Health inspection·October 9, 2025

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and medical record review, the facility failed to provide the necessary care and services to maintain the highest practicable well-being for one of three sampled residents (Resident 1). * LVN 1 delayed contacting emergency services after Resident 1 who was on an anticoagulant, had an unwitnessed fall and injury to his forehead. This failure had the potential to negatively affect the resident's well-being as the necessary care and services were not provided.Findings: Medical record review for Resident 1 was initiated on 10/1/25. Resident 1 was admitted to the facility on [DATE]. Resident 1 had diagnoses which included anoxic brain damage, diffuse traumatic brain injury, and epilepsy. Review of Resident 1's H&P examination dated 4/24/25, showed Resident 1 had no capacity to make medical decisions. Review of Resident 1's eINTERACT Change of Condition Evaluation - V 5.1 dated 9/18/25 at 0840 hours, showed Resident 1 had an unwitnessed fall, where he was found on the floor next to his bed. Resident 1 was noted to have a bump on his right forehead. The physician was notified at 0905 hours and recommended to transfer Resident 1 to the acute care hospital for an evaluation and treatment. Review of Resident 1's progress note showed a late entry dated 9/18/25 at 1000 hours, showing the licensed staff called 911 and the paramedics arrived at 0950 hours. Resident 1 left the facility via gurney at 0958 hours. Review of Resident 1's admission H&P note from Acute Care Hospital A dated 9/18/25, showed Resident 1 fell around two feet from the bed onto the ground and striking his head. The CT of the head result showed a small 2 mm right frontal subdural hematoma. On 10/1/25 at 1600 hours, an interview was conducted with LVN 1. LVN 1 stated on 9/18/25 at around 0840 hours, she found Resident 1 on the floor near the right side of his bed. LVN 1 stated she assessed Resident 1 and saw a bump on his forehead, before placing him back on his bed with CNA 1's assistance. LVN 1 stated the physician ordered to transfer Resident 1 to the acute care hospital for an evaluation. LVN 1 stated she contacted a regular ambulance but was told by the ambulance company that since Resident 1 was on a blood thinner medication and had a bump on his head, she should contact 911. LVN 1 stated she attempted to contact another regular ambulance but was told the same instructions. LVN 1 then contacted 911 for Resident 1. On 10/2/25 at 1548 hours, an interview was conducted with the DON. The DON stated if the resident had an unwitnessed fall and was on blood thinner medications, the resident would be transferred to the acute care hospital for an evaluation via a regular ambulance or 911. When asked what would determine the licensed staff to contact 911, the DON stated if the resident had a bump or a headache. The DON verified Resident 1 had a bump on his head due to the unwitnessed fall incident. In addition, the DON stated the licensed staff should have contacted 911 for Resident 1. On 10/10/25 at 1607 hours, a telephone interview was conducted with the DON and Medical Records Director. The DON and Medical Records Director were informed and acknowledged the above findings. Cross reference F689. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055674 If continuation sheet Page 2 of 10 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 10/09/2025 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 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, facility document review, and facility P&P review, the facility failed to provide the necessary care and services to ensure one of three sampled residents (Resident 1) was free from accident hazards. * Resident 1 had an unwitnessed fall incident on 9/18/25. The facility failed to investigate Resident 1's family member's grievance regarding Resident 1's position near the edge of the bed on 9/16/25. Resident 1's fall risk assessment was inaccurate resulting in an incorrect fall risk score status. In addition, the facility failed to update Resident 1's care plan addressing the resident's risk for fall and his behavior of dangling his legs off the bed prior to his fall incident. These failures resulted in Resident 1 sustaining a subdural hematoma (a collection of blood that accumulates between the brain and the inner layer of the skull) and hospitalization.Findings: Review of the facility's P&P titled Grievance/Complaint Log revised 4/2008 showed the Social Services