Other·February 21, 2020

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 during the RECERTIFICATION survey. Representing the California Department of Public Health: Surveyor 37689, HFEN; Surveyor 35346, HFEN; Surveyor 38764, HFEN; Surveyor 39629, HFEN; Surveyor 41316, HFEN; and Surveyor 39856, Nutrition Consultant. The survey team entered the facility on 1/7/2020 at 1230 hours. The resident census was 98. GLOSSARY OF DEFINITIONS AND ABBREVIATIONS: ADL - activities of daily living BiPAP/CPAP - bi-level or constant positive airway pressure (used to treat obstructive sleep apnea) cm - centimeter(s) CNA - Certified Nursing Assistant CPR - cardiopulmonary resuscitation DON - Director of Nursing DSD - Director of Staff Development DSS - Dietary Services Supervisor F - Fahrenheit GT - gastrostomy tube (a tube placed through the abdominal wall into the stomach used to provide feeding formula and/or administer medications) g/dl - gram(s) per deciliter IDT - Interdisciplinary Team LVN - Licensed Vocational Nurse MDS - Minimum Data Set (a standardized assessment tool) mg - milligram(s) ml - milliliter(s) P&P - policy and procedure 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: 0LVL11 Facility ID: CA060000052 If continuation sheet 1 of 77 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 01/14/2020 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 POLST - Physician Orders for Life-Sustaining Treatment RD - Registered Dietician SSD - Social Service Director

F578 SS=D Request/Refuse/Dscntnue Trmnt;Formlte Adv Dir CFR(s): 483.10(c)(6)(8)(g)(12)(i)-(v)

F578 02/14/2020 §483.10(c)(6) The right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. §483.10(c)(8) Nothing in this paragraph should be construed as the right of the resident to receive the provision of medical treatment or medical services deemed medically unnecessary or inappropriate. §483.10(g)(12) The facility must comply with the requirements specified in 42 CFR part 489, subpart I (Advance Directives). (i) These requirements include provisions to inform and provide written information to all adult residents concerning the right to accept or refuse medical or surgical treatment and, at the resident's option, formulate an advance directive. (ii) This includes a written description of the facility's policies to implement advance directives and applicable State law. (iii) Facilities are permitted to contract with other entities to furnish this information but are still legally responsible for ensuring that the requirements of this section are met. (iv) If an adult individual is incapacitated at the time of admission and is unable to receive information or articulate whether or not he or she has executed an advance directive, the facility may give advance directive information to the individual's resident representative in FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0LVL11 Facility ID: CA060000052 If continuation sheet 2 of 77 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 01/14/2020 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 accordance with State Law. (v) The facility is not relieved of its obligation to provide this information to the individual once he or she is able to receive such information. Follow-up procedures must be in place to provide the information to the individual directly at the appropriate time. This REQUIREMENT is not met as evidenced by: Based on interview and medical record review, the facility failed to maintain a copy of the resident's advance directive in the medical record for one of 20 final sampled residents (Resident 86). This had the potential for the resident's decisions regarding her healthcare and treatment options not being honored. Findings: Medical record review for Resident 86 was initiated on 1/8/20. Resident 86 was readmitted to the facility on 3/15/19. Review of the MDS dated 11/14/19, showed Resident 86 had moderate cognitive impairment. Review of the Advance Healthcare Directive Acknowledgement Form dated 3/15/19, showed Resident 86 had an advance directive. However, review of the medical record failed to show a copy of the advance directive was maintained in Resident 86's medical record. Resident 86 did not have a POLST. On 1/9/20 at 0717 hours, an interview and concurrent medical record review was conducted with the SSD. The SSD reviewed the medical record and verified the above findings. The SSD stated she was going to follow up and ask Resident 86's family member FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0LVL11 Facility ID: CA060000052 If continuation sheet 3 of 77 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 01/14/2020 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 for a copy of the advance directive. On 1/9/20 at 0756 hours, an interview was conducted with LVN 1. LVN 1 stated, in the event a resident went into cardiac arrest, they would look for the advance directive. If the resident did not have an advance directive, they would refer to the POLST. If the resident had no POLST, then the resident was considered a full code. Review of the Physician Orders showed an order dated 3/15/19, showing Resident 86's code status was "No CPR."

