Healthcare Center Of Orange County

F 0657 Level of Harm - Potential for minimal harm Residents Affected - Some

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **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 comprehensive person-centered care plan was revised for one of three sampled residents (Resident 2). * The facility failed to revise Resident 2's care plan when Resident 2 had a fall. This failure placed the resident at risk of not being provided appropriate, consistent, and individualized care. Findings: Review of the facility's P&P titled Care Planning Interdisciplinary Team revised 9/2013 showed the assessments of the residents are ongoing and care plans are revised as information about the residents and the residents' conditions change.

Medical record review for Resident 2 was initiated on 10/1/25. Resident 2 was admitted to the facility on [DATE REDACTED]. Review of Resident 2's eINTERACT Change in Condition Evaluation dated 8/23/25, showed Resident 2 was found lying on the floor on the right side of the bed holding the siderail. Review of Resident 2's Fall Risk Evaluation dated 8/23/25, showed Resident 2 was at a high risk for falls. Review of Resident 2's plan of care dated 8/23/25, showed a care plan problem addressing Resident 2's moderate risk for falls.

In addition, the care plan showed Resident 2 had a fall on 8/23/25. However, the care plan was not revised to show Resident 2's high risk for fall based on the resident's Fall Risk Evaluation dated 8/23/25. On 10/3/25 at 1139 hours, an interview and concurrent medical record review was conducted with LVN 3. LVN 3 verified Resident 2 was at high risk for fall and the resident's care plan was not revised to show the resident's high risk for fall after his fall incident on 8/23/25. On 10/3/25 at 1420 hours, an interview was conducted with the DON. The DON was informed and verified the above findings.

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date

these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE

TITLE

(X6) DATE

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

Facility ID:

If continuation sheet

Event ID:

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

10/09/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Healthcare Center of Orange County

9021 Knott Ave Buena Park, CA 90620

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 0684

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Level of Harm - Minimal harm or potential for actual harm

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

interview and medical record review, the facility failed to provide the necessary care and services to maintain the highest practicable well-being for one of three sampled residents (Resident 1). * LVN 1 delayed contacting emergency services after Resident 1 who was on an anticoagulant, had an unwitnessed fall and injury to his forehead. This failure had the potential to negatively affect the resident's well-being as

the necessary care and services were not provided.Findings: Medical record review for Resident 1 was initiated on 10/1/25. Resident 1 was admitted to the facility on [DATE REDACTED]. Resident 1 had diagnoses which included anoxic brain damage, diffuse traumatic brain injury, and epilepsy. Review of Resident 1's H&P examination dated 4/24/25, showed Resident 1 had no capacity to make medical decisions. Review of Resident 1's eINTERACT Change of Condition Evaluation - V 5.1 dated 9/18/25 at 0840 hours, showed Resident 1 had an unwitnessed fall, where he was found on the floor next to his bed. Resident 1 was noted to have a bump on his right forehead. The physician was notified at 0905 hours and recommended to transfer Resident 1 to the acute care hospital for an evaluation and treatment. Review of Resident 1's progress note showed a late entry dated 9/18/25 at 1000 hours, showing the licensed staff called 911 and

the paramedics arrived at 0950 hours. Resident 1 left the facility via gurney at 0958 hours. Review of Resident 1's admission H&P note from Acute Care Hospital A dated 9/18/25, showed Resident 1 fell around two feet from the bed onto the ground and striking his head. The CT of the head result showed a small 2 mm right frontal subdural hematoma. On 10/1/25 at 1600 hours, an interview was conducted with LVN 1. LVN 1 stated on 9/18/25 at around 0840 hours, she found Resident 1 on the floor near the right side of his bed. LVN 1 stated she assessed Resident 1 and saw a bump on his forehead, before placing him back on his bed with CNA 1's assistance. LVN 1 stated the physician ordered to transfer Resident 1 to the acute care hospital for an evaluation. LVN 1 stated she contacted a regular ambulance but was told by the ambulance company that since Resident 1 was on a blood thinner medication and had a bump on his head,

she should contact 911. LVN 1 stated she attempted to contact another regular ambulance but was told the same instructions. LVN 1 then contacted 911 for Resident 1. On 10/2/25 at 1548 hours, an interview was conducted with the DON. The DON stated if the resident had an unwitnessed fall and was on blood thinner medications, the resident would be transferred to the acute care hospital for an evaluation via a regular ambulance or 911. When asked what would determine the licensed staff to contact 911, the DON stated if

the resident had a bump or a headache. The DON verified Resident 1 had a bump on his head due to the unwitnessed fall incident. In addition, the DON stated the licensed staff should have contacted 911 for Resident 1. On 10/10/25 at 1607 hours, a telephone interview was conducted with the DON and Medical Records Director. The DON and Medical Records Director were informed and acknowledged the above findings. Cross reference F-F689.

