Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Buena Park Nursing Center during CMS and state inspections, most recent first.
A resident with a left hand mitten restraint ordered to prevent pulling out a GT had a care plan and facility policy requiring the mitten to be released every two hours for circulation, comfort, and exercise. Record review showed only shift-level monitoring of mitten placement, with no documentation that the mitten was released every two hours as care-planned. An RN confirmed the protocol to remove the mitten every two hours and assess circulation and skin, but acknowledged there was no corresponding order or documentation showing these checks were performed.
A resident with glaucoma and no decision-making capacity had multiple missed doses of ordered ophthalmic medications, including Refresh Plus, Timoptic, and Lumify. MAR review showed numerous administrations not given, some coded as held or to see progress notes without clear reasons, and others marked as awaiting pharmacy delivery or out of stock. Nursing documentation reflected calls to the pharmacy but did not show that the physician was notified of the repeated missed doses. During interviews, RN staff acknowledged that charge nurses were responsible for timely refill requests and that the physician should have been informed when medications were not administered as ordered.
A resident who lacked decision-making capacity experienced a fall, but staff did not update the care plan to address this incident. Review of the medical record and interviews with an RN and the DON confirmed that no care plan problem or intervention was developed for the fall, despite facility policy requiring care plan updates after such events.
Two residents did not receive necessary care and monitoring as required by physician recommendations and facility policy. One resident did not have a recommended medication initiated, did not receive neurological checks after a fall, and was not monitored for orthostatic hypotension while on Seroquel. Another resident did not receive neurological checks after an unwitnessed fall, despite documentation indicating they should have. These deficiencies were confirmed by staff interviews and record reviews.
A resident who lacked decision-making capacity was administered Ativan for anxiety without documented informed consent, as required by facility policy. Staff confirmed that when the medication was reordered after an initial period, the necessary informed consent process was not completed, and this was acknowledged by the DON.
The facility did not ensure consistent and accurate posting of Enhanced Barrier Precaution (EBP) signs for multiple residents colonized with MDROs, leading to staff confusion about required PPE. Staff interviews revealed uncertainty about the meaning of different colored isolation signs and the appropriate use of masks and gowns, while training records lacked evidence of specific instruction on these distinctions. These failures resulted in improper infection control practices for residents on EBP.
A resident with complex medical needs, including diabetes and gastroparesis, did not receive enteral feeding and medication through the correct ports of a GJ tube as ordered by the physician. Facility staff were unable to identify the G and J ports, did not notify the physician when unable to verify port placement, and had not received in-service training on GJ tube care. Additionally, there was no physician's order for the maintenance or discontinuation of the G tube drainage bag, resulting in the resident's transfer to an acute care hospital after the J tube became clogged and the resident experienced severe hypoglycemia.
A facility failed to ensure a POLST was signed and dated by a physician for a resident who lacked decision-making capacity. The POLST was incomplete, missing the healthcare provider's signature and date. Additionally, the facility did not provide an Advance Directive Acknowledgement form to the resident or their representative, as confirmed by staff interviews and medical record reviews.
The facility failed to complete PASRR screenings for two residents, leading to potential gaps in care. A resident readmitted after a hospital stay did not receive a new Level 1 PASRR screening, despite a recent depression diagnosis. Another resident, diagnosed with mild depression and prescribed mirtazapine, did not have a PASRR Level 1 Screening Resident Review Status Change performed. Staff confirmed these oversights, acknowledging the need for updated screenings to ensure appropriate care and resources.
The facility failed to develop comprehensive care plans for two residents, leading to potential risks. One resident did not have a care plan for the use of elevated side rails, despite a physician's order. Another resident's care plan did not address their preference for a high bed, which increased the risk of falls. Staff confirmed the lack of appropriate care plans and interventions for these issues.
The facility failed to prevent pressure ulcers and ensure proper care for several residents. A resident developed a new blister that was not assessed or treated appropriately. Additionally, the facility did not consistently monitor and adjust the settings of low air loss (LAL) mattresses according to residents' weights, leading to incorrect settings for three residents. These deficiencies were confirmed by staff observations and interviews.
A facility failed to ensure a resident's GT feeding was properly connected, resulting in the feeding dripping onto the floor. The resident had a physician's order for continuous enteral feeding, but during an observation, it was found disconnected. Staff suggested the disconnection might have occurred after dialysis or during a shower. The issue was verified by RN and LVN, and the Administrator and DON were informed.
The facility failed to provide appropriate respiratory care for several residents, including incorrect oxygen administration, lack of required signage, and improper storage of respiratory equipment. These deficiencies were confirmed through observations and staff interviews.
A facility failed to provide appropriate dialysis care for a resident with ESRD by not completing required dialysis communication forms. The facility's P&P required pre- and post-dialysis checklists to be completed, but multiple entries were left blank. An LVN confirmed the oversight, acknowledging the forms should have been filled out.
The facility failed to ensure resident safety by not attempting alternatives or obtaining informed consent before using bed rails for two residents. One resident with impaired cognition used grab bars without documented consent or alternatives, while another with seizures had no assessment for entrapment risk or informed consent. Staff confirmed these omissions, posing potential entrapment risks.
A facility failed to administer medications via GT by gravity as per policy and did not check a resident's bowel pattern before giving a stool softener. An LVN used a syringe to push medication through the GT and relied on inaccurate verbal reports instead of reviewing the resident's documented history of loose stools.