will be responsible for the grievance log. The following information as a minimum must be recorded:a) The date the grievance/complaint was received;b) The name and room number of the resident following the grievance complaint;c) The name and relationship of the person filing the grievance/complaint in behalf of the resident;d) The date the alleged incident took place;e) The name of the person (s) investigating the incident;f) The disposition of the grievance (i.e., resolved, dispute, etc.,).Review of the facility's Fall Program: Falling (Yellow) Star Program (undated) showed the IDT (Interdisciplinary Team) will review appropriate interventions for the residents identified as a fall risk; interventions will be based on the resident's fall risk factors from assessments, history of falls, and other fall risk determinants. The DON and DSD will re-educate the nursing staff about the Falling Star Program which will include the frequency of monitoring the residents and interventions to minimize injuries from a potential fall. a. Medical record review for Resident 1 was initiated on 10/1/25. Resident 1 was admitted to the facility on [DATE]. Resident 1 had diagnoses which included diffuse traumatic brain injury (a disruption in the normal function of the brain that can be caused by a bump, blow or jolt to the head), history of falling, and anoxic brain damage (a condition where the brain was deprived of oxygen for a period of time). In addition, Resident 1 was hospitalized on [DATE], and returned to the facility on 9/25/25. Review of Resident 1's H&P examination dated 4/24/25, showed Resident 1 was nonverbal and had no capacity to make medical decisions. Review of Resident 1's MDS assessment dated [DATE], showed Resident 1 was dependent on the facility staff assistance to roll from lying on his back, to the left and right sides, and return to lying on his back on the bed. Further review of Resident 1's MDS assessment showed to code the resident dependent when the resident did not provide any effort to complete the activity, or the assistance of two or more helpers were required for the resident to complete the activity. In addition, the MDS assessment showed Resident 1 had an impairment on both upper and lower extremities that interfered with daily functions. Review of Resident 1's Grievance / Complaint Report Form dated 9/16/25, showed the department manager would investigate the allegations and submit a written report of the findings to the Administrator within five working days of receiving the grievance. Resident 1's grievance form showed Resident 1's family member complained regarding the resident's legs positioned towards the edge of the bed and informing a CNA to reposition the resident. Under the sections for witnesses and employees to describe the incident and to describe the findings of the incident showed N/A was documented. Under the Recommendations/Corrective Action Taken section showed an in-service was initiated for the licensed nurses and CNAs on 9/17/25, about proper positioning in bed. However, further review of Resident 1's medical record failed to show documentation the facility monitored and/or provided (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055674 If continuation sheet Page 3 of 10 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 10/09/2025 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 0689 Level of Harm - Actual harm Residents Affected - Few additional interventions to prevent the resident from falling after the grievance from the resident's family member was filed. Review of Resident 1's eINTERACT Change in Condition Evaluation - V 5.1 dated 9/18/25, showed Resident 1 had an unwitnessed fall incident, where he was found lying on the floor near the right side of his bed. Resident 1 was noted to have a bump on the right side of his forehead. Resident 1 was on an anticoagulant (blood thinner) medication and the physician ordered to transfer Resident 1 to the acute care hospital for an evaluation and treatment. Review of Resident 1's admission H&P note from Acute Care Hospital A dated 9/18/25, showed Resident 1 fell around two feet from the bed onto the ground and striking his head. The CT of the head (computed tomography scan of the head is an imaging test that uses X-rays to create detailed cross-sectional images of the brain, skull, and sinuses) result showed a small 2 mm (size) right frontal subdural hematoma. b. Review of the facility's P&P titled Falls - Clinical Protocol revised 3/2018 showed the staff will identify