F 0584
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited
to receiving treatment and supports for daily living safely.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview, and medical record review, the facility failed to provide a homelike environment by
maintaining the comfortable sound levels for one of six sampled residents (Resident 3).
* Resident 3's roommates (Residents A and B) had caused the disruption due to their noise levels and
Resident 3 reported the noise issue to the staff and subsequently requested a room change; however,
there was no resolution or follow up to Resident 3's concern. This failure had to the potential for Resident 3
to continuously have interruption of sleep and disrupting their homelike environment.
Findings
a. Medical Record Review for Resident 3 was initiated on 3/25/24. Resident 3 was admitted to the facility on
[DATE].
Review of Resident 3's H&P examination dated 9/21/23, showed Resident 3 could make needs known but
was unable to make medical decisions.
b. Medical record review of Resident A was initiated on 3/26/24. Resident A was admitted to the facility on
[DATE], and readmitted on [DATE].
Review of Resident A's H&P examination dated 6/7/23, showed Resident A had no capacity to understand
and make decisions.
c. Medical record review of Resident B was initiated on 3/26/24. Resident A was admitted to the facility on
[DATE].
Review of Resident B's H&P examination dated 1/30/24, showed Resident B had no capacity to understand
and make decisions.
On 3/25/24 at 1430 hours, a concurrent observation and interview was conducted with the Resident 3.
Resident 3 was observed sitting upright in bed. Resident 3's roommates were Residents A and B. Resident
A was observed lying in bed with the head of the bed more than 45 degrees and talking to himself.
Resident 3 had expressed concern with the noise level from Residents A and B, especially at night.
Resident 3 stated Resident A would talk to himself and sometimes screamed when the staff came in.
Resident B's radio or TV was loud especially at night. Resident 3 stated he reported the noise issue to the
staff and wanted to move to a quieter room, but there was no resolution or follow up to his concern.
Resident 3 further stated the noise level was disturbing his sleep.
(continued on next page)
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
Page 1 of 2
Event ID:
055674
Printed: 05/15/2026
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
055674
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/26/2024
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 0584
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
On 3/25/24 at 1530 hours, an interview was conducted with the SSD. The SSD stated she was new to the
facility and was not aware of Resident 3's concerns regarding the noise level and requested a room
change. The SSD stated no one hadreported to her regarding the above issue.
On 3/25/24 at 1620 hours, an interview was conducted with CNA 1. CNA 1 stated Resident A was confused
when talking to self and sometimes screamed or yelled when the staff came into the room. Resident B
turned on the TV or radio loud at night. CNA 1 stated Resident 3 complained about Resident B and when
CNA 1 asked Resident B to turn off the TV or turn the volume down, Resident B became upset. CNA 1
stated sometimes they turned off the devices, but Resident B turned it back on. CNA 1 stated it was an
ongoing issue.
ON 3/25/24 at 1645 hours, an interview was conducted with CNA 2. CNA 2 stated Resident 3 complained
about Resident B's television or radio being too loud especially at night. Resident 3 could not relax and
sleep due to the noise level. CNA 2 reported it to the charge nurse, and the charge nurse was able to turn it
off but once the charge nurse went outside of room, Resident B turned on the radio. CNA 2 stated Resident
A could be redirected but continued to talk to himself and staff.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055674
If continuation sheet
Page 2 of 2