A facility failed to monitor a resident's blood pressure and heart rate before administering amlodipine and losartan, as prescribed. The resident's physician orders required holding the medications if the systolic blood pressure was below 110 mmHg or the heart rate was below 60 bpm. From November 1 to 19, there was no documented evidence of these checks, confirmed by an RN during a review.
The facility failed to ensure that two residents were free from unnecessary medications. A resident was prescribed zolpidem without a 14-day stop date, and another was given quetiapine fumarate without a documented diagnosis or clinical rationale. These issues were confirmed by facility staff during interviews.
The facility failed to ensure safe storage and management of medications, with expired medications found in a medication room and carts, unauthorized bedside storage of antifungal cream, and improper disposal of controlled substances. Additionally, medication carts contained expired supplies and improper storage of items, risking cross-contamination and unsafe administration.
The facility failed to follow food safety and sanitation guidelines, including improper air-drying of a blender, use of corroded frying pans, and staff's lack of knowledge on proper food cooling procedures. Additionally, the storage area for water pitchers and cups was unsanitary. These issues were acknowledged by staff and reported to the DON and administrator.
The facility failed to label and date food items in a resident refrigerator, as required by their policy. During an observation, an RN and an LVN found several unlabeled and undated food items, including yogurts, cookies, kimbap, soy milk, a dirty Tupperware, and a jar of chia seeds. The RN confirmed that food should be labeled and dated, and noted that staff should not store their food in the resident's refrigerator. The refrigerator was also found to be dirty and sticky.
The facility failed to maintain accurate medical records for three residents, leading to discrepancies in health care directives and assessments. A resident's POLST was not updated to reflect their advance directive, another resident's record contained conflicting information about an advance directive, and a third resident's smoking assessment and care plan were incomplete and inaccurate. These issues were confirmed by facility staff.
An LVN failed to change gloves and PPE between administering medications to two residents on enhanced barrier precautions, risking infection transmission. The residents had conditions requiring specific precautions, and the LVN acknowledged the oversight.
The facility failed to notify physicians when residents were prescribed antibiotics without meeting McGeer's Criteria for a true infection. This oversight involved multiple residents over several months, despite the facility's policy to promote appropriate antibiotic use. The Infection Preventionist confirmed that physicians were not informed, potentially leading to unnecessary antibiotic use and associated risks.
The facility failed to ensure proper calibration and quality control of glucometers, with missing entries and discrepancies in records for devices in Medication Carts A, F, and D. These lapses were confirmed by LVNs and the DON, potentially leading to inaccurate blood glucose readings for residents.
A resident's call light was found out of reach, contrary to the facility's policy requiring it to be easily accessible. The resident, who was dependent on staff for care due to medical conditions, was unable to summon help when needed. An LVN confirmed the call light's inaccessibility, acknowledging the resident's occasional use of it for assistance.
The facility failed to maintain a clean and homelike environment, as observed in several resident rooms. In one room, the door frame casings were in disrepair, with cracks, scratches, and missing paint, which the DON acknowledged might have been caused by resident beds. Additionally, curtains in four other rooms were found to be yellowish stained and dirty, a condition confirmed by an LVN who noted they needed changing. These issues posed a risk for unsanitary and unsightly conditions, potentially affecting residents' quality of life.
A resident on anticoagulant medication was not properly assessed or monitored for bruises reported by a CNA. Despite the facility's policy requiring assessment and physician notification for changes in condition, there was no documentation or care plan developed for the bruises. The DON and ADON confirmed the lack of adherence to the facility's policy.
A resident was subjected to the use of hand mittens as physical restraints without obtaining informed consent or a physician's order, and without a care plan addressing their use. The facility's policy requires informed consent and a physician's order for restraints, which were not documented in this case. The resident had severely impaired cognitive skills, and the deficiency was confirmed by an RN during an interview.
A resident's room was found with a disconnected portable AC unit tubing lying on the floor, covered in dust, during a survey. The Maintenance Assistant was unaware of the disconnection and admitted to not cleaning the unit per guidelines. The facility's policy requires maintaining a clean environment, which was not followed.
A resident's sexual abuse allegation against a CNA was not reported to the appropriate authorities in a timely manner, as required by the facility's policy. The incident was reported to RN 1 on a specific date, but the Administrator and DON were not informed until three days later, resulting in a delay in notifying the CDPH L&C Program, Ombudsman office, and law enforcement.
A resident reported a sexual abuse allegation against a CNA, but the facility failed to investigate the claim promptly. The incident was reported to an RN, who did not notify the Administrator or DON as per policy, resulting in the CNA continuing to work and interact with the resident until the investigation began three days later. This delay potentially increased the risk of further abuse.
Failure to Follow Care Plan for Hand Mitten Restraint Use
Penalty
Summary
Surveyors identified that the facility did not follow the care plan and policy for restraint use for one resident who had a physician’s order for a left hand mitten due to persistent pulling out of a gastrostomy tube (GT). The facility’s Physical Restraints policy, revised 1/2017, required that when restraints are used, the resident must be provided with motion and exercise for at least 10 minutes during each two-hour period. The resident’s care plan for use of the left hand mitten, initiated on 3/10/25 and revised on 11/9/25, included an intervention to apply the left hand mitten to prevent pulling out the tube and to release it every two hours for 15 minutes for circulation and comfort. Review of the resident’s medical record, including the MAR for March 2025, showed that the left hand mitten placement was monitored every shift from 3/10 to 3/31/25, but there was no documented evidence that the mitten was released every two hours as required by the care plan. During an interview and concurrent record review, an RN stated that the facility protocol for hand mitten restraints was to remove them every two hours and check circulation and skin condition, but confirmed that there was no physician order to monitor circulation and skin condition every two hours and no documentation that the mitten was released every two hours for circulation and comfort. The Administrator was informed of and acknowledged these findings.
Failure to Provide and Document Ordered Ophthalmic Medications
Penalty
Summary
The facility failed to provide ordered ophthalmic medications for a resident and did not ensure timely administration or appropriate documentation when doses were missed. The resident, who had glaucoma and no capacity to understand or make decisions, had physician orders for Refresh Plus eye lubricant every two hours for dry eyes and ocular surface irritation, Timoptic (timolol) twice daily for uncontrolled primary open angle glaucoma, and Lumify (brimonidine tartrate) twice daily for ocular hyperemia. Review of the MAR showed multiple missed doses of these medications. On one date, Refresh Plus was coded as held and as not given due to vitals being outside parameters, but the progress notes did not document the reason or specify what parameters were not met. On subsequent dates, Refresh Plus was not administered numerous times over two days, with MAR notes indicating the facility was awaiting medication from the pharmacy. Further review showed that Timoptic was not administered at scheduled times on two separate dates, with one entry lacking any documented reason and another indicating the facility was awaiting delivery. Lumify was also not administered at a scheduled time, and nursing notes documented multiple follow-up calls to the pharmacy, which reported it did not have Lumify in stock. There was no documentation that the physician was notified of the multiple missed doses of these ordered medications. During interviews, RN 1 confirmed that charge nurses were responsible for requesting refills five days before medications ran out and acknowledged that the physician should have been informed when medications were not administered as ordered. The DON and Administrator were informed of and acknowledged these findings.
Failure to Develop Individualized Care Plan After Resident Fall
Penalty
Summary
The facility failed to develop an individualized care plan to address a resident's actual fall incident that occurred on 11/22/24. Review of the resident's medical record showed that the resident was found on the floor on the right side of the bed in a side-lying position. The resident's history and physical examination indicated that the resident lacked the capacity to understand and make decisions. Despite this incident, the resident's plan of care did not include a problem or intervention related to the fall. Interviews with facility staff, including an RN and the DON, confirmed that there was no care plan developed to address the resident's fall. The facility's policy on comprehensive care planning requires that the plan of care include measurable objectives and timeframes and describe the services to be provided to maintain the resident's highest practicable level of well-being. The DON acknowledged that it was the responsibility of the licensed nurse to update the care plan with each change of condition, which was not done in this case.
Failure to Follow Physician Orders and Complete Required Monitoring After Falls
Penalty
Summary
The facility failed to provide necessary care and services for two residents by not following physician recommendations and not completing required monitoring after incidents. For one resident, a psychiatric evaluation recommended starting Depakote for poor impulse control, but there was no documentation that this recommendation was communicated to or obtained from the physician, and the medication was not initiated. Additionally, after this resident experienced a fall, the medical record did not show evidence that neurological checks were performed as documented in the progress note, despite facility policy and staff statements indicating that such checks should be completed for 72 hours post-fall. The same resident was later prescribed Seroquel for mood disturbance, with informed consent obtained from the responsible party. However, there was no documented evidence that orthostatic hypotension monitoring was implemented, even though this is a known side effect of Seroquel and was acknowledged as necessary by the DON. The lack of monitoring for orthostatic hypotension was verified during interviews and record reviews with facility staff. For a second resident, after an unwitnessed fall, the progress note and IDT recommendation indicated that neurological checks should be performed for 72 hours. However, the medical record did not contain documentation that these checks were initiated. Both RN 1 and the DON confirmed that neurological checks were not completed as required, despite the resident's lack of capacity to make decisions and the facility's policy to monitor for changes in neurological status after a fall.
Failure to Obtain Informed Consent for Psychotropic Medication
Penalty
Summary
The facility failed to obtain informed consent for the administration of a psychotropic medication, Ativan, for one resident. According to the facility's policy and procedure on psychotherapeutic drug treatment, informed consent must be obtained from the resident or their representative prior to the use of such medications, including providing information about the need for the medication, its desired effects, and potential side effects. The resident in question was determined to lack capacity to make decisions, and a physician's order was given to administer Ativan for anxiety. However, a review of the resident's medical record did not show any documented evidence that informed consent was obtained for the use of Ativan as ordered. Interviews with facility staff, including an RN and the DON, confirmed that a new informed consent was not obtained when the Ativan medication was ordered. The Ativan prescription was not renewed after an initial 14-day period, and when it was reordered, the required informed consent process was not completed. This failure was acknowledged and verified by the DON during the survey.