the resident's risk factors for falls and history of falling. The nurse shall assess the resident and document the resident's vital signs, musculoskeletal function, and observe for change in normal range of motion. In addition, the staff will identify, monitor, and document the interventions related to the residents' risk of falls and re-evaluate the current approaches as needed to prevent subsequent falls. Review of the facility's P&P titled Charting and Documentation revised 7/2017 showed documentation in the medical record will be objective, complete, and accurate. Review of Resident 1's IDT (Interdisciplinary Team) Conference Record-RNA Follow Up dated 4/5/25, showed Resident 1 was bed bound. Review of Resident 1's Quarterly MDS assessment dated [DATE], showed Resident 1 was dependent on the facility staff assistance on toileting hygiene, and was always incontinent with the urinary and bowel continence. Review of Resident 1's MAR for July 2025 showed Resident 1 was administered with the following medications:- from 7/1 to 7/31/25, Resident 1 was administered amlodipine (used to treat high blood pressure)10 mg one tablet via GT in the morning for hypertension (high blood pressure);- from 7/1 to 7/31/25, Resident 1 was administered 5 ml of levetiracetam (anticonvulsant) 100 mg/ml oral solution via GT one time a day for seizures (a sudden burst of electrical activity in the brain);- on 7/17/25 at 2218 hours, Resident 1 was administered Ativan (antianxiety) 2 mg/ml intravenously every four hours as needed for seizure disorder. Review of Resident 1's N Adv - Fall Risk Evaluation dated 7/24/25 at 1604 hours, showed the following:- For the ambulation and elimination status, the documentation showed Resident 1 was chairbound/incontinent; however, Resident 1 was bedbound and incontinent.- For medications, the documentation showed Resident 1 was taking one to two of these medication classes (anesthetics, antihistamines, antihypertensives, antiseizure, benzodiazepines, cathartics, diuretics, hypoglycemics, narcotics, psychotropics, sedatives/hypnotics) within the last seven days; however, Resident 1 was taking three of the medication classes (antihypertensive, antiseizure, and psychotropic medication) . The Fall Risk Evaluation further showed if the total score was 10 or greater, the resident would be considered at high risk for potential falls and preventions should be initiated immediately and documented on the care plan. Review of Resident 1's progress notes correlating with the N Adv - Fall Risk Evaluation dated 7/24/25 at 1604 hours, showed the resident's fall risk score was nine. On 10/2/25 at 1256 hours, a follow up interview and concurrent medical record review for Resident 1 was conducted with LVN 1. LVN 1 verified the Fall Risk Evaluation was inaccurate and based on the resident's MAR, the fall risk score would be higher than nine, to show Resident 1 would be at a high risk for fall. c. Review of the facility's P&P titled Care Plans, Comprehensive Person-Centered revised 12/2016 showed the care plan interventions are implemented after careful data gathering of the resident's problem areas and their causes. In addition, the assessments of the residents are ongoing, and care plans are revised as information about the residents change. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055674 If continuation sheet Page 4 of 10 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 10/09/2025 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 0689 Level of Harm - Actual harm Residents Affected - Few Review of Resident 1's plan of care initiated 12/10/24, and revised 10/1/25, showed a care plan problem addressing the resident's risk for falls. The interventions included to anticipate and meet the resident's needs, review information on past falls and attempt to determine the cause of the falls, record the possible roots cause, remove potential causes (for the falls) if possible, initiate the Falling Star Program, apply the yellow wrist band on the resident, place a yellow star by the door next to the resident's name, place the resident's bed in the lowest position and place the call light within reach. The care plan failed to show a new intervention was added or modified to prevent fall after the grievance of the resident's family member regarding the resident's episode of resident's legs positioned towards the edge of the bed or the behavior of dangling his legs over the bed. Further review Resident 1's care plan showed interventions were added to the