Orange Healthcare & Wellness Centre, Llc

F 0558

was conducted. The Administrator and the DON were informed and verified the findings.

Level of Harm - Minimal harm or potential for actual harm 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

09/03/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Orange Healthcare & Wellness Centre, LLC

920 West LA Veta Street Orange, CA 92868

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 - Minimal harm or potential for actual harm Residents Affected - Few

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 maintain an accurate and complete medical record for two of 13 sampled residents (Residents 12 and 13). * The facility failed to ensure the licensed nurses documented their initials on Residents 12 and 13's TARs (indicating the treatments were provided) as per the facility's P&P. This failure had the potential for the residents' care needs not being met as their medical record information was inaccurate and/or incomplete.Findings:

Review of the facility's P&P titled Completion and Correction revised 1/1/2012, showed the facility will work to complete and correct medical records in a standardized manner to provide the highest quality and accuracy in documentation. The facility will ensure the medical records are complete and accurate. Entries will be recorded promptly as the event occurs. 1. Medical record review for Resident 12 was initiated 8/29/25. Resident 12 was admitted to the facility on [DATE REDACTED]. Review of Resident 12's Order Summary Report showed a physician's order dated 5/20/25, to cleanse Resident 12's sacrum fragile scar tissue with soap and water, pat dry, then apply zinc oxide (skin barrier cream), every shift for skin maintenance. Review of Resident 12's TAR (Treatment Administration Record) for 7/2025 failed to show documentation the licensed nurse performed Resident 12's treatment on 7/7, 7/18, 7/19, and 7/28/25, on the evening shift. The licensed nurse failed to document their initials on the TAR for the cleansing of Resident 12's sacrum and

the application of her barrier cream. 2. Medical record review for Resident 13 was initiated on 8/29/25.

Resident 13 was admitted to the facility on [DATE REDACTED]. Review of Resident 13's Order Summary Report showed an order dated 7/12/25, to cleanse Resident 13's MASD (sacrococcyx and right left buttocks) with normal saline, pat dry, then apply moisture barrier cream every shift. Review of Resident 13's TAR for 7/2025 failed to show documentation the licensed nurse performed Resident 13's treatment on 7/18/25 and 7/19/25, on the evening shift. The licensed nurse failed to document their initials on the TAR for the cleansing of Resident's 13 MASD (sacrococcyx and right left buttocks) and the application of her barrier cream. On 9/2/25 at 1550 hours, an interview and concurrent medical record review was conducted with

the DON. The DON verified the findings and stated after a licensed nurse provided resident treatment, the licensed nurse would then document the treatment provided in the resident's medical record (TAR). The DON stated she would contact the nurses who failed to document Resident 12 and 13's treatments were provided and determine whether the nurses failed to provide the treatments or had provided the residents' treatments, however, forgot to document in the residents' medical record.

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

09/03/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Orange Healthcare & Wellness Centre, LLC

920 West LA Veta Street Orange, CA 92868

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 potential for actual harm

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

observation, interview, medical record review and facility P&P review, the facility failed to ensure the infection control practices were observed. * LVN 1 failed to follow the EBP infection control practices while performing the wound care for Resident 1. * LVN 2 failed to follow the infection control practices on wearing PPE in the hallway. These failures posed the risk for transmission of disease-causing microorganisms and infections.Findings: Review of the facility's P&P titled Enhanced Barrier Precaution dated 5/28/24, showed it is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms. The facility will have the discretion on how to communicate to staff which residents require the use of EBP, as long as staff are aware of which residents require the use of EBP prior to providing high-contact care activities. EBP are indicated for residents with any of the following: wounds (e.g., chronic wounds such as pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and chronic venous stasis ulcers). In addition, to facilitate compliance with EBP, gowns and gloves are to be donned

before each high contact task, not prior to entering the room. Health care personnel should not routinely wear gowns and gloves in the hallway. Review of the facility's Enhanced Standard Precaution signage showed everyone must perform hand hygiene before entering the room. Anyone participating in any of

these six moments must also don gown and gloves for morning and evening care, toileting and changing incontinence briefs, caring for devices and giving medical treatments, wound care, cleaning and disinfecting

the environment, and mobility assistance and preparing to leave room. a. On 8/28/25 at 0900 hours, during

the initial tour of the facility, an observation and concurrent interview for Resident 1 was conducted with LVN 1. An EBP signage was observed outside of Resident 1's room. There was a small drawer on Resident 1's door which contained gloves, gowns, and a bottle of alcohol-free wipes. LVN 1 was observed providing wound care to Resident 1 in bed without wearing the gown. LVN 1 verified Resident 1 was on EBP for wound. LVN 1 verified he was not wearing a gown while providing wound care to Resident 1. Medical

record review for Resident 1 was initiated on 8/28/25. Resident 1 was admitted to the facility on [DATE REDACTED].

Review of Resident 1's Order Summary Report showed a physician's order dated 6/17/25, for low air loss mattress for wound management re-opened right buttock pressure injury stage four every shift for wound management. b. On 8/28/25 at 0930 hours, an observation and concurrent interview for Resident 2 was conducted with LVN 2. Resident 2's room was closed and had a sign for COVID-19 isolation. There was a small drawer on Resident 2's door which contained gloves, gowns, and a bottle of alcohol-free wipes. LVN 2 was observed preparing medication from the medication cart in front of Resident 2's room. LVN 2 donned PPE and went to the medication room in the hallway wearing PPE. LVN 2 stated she did not enter Resident 2's room because she needed medication inside the medication room. On 8/28/25 at 1520 hours, an

interview was conducted with the IP. The IP was informed of the observation and verified the findings. IP stated LVN 1 should have been wearing a gown while providing wound care to Resident 1 and LVN 2 should not be wearing any PPE when in the hallway. On 8/28/25 at 1630 hours, an interview was conducted with the Administrator. The Administrator was informed and verified the findings.

Residents Affected - Few

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

Event ID:

Facility ID:

If continuation sheet