Failure to Implement Consistent Enhanced Barrier Precautions and Staff Training
Penalty
Summary
The facility failed to implement effective infection control practices for seven non-sampled residents who were under Enhanced Barrier Precautions (EBP) due to colonization with multidrug-resistant organisms (MDROs) such as CRE, C. auris, and CRAB. Observations revealed that EBP signs posted outside resident rooms were inconsistent and, in some cases, incorrect. For example, one room displayed a red sign requiring staff to wear an N-95 mask for a resident with CRE, which was not necessary according to facility policy. Other rooms had both standard EBP signs and additional colored signs (red or pink), each listing different PPE requirements, leading to confusion among staff. Interviews with staff, including LVNs, CNAs, RNs, and the Infection Preventionist (IP), demonstrated a lack of understanding regarding the meaning and requirements of the different colored isolation signs. Some staff incorrectly believed that an N-95 mask was required for EBP precautions, while others could not distinguish between the red and pink signs or their associated PPE protocols. The IP confirmed that the red and pink signs were intended to indicate additional infections and PPE needs but acknowledged that the signage was not always accurate and that staff training on the distinction between the signs was insufficient. Further review of training records showed that while staff had received general in-service training on EBP precautions, there was no documentation of specific training on the differences between the red and pink isolation signs. The lack of clear, consistent signage and inadequate staff training on EBP protocols resulted in improper implementation of infection control measures for residents colonized with MDROs.
Failure to Provide Appropriate GJ Tube Care and Adhere to Physician Orders
Penalty
Summary
The facility failed to provide necessary enteral care and services to a resident with a GJ tube, resulting in the resident receiving enteral feeding through the incorrect port. Staff were unable to accurately identify the G and J ports of the GJ tube, and as a result, enteral feeding was administered through the G tube port instead of the J tube port as ordered by the physician. Additionally, medications were administered through the incorrect port, and staff did not notify the physician when they were unable to verify the correct ports. The staff also did not receive in-service training on the care and management of a resident with a GJ tube prior to being assigned to the resident. The resident in question had significant medical needs, including diabetes, gastroparesis, ventilator-dependent respiratory failure, and was dependent on staff for activities of daily living. The resident was admitted with a GJ tube, with physician orders specifying that enteral feeding should be administered through the J tube port and medications through the G tube port. Despite these orders, staff were unable to confirm the correct port for feeding and medication administration, and did not seek clarification from the physician or other clinical leaders. The ports on the GJ tube were not labeled, contributing to the confusion among staff. Furthermore, the facility failed to obtain a physician's order for the maintenance and discontinuation of the G tube drainage bag. The resident was admitted with a drainage bag attached to the G tube port, but there was no documentation of a physician's order for its use or discontinuation. These failures led to the resident's transfer to an acute care hospital for medical intervention after the J tube became clogged, and the resident experienced a critical drop in blood sugar level.
Incomplete POLST and Missing Advance Directive Acknowledgement
Penalty
Summary
The facility failed to ensure that a Physician Orders for Life-Sustaining Treatment (POLST) form was signed and dated by a physician, nurse practitioner (NP), or physician assistant (PA) for a resident who lacked the capacity to understand and make decisions. The POLST, dated 7/24/24, was incomplete in the Information and Signatures section, lacking the necessary documentation of the healthcare provider's name and date signed. This oversight was confirmed during an interview and medical record review with RN 1, who acknowledged the absence of the required signature and date on the POLST. Additionally, the facility did not provide an Advance Directive Acknowledgement form to the resident or their representative, which is used to offer information about advance directives. This was verified by both RN 1 and the Social Services Director (SSD), who confirmed the absence of the form in the resident's medical record. The Administrator and Director of Nursing (DON) also verified these findings during an interview, acknowledging the lack of documentation for both the POLST and the Advance Directive Acknowledgement form.
Failure to Complete PASRR Screenings for Residents
Penalty
Summary
The facility failed to ensure the completion of PASRR screenings for two residents, leading to potential gaps in care for mental illness or intellectual disabilities. Resident 76 was readmitted to the facility after a hospital stay exceeding 72 hours, which should have triggered a new Level 1 PASRR screening according to the facility's policy. However, the medical record showed no evidence of a PASRR being completed upon readmission, despite the resident's recent diagnosis of depression. Interviews with the LVN and ADON confirmed the oversight, acknowledging that the PASRR should have been updated to ensure appropriate care and resources were provided. Similarly, Resident 61 was diagnosed with mild depression and prescribed mirtazapine after the initial PASRR Level 1 screening indicated no serious mental illness or psychotropic medication use. Despite this change in mental health status, a PASRR Level 1 Screening Resident Review Status Change was not performed. The DON confirmed that the screening should have been updated to reflect the resident's new diagnosis and medication, which would have ensured the facility provided the necessary care for the resident's mental health needs.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop a comprehensive care plan for two residents, which posed a risk for not providing appropriate and individualized care. For Resident 73, the facility did not create a care plan to address the use of elevated side rails, despite a physician's order for bilateral grab bars for bed mobility and repositioning. During an interview, RN 1 confirmed that a care plan specific to the use of side rails was not developed for Resident 73, even though the resident utilized the grab bars to get up in bed. For Resident 88, the care plan did not address the resident's preference for a high bed, which was contrary to the intervention of maintaining the bed in the lowest or locked position to prevent falls. Despite the resident's noncompliance and preference for a high bed, no interventions or alternatives were offered to mitigate the risk of falls. RN 3, LVN 7, and CNA 3 acknowledged the resident's preference and the absence of floor mats, confirming that no care plan was developed to address the resident's noncompliance and risk of falls.
