Health inspection·June 24, 2025

F 0679 - Residents are provided assistance as needed to engage in their preferred activities on a routine basis. Level of Harm - Minimal harm or potential for actual harm 1. On 6/19/25 at 0851 hours, an observation and concurrent interview was conducted with Resident 1. Resident 1 was sitting up in his wheelchair outside his room. Resident 1 was awake, alert, oriented, and verbally responsive. Resident 1 stated the television (TV) channels kept on going out and this problem had been happening for the past three months. Resident 1 stated watching TV was his usual activity in the facility. Resident 1 stated watching TV and eating food were the only activities he enjoyed. Resident 1 stated the facility offered activities; however, he was not a social person. Resident 1 stated he enjoyed watching his TV shows. Resident 1 stated when he turned on the TV, certain channels did not show, or were gone and not showing. Resident 1 stated the last time the TV channels were not working was on 6/10/25 between 0900 to 1000 hours. Resident 1 stated he requested for the maintenance staff to check it. Per Resident 1, the maintenance staff said he needed to tell the Administrator to fix it. Resident 1 stated the maintenance staff did not fix his TV and he also informed the nurses. In addition, Resident 1 stated he did not inform the Administrator, and he did not meet the Administrator before. Resident 1 stated this facility has had different administrators since he was admitted . Residents Affected - Few Medical record review for Resident 1 was initiated on 6/24/25. Resident 1 was readmitted to the facility on [DATE]. Review of Resident 1's MDS assessment Section F for Customary Routine and Activities dated 10/4/24, showed was coded 1 (one) for very important to do resident's favorite activities while in the facility. Review of Resident 1's Activities Quarterly Participation review dated 10/4/24, showed the resident preferred self-directive activities. Resident 1's favorite activities showed he had a huge passion for motorcycles, cars, and music. Resident 1 enjoyed watching TV in his room and spending time with his sister when she comes to visit him in the facility. Review of Resident 1's H&P examination dated 10/29/24, showed Resident 1 had the capacity to understand and make decisions. Review of Resident 1's MDS assessment dated [DATE], showed Resident 1's Brief Interview for Mental Status (BIMS) score was 15, indicating cognitively intact. Review of Resident 1's Interdisciplinary Team (IDT) Conference Note dated 4/15/25, failed to show discussion of Resident 1's TV channel concerns with Resident 1's sister. The note further showed the interventions and plan of care discussed in the IDT meeting were to encourage Resident 1 to attend activity of choice. Review of Resident 1's Grievance report dated on 6/16/25, showed the incident occurred on 6/16/25 at 1400 hours regarding TV channels disappearing. Further review of the Grievance report showed the SSD received the grievance from the resident and the Administrator was notified on 6/16/25. The follow-up section of the report dated 6/17/25, showed the maintenance staff was resetting the TV channels and will continue to follow up. On 6/19/25 at 1339 hours, an observation and concurrent interview was conducted with Resident 1. Resident 1 was lying in bed awake and watching TV. Resident 1 was asked to check if his favorite TV (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055674 If continuation sheet Page 2 of 8 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 06/24/2025 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 0679 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few channels were working. Resident 1 stated he woould check tomorrow and on the weekend if the TV channels were working. Resident 1 verified he filed a grievance on 6/16/25. Resident 1 stated he did not directly speak to the SSD, he reported the concern to the nursing staff and maybe it was reported to the SSD. Resident 1 stated the maintenance staff and Administrator did not see him after he filed the grievance. Resident 1 stated the maintenance staff did not come in to fix the tv or check the channels, and the other staff did not offer any assistance to the problem. Resident 1 stated the TV channels were not working for at least five days prior to him filing a grievance report, and he had heard other residents complaining of their TV not working. Resident 1 stated he never even met the Administrator to talk or inform him of the issue. Resident 1 stated he told the maintenance staff last month regarding the tv and the maintenance staff told Resident 1 it is not about the TV, but the cable company. Resident 1 stated he was upset and bought Netflix for his phone so he can watch shows or movies since the tv channels were not working for a couple of days. On 6/19/25 at 1355 hours, an interview was conducted with the Administrator and Maintenance Director. The Administrator was asked regarding concerns with TV channels not working in residents' rooms. The Administrator stated it was not the TV or the cable company. The Administrator stated all the TV channels listed were working [NAME] the current TV channel guide, which were posted in each resident's room. In addition, the Administrator stated the facility notified the resident and the resident's family and had provided the updated TV channel guide list in each of the resident's room and to the family. Furthermore, the Administrator stated if the residents wanted other channels not listed on the facility current channel guide list, the resident and family must provide themselves. The Maintenance Director stated he only checked if the resident complained of the TV not working. On 6/19/25 at 1424 hours, an observation and concurrent interview were conducted with Administrator and Maintenance Director. The Administrator and Maintenance Director were asked to check Resident 1's roommate TV since Resident 1 refused to have the Maintenance Director check his TV. The Maintenance Director verified the posted TV channel guide posted was the updated list. The Maintenance Director turned on the TV and checked each channel per the channel list posted on the resident's wall. Channels 12, 16, 18, 19, 20, 21, 22, 24, 27, 28, 29, 31, 32, and 39, which were on the channel list, were not working. The Administrator and Maintenance Director verified the above findings. The Maintenance Director stated he would reset the TV. If the TV channels were not working after three attempts to reset the TV, the Maintenance Director stated he would look for a replacement TV. The Maintenance Director stated the TV might not be receiving signal since it was old and not a smart TV. The Maintenance Director stated the problem is not the cable company or internet, he stated it must be the facility's TVs. The Maintenance Director was asked if he had reset the Resident 1's TV for the past two months and he stated he never reset the TV for room Resident 1, only for Resident 1's roommate in room [ROOM NUMBER] A. The Administrator stated the current TV channel guide list in resident's rooms were not the updated list. The Administrator was reminded of his earlier statement regarding the updated list of available channels were currently provided and posted in each of resident's room. On 6/19/25 at 1619 hours, an interview and concurrent facility document review was conducted with the SSD. The SSD stated she filled out the Grievance form for Resident 1 on 6/16/25, when Resident 1 reported concerns with the TV channels not working. The SSD stated she reported to the Maintenance Director and Administrator. The SSD verified the Grievance report form dated 6/16/25 with Administrator's signature of acknowledgement. The SSD stated the facility's grievance process would take five days to respond to the concern/issue. The SSD verified the Grievance report follow up dated 6/17/25, showed maintenance is currently resetting tv channels under the question to describe the findings of the incident. The SSD stated (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055674 If continuation sheet Page 3 of 8 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 06/24/2025 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 0679 Level of Harm - Minimal harm or potential for actual harm this was follow up was not completed by the Maintenance Director. The SSD stated this was the plan for the maintenance staff to reset the TV channel. In addition, the SSD stated she informed the Maintenance Director on 6/16/25, regarding Resident 1's TV channel concerns and she did not inform the Maintenance Director again on the 6/17/25, since it was a follow up. Furthermore, the SSD stated no follow up was done since 6/16/25, to fix Resident 1's TV concerns from the Maintenance Director. Residents Affected - Few On 6/24/25 at 0805 hours, an interview and concurrent medical record review was conducted with RN 1. RN 1 verified Resident 1's Activity assessment dated [DATE], showed his favorite activities were self-directed activities like music, passion for motorcycles, watching tv in his room and spending time with his sister when she visits. RN 1 was asked what the implication would be when Resident 1's preferred activity like watching TV would not be provided. RN 1 stated Resident 1 would be greatly affected in a negative way if the TV did not work since it was one of his specified preferences of enjoyment while in the facility. RN 1 reviewed Resident 1's care plan for activities with RN 1 and verified there was no care plans addressing his TV concern. RN 1 stated it must be the facility's responsibility to provide maintenance to Resident 1's TV if it was not working. In addition, RN 1 stated the Administrators and/or DON failed to inform her or any of the nursing staff of the recommendation for advising residents and their families to buy Roku, firestick, or Netflix when there would be complaints of the TV channels. Furthermore, RN 1 stated facility must do whatever it takes to fix the TV and provided channels to work. 2. On 6/19/25 at 1140 hours, an observation and concurrent interview was conducted with Resident 2. Resident 2 was sitting in a gerichair, awake, oriented x 4, and verbally responsive. Resident 2 was asked if he had any TV concerns during his stay in the facility. Resident 2 stated he did have concerns with the TV channels because they were constantly not working every day for the past year. Resident 2 stated he has been staying in the facility for five years. Resident 2 stated he gets pissed when the TV channels did not work. Resident 2 stated Channels 43 through 60 were static, meaning channels were not showing. Resident 2 stated he likes to watch baseball on Channel 23 since he used to be a baseball player and currently Channel 23 was not working. In addition, Resident 2 stated he reported this TV concern to the DON a couple months ago but nobody came to fix the TV. Resident 2 stated he received a copy of the updated TV channel guide, however, no one from the facility assisted him to get the firestick. Furthermore, Resident 2 stated watching TV was one of his main activities and reading his books since his accident. Resident 2 was asked to have his TV channels checked by CNA 1 and he agreed. On 6/19/25 at 1150 hours, an observation and concurrent interview was conducted with CNA 1 in Resident 2's room. CNA 1 was asked to check Resident 2's TV channels with Resident 2's permission. The TV channel guide list was observed posted on Resident 2's wall. CNA 1 was asked to check each channel listed on the TV channel guide. CNA 1 was observed going through each channel listed on the channel guide and channels 3, 9, 21, 22, 23, and 27 were observed not working. CNA 1 verified the findings. CNA 1 stated Rooms 106 A and 108 B also complained of their TV channels not showing. CNA 1 stated if there would be any TV concerns, he must report to the Maintenance Director. Medical record review for Resident 2 was initiated on 6/24/25. Resident 2 was admitted to the facility on [DATE]. Review of Resident 2's MDS assessment dated [DATE], showed Resident 2's BIMS score was 15, indicating cognitively intact. Review of Resident 2's care plan initiated 3/21/25, showed Resident 2 preferred independent (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055674 If continuation sheet Page 4 of 8 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 06/24/2025 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 0679 activities like watching TV, listening to music, and reading. Level of Harm - Minimal harm or potential for actual harm Review of Resident 2's MDS assessment Section F for Customary Routine and Activities dated 6/19/24, was coded 1 for very important to do resident's favorite activities while in the facility. Residents Affected - Few On 6/19/25 at 1405 hours, an observation and concurrent interview was conducted with the Administrator and Maintenance Director. The Administrator reviewed the updated TV channel guide listed 33 channels and stated all the channels listed in the channel guide worked and posted in each resident's room. The Administrator and Maintenance Director stated they were certain the all the channels worked. The Administrator and Maintenance Director were requested to check the TV channels in Resident 2's room. The TV channel guide list was observed posted on Resident 2's wall near the TV. The Maintenance Director verified the channel guide list. The Administrator and Maintenance Director checked Resident 2's TV channel guide list and the Maintenance Director turned on Resident 2's TV. The Maintenance Director checked each channel listed on the channel guide. Channels 3, 9, 12, 16, 18, 19, 20, 21, 22, 24, 27, 28, 29, and 32 were not working or showing. The Maintenance Director stated he would reset Resident 2's TV and then all channels should work. On 6/19/25 at 1415 hours, a follow up concurrent observation and interview was conducted with the Maintenance Director and the Administrator. The Maintenance Director reset the TV, however Channels 3, 9, 12, 16, 18, 19, 20, 21, 22, 24, 27, 28, 29, and 32 were not showing . The Administrator asked the Maintenance Director to check the listed channels again and the channels were still not working or showing. The Administrator and Maintenance Director verified the above findings. 3. On 6/19/25 at 1200 hours, an observation and concurrent interview was conducted with Resident 3. Resident 3 was lying in bed awake, alert, and oriented x 3. Resident 3 stated she had been living in the facility for about six years. Resident 3 stated her favorites activities were puzzles books and watching TV. Resident 3 stated a lot of the TV channels did not work for the past two to three months and she reported it to the nurse. Resident 3 stated Channels 7, 13, 14, 16, and 29 were not working. In addition, Resident 3 stated she missed her soap operas, which she had been watching for years and the game shows. Resident 3 was observed with a sad face and teary eyes. Furthermore, Resident 3 stated she felt sad due to the TV channels not working. Medical record review for Resident 3 was initiated on 6/24/25. Resident 3 was readmitted to the facility on [DATE]. Review of Resident 3's Activities Quarterly Review dated 11/21/24, showed Resident 3's favorite activities were word search, crossword puzzles, read the bible, and watch television. Review of the Resident Council Minutes dated 5/5/25, showed there were identified issues during the meeting where the TV channels were not showing consistently. The Resident Council Response form dated 5/6/25, showed the activities department provided an updated list of all the available TV channels to the residents. The Resident Council Response form further showed a suggestion for the residents to provide their own firestick or roku box if they would like other channels not listed. The Resident Council Response form failed to show the issue had been resolved to the residents' reasonable satisfaction. Review of Resident 3's H&P examination dated 5/22/25, showed Resident 3 had the capacity to understand and make decisions. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055674 If continuation sheet Page 5 of 8 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 06/24/2025 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 0679 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of Resident 3's MDS assessment dated [DATE], showed Resident 3's BIMS score was 15, indicating cognitively intact. Review of Resident 3's MDS assessment Section F Preferences for Customary Routine and Activities dated 5/22/25, showed was coded 1 for favorite activities were very important to the resident while in the facility. On 6/19/25 at 1446 hours, an interview was conducted with the Maintenance Director. The Maintenance Director stated he checked and resets the TV after receiving a complaint from the staff and/or family. The Maintenance Director stated the resident's family usually ask for the remote control and the staff usually requested for the TV to be reset since some channels did not work. The Maintenance Director stated Channels 35 to 64 usually work and Channels 20 through 30 did not work and have to reset on by one. The Maintenance Director stated he would go to the resident's room with TV concerns immediately and attempt to fix it. The Maintenance Director stated he never provided maintenance or resetting of the TV since 1/2025 for Resident 1. In addition, the Maintenance Director stated he did not receive any request or report regarding TV channels not working or available this month in room [ROOM NUMBER] ABC. The Maintenance Director stated did not receive any report from Social Service Director of any TV concerns or complaints for Resident 1 this month. The Maintenance Director stated since he started two and a half years ago, the TV issue had been going on and off. The Maintenance Director stated he had been informing the Administrators since he started, but the problem keeps going in circles. The Maintenance Director stated he did what he could to fix it, however he was waiting for the Administrator's plan to resolve it. Furthermore, the Maintenance Director stated he reported this TV channel problem in the stand up meeting and Administrator and Assistant Administrator were informed of the TV channels not working. On 6/19/25 at 1520 hours, an interview and concurrent facility document review was conducted with the Administrator. The Administrator stated he was aware of the tv channels not available or working since 5/5/25, due to the grievance. The Administrator stated he was informed by Activity Director. In addition, the Administrator stated this concern was brought up to his attention during the recent survey on 6/2-6/5/25. The Administrator reviewed Resident 1's grievance form dated 6/16/25, and verified his signature. The Administrator stated they were planning to follow up since this was ongoing issue. The Administrator was asked if he went to Resident 1's room to check his TV if it was working or to reset and he stated he did not go to the Resident 1's room since 6/16/25. The Administrator stated the Maintenance Director did not check Resident 1's TV since they were still resetting the box and pinpointing the cause. Furthermore, the Administrator stated his plan to fix it was whenever the TV channel issue comes up, he would have Maintenance Director reset the tv and no other plans or action. On 6/19/25 at 1527 hours, an interview was conducted with the Assistant Administrator. The Assistant Administrator stated the Administration including herself were aware of the TV channels not working since it was a constant issue and she had received complaints from the Ombudsman. The Assistant Administrator stated the all the resident rooms in the facility have a TV and the admission packet does not mention or inform the resident or family requiring to provide their TV. The Assistant Administrator stated the resident's activities were very important, it helps the residents with their quality of life and psychosocial well-being. On 6/19/25 at 1646 hours, an interview was conducted with the Activity Director. The Activity Director stated the importance of activities for the residents were to be able to socialize, entertainment, be productive, exercise, and stimulate their brain. The Activity Director stated an activity (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055674 If continuation sheet Page 6 of 8 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 06/24/2025 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 0679 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few assessment includes the resident's interests and preferences. In addition, the Activity