F641 SS=D Accuracy of Assessments CFR(s): 483.20(g)

F641 02/14/2020 §483.20(g) Accuracy of Assessments. The assessment must accurately reflect the resident's status. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and medical record review, the facility failed to ensure two of 20 final sampled residents (Residents 54, 60, and 87) received accurate assessments reflective of the residents' status at the time of the assessments. This had the potential for the residents' care needs not being met effectively. * The facility failed to accurately code Resident 60's special treatments, procedures and programs for hospice care on the MDS dated 7/10/19. * The facility failed to accurately code Resident 54's bowel continence on the MDS dated 11/19/19. * The facility failed to accurately code Resident FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0LVL11 Facility ID: CA060000052 If continuation sheet 4 of 77 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 01/14/2020 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 87's tube feeding. These failures posed the risk of the residents not receiving individualized plans of care based on their specific needs. Findings: 1. On 1/7/20 at 1520 hours, during the initial tour of the facility, a telephone interview was conducted with Family Member A. Family Member A stated Resident 60 was receiving hospice care services. Medical record review for Resident 60 was initiated on 1/7/20. Resident 60 was readmitted readmitted to the facility on 5/7/19. Review of Resident 60's MDS dated 7/10/19, did not show Resident 60 was receiving hospice care. Review of Resident 60's Status Review for Significant Change of Condition dated 7/10/19, showed the resident was enrolled in hospice care. Review of Resident 60's hospice certification form with a verbal order dated 10/2/19, showed the resident' s prognosis was six months or less if the disease runs its normal course. On 1/10/20 at 1543 hours, a concurrent interview and medical record review was conducted with MDS Coordinator 2. MDS Coordinator 2 verified the above findings. MDS Coordinator 2 acknowledged Resident 60 was receiving hospice care at the time of assessment, and the MDS was coded incorrectly. 2. On 1/7/20 at 1438 hours, during the initial FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0LVL11 Facility ID: CA060000052 If continuation sheet 5 of 77 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 01/14/2020 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 tour of the facility, Resident 54 was observed wearing an incontinence brief. Medical record review was initiated for Resident 54. Resident 54 was readmitted to the facility on 11/12/19. Review of Resident 54's MDS dated 11/19/20, showed Resident 54 was always continent with bowel function. Review of Resident 54's care plan dated "11/12" (unidentifiable date format), showed a care plan problem addressing the resident's incontinence of bowel function, including the need of incontinence briefs and pads. On 1/9/19 at 1331 hours, a concurrent interview and medical record review was conducted with MDS Coordinator 2. MDS Coordinator 2 acknowledged the above findings. MDS Coordinator 2 was asked how she conducted the MDS assessment of bowel continence for Resident 54. MDS Coordinator 2 stated she conducted the assessment, including a review of the resident's ADL flowsheet completed by the CNAs. Review of Resident 54's ADL Flowsheet dated November 2019 showed the resident had multiple episodes of bowel incontinence; for example, on the night shift of 11/12, 11/13, 11/14, 11/15, 11/16, 11/17, 11/18, and 11/19/19, bowel function was documented with the letter "I" on the above dates. The flowsheet showed the letter "I" meant incontinent. MDS Coordinator 2 acknowledged the above findings. MDS Coordinator 2 verified Resident 54's MDS should had been coded to show the resident was incontinent of bowel function, and the MDS was coded inaccurately. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0LVL11 Facility ID: CA060000052 If continuation sheet 6 of 77 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 01/14/2020 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 Cross reference to F690. 3. On 1/8/20 at 0806 hours, Resident 87 was observed lying in bed. A tube feeding pump on a pole was observed next to his bed. Medical record review for Resident 87 was initiated on 1/8/20. Resident 87 was admitted to the facility on 11/8/19, and was readmitted to the facility on 12/21/19. Review of the quarterly MDS dated 11/27/19, showed Section K for Swallowing/Nutritional Status, tube feeding was not coded. Review of the Medication Administration Record for November 2019 showed Resident 87 received Jevity 1.5 (nutritional formula) at 75 ml per hour daily from 1400 to 1000 hours. On 1/8/20 at 1237 hours, an interview and concurrent medical record review was conducted with MDS Coordinator 1. MDS Coordinator 1 verified the above findings and stated the tube feeding should have been coded on the MDS.