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

10/09/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Healthcare Center of Orange County

9021 Knott Ave Buena Park, CA 90620

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

falls, the Interim DSD stated just the intervention to reposition the resident. On 10/8/25 at 1045 hours, an

interview and concurrent facility document review of Resident 1's Grievance Form was conducted with the SSD. The SSD stated she was responsible for investigating the facility's grievances. When asked how the SSD investigated the grievance from Family Member 1, the SSD stated she informed the Interim DSD about Family Member 1's concern and the Interim DSD agreed to do an all-facility staff in-service about positioning the residents. The SSD verified she did not interview any facility staff members about Resident 1's behavior of hanging his legs over the bed. On 10/8/25 at 1156 hours, a follow-up interview and concurrent facility document review for Resident 1 was conducted with the DON. The DON stated based on Resident 1's Grievance Form, the documented N/A on the form showed the grievance was not investigated because the facility staff were not interviewed. In addition, the DON stated the facility should have implemented interventions for Resident 1 regarding Family Member 1's grievance. The DON verified Resident 1's fall risk evaluation was inaccurate and stated if the correct assessment was conducted, Resident 1's fall risk score would have increased to show the resident was high risk for fall. On 10/10/25 at 1607 hours, a telephone interview was conducted with the DON and Medical Records Director. The DON and Medical Records Director were informed 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

10/09/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Healthcare Center of Orange County

9021 Knott Ave Buena Park, CA 90620

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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

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

review for Residents 1 and 2 was conducted with the DON. The DON stated the licensed nurses needed to document on the MAR when they administered or held the resident's medications. When asked what the blank space meant on a Resident 1's MAR, the DON stated it meant the medication was not given. The DON was informed and verified the above findings. On 10/10/25 at 1607 hours, a telephone interview was conducted with the DON and Medical Records Director. The DON and Medical Records Director were informed 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

10/09/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Healthcare Center of Orange County

9021 Knott Ave Buena Park, CA 90620

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

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **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 residents' medical

record were complete and accurate for two of three sampled residents (Residents 2 and 3). * Resident 2's fall risk assessments were incomplete. * Resident 3's fall risk assessments were incomplete. These failures posed the risk for the residents care needs not being met as their medical record information were inaccurate and incompleteFindings: Review of the facility's P&P titled Charting and Documentation revised 7/2017 showed documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate. 1. Medical record review for Resident 2 was initiated on 10/1/25. Resident 2 was admitted to the facility on [DATE REDACTED]. Review of Resident 2's Fall Risk Evaluation dated 6/19/25, showed blank entries for the following sections: systolic blood pressure, and vision status. Review of Resident 2's Fall Risk Evaluation dated 8/23/25, showed blank entries for the following sections: ambulation, and systolic blood pressure. 2. Medical record review for Resident 3 was initiated on 10/1/25. Resident 3 was admitted to the facility on [DATE REDACTED]. Review of Resident 3's Order Summary Report dated 10/1/25, showed the following physician's orders: - dated 2/16/25, to administer benazepril (antihypertensive) 20 mg one tablet orally one time a day for hypertension;- dated 2/16/22, to administer hydralazine HCl (antihypertensive) 100 mg one tablet orally three times a day for hypertension;- dated 2/16/22, to administer hydrochlorothiazide (diuretic) 12.5 mg one capsule orally in the evening for CHF; - dated 2/16/22, to administer metoprolol tartrate (antihypertensive) 25 mg one tablet orally two times a day; and- dated 4/26/23, to inject Humulin R (hypoglycemic/lowers blood sugar) 100 unit/ml subcutaneously per sliding scale one time a day for diabetes. Review of Resident 3's MAR for July 2025 showed Resident 3 was administered the benazepril, Humulin R, hydrochlorothiazide, hydralazine, and metoprolol medications. Review of Resident 3's Fall Risk Evaluation dated 7/21/25, showed Resident 3 took one to two classes of medications listed on the evaluation form (anesthetics, antihistamines, antihypertensive, antiseizure, benzodiazepines, cathartics, diuretics, hypoglycemics, narcotics, psychotropics and sedative/hypnotics) currently or within the last seven days. However, Resident 3 was taking three classes of the medications listed (antihypertensive, diuretic, and hypoglycemic). On 10/2/25 at 1256 hours, an interview and concurrent medical record review was conducted with LVN 1. LVN 1 verified Resident 2 and 3's Fall Risk Evaluations had blank entries and were inaccurate. On 10/8/25 at 1150 hours, an interview was conducted with the DON. The DON stated the responses checked off on the Fall Risk Evaluation should be filled out completely, as the responses affected the overall fall risk score for the residents.

Event ID:

Facility ID:

If continuation sheet