Failure to Monitor and Adjust LAL Mattress Settings and Address Pressure Ulcers
Penalty
Summary
The facility failed to provide necessary care and services to prevent pressure ulcers for several residents, including Resident 334, who developed a new blister on the right great toe. The facility did not assess the skin, inform the physician of the new skin condition, or provide appropriate treatment. A family member had notified a nurse about the blister, but the dressing was incorrectly placed on the opposite side of the toe. LVN 3 later acknowledged the presence of the blister and confirmed it was a Stage 2 pressure injury, but no prior assessment or treatment had been conducted. For Resident 3, the facility did not consistently monitor the settings of the low air loss (LAL) mattress, which was set incorrectly for the resident's weight. Despite a physician's order to use the LAL mattress for skin maintenance and monitor its placement every shift, the mattress was set to less than 80 pounds, while the resident's weight was 119 pounds. LVN 9 confirmed the incorrect setting and acknowledged that the mattress should have been set between 100 - 120 pounds. Similarly, Resident 102 and Resident 103 also experienced issues with the LAL mattress settings. Resident 102's mattress was set to more than 150 pounds, while the resident weighed 100 pounds. LVN 4 verified the incorrect setting. For Resident 103, the mattress was set between 120 to 155 pounds, although the resident weighed 88 pounds. LVN 3 confirmed the discrepancy and stated that the mattress pressure setting should be based on the resident's weight to prevent skin breakdown or worsening of wounds.
Failure to Ensure Proper GT Feeding Connection
Penalty
Summary
The facility failed to provide the necessary gastrostomy tube (GT) care and services for a resident who was reviewed for tube feeding. The resident, who was readmitted to the facility, had a physician's order to receive Nepro 1.8 enteral feeding via an enteral pump at a rate of 50 ml per hour over 16 hours. However, during an observation, it was found that the GT feeding was not connected to the resident, and the feeding was dripping onto the floor instead. This oversight was verified by RN 4, who acknowledged the issue and stated the need to inform the charge nurse. Further investigation revealed that the disconnection might have occurred after the resident's dialysis session or during a shower given by the facility staff, as mentioned by LVN 10. The LVN confirmed that the GT feeding was not connected and indicated that the entire feeding setup needed to be changed. The facility's Administrator and Director of Nursing (DON) were informed of these findings and acknowledged the deficiency.
Inadequate Respiratory Care and Safety Measures
Penalty
Summary
The facility failed to provide appropriate respiratory care for several residents, as evidenced by multiple observations and interviews. Resident 75 was observed receiving oxygen at three liters per minute, contrary to the physician's order of two liters per minute. Additionally, there was no 'No Smoking/Oxygen in Use' sign outside the resident's room, and the suction machine at the bedside lacked a physician's order and care plan. The suction storage bag was also undated and unlabeled, which was confirmed by LVN 15 and LVN 4 during their interviews. Resident 8 was observed with oxygen at three liters per minute, but there was no 'No Smoking/Oxygen in Use' sign posted as required by the facility's policy. Furthermore, the nasal cannula attached to Resident 8's wheelchair was not stored in a sanitary manner, as it was hanging on the wheelchair without a clean bag. This was verified by RN 5 and LVN 6, who acknowledged the need for proper signage and infection control measures. Resident 58's CPAP mask was found on the floor, and there was no respiratory bag at the bedside for proper storage. The facility also failed to have a physician's order for the CPAP settings, which was confirmed by the DON. Resident 44 was observed receiving oxygen at a rate higher than prescribed, and Resident 29 did not have the required 'No Smoking/Oxygen in Use' sign posted. These deficiencies were acknowledged by the facility's staff, including the Administrator and DON, during interviews.
Failure to Complete Dialysis Communication Forms
Penalty
Summary
The facility failed to provide appropriate dialysis care for a resident, identified as Resident 82, who required such services. The deficiency was identified through interviews, medical record reviews, and a review of the facility's policies and procedures (P&P) regarding dialysis care. The facility's P&P, revised in January 2019, mandates that a pre-dialysis checklist be completed each time a resident is scheduled for dialysis, which includes assessing the type and condition of the access site and dressing. Additionally, a post-dialysis checklist is required to document similar information. However, the review of Resident 82's dialysis communication assessment forms revealed multiple instances of incomplete documentation, with blank entries on specific dates for both pre-dialysis and post-dialysis assessments. Resident 82, who was admitted to the facility with a diagnosis of end-stage renal disease (ESRD) and was dependent on renal dialysis, had no capacity to understand and make decisions, as noted in their health and physical examination. The resident's medical records showed a physician's order for hemodialysis three times a week. Despite this, the facility failed to complete the necessary dialysis communication forms on several occasions, as verified by LVN 12 during an interview. LVN 12 acknowledged that the forms should not have been left blank and should have been filled out as required, indicating a lapse in the facility's adherence to its own dialysis care policies.
Failure to Ensure Resident Safety with Bed Rail Use
Penalty
Summary
The facility failed to ensure that two residents, identified as Residents 46 and 73, remained free from accident hazards related to the use of bed rails. For Resident 73, the facility did not attempt alternatives or obtain informed consent before using side rails. The resident, who had moderately impaired cognition, was observed using the grab bars for bed mobility, but there was no documentation of informed consent or attempts at alternative measures in the medical record. RN 1 confirmed these omissions during a review of the resident's medical record. For Resident 46, the facility did not assess the risk of entrapment or attempt alternatives before using side rails, nor did they inform the responsible party about the use of side rails. The resident had a physician's order for bilateral padded side rails due to medical necessity for seizures, but there was no documented evidence of an assessment for bed zone entrapment. RN 5 and the Medical Record Assistant were unable to locate documentation for the assessment or informed consent, acknowledging that these were not completed. These failures had the potential to place the residents at risk for entrapment.