F656 SS=D Develop/Implement Comprehensive Care Plan F656 CFR(s): 483.21(b)(1) 02/14/2020 §483.21(b) Comprehensive Care Plans §483.21(b)(1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at §483.10(c)(2) and §483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following (i) The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0LVL11 Facility ID: CA060000052 If continuation sheet 7 of 77 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 01/14/2020 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 well-being as required under §483.24, §483.25 or §483.40; and (ii) Any services that would otherwise be required under §483.24, §483.25 or §483.40 but are not provided due to the resident's exercise of rights under §483.10, including the right to refuse treatment under §483.10(c)(6). (iii) Any specialized services or specialized rehabilitative services the nursing facility will provide as a result of PASARR recommendations. If a facility disagrees with the findings of the PASARR, it must indicate its rationale in the resident's medical record. (iv)In consultation with the resident and the resident's representative(s)(A) The resident's goals for admission and desired outcomes. (B) The resident's preference and potential for future discharge. Facilities must document whether the resident's desire to return to the community was assessed and any referrals to local contact agencies and/or other appropriate entities, for this purpose. (C) Discharge plans in the comprehensive care plan, as appropriate, in accordance with the requirements set forth in paragraph (c) of this section. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and medical record review, the facility failed to develop and implement the plans of care to reflect the individual care needs for three of 20 final sampled residents (Residents 87, 68 and 9). * The facility failed to develop a care plan problem to address Resident 87's GT feeding, seizure disorder, and hypotension (low blood pressure). * The facility failed to develop a care plan problem to address Resident 68's need for FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0LVL11 Facility ID: CA060000052 If continuation sheet 8 of 77 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 01/14/2020 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 close supervision while eating. These failures posed the risk of not providing appropriate, consistent, and individualized care to the residents. Findings: 1. Medical record review for Resident 87 was initiated on 1/8/20. Resident 87 was readmitted to the facility on 12/21/19. Review of the Physician Orders showed the following orders dated 12/21/19: - Jevity 1.5 (nutritional formula) at 75 ml per hour times 20 hours; - phenytoin (antiseizure medication) 200 mg suspension, via GT every 12 hours for seizure disorder; - Keppra 500 mg via GT two times a day for seizures; - valproic acid 1000 mg, via GT two times a day for seizures; and - midodrine hydrochloride (blood pressure medication) 5 mg, give two tablets via GT three times a day for hypotension. Review of the plan of care failed to show care plan problems were created to address Resident 87's GT feeding, seizure disorder, and hypotension. On 1/10/20 at 1114 hours, an interview and concurrent medical record review was conducted with MDS Coordinator 2. MDS Coordinator 2 reviewed the plan of care and verified the above findings. MDS Coordinator 2 stated Resident 87 should have had care plan problems to address his GT feeding, seizure disorder, and hypotension. 2. On 1/8/20 at 0817 hours, during an initial tour, a concurrent observation and interview was conducted with Resident 68 in their room. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0LVL11 Facility ID: CA060000052 If continuation sheet 9 of 77 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 01/14/2020 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 Pureed food items were observed on Resident 68's meal tray. Resident 68 was asked if she tried the yellow-colored food item on her plate. The resident stated yes. Resident 68 was asked how the yellow-colored food item on her plate tasted. The resident stated the yellowcolored food item on her plate tasted like an egg. There was no facility staff observed at the bedside assisting Resident 68 with eating. Medical record review for Resident 68 was initiated on 1/8/20. Resident 68 was readmitted to the facility on 7/16/19. Review of Resident 68's Physician Orders for the month of January 2020 showed a physician's order dated 10/3/19, for a pureed texture diet with nectar thickened liquids for oral gratification only. Review of the Resident 68's Speech Therapy SLP Discharge Summary dated 11/15/19, showed discharge recommendations included close supervision of the resident for oral intake. On 1/10/20 at 0959 hours, an interview was conducted with CNA 6. CNA 6 was asked to describe how Resident 68 ate her meals. CNA 6 stated the resident ate her meals independently. On 1/10/19 at 1035 hours, a concurrent interview and medical review was conducted with the Speech Therapist. The Speech Therapist was asked to describe close supervision for Resident 68 as one of the discharge recommendations from speech therapy services. The Speech Therapist stated Resident 68 should have a staff member at the bedside the entire time while the resident was eating. On 1/10/20 at 1123 hours, a concurrent FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0LVL11 Facility ID: CA060000052 If continuation sheet 10 of 77 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 01/14/2020 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 interview and medical record review was conducted with LVN 1. LVN 1 was asked if there was a plan of care developed addressing Resident 68's requirement for close supervision when eating. LVN 1 was observed reviewing Resident 68's medical record; however, the LVN acknowledged there was no plan of care developed addressing the requirement for close supervision when eating. Cross reference to F689.