Director stated after assessment, they develop an activity care plan based on each resident's preferences/interest and family's input or request from IDT meeting. The Activity Director stated Resident 1 likes to watch TV in his room and talks to his sister over the phone. The Activity Director stated the TV channel concerns were brought up last month during the Resident Council meeting and had been an ongoing issue for the last two to three months. The Activity Director stated she informed the Maintenance Director and Assistant Administrator for the past three months. In addition, the Activity Director stated the Maintenance Director had checked TVs of the residents with complaints. The Activity Director stated the Maintenance Director did what he could to fix the TV channels, however, it had been a recurrent issue per the residents. The Activity Director stated there were no new recommendations or plan from the Assistant Administrator. The Activity Director stated the residents could be greatly affected in a negative way if their preferred activities would not be available like watching TV. Furthermore, the Activity Director stated the facility must provide a home like environment and part of it was having working TV channels especially if that was the residents' preferred interest and activity. On 6/19/25 at 1720 hours, an interview was conducted with the Administrator. The Administrator was asked if the Maintenance Director works over the weekend, after hours or on call for example for TV concerns or TV channels not working and he stated no, there was no maintenance staff after hours or over the weekend. The Administrator stated he will not have the Maintenance Director come in after hours or over the weekend just to fix TV concerns. The Administrator was asked if there were TV or channels problems after hours and weekends, who was responsible to fix it and the Administrator stated the Maintenance Director will have fix the TV concerns on Monday. On 6/24/25 at 0815 hours, an interview was conducted with RN 1. RN 1 stated activities were very important on the resident's daily life. The negative outcome of residents' preferred activities like music or tv not being provided would affect their mood, the would be sad or depressed. In addition, RN 1 stated it would affect residents' participation with their ADLs and high chance that residents will decline in their health and well-being. Furthermore, RN 1 stated we cannot say it's just tv since it's part of the residents' daily life, it's something they look forward to before they go to sleep and when they wake up. On 6/24/25 at 0905 hours, an interview was conducted with the Administrator. The Administrator stated there was no work order requested from Spectrum or any cable company prior to 6/19/25. The Administrator stated he spoke to a technician who would fix the rest of the channels. The Administrator stated he did not inform the residents or family upon admission they must provide their own TV, firestick or roku. In addition, the Administrator stated the Activity Director and the Maintenance Director manually checked the TV channels last Friday 6/20/25, and they were all working. On 6/24/25 at 1000 hours, a telephone interview was conducted with the Ombudsman. The Ombudsman stated since she took over last March 2025 she was aware of the TV channel issues and it has been ongoing issue. The Ombudsman stated the previous ombudsman was aware of the TV channel problem and facility's Administrators were disregarding the issue. Furthermore, the Ombudsman stated the Administrators did not seem to understand the TV channel concerns and it was important to the residents, especially if that was their favorite activity to do while in the facility. On 6/24/25 at 1242 hours, an interview was conducted with the DON. The DON stated the facility provided TV with cable channels and if any concerns, the facility was responsible to fix problem. The DON stated resident's personal interest or activities were very important for the residents since this (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055674 If continuation sheet Page 7 of 8 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 06/24/2025 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 0679 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete place was a continuation of their homelike environment. The DON stated implications will be residents will be depressed and may get irritable. Furthermore, the DON stated she could not tell the resident No, you cannot watch TV. On 6/24/25 at 1305 hours, an interview was conducted with the Administrator, Assistant Administrator, and DON. The Administrator failed to provide evidence in documentation or any cable company work order receipt prior to 6/19/25, in attempts to resolve the TV channel problem. The Administrator and DON stated they have not discussed or had care plan meeting with Resident 1 regarding the TV concerns or issues. The DON stated Resident 1 had no care plan regarding TV concerns or issues. The Administrator, Assistant Administrator, and DON were informed and acknowledged the above findings. Event ID: Facility ID: 055674 If continuation sheet Page 8 of 8