resident's care plan on 9/20/25, after the resident's fall on 9/18/25, which included providing frequent visual checks, positioning the resident in the middle of the bed, and putting pillows on the resident's sides. On 10/1/25 at 1600 hours, an interview was conducted with LVN 1. LVN 1 stated on 9/18/25 at around 0840 hours, she found Resident 1 on the floor near the right side of his bed. LVN 1 stated she assessed Resident 1 and saw a bump on his forehead, before placing him back on his bed with CNA 1's assistance. LVN 1 stated the physician ordered to transfer Resident 1 to the acute care hospital for an evaluation. When asked if LVN 1 was aware of Resident 1's behavior of dangling his legs over the bed, LVN 1 stated the resident would cross his legs near the edge of his bed and slide down on the bed, when he was on the low air loss mattress. On 10/2/25 at 1020 hours, an interview was conducted with CNA 1. CNA 1 stated Resident 1 would cross his legs all the time during his scheduled shifts. CNA 1 added the resident's legs would hang over the bed, and the resident would slide down on the low air loss mattress. CNA 1 stated he had informed the licensed nurses about Resident 1's behavior but was not aware if interventions were implemented for Resident 1 regarding the behavior of hanging his legs over the bed. On 10/2/25 at 1233 hours, a telephone interview was conducted with Family Member 1. Family Member 1 stated she filed a grievance on 9/16/25, with the facility, because Resident 1's legs were hanging off the bed and he was close to falling from the bed. Family Member 1 stated the facility staff informed her they would speak to the DON to address Resident 1's behavior and come up with a plan. On 10/2/25 at 1256 hours, a follow up interview and concurrent medical record review for Resident 1 was conducted with LVN 1. LVN 1 stated she did not document Resident 1's ability to cross his legs in his medical record and verified there was no documentation in Resident 1's progress notes regarding his ability to cross or move his legs over the bed. LVN 1 further stated she would have initiated a care plan for Resident 1's behavior of hanging his leg over the bed so the facility staff would be aware of any interventions implemented. LVN 1 reviewed Resident 1's N Adv - Fall Risk Evaluation dated 7/24/25, and Resident 1's MAR for 7/2025. LVN 1 verified the Fall Risk Evaluation was inaccurate and based on the resident's MAR, the fall risk score would be higher and show Resident 1 would be at a high risk for fall. On 10/2/25 at 1548 hours, an interview and concurrent medical record review was conducted with the DON. The DON stated when a grievance was filed, the SSD should notify the responsible staff who oversaw the department, interview the facility staff involved, and update the resident's care plan. The DON verified she only updated Resident 1's care plan regarding the grievance after the resident's fall incident. On 10/8/25 at 0957 hours, an interview was conducted with the Interim DSD. The Interim DSD stated the SSD spoke to her regarding Family Member 1's grievance about Resident 1's legs dangling off the bed and their concern of Resident 1 falling out of bed. The Interim DSD stated she provided an in-service to the facility staff about repositioning the residents. When asked if the Interim DSD implemented any additional interventions for Resident 1's risk for (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055674 If continuation sheet Page 5 of 10 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 10/09/2025 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 0689 Level of Harm - Actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete falls, the Interim DSD stated just the intervention to reposition the resident. On 10/8/25 at 1045 hours, an interview and concurrent facility document review of Resident 1's Grievance Form was conducted with the SSD. The SSD stated she was responsible for investigating the facility's grievances. When asked how the SSD investigated the grievance from Family Member 1, the SSD stated she informed the Interim DSD about Family Member 1's concern and the Interim DSD agreed to do an all-facility staff in-service about positioning the residents. The SSD verified she did not interview any facility staff members about Resident 1's behavior of hanging his legs over the bed. On 10/8/25 at 1156 hours, a follow-up interview and concurrent facility document review for Resident 1 was conducted with the DON. The DON stated based on