F657 SS=D Care Plan Timing and Revision CFR(s): 483.21(b)(2)(i)-(iii)

F657 02/14/2020 §483.21(b) Comprehensive Care Plans §483.21(b)(2) A comprehensive care plan must be(i) Developed within 7 days after completion of the comprehensive assessment. (ii) Prepared by an interdisciplinary team, that includes but is not limited to-(A) The attending physician. (B) A registered nurse with responsibility for the resident. (C) A nurse aide with responsibility for the resident. (D) A member of food and nutrition services staff. (E) To the extent practicable, the participation of the resident and the resident's representative(s). An explanation must be included in a resident's medical record if the participation of the resident and their resident representative is determined not practicable for the development of the resident's care plan. (F) Other appropriate staff or professionals in disciplines as determined by the resident's needs or as requested by the resident. (iii)Reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0LVL11 Facility ID: CA060000052 If continuation sheet 11 of 77 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 01/14/2020 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 assessments. This REQUIREMENT is not met as evidenced by: Based on interview and medical record review, the facility failed to ensure the plan of care for one of 20 final sampled residents (Resident 79) was revised to reflect her current resident assessments. The facility failed to revise Resident 79's care plan to reflect her weight loss and change in activities. This failure placed the resident at risk of not being provided appropriate, consistent, and individualized care. Findings: Medical record review for Resident 79 was initiated on 1/8/20. Resident 79 was readmitted to the facility on 3/31/16. a. Review of the medical record showed Resident 79 had continued severe unplanned weight loss from August to December 2019. Review of the plan of care showed a care plan problem was developed to address Resident 79's nutrition and hydration dated 8/12/19. The care plan failed to address Resident 79's current and continued severe unplanned weight loss. The interventions were not modified to reflect the current plan of care. Cross reference to F692, example #1. On 1/9/20 at 0850 hours, an interview and concurrent medical record review was conducted with the RD. The RD reviewed the medical record and verified the above findings. b. Review of the Resident Participation Logs from July to November 2019 showed Resident 79 participated and attended the facility's group activities. However, review of the 1 x 1 Activity FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0LVL11 Facility ID: CA060000052 If continuation sheet 12 of 77 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 01/14/2020 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 Attendance Records for December 2019 and January 2020 showed Resident 79 had not participated in group activities, but received room visits. Review of the plan of care showed a care plan problem was developed to address Resident 79's activities dated 2/24/19. The care plan did not reflect the changes in Resident 79's activities participation. On 1/10/20 at 1553 hours, an interview and concurrent medical record review was conducted with the Activities Assistant. The Activities Assistant verified the above findings and stated Resident 79 had not been attending group activities and was now provided room visits. The Activities Assistant stated the care plan should have been revised.

F679 SS=D Activities Meet Interest/Needs Each Resident CFR(s): 483.24(c)(1)

