Orange Healthcare & Wellness Centre, Llc

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].

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.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

09/03/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Orange Healthcare & Wellness Centre, LLC

920 West LA Veta Street Orange, CA 92868

SUMMARY STATEMENT OF DEFICIENCIES

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.

Facility ID: