs three rinse cycle.

- When the control board start beeping (five beeps sequence), remove the front panel. Move the control switch to the OFF position

- Clean the dispenser unit/ice storage bin liner using a neutral cleaner. Rinse thoroughly after cleaning.

On 3/11/25 at 1043 hours, an observation of the ice machine and concurrent interview was conducted with

the Maintenance Director, RD, and DSS. When the Maintenance Director was asked about the cleaning of

the ice machine, the Maintenance Director stated he cleaned the ice machine once a month. The Maintenance Director stated he used [Nucalgon] cleaner to clean the ice machine. The Maintenance Director stated he put the [Nucalgon] cleaner into the machine and ran the clean cycle. The internal hose was removed and cleaned using a brush and hot water. The ice machine chute (the channel through which ice was dispensed) was cleaned and sanitized on 2/28/25, with Pure Bright Germicidal Ultra Bleach 6% Sodium Hypochlorite. Upon inspection of the ice machine internal components, the chute had a black residue (with picture taken). The Maintenance Director verified the findings. The DSS stated the ice machine storage bin was cleaned with the bleach and rinsed with water.

2. According to the USDA Food Code 2022 Annex 3 Section 4-201.11 Equipment and Utensils showed Equipment and utensils must be designed and constructed to be durable and capable of retaining their original characteristics so that such items can continue to fulfill their intended purpose for the duration of their life expectancy and to maintain their easy cleanability. If they cannot maintain their original characteristics,

they may become difficult to clean, allowing for the harborage of pathogenic microorganisms, insects, and rodents.

On 3/11/25 at 0800 hours, during the initial tour of the kitchen with DSS, the walk-in refrigerator floor was observed with gray paint that was excessively worn exposing the cement floor surface.

On 3/12/25 at 0847 hours, an interview was conducted with the Maintenance Director. The Maintenance Director confirmed there was no communication log between the Dietary and Maintenance department for any Dietary concerns. Furthermore, the Maintenance Director confirmed there was no communication regarding the walk-in refrigerator floor condition.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 76 of 77 555035 Department of Health & Human Services Printed: 09/04/2025 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 555035 B. Wing 03/14/2025

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)

F 0908 On 3/12/25 at 0859 hours, an observation of the kitchen walk-in refrigerator and concurrent interview was conducted with the Maintenance Director. The Maintenance Director confirmed the walk-in refrigerator floor Level of Harm - Minimal harm or was in need of repair, and he was not aware of the condition of the floor. The Maintenance Director agreed potential for actual harm the walk-in refrigerator floor was not a cleanable surface.

Residents Affected - Few 3. On 3/12/25 at 0826 hours, an observation of one of two microwaves located in the dining room, used to heat the residents' food brought from the outside and concurrent interview was conducted with RN 1. The microwave was dirty with excess food debris. RN 1 verified the findings and stated she was not sure who was responsible to clean the microwave.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 77 of 77 555035