F679 02/14/2020 §483.24(c) Activities. §483.24(c)(1) The facility must provide, based on the comprehensive assessment and care plan and the preferences of each resident, an ongoing program to support residents in their choice of activities, both facility-sponsored group and individual activities and independent activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and medical record review, the facility failed to offer activities to meet the needs of one of 20 final sampled residents (Resident 36). This failure had the potential to negatively affect the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0LVL11 Facility ID: CA060000052 If continuation sheet 13 of 77 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 01/14/2020 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 resident's psychosocial well-being. Findings: Medical record review for Resident 36 was initiated on 1/9/20. Resident 36 was admitted to the facility on 10/19/18, and was readmitted to the facility on 10/8/19. Review of Resident 36's History and Physical Examination dated 10/11/19, showed Resident 36 did not have the capacity to make decisions. Review of Resident 36's MDS dated 9/27/19, showed the resident's only activity preference was listening to music. Review of Resident 36's Activity Assessment dated 10/23/19, showed Resident 36 preferred one on one activities, large group activities and staying in his room. Activity preferences included music when attending activities, listening to music, and TV/radio. Review of Resident 36's care plan problem dated 10/23/19, showed Resident 36's activity preferences included watching TV and family visits. During observations on 1/7/20 at 1400 hours, 1/8/20 at 0745 hours, 1/8/20 at 1419 hours, 1/9/20 at 1420 hours, and 1/10/20 at 1611 hours, Resident 36 was lying in bed, awake. There was no radio or music playing and Resident 36's television was turned off. Review of the Resident Participation Log for 10/19 - 1/20 for Resident 36 showed the following group activity entries: - Month of October 2019, Resident 36 observed three group activities; - Month of November 2019, Resident 36 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0LVL11 Facility ID: CA060000052 If continuation sheet 14 of 77 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 01/14/2020 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 observed three group activities; - Month of December 2019, Resident 36 observed four group activities; - January 1 to January 14 2020, Resident 36 observed three group activities; Review of the 1 x 1 Activity Attendance Record Log for 10/19 - 1/20 for Resident 36 failed to show Resident 36 was provided his preference of in-room music activity. Review of the Resident Participation Log and 1x1 Activity Attendance Record for 10/19 - 1/20 for Resident 36 showed the resident was not provided any activities including group activities or independent activities such as listening to music and watching TV on the following dates: - October 8 to October 31 2019: 10/12, 10/13, 10/17, 10/18, 10/20, 10/24, 10/26, 10/27, and 10/31/19. - Month of November 2019: 10/2, 10/3, 10/9, 10/10, 10/14, 10/16, 10/17, 10/18, 10/21, 10/23, 10/24, 10/29, and 10/30/19. - Month of December 2019: 12/4, 12/5, 12/7, 12/8, 12/10, 12/13, 12/14, 12/15, 12/18, 12/19, 12/21, 12/26, 12/28, and 12/29/19. - January 1 to January 14, 2020: 1/1, 1/4, 1/5, 1/7, 1/9, 1/11 and 1/12/20. On 1/14/20 at 0735 hours, an interview and concurrent medical record review was conducted with the Assistant Activities Director (AD). When asked what program of activities was developed for Resident 36, the Assistant AD stated Resident 36 received one on one room visits with her three to four times a week for 10 to 15 minutes. When asked about Resident 36's other activities, the Assistant AD stated Resident 36 did not attend group activities much and she left the TV on for him after room visits. The Assistant AD stated she had not seen Resident 36 with music playing in his room and did not know why. The Assistant FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0LVL11 Facility ID: CA060000052 If continuation sheet 15 of 77 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 01/14/2020 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 AD stated she had never seen Resident 36 taken to group activities. When asked why, the Assistant AD stated nobody had shared with her the reason why he was not taken to group activities. When asked if she believed the resident was receiving enough activities, the Assistant AD stated she thought so. The Assistant AD verified Resident 36's care plan showed Resident 36's preferences was watching TV and family visits and the care plan did not include listening to music. When asked if she believed this was an appropriate care plan for the resident, the Assistant AD stated Resident 36 should have been more involved in group activities and received more room visits. The Assistant AD stated she wanted to visit the resident Monday through Friday for room visits to provide more sensory stimulation such as hand massage and reading. On 1/14/20 at 0752 hours, Resident 36 was observed lying in bed watching TV with no sound. Resident 36's roommate's TV was drawn behind the curtain, not visible to Resident 36, with the sound turned up. On 1/14/20 at 0758 hours, a follow-up interview was conducted with the Assistant AD. When asked why Resident 36's roommate's TV was on with sound while Resident 36 had the TV on without sound, the Assistant AD stated she did not know. The Assistant AD stated the sound level should be equal volume for both TVs in the residents' rooms.

F684 SS=D Quality of Care CFR(s): 483.25

F684 02/14/2020 § 483.25 Quality of care Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0LVL11 Facility ID: CA060000052 If continuation sheet 16 of 77 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 01/14/2020 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 ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive personcentered care plan, and the residents' choices. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and medical record review, the facility failed to provide the necessary care and services to ensure one of 20 final sampled residents (Resident 68) maintained their highest practicable physical well-being. * The facility discontinued Resident 68's Dermaseptin (a topical ointment used as a skin barrier to prevent irritation from moisture, and to promote healing) ointment order without a physician' s order. This failure posed the risk for the development of skin breakdown affecting the resident's medical condition. Findings: Medical record review for Resident 68 was initiated on 1/8/20. Resident 68 was admitted to the facility on 2/28/13, and readmitted on 7/16/19. Review of Resident 68's Physician Orders for January 2020 showed a physician's order dated 10/3/19, to apply Dermaseptin ointment to the resident's sacral area and buttocks every shift and as needed for skin maintenance. Review of Resident 68's Treatment Administration Record showed the following; * For December 2019, the Dermaseptin ointment order was not reflected on the administration record, * For January 2020, the Dermaseptin order was reflected on the treatment administration record; however, the record showed "D/C" FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0LVL11 Facility ID: CA060000052 If continuation sheet 17 of 77 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 01/14/2020 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 (discontinued). Review of Resident 68's care plan showed care plan problem dated 7/17/19, addressing incontinence, placing the resident at risk for skin breakdown. On 1/9/20 at 1427 hours, a concurrent interview and medical record review was conducted with LVN 2. LVN 2 acknowledged the "D/C" meant the application of Dermaseptin was discontinued for Resident 68. LVN 2 was asked why the Dermaseptin ointment was ordered for Resident 68. LVN 2 stated the Dermaseptin ointment was used to protect the resident's skin from moisture damage. LVN 2 was asked if the resident was incontinent. LVN 2 stated the resident was incontinent of bowel and bladder. LVN 2 was asked when the Dermaseptin order was discontinued. LVN 2 was observed reviewing Resident 68's medical record; however, the LVN acknowledged he could not find a physician's order showing to discontinue the Dermaseptin ointment. LVN 2 was asked if a physician's order was required to discontinue the Dermaseptin ointment order for Resident 68. LVN 2 stated a physician's order was required to discontinue the Dermaseptin ointment for Resident 68.

F686 Treatment/Svcs to Prevent/Heal Pressure Ulcer F686 02/14/2020 SS=D CFR(s): 483.25(b)(1)(i)(ii) §483.25(b) Skin Integrity §483.25(b)(1) Pressure ulcers. Based on the comprehensive assessment of a resident, the facility must ensure that(i) A resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable; and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0LVL11 Facility ID: CA060000052 If continuation sheet 18 of 77 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 01/14/2020 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 (ii) A resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing. 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 the necessary care and services were provided to prevent the development and worsening of a pressure ulcer for one of 20 final sampled residents (Resident 79). * Resident 79 was incontinent and developed a deep tissue pressure injury on the sacrococcyx (tailbone) observed on 11/26/19, which deteriorated to an unstageable pressure ulcer on 12/5/19, and progressed to a Stage 4 on 12/12/19. The facility failed to provide appropriate and necessary services to ensure Resident 79 did not develop a pressure ulcer in the facility and failed to ensure the pressure ulcer did not deteriorate. Findings: Review of the facility's P&P titled Pressure Injury and Skin Integrity Treatment revised date 8/12/16, showed the dietary needs will be evaluated by the RD on admission and when there is significant change in the skin condition. The diet should contain adequate calories, nutrients and fluids to support wound healing. If food and fluid needs are not met, the attending physician and RD will be notified by the Licensed Nurse. The National Pressure Ulcer Advisory Panel released definitions of pressure ulcers on April 13, 2016. They are as follows: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0LVL11 Facility ID: CA060000052 If continuation sheet 19 of 77 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 01/14/2020 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 - Stage 1 pressure ulcer - intact skin with a localized area of non-blanchable erythema (redness). - Stage 2 pressure ulcer - partial thickness skin loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough (dead tissue). May also present as an intact or open/ruptured serum-filled blister. - Stage 3 pressure ulcer - full thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon, or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling (damage to tissue beneath the skin surrounding the pressure ulcer). - Stage 4 pressure ulcer - full thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar (dead tissue) may be present on some parts of the wound bed. Often includes undermining and tunneling. - Unstageable pressure ulcer - full thickness tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. - Deep Tissue Pressure Injury - Intact or nonintact skin with localized area of persistent nonblanchable deep red, maroon, purple discoloration or epidermal separation revealing a dark wound bed or blood filled blister. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. On 1/7/19 at 1344 hours, Resident 79 was observed lying on her right side on a low air loss mattress (mattress used for prevention or treatment of skin breakdown). Medical record review for Resident 79 was initiated on 1/8/20. Resident 79 was readmitted to the facility on 3/3/16. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0LVL11 Facility ID: CA060000052 If continuation sheet 20 of 77 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 01/14/2020 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 the MDS dated 12/2/19, showed Resident 79 had severe cognitive impairment. Resident 79 required total assistance of one person for bed mobility (how the resident moved to and from a lying position, turned side to side, and positioned her body while in bed) and toilet use (including how the resident was cleaned after elimination and pad changes). Resident 79 was always incontinent of bowel and bladder. Review of the Weekly Pressure Injury/Ulcer