Park Vista At Morningside

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

1508 hours, an interview was conducted with LVN 2. LVN 2 stated Resident 1's skin tear was being monitored. When asked how the wound was monitored, LVN 2 stated no complaints of pain and was observed for redness. When asked if the foam dressing was opened, LVN 2 stated no, we did not open it unless there was a lot of drainage. When asked how the wound was being monitored if the foam dressing was not removed, LVN 2 stated we monitor around the foam dressing, monitor for increased discharge, and monitor for pain. On 9/4/25 at 1556 hours, an interview and concurrent medical record review was conducted with Treatment Nurse 1. Treatment Nurse 1 stated Resident 1 was observed with a foam dressing on her right lower leg. When asked if a treatment was rendered, Treatment Nurse 1 stated when I saw it, it was covered with a foam dressing, I lifted it up, cleansed with normal saline, and covered it with a foam dressing. When asked what the physician's treatment order for Resident 1's wound, Treatment Nurse 1 stated she assumed the treatment included cleaning the wound because that was what the facility would normally do. Treatment Nurse 1 verified there were no cleansing orders, and stated Resident 1's wound orders were not complete and should have been clarified. On 9/16/25 at 1422 hours, the Administrator was made aware and acknowledged the above findings.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/16/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Park Vista at Morningside

2525 Brea Blvd.

Fullerton, CA 92835

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 0689 Level of Harm - Actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

was assessed, the physician was notified, treatment was obtained and provided, and the resident was monitored. The documentation was not initiated until 9/4/25 at 1830 hours, approximately 30 hours later. On 9/10/25 at 1119 hours, an interview was conducted with Treatment Nurse 1. Treatment Nurse 1 stated CNA 4 had notified her on 9/3/25, close to 1300 hours, of the incident when Resident 4 had spilled hot tea onto her lap and her clothes were warm. When asked if that would be considered a change in condition, Treatment Nurse 1 stated yes. When asked what the process for a change of condition, Treatment Nurse 1 stated to inform the physician and the resident's family, document, provide the treatment as ordered by the physician, and monitor the resident. Treatment Nurse 1 verified there were no documentation to show a change of condition was initiated on 9/3/25, for Resident 4. On 9/11/25 at 0955 hours, a telephone interview was conducted with RN 2. RN 2 stated on 9/3/25, when she was notified of Resident 4 spilling hot tea on her thigh. RN 2 stated she assessed her skin, noticed slight redness, and was informed by Treatment Nurse 1 that she applied ice to the area. When asked what Resident 4's leg looked like on the second day, RN 2 stated she developed blisters. When asked what type of burn Resident 4 had, RN 2 stated on the first day it was redness, on the second day it was second to third degree burns. RN 2 verified the physician should have been notified on 9/3/25.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/16/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Park Vista at Morningside

2525 Brea Blvd.

Fullerton, CA 92835

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 0695

Provide safe and appropriate respiratory care for a resident when needed.

Level of Harm - Minimal harm or potential for actual harm

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility P&P review, the facility failed to ensure the necessary respiratory care services were provided for one of nine sampled residents (Resident 2). * The facility failed to ensure Resident 2 was provided with the continuous oxygen via nasal cannula and Resident 2's oxygen saturation was maintained greater than 92% as ordered by the physician. These failures had the potential for the resident to not receive the necessary respiratory services and negatively impact the resident's well-being.Findings: Review of the facility's P&P titled Physicians Orders and Telephone Orders dated 11/2017 showed the physicians orders shall be obtained prior to the administration of any medication or treatment from a personal lawfully authorized to prescribe for and treat human illness. All orders must be specific and complete and no standing orders shall be accepted. All orders shall be specific and complete with all the necessary details to carry out the prescribed order without any question. Medical record review for Resident 2 was initiated on 8/27/25. Resident 2 was admitted to the facility on [DATE REDACTED], and transferred to

an acute care facility on 8/27/25. Resident 2's diagnosis included lung cancer, acute and chronic respiratory failure with hypoxia (condition where there is an inadequate supply of oxygen to the body's tissues) and dependence on supplemental oxygen. Review of Resident 2's Order Summary Report showed a physician's order dated 8/25/25, to administer oxygen at two to five liters per minute via nasal canula to keep the oxygen saturation greater than 92% every shift. Review of Resident 2's Weights and Vitals Summary showed the oxygen saturation on the following dates and times:- dated 8/26/25 at 1006 hours, 92% on room air;- dated 8/26/25 at 1709 hours, 92% oxygen via nasal cannula; and- dated 8/27/25 at 0323 hours, 93% on room air. Review of Resident 2's Progress Note dated 8/27/25, showed Resident 2 was desaturating with an oxygen saturation of 93% at 0430 hours to 51% at 0520 hours. Resident 2 was sent to

an acute care facility via paramedics. On 9/11/25 at 1248 hours, an interview and concurrent medical

record review was conducted with RN 1. RN 1 verified Resident 2's order showed to keep Resident 2 on continuous oxygen, and the oxygen should remain on at all times. RN 1 verified the oxygen should have been titrated to maintain an oxygen saturation greater than 92% as per the physician's orders . On 9/16/25 at 1422, the Administrator was made aware and acknowledged the above findings.

Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/16/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Park Vista at Morningside

2525 Brea Blvd.

Fullerton, CA 92835

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 Level of Harm - Potential for minimal harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

relevant information for the provider, including (for example) information prompted by the Interact SBAR Communication Form, and4. Except in medical emergencies, notifications will be made within twenty-four (24) hours of a change occurring in the resident's medical/mental condition or status. Medical record review for Resident 4 was initiated on 9/9/25. Resident 4 was admitted to the facility on [DATE REDACTED]. Review of Resident 4's Progress Note dated 9/4/25, showed at approximately 1830 hours, CNA alerted the charge nurse and RN supervisor of the redness on Resident 4's left upper thigh while providing care to the resident. The note further showed Resident 4 had blisters on her left thigh. Review of Resident 4's Interdisciplinary Progress Note dated 9/5/25, showed during the routine care on 9/4/25, the assigned CNA observed blisters to Resident 4's left upper thigh. The charge nurse and RN supervisor evaluated the resident and observed three blisters to the resident's left upper thigh and the surrounding skin was intact. The note further showed

on 9/3/25, during the lunch time in the main dining room, Resident 4 spilled warm tea on her lap and upon returning to the resident's room, Resident 4 was evaluated by the nursing staff and noted slight redness to her left upper thigh to which an ice was applied to the area. Review of Resident 4's medical record failed to show any documentation regarding the incident when Resident 4 had spilled hot tea on her left thigh on 9/3/25. On 9/10/25 at 1119 hours, an interview was conducted with Treatment Nurse 1. Treatment Nurse 1 stated CNA 4 had notified her on 9/3/25, close to 1300 hours regarding Resident 4 had spilled hot tea onto her lap, and her clothes were warm. When asked if that would be considered a change in condition, Treatment Nurse 1 stated yes. When asked if a change of condition was initiated for Resident 4 on 9/3/25, Treatment Nurse 1 stated no. On 9/11/25 at 0955 hours, a telephone interview was conducted with RN 2.

RN 2 stated she forgot to document and she had endorsed it to Treatment Nurse 1. On 9/12/25 at 0950 hours, an interview and concurrent medical record review was conducted with the MDS Nurse. The MDS Nurse verified Resident 4's medical record did not show any documentation when Resident 4 spilled hot tea on her left thigh on 9/3/25. Cross reference to F-F689.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/16/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Park Vista at Morningside

2525 Brea Blvd.

Fullerton, CA 92835

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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

removing the old dressing and to throw away the unused and contaminated gauze. On [DATE REDACTED] at 1523 hours, an interview was conducted with the DON. The DON acknowledged the expired hand sanitizer should have been discarded. The DON stated the process for proper hand hygiene while providing wound care would be to perform hand hygiene after removing the soiled dressing. The DON stated any unused disposable supplies would be disposed of if they were brought into a resident's room. 2. On [DATE REDACTED] at 1209 hours, an observation was conducted for CNA 4 delivering the lunch trays. a. CNA 4 was observed holding

a lunch tray, placed the lunch tray on top of the contact isolation cart outside the room, and donned an isolation gown before entering Resident 4's room. CNA 4 placed the lunch tray on Resident 4's bedside table, with bare hands moved Resident 4's bedside table around to accommodate Resident 4's sitting position and then removed the lids from her plateware. CNA 4 proceeded to place the lids of the plateware

on top of the isolation cart outside the resident's room and washed her hands inside Resident 4's room.

However, after performing hand hygiene, CNA 4 grabbed the same lid on top of the isolation cart outside Resident 4's room and placed it on top of the lunch cart. CNA 4 then grabbed another lunch tray and delivered it to Resident 7 without performing hand hygiene. b. On [DATE REDACTED] at 1219 hours, CNA 4 was observed entering Resident 6's contact isolation room with an isolation gown with no gloves on to deliver a lunch tray to Resident 6. CNA 4 was observed touching Resident 6's bedside table, adjusting the height of

the bed and adjusting Resident 6's blanket with no gloves on. CNA 4 then proceeded to feed Resident 6 without performing hand hygiene. On [DATE REDACTED] at 1247 hours, an interview was conducted with CNA 4. CNA 4 stated the policy for the PPE for a contact isolation room would include wearing the gown and gloves. On [DATE REDACTED] at 1325 hours, a follow up interview was conducted with CNA 4. When asked if she wore gloves when dropping off the lunch trays and entering a contact isolation rooms, CNA 4 stated, no and only when working with the residents. When asked what the proper hand hygiene practices would be for contact isolation was, CNA 4 stated to wash hands. CNA 4 acknowledged she did not use the proper PPE and perform hand hygiene practices when entering contact isolation rooms. On [DATE REDACTED] at 1550 hours, an

interview was conducted with the DON. The DON stated the process for entering the contact isolation rooms would include hand washing or sanitizing and wearing a gown and gloves. The DON stated after leaving an isolation room, hand hygiene should be performed. The DON was made aware and acknowledged the above findings. On [DATE REDACTED] at 1422 hours, the Administrator was made aware and acknowledged the above findings.

Event ID:

Facility ID:

If continuation sheet