Improper Medication Administration via GT and Inadequate Bowel Pattern Check
Penalty
Summary
The facility failed to ensure proper pharmaceutical services for a resident, specifically in the administration of medications via a gastrostomy tube (GT). The policy required medications to be administered by gravity, but during an observation, a Licensed Vocational Nurse (LVN) was seen using a syringe to push a crushed docusate sodium tablet through the resident's GT, contrary to the policy. This deviation from the policy was acknowledged by the LVN during a follow-up interview. Additionally, the facility did not ensure that the resident's bowel pattern was checked for loose stools or diarrhea before administering the stool softener, docusate sodium. The resident had a documented history of loose stools/diarrhea for several weeks, yet the LVN did not review this information before administering the medication. The LVN relied on a verbal endorsement from the previous nurse, which inaccurately reported the resident's bowel condition. This oversight was confirmed during an interview with the LVN, who admitted the medication should not have been given under the circumstances.
Failure to Monitor Vital Signs Before Medication Administration
Penalty
Summary
The facility failed to adequately monitor a resident's blood pressure and heart rate before administering prescribed medications, leading to a deficiency. Resident 73, who was on amlodipine and losartan for hypertension, had specific physician orders to hold the medications if the systolic blood pressure was less than 110 mmHg or if the heart rate was less than 60 beats per minute. However, from November 1 to November 19, 2024, there was no documented evidence that the licensed staff checked these vital signs before administering the medications at the prescribed times of 0900 and 1700 hours. This oversight was confirmed during an interview and concurrent medical record review with RN 5 on November 20, 2024.
Failure to Ensure Residents are Free from Unnecessary Medications
Penalty
Summary
The facility failed to ensure that two residents were free from unnecessary medications, as evidenced by the prescription practices for psychotropic drugs. Resident 124 was prescribed zolpidem, a hypnotic medication, on an as-needed basis for insomnia without a 14-day stop date, contrary to the facility's policy. This oversight was confirmed during interviews with RN 2 and the Director of Nursing (DON), who acknowledged the absence of a stop date for the medication. Resident 86 was prescribed quetiapine fumarate, an antipsychotic medication, for intermittent explosive disorder without a documented diagnosis or clinical rationale at the time of prescription. The resident's medical records did not show a diagnosis of psychosis or intermittent explosive disorder prior to the continuation of the medication. This was verified by RN 1 and the Assistant Director of Nursing (ADON), who confirmed the lack of documentation supporting the prescription of quetiapine fumarate before the resident was seen by a psychiatrist.
Medication Storage and Management Deficiencies
Penalty
Summary
The facility failed to ensure the safe storage and management of medications and supplies in one of its medication rooms and several medication carts. In Medication Room A, multiple expired medications were found, including acetaminophen, vitamin B6, and normal saline vials. This oversight had the potential to lead to the unsafe administration of medications. Additionally, the facility did not prevent the storage of antifungal cream at a resident's bedside, which could have allowed unauthorized access to the medication. The resident in question had moderate cognitive impairment and was not assessed as a candidate for self-administration of medications, and there was no physician's order for the cream. Medication carts also exhibited significant deficiencies. Medication Cart D contained a mix of external and internal medications alongside bleach germicidal wipes, posing a risk of unsafe administration. Medication Cart E was found to have expired vials of normal saline, and Medication Cart F had germicidal wipes, adult washcloths, and Povidone-Iodine swabsticks stored with nutritional supplements, risking cross-contamination. Additionally, albuterol inhalation solutions were not stored according to the manufacturer's recommendations, as they were found outside their foil pouches. The facility's procedures for the disposal of controlled medications were not followed correctly. The Director of Nursing (DON) did not sign the narcotic disposition log when controlled medications were disposed of, which could lead to drug diversion. Furthermore, several medication carts contained expired supplies, such as alcohol-free liquid skin prep, wound dressing supplies, and povidone-iodine prep pads. These expired items were not discarded as required, and opened sterile gloves were found, which compromised their sterility. The facility's failure to adhere to its policies and procedures for medication storage and disposal was verified by the DON and other staff members.
Food Safety and Sanitation Deficiencies in LTC Facility
Penalty
Summary
The facility failed to adhere to food safety and sanitation guidelines, as evidenced by several deficiencies observed during the survey. The blender used for preparing pureed food was not allowed to air dry properly before use, which is against the facility's policy for maintaining food machines in a sanitary condition. Additionally, two frying pans in the kitchen were found to be corroded, with the potential for the black substance from the corrosion to come into contact with food. These observations were verified by the staff member involved in food preparation. Furthermore, staff members lacked knowledge of proper food cooling procedures. One staff member described an incorrect cooling method for roasted meats, which did not comply with the facility's policy or USDA guidelines. Another staff member admitted to not knowing how to perform the cooling process. Additionally, the storage area for water pitchers and cups was found to be unsanitary, with a dirty curtain stained with brown residue covering the cart. These failures were acknowledged by the staff and reported to the Director of Nursing and the administrator.
