Buena Park Nursing Center

In the surveyor’s words

From the most serious findings on record at Buena Park Nursing Center, in the surveyor’s own words.

• Actual harm, isolatedF693Oct 30, 2025

  Based on interview, medical record review, and facility's P&P review, the facility failed to provide the necessary enteral care and services to one of four sampled residents (Resident 1) who had a GJ tube.* The facility failed to ensure Resident 1's enteral feeding was given through the J tube port and medications were given through the G tube port as ordered by the physician. In addition, the facility staff failed to notify the physician when the staff were unable to accurately identify the G and J ports of the GJ tube and provide the in-service training on the care and management of a resident with a GJ tube.* The facility failed to ensure Resident 1 had a physician's order for Resident 1's G tube drainage bag maintenance and discontinuation.These failures resulted in Resident 1's… […]

• No harm, potential for more than minimal, patternF605Mar 18, 2026

  Based on interview, medical record review, and facility P&P review, the facility failed to ensure three of five final sampled residents (Residents 3, 14, and 16) reviewed for the unnecessary medications were free from the unnecessary psychotropic medication. * The facility failed to implement and document the nonpharmacological interventions for Resident 14 when the resident experienced behavioral episodes associated with the use of Rexulti (antipsychotic medication) and venlafaxine (antidepressant medication). * The facility failed to ensure the orthostatic blood pressure was accurately monitored for Resident 3 related to the use of the psychotropic medication. […]

• No harm, potential for more than minimal, patternF686Mar 18, 2026

  Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the necessary care and services were provided to prevent the development of pressure injuries for two of three final sampled residents (Residents 8 and 110) reviewed for pressure injuries. * The facility failed to ensure the LAL mattress setting was appropriate to the residents' weight for Residents 8 and110. These failures had the potential for the residents to develop pressure injuries or worsening of the existing pressure injuries.Findings: Review of facility's P&P titled Low Air Loss Mattress revised dated 3/2017 showed the manufacturer's guidelines should be reviewed for each individual mattress to ensure this policy is what recommended; if this policy is not in agreement… […]

• No harm, potential for more than minimal, patternF695Mar 18, 2026

  Based on observations, interviews, medical record reviews, and facility P&P review, the facility failed to provide the necessary respiratory care services for six of 25 final sampled residents (Residents 3, 4, 7, 21, 69, and 136) and one nonsampled resident (Resident 94 ) reviewed for respiratory care. * The facility failed to ensure the manufacturer's recommendation for cleaning and disinfecting of the ventilator machines was followed for Resident 3, 4, and 7. * The facility failed to ensure Resident 69 received the oxygen therapy as ordered by the physician. Additionally, the facility failed to ensure the staff followed the proper infection control practices when a staff member attempted to place a nasal cannula on the resident after it had been on the floor. […]

• No harm, potential for more than minimal, patternF803Mar 18, 2026

  Based on observation, interview, and facility document review, the facility failed to ensure the menu was followed for 10 residents who received pureed food. * The facility failed to ensure the Korean menu was followed during pureed preparation observation when the cook did not puree one food item (roasted [NAME]) posted on menu, and the cook liquified seaweed soup. This failure posed the risk for the residents who received food prepared in the kitchen to not have their nutritional needs met.Findings: Review of the facility's document titled Order Listing Report dated 3/12/26, showed a total of 48 of 124 residents (including 10 on puree diets) received meals prepared in the facility's kitchen. […]