Orange Healthcare & Wellness Centre, Llc
ORANGE HEALTHCARE & WELLNESS CENTRE, LLC in ORANGE, CA — inspection on September 3, 2025.
Found 3 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
Review of Resident 3's MDS assessment dated [DATE], showed Resident 3 had severe cognitive impairment and needed substantial to maximum assistance for ADL care from the staff. b. On 8/28/25 at 1025 hours, an observation and concurrent interview for Resident 2 was conducted with CNA 1. Resident 2's call light was turned on from hallway and there was an audible beeping sound on the call light panel at the nurses station. LVNs 2 and 3 were sitting at the nurses station. RNA 1 passed by Resident 2's room without answering the resident's call light. No facility staff answered the call light to provide assistance to Resident 2. On 8/28/25 at 1045 hours, 20 minutes after Resident 2's call light was on, CNA 1 answered Resident 2's call light. In a concurrent interview, CNA 1 stated Resident 2 wanted the lunch tray removed from her room. On 8/28/25 at 1050 hours, an interview was conducted with LVNs 2 and 3, and RNA 1. LVN 2 verified she heard the beeping sound of the call light for Resident 2. LVN 2 stated they needed to answer the call light right away when it was turned on. LVN 2 verified she did not answer the call light of Resident 2 right away. LVN 3 verified he heard the beeping sound of the call light for Resident 2. LVN 3 verified he did not answer the call light of Resident 2 right away. RNA 1 verified the call light of Resident 2 was turned on when he passed by the room and acknowledged he did not answer the call light of Resident 2 right away. RNA 1 stated the call light of Resident 2 should have been answered right away. On 9/3/25 at 1655 hours, an interview was conducted with the Administrator and DON was conducted.
The Administrator and the DON were informed and verified the 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 TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE
055252 09/03/2025
Orange Healthcare & Wellness Centre, LLC 920 West LA Veta Street Orange, CA 92868
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].
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.
055252 09/03/2025
Orange Healthcare & Wellness Centre, LLC 920 West LA Veta Street Orange, CA 92868
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].
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.
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.