Failure to Label and Date Food in Resident Refrigerator
Penalty
Summary
The facility failed to ensure that food items in the residents' refrigerator were labeled and dated, as required by their policy and procedure (P&P) titled 'Bringing in Food for a Resident' dated 2023. This policy mandates that food or beverages should be labeled and dated to monitor for food safety, and any food in unmarked or unlabeled containers should be marked with the current date and the resident's name. During an observation and interview with an RN and an LVN, it was found that several food items in the resident refrigerator in Nursing Station 1 were unlabeled and undated, including yogurts, cookies, kimbap, soy milk, a dirty Tupperware, and a jar of chia seeds. The RN confirmed that food brought from outside should be labeled with the resident's name and dated, and noted that the jar belonged to the staff, who should not keep their food in the resident's refrigerator. Additionally, the bottom inner part of the refrigerator was observed to be dirty and sticky. These findings were verified by the RN and LVN, and later communicated to the DON and administrator.
Inaccurate Medical Records and Assessments for Residents
Penalty
Summary
The facility failed to maintain accurate and complete medical records for three residents, leading to discrepancies in their health care directives and assessments. For Resident 73, the POLST was not updated to reflect the resident's advance directive, despite the resident having the capacity to make decisions and having signed an advance directive. This discrepancy was confirmed by both an LVN and the SSD, who acknowledged that the POLST should have been updated to reflect the resident's current health care directive. Resident 100's medical record contained conflicting information regarding the existence of an advance directive, with the POLST indicating both the presence and absence of such a directive. This inconsistency was verified by an RN, who noted the need for clarification. Additionally, Resident 124's smoking assessment and care plan were incomplete and inaccurate. The care plan incorrectly identified the resident as an independent smoker, despite the resident lacking the capacity to make decisions and requiring supervision while smoking. The Activities Director confirmed the absence of necessary entries in the smoking assessments, such as cognitive and visual function evaluations.
Infection Control Breach During Medication Administration
Penalty
Summary
The facility failed to implement a safe and sanitary environment to prevent the transmission of infections. During a medication observation, a Licensed Vocational Nurse (LVN) did not change gloves between administering medications through different routes. This oversight occurred while administering various medications, including oral tablets and a topical patch, to a resident who was under enhanced barrier precautions due to a colostomy diagnosis. The facility's policy requires adherence to infection control procedures, including glove changes between different routes of medication administration. Additionally, the LVN did not change personal protective equipment (PPE) between administering medications to two residents on enhanced barrier precautions. The same gown was used for both residents, one of whom had a colostomy and the other a gastrostomy tube. Both residents had physician orders for enhanced barrier precautions every shift. The LVN acknowledged the failure to change gloves and PPE, which posed a risk for the transmission of disease-causing microorganisms.
Failure to Notify Physicians of Inappropriate Antibiotic Use
Penalty
Summary
The facility failed to inform the physician of residents who were prescribed antibiotics without meeting McGeer's Criteria for a true infection. This deficiency was identified for two of the 26 final sampled residents and five nonsampled residents. The facility's Infection Preventionist (IP) confirmed that the antibiotic stewardship program was designed to review prescribed antibiotics and notify physicians if residents did not meet the criteria for a true infection. However, the IP verified that the physicians were not notified for several residents across August, September, and October 2024, who did not meet McGeer's Criteria. The facility's policy on Infection Control - Antibiotic Stewardship, revised in January 2018, aimed to promote appropriate antibiotic use and monitor to improve resident outcomes and reduce antibiotic resistance. Despite this policy, the facility's monthly Infection Prevention and Control Surveillance Logs showed multiple instances where residents were prescribed antibiotics without meeting the necessary criteria, and their physicians were not informed. This oversight had the potential to lead to unnecessary antibiotic use, which could result in adverse reactions and the development of antibiotic-resistant bacteria.
Glucometer Calibration and Quality Control Failures
Penalty
Summary
The facility failed to ensure that glucometers used for blood glucose monitoring were properly calibrated and underwent quality control checks as per their policy and procedure. Specifically, the glucometer in Medication Cart A was not calibrated, and quality control was not performed on several dates in November 2024. Additionally, the glucometers in Medication Cart F were not calibrated or maintained in safe operating condition, with missing entries in the calibration log for October and November 2024. Similarly, the glucometer in Medication Cart D was not maintained in safe operating condition, with discrepancies between the documented quality control results and the actual quality control history. These failures were confirmed through observations, interviews with licensed vocational nurses (LVNs), and reviews of facility documents. The LVNs and the Director of Nursing (DON) verified the findings, acknowledging that the quality control records did not match the glucometer serial numbers and that the required nightly checks were not consistently documented. These lapses had the potential to result in inaccurate blood glucose readings for residents requiring such checks.
Call Light Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that the call light was within reach for a resident, identified as Resident 110, which had the potential to prevent the resident from summoning help when needed. The facility's policy and procedure, dated January 2017, required staff to ensure the call light was within easy reach of residents when they were in bed or seated in a wheelchair or chair. On November 18, 2024, during an observation at 0900 hours, Resident 110 was found awake with the call light hanging on the wall, out of reach. Later, at 1030 hours, a Licensed Vocational Nurse (LVN) confirmed the call light was not accessible to the resident. Resident 110's care plan, dated November 6, 2024, indicated the resident was totally dependent on staff for toileting and hygiene due to impaired self-care and functional mobility related to a history of acute renal failure, transient ischemic attack, and cerebrovascular accident. The LVN acknowledged that the resident sometimes used the call light to request assistance.
