Other·August 12, 2019

F000 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The following reflects the findings of the California Department of Public Health (CDPH) during an ABBREVIATED survey for FACILITY REPORTED INCIDENT (FRI) NO: CA00640491. Inspection was limited to the specific FRI investigated and does not represent the findings of a full inspection of the facility Representing the CDPH: Surveyor 28951, HFEN. THE DEPARTMENT SUBSTANTIATE THE FRI. FINDINGS WERE CITED AT F689 FOR RESIDENT 1. GLOSSARY OF ABBREVIATIONS & BRIEF DEFINITIONS: 5150 - a 72-hour psychiatric hospitalization when a person identified or evaluated to be a danger to themselves or others or is gravely disabled CDPH, L&C Program - California Department of Public Health, Licensing and Certification Program CNA - Certified Nursing Assistant IDT - Interdisciplinary Team MDS - Minimum Data Set (a standardized assessment tool) P&P - policy and procedure RN - Registered Nurse

F689 SS=D Free of Accident Hazards/Supervision/Devices F689 CFR(s): 483.25(d)(1)(2) §483.25(d) Accidents. The facility must ensure that §483.25(d)(1) The resident environment LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE 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. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: Q8EO11 Facility ID: CA060000052 If continuation sheet 1 of 6 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055252 (X3) DATE SURVEY COMPLETED 07/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ORANGE HEALTHCARE & WELLNESS CENTRE, LLC 920 W La Veta Ave Orange, CA 92868 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE remains as free of accident hazards as is possible; and §483.25(d)(2)Each resident receives adequate supervision and assistance devices to prevent accidents. This REQUIREMENT is not met as evidenced by: Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure one of two sampled residents (Resident 1) was supervised while Resident 1 had a lighter in his possession. Resident 1 was left alone outside and started a fire in the facility's garbage can located directly outside the facility's front entrance door. The flames melted the garbage can and spread to a nearby tree, which was in direct contact with the building. This put all residents at risk for harm, injury, or death. Findings: On 6/5/19, the CDPH, L&C Program received a FRI which identified Resident 1 had started a fire in a garbage can outside the facility. The report showed on 6/4/19, Resident 1 was exhibiting aggressive behaviors and on one to one supervision for the resident and staff safety. The report showed Resident 1 was left alone for one to two minutes while the staff member left to find another staff member to supervise Resident 1. The fire was identified when another staff member arrived to supervise Resident 1. Review of the facility's P&P titled Smoking by Residents revised January 2017 showed for the residents who smoke, the IDT will develop an individualized plan for safe storage of smoking materials, provide assistance, and supervision to residents, if necessary. The FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: Q8EO11 Facility ID: CA060000052 If continuation sheet 2 of 6 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055252 (X3) DATE SURVEY COMPLETED 07/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ORANGE HEALTHCARE & WELLNESS CENTRE, LLC 920 W La Veta Ave Orange, CA 92868 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE staff are to complete a Resident Smoking Assessment, a care plan and discuss with the resident and responsible party at resident care conference meetings. Medical record review for Resident 1 was initiated on 6/18/19. Resident 1 was admitted to the facility on 5/15/19. Review of Resident 1's MDS dated 5/22/19, showed the resident had moderately impaired cognition and was independent with the use of a wheelchair. Review for Resident 1 showed a physician's order dated 5/15/19, to monitor Resident 1 for behaviors of schizophrenia and delusions. Review of the History and Physical Examination dated 5/16/19, showed Resident 2 was assessed to not have the capacity to understand and make decision. Review of a care plan problem dated 5/28/19, titled Smoking showed Resident 1 was alert with periods of confusion. The interventions showed the resident required supervision with smoking and his smoking materials were to be maintained in medication cart. One of the interventions showed to respect the resident's rights and the resident refused to keep his smoking materials in the medication cart. However, there was no further documentation to show how the facility was to secure Resident 1's smoking materials for safety. Review of Resident 1's Safe Smoking Assessment dated 5/25/19, showed the resident smoked and his smoking materials should be kept in the medication cart. The assessment showed Resident 1's had impulsive behaviors and required supervision when he smoked. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: Q8EO11 Facility ID: CA060000052 If continuation sheet 3 of 6 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055252 (X3) DATE SURVEY COMPLETED 07/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ORANGE HEALTHCARE & WELLNESS CENTRE, LLC 920 W La Veta Ave Orange, CA 92868 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Review of Resident 1's care plan problem dated 5/25/19, addressing the resident's smoking showed the plan was to for the facility staff to keep the resident's smoking materials in the medication cart. Resident 1 did not agree with the facility keeping his cigarettes and lighter in the medication cart; he wanted to keep them. There was no further documentation to show how the facility was to secure Resident 1's smoking materials for safety. On 6/4/19 at approximately 0330 hours, Resident 1 was sitting outside and set fire to a garbage can which spread to a tree. The tree was next to the facility's building. The staff called 911 and the Fire Department and police responded. Review of the Fire Department report dated 6/4/19 at 0334 hours, showed the Fire Department responded due to a 911 call. The report showed the fire was started by a resident lighting a fire in a garbage can which was directly below the tree. The report showed Resident 1 had been acting erratically for several hours. The resident denied lighting the fire; however, the police transported Resident 1 to the acute care hospital emergency department on a 5150 hold. On 6/18/19 at 0650 hours, an interview was conducted LVN 1. He stated he had worked at the facility a few months. When asked if he had received any training on the facility's smoking policy or where the designated smoking area was, he said no. On 6/18/19 at 0655 hours, an interview was conducted LVN 2. LVN 2 stated she had worked at the facility for several years. When asked if there were any smoking materials kept FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: Q8EO11 Facility ID: CA060000052 If continuation sheet 4 of 6 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055252 (X3) DATE SURVEY COMPLETED 07/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ORANGE HEALTHCARE & WELLNESS CENTRE, LLC 920 W La Veta Ave Orange, CA 92868 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE in her medication cart, she said no. On 6/18/19 at 0705 hours, a lighter was observed sitting on top of an unattended medication cart. On 6/21/19 at 0913 hours, a telephone interview was conducted with CNA 1. CNA 1 stated on the night of the fire, Resident 1 was really acting out; he was taking everything off the reception desk and throwing things onto the floor. He was grabbing everything, including the electronic stuff, cables and throwing everything to the ground. Resident 1 was being "very aggressive that night." No one would get too close to him because he was so aggressive. CNA 1 stated the Supervisor had called the police and Resident 1 calmed down, but only while the police was there. CNA 1 stated she was not assigned to care for Resident 1. CNA 1 stated she was scheduled to take her break and the Supervisor asked her if she would watch Resident 1 while she was on her 30-minute break. CNA 1 stated watched Resident 1 who was outside the facility's front entrance and was sitting inside. CNA 1 she stated she could see Resident 1 through the glass front door. CNA 1 stated she did not observe Resident 1 smoking but saw he had a lighter. CNA 1 stated she watched Resident 1 "play with the lighter" and was flicking it on and off many times. CNA 1 stated when her 30-minute break was over, she stopped watching Resident 1 and went to clock back in to return to caring for her assigned residents. CNA 1 stated she then heard someone yelling and went to see what was happening. She stated she observed the garbage can outside where Resident 1 had been on fire and it was burning to the ground. CNA 1 explained the flames caught the tree on fire. CNA 1 stated she saw the Supervisor outside using a hose trying to put the flames FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: Q8EO11 Facility ID: CA060000052 If continuation sheet 5 of 6 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055252 (X3) DATE SURVEY COMPLETED 07/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ORANGE HEALTHCARE & WELLNESS CENTRE, LLC 920 W La Veta Ave Orange, CA 92868 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE out. CNA 1 stated she did not inform anyone Resident 1 had a lighter. When asked if she informed the Supervisor she was done with her break and needed to return to care for her residents, she said no, but he witnessed her clock back in. On 6/28/19 at 0600 hours, observation of the front of the facility was conducted with RN 2. RN 2 stated he was the RN Supervisor on duty the night of the fire. RN 2 stated Resident 1's baseline behavior varied from being nice to being uncooperative. RN 2 stated the night of the fire, Resident 1 was agitated, and kept going in and out of the facility. RN 1 stated he was concerned Resident 1 would do something to harm himself or staff, so they were watching Resident 1. RN 2 explained at one point during the night, Resident 1 was sitting in his wheelchair outside the facility near the front door and asked CNA 1 to watch Resident 1. RN 2 stated he saw CNA 1 clock back in and he then went out to watch Resident. That was when he saw the garbage can and tree above the garbage can on fire. RN 2 stated Resident 1 was sitting in his wheelchair watching the fire while clapping, yelling, and laughing. RN 2 stated Resident 1's laugh was like a "devil laugh." RN 2 stated he pulled the hose over to the fire and was able to put the fire out prior to the Fire Department's arrival. RN 2 stated he did not see how the fire had started. There was a tall tree with green leaves observed next to the front of the facility. However, the portion of the tree touching the building was burnt. There was an area approximately six feet in diameter that had burned on the tree. RN 2 stated the fire started in the garbage can which then ignited the tree. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: Q8EO11 Facility ID: CA060000052 If continuation sheet 6 of 6