Resident 1's Grievance Form, the documented N/A on the form showed the grievance was not investigated because the facility staff were not interviewed. In addition, the DON stated the facility should have implemented interventions for Resident 1 regarding Family Member 1's grievance. The DON verified Resident 1's fall risk evaluation was inaccurate and stated if the correct assessment was conducted, Resident 1's fall risk score would have increased to show the resident was high risk for fall. On 10/10/25 at 1607 hours, a telephone interview was conducted with the DON and Medical Records Director. The DON and Medical Records Director were informed and acknowledged the above findings. Event ID: Facility ID: 055674 If continuation sheet Page 6 of 10 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 10/09/2025 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **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 ensure the pharmaceutical services were provided to meet the residents needs for two of three sampled residents (Residents 1 and 2). * The facility failed to administer Resident 1's medications scheduled. In addition, the facility documented Resident 1's medications were administered on 9/19/25 at 1700, 1800, 1900, and 2100 hours, after the resident was transferred to the acute care hospital. * The facility failed to administer Resident 2's medications scheduled on 9/15 and 9/22/25 at 2100 hours. These failures had the potential to negatively affect the residents health conditions and posed the risk for diversion of the medications.Findings: Review of the facility's P&P titled Administering Medications revised 4/2019 showed the medications are administered in a safe and timely manner and as prescribed. The individual administering the medication initials the resident's MAR on the appropriate line after giving each medication and before administering the next ones. If a medication is withheld, refused, or given at a time other than the scheduled time, the individual administering the medication shall initial and circle the appropriate line on the resident's MAR. Review of the facility's P&P titled Charting and Documentation revised 7/2017 showed documentation in the medical record will be objective, complete, and accurate. 1. Medical record review for Resident 1 was initiated on 10/1/25. Resident 1 was admitted to the facility on [DATE]. Resident 1 had diagnoses which included anoxic brain damage, epilepsy, tachycardia, dysphagia and chronic respiratory failure with hypoxia. Review of Resident 1's H&P examination dated 4/24/25, showed Resident 1 had no capacity to make medical decisions and had a GT. Review of Resident 1's Order Summary Report showed the following physician's orders:- dated 4/23/25 and discontinued on 9/25/25, to administer gabapentin (antiseizure) 300 mg one capsule via GT three times a day for seizure disorder and methocarbamol (used as a muscle relaxant) 750 mg one tablet via GT three times a day for muscle spasm;- dated 4/24/25 and discontinued on 9/25/25, to administer docusate sodium (stool softener) 100 mg one tablet via GT at bedtime for bowel management, multivitamin-minerals (supplement) one tablet via GT at bedtime for supplement, 10 ml of levetiracetam (antiseizure) 100 mg/ml via GT two times a day for seizure disorder, metoprolol tartrate (antihypertensive) 50 mg one tablet via GT every twelve hours for hypertension/tachycardia, and two drops of artificial tears solution in both eyes four times a day for dry eyes;- dated 5/5/25 and discontinued on 9/25/25, to swab povidone-iodine (used to prevent infections in minor cuts and burns) 10 % external swab in each nostril every twelve hours every two weeks on Monday, Tuesday, Wednesday, Thursday, and Friday for decolonization (process aimed to reduce or eliminate the presence of bacteria or microorganisms on the body or environment);- dated 5/17/25 and discontinued on 9/25/25, to administer vitamin D (supplement) 25 mcg one tablet via GT one time a day for supplement, and magnesium oxide (supplement) 400 mg one tablet via GT two times a day for magnesium supplement;dated 6/3/25 and discontinued on 9/25/25, to administer sodium chloride (supplement) 1 g two tablets via GT three times a day for hyponatremia;- dated 6/16/25 and discontinued on 9/25/25, to administer melatonin (supplement) 5 mg one tablet via GT at bedtime for circadian rhythm disruption; - dated 7/5/25 and discontinued on 9/25/25, to inject enoxaparin sodium (blood thinner) 30mg/0.3 ml subcutaneously two times a day for DVT prophylaxis, - dated 7/23/25 and discontinued on 9/25/25, to administer amantadine HCl (used to treat stiffness, tremors and slowness of movement) 100m g via GT two times a day for dyskinesia;- dated 8/4/25 and discontinued on 9/25/25, to administer 1.25 mg of levalbuterol HCl (prevents and treats shortness of breath) 1.25 mg/3 ml via nebulizer four times a day for respiratory failure; -dated 9/25/25, to administer gabapentin (anticonvulsant medication) 300 mg one (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055674 If continuation sheet Page 7 of 10 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 10/09/2025 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few capsule via GT three times a day for seizure disorder; and- dated 9/26/25, to administer 2 ml of budesonide (used to treat shortness of breath) 0.5 mg/2 ml orally every twelve hours for respiratory failure, acetaminophen (pain reliever) 325 mg two tablets via GT three times a day for pain management, 10 ml of levetiracetam 100 mg/ml via GT every twelve hours for seizure, enoxaparin sodium 30 mg/0.3 ml subcutaneously two times a day for DVT prophylaxis, magnesium oxide 400 mg one tablet via GT two times a day for magnesium supplement, metoprolol tartrate 50 mg one tablet via GT every twelve hours for hypertension/tachycardia, amantadine HCl 100 mg one tablet via GT three times a day for involuntary movements, and methocarbamol 750 mg one tablet via GT three times a day for muscle spasm. a. Review of Resident 1's MAR for 9/2025 failed to show documented evidence the following medications were administered:- the ratification tears medication on 9/9/25 at 1700 hours;- the enoxaparin, levetiracetam, magnesium oxide, and vitamin D medications on 9/9/25 at 1800 hours;- the levalbuterol HCl medication on 9/9/25 at 1900 hours;- the artificial tears, amantadine, docusate sodium, melatonin, metoprolol tartrate, multivitamin-minerals, and povidone-iodine swab medications on 9/9/25 at 2100 hours;- the gabapentin, methocarbamol and sodium chloride medications on 9/9/25 at 2200 hours;- the enoxaparin and magnesium medications on 9/26/25 at 1800 hours;- the budesonide, levetiracetam, and metoprolol medications on 9/26 and 9/27/25 at 2100 hours; and- the acetaminophen, amantadine, gabapentin, and methocarbamol medications on 9/26 and 9/27/25 at 2200 hours. Further review of Resident 1's medical record failed to show documented evidence the medications listed above were administered to Resident 1. On 10/2/25 at 1256 hours, an interview and concurrent medical record review for Resident 1 was conducted with LVN 1. When asked what the blank space meant on a resident's MAR, LVN 1 stated it meant the medication was not given. LVN 1 reviewed Resident 1's medical record and verified the above findings. b. Review of Resident 1's MAR for 9/2025 showed the following medications were administered on 9/19/25:- the artificial tears medication at 1700 hours,,- the enoxaparin, levetiracetam, and magnesium oxide medications at 1800 hours;- the levalbuterol HCl medication at 1900 hours; and- the amantadine, artificial tears, melatonin, and vitamin D medications at 2100 hours. However, review of Resident 1's progress notes for September 2025 showed the following:- dated 9/18/25, Resident 1 was transferred to the acute care hospital for evaluation and treatment;- dated 9/19/25, Resident 1 was still hospitalized ; and- dated 9/25/25, Resident 1 returned to the skilled nursing facility via ambulance. On 10/9/25 at 1525 hours, an interview and concurrent medical record review for Resident 1 was conducted with the DON. The DON stated a check mark on the resident's MAR indicated the medication was administered. The DON verified Resident 1 was not in the facility on 9/19/25, and verified the above findings. 2. Medical record review for Resident 2 was initiated on 10/2/25. Resident 2 was admitted to the facility on [DATE]. Resident 2 had diagnoses which included epilepsy and occlusion and stenosis of right carotid artery. Review of Resident 2's Order Summary Report showed the following physician's orders:- dated 11/21/24, to administer one drop of artificial tears ophthalmic solution in both eyes two times a day for dry eyes; and- dated 6/13/25, to administer lactobacillus (supplement) one capsule by mouth two times day for GI stabilizer, clopidogrel bisulfate (prevents blood clots) 75 mg one tablet by mouth at bedtime for CVA prophylaxis, docusate sodium 250 mg one capsule by mouth two times a day for constipation, 7.5 ml of levetiracetam 100 mg/ml by mouth every twelve hours for seizures, and metoprolol tartrate 50 mg one tablet by mouth every twelve hours for hypertension. Review of Resident 2's MAR for 9/2025 failed to show documented evidence the following medications were administered:- the artificial tears medication on 9/15/25 at 1800 hours; and- the clopidogrel, docusate sodium, lactobacillus, levetiracetam and metoprolol tartrate medications on 9/15 and 9/22/25 at 2100 hours. On 10/8/25 at 1156 hours, an interview and concurrent medical record (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055674 If continuation sheet Page 8 of 10 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 10/09/2025 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete review for Residents 1 and 2 was conducted with the DON. The DON stated the licensed nurses needed to document on the MAR when they administered or held the resident's medications. When asked what the blank space meant on a Resident 1's MAR, the DON stated it meant the medication was not given. The DON was informed and verified the above findings. On 10/10/25 at 1607 hours, a telephone interview was conducted with the DON and Medical Records Director. The DON and Medical Records Director were informed and acknowledged the above findings. Event ID: Facility ID: 055674 If continuation sheet Page 9 of 10 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 10/09/2025 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 0842 Level of Harm - Potential for minimal harm Residents Affected - Some 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 ensure the residents' medical record were complete and accurate for two of three sampled residents (Residents 2 and 3). * Resident 2's fall risk assessments were incomplete. * Resident 3's fall risk assessments were incomplete. These failures posed the risk for the residents care needs not being met as their medical record information were inaccurate and incompleteFindings: Review of the facility's P&P titled Charting and Documentation revised 7/2017 showed documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate. 1. Medical record review for Resident 2 was initiated on 10/1/25. Resident 2 was admitted to the facility on [DATE]. Review of Resident 2's Fall Risk Evaluation dated 6/19/25, showed blank entries for the following sections: systolic blood pressure, and vision status. Review of Resident 2's Fall Risk Evaluation dated 8/23/25, showed blank entries for the following sections: ambulation, and systolic blood pressure. 2. Medical record review for Resident 3 was initiated on 10/1/25. Resident 3 was admitted to the facility on [DATE]. Review of Resident 3's Order Summary Report dated 10/1/25, showed the following physician's orders: - dated 2/16/25, to administer benazepril (antihypertensive) 20 mg one tablet orally one time a day for hypertension;- dated 2/16/22, to administer hydralazine HCl (antihypertensive) 100 mg one tablet orally three times a day for hypertension;- dated 2/16/22, to administer hydrochlorothiazide (diuretic) 12.5 mg one capsule orally in the evening for CHF; - dated 2/16/22, to administer metoprolol tartrate (antihypertensive) 25 mg one tablet orally two times a day; and- dated 4/26/23, to inject Humulin R (hypoglycemic/lowers blood sugar) 100 unit/ml subcutaneously per sliding scale one time a day for diabetes. Review of Resident 3's MAR for July 2025 showed Resident 3 was administered the benazepril, Humulin R, hydrochlorothiazide, hydralazine, and metoprolol medications. Review of Resident 3's Fall Risk Evaluation dated 7/21/25, showed Resident 3 took one to two classes of medications listed on the evaluation form (anesthetics, antihistamines, antihypertensive, antiseizure, benzodiazepines, cathartics, diuretics, hypoglycemics, narcotics, psychotropics and sedative/hypnotics) currently or within the last seven days. However, Resident 3 was taking three classes of the medications listed (antihypertensive, diuretic, and hypoglycemic). On 10/2/25 at 1256 hours, an interview and concurrent medical record review was conducted with LVN 1. LVN 1 verified Resident 2 and 3's Fall Risk Evaluations had blank entries and were inaccurate. On 10/8/25 at 1150 hours, an interview was conducted with the DON. The DON stated the responses checked off on the Fall Risk Evaluation should be filled out completely, as the responses affected the overall fall risk score for the residents. Event ID: Facility ID: 055674 If continuation sheet Page 10 of 10