Facility Fails to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to maintain a clean and homelike environment for several residents, as observed during a survey. In Room E, where two residents resided, the door frame casings were found in disrepair, with cracks, scratches, and missing paint. The Director of Nursing (DON) acknowledged these findings and suggested that the damage might have been caused by resident beds hitting the door frame. Additionally, the facility was in the process of refurbishing resident rooms. In Rooms A, B, C, and D, the curtains were observed to be yellowish stained and dirty. These rooms housed four different residents. A Licensed Vocational Nurse (LVN) confirmed the condition of the curtains and acknowledged that they needed to be changed. These deficiencies posed a risk for unsanitary and unsightly conditions, potentially impacting the residents' quality of life.
Failure to Assess and Document Bruises in Resident on Anticoagulant
Penalty
Summary
The facility failed to provide necessary care and services to Resident 1, who was on anticoagulant medication, by not assessing and monitoring reported bruises on the resident's lower legs. Despite a CNA reporting the bruises to the charge nurse, there was no documented evidence of an assessment or notification to the physician or the resident's representative. The facility's policy required thorough assessment and physician notification for changes in a resident's condition, which was not followed in this case. Resident 1 was admitted with redness on the right cheek and forehead and was on Eliquis for atrial fibrillation. The facility's records showed no signs of bleeding or bruising documented from early June to late June, despite initial assessments noting skin discoloration. The DON and ADON confirmed the lack of documentation and care planning for the bruises, acknowledging that the facility's policy was not adhered to, which required documentation of such changes in condition.
Failure to Obtain Consent and Physician's Order for Restraint Use
Penalty
Summary
The facility failed to ensure that a resident was free from the use of physical restraints, specifically hand mittens, without obtaining informed consent or a physician's order. The facility's policy and procedure on physical restraints, revised in January 2017, mandates that restraints should only be used with informed consent from the resident, physician, and/or representatives, and that a written order specifying the use of restraints should be obtained. Additionally, an interdisciplinary assessment team should develop and maintain comprehensive care plans for residents, which should include the use of restraints if applicable. In the case of the resident in question, the medical record review revealed that hand mittens were applied on two consecutive days to prevent the resident from pulling out medical devices. However, there was no documented evidence of informed consent, a physician's order, or a care plan addressing the use of hand mittens. The resident's cognitive skills for daily decision-making were severely impaired, as noted in the Minimum Data Set (MDS). An interview with an RN confirmed these findings, indicating a failure to adhere to the facility's policies and procedures regarding the use of physical restraints.
Failure to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to maintain a clean and homelike environment for a resident, as observed during a survey. The portable air conditioning unit in the resident's room had its tubing disconnected and lying on the floor, with visible dust particles on both the tubing and the floor. This situation was identified during an observation and interview with the Maintenance Assistant, who was unaware of how the tubing became disconnected and admitted to not cleaning the unit according to the manufacturer's guidelines. The facility's policy, revised in January 2018, mandates maintaining a safe, clean, and comfortable environment for residents, which was not adhered to in this instance. The Administrator confirmed that the AC unit should be cleaned as per the manufacturer's instructions.
Failure to Timely Report Sexual Abuse Allegation
Penalty
Summary
The facility failed to report a sexual abuse allegation made by Resident 1 against a Certified Nursing Assistant (CNA) to the California Department of Public Health Licensing and Certification (CDPH L&C) Program, Ombudsman office, and local law enforcement agency in a timely manner. According to the facility's policy and procedure (P&P) on abuse reporting and prevention, such allegations should be reported immediately or within two hours. However, the allegation, which was reported by Resident 1 to RN 1 on 5/25/24, was not communicated to the appropriate authorities until 5/28/24, three days later. Interviews conducted with facility staff revealed that RN 1, who was informed of the allegation by Resident 1, did not notify the Administrator or Director of Nursing (DON) as required by the facility's policy. RN 2, who was informed of the incident by RN 1, instructed RN 1 to write an incident report but did not take further action until she returned to work on 5/28/24. The DON confirmed that all staff are mandated reporters and acknowledged the delay in reporting the allegation to the necessary authorities, which was contrary to the facility's policy of immediate reporting upon awareness of such incidents.
Delayed Investigation of Abuse Allegation
Penalty
Summary
The facility failed to investigate a reported allegation of sexual abuse in a timely manner, which involved a resident and a certified nursing assistant (CNA). The resident reported the incident to a registered nurse (RN) on 5/25/24, but the RN did not notify the facility's Administrator or Director of Nursing (DON) as required by the facility's policy. Consequently, the alleged abuser, CNA 1, continued to work and had access to the resident until 5/28/24, when the incident was finally reported to the Administrator and DON, and the investigation was initiated. The facility's policy mandates immediate action to ensure resident safety and the removal of the suspected abuser from resident care. However, the delay in reporting and initiating the investigation allowed CNA 1 to interact with the resident after the allegation was made. The DON confirmed that the investigation should have started on 5/25/24, the day the allegation was reported, but it was not initiated until three days later, on 5/28/24. This delay potentially exposed the resident and other vulnerable residents to further risk of abuse.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
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What surveyors actually found near you
We read the 4,509 citations issued within 25 miles in the last 12 months — including the 15 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Buena Park
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Healthcare Center Of Orange County | 0.6 mi | — | 10 | 0 |
| Anaheim Terrace Care Center | 0.8 mi | — | 2 | 0 |
| Anaheim Crest Nursing Center | 1 mi | — | 2 | 0 |
| West Anaheim Medical Center D/p Snf | 1 mi | — | 16 | 0 |
| Anaheim Healthcare Center, Llc | 1.1 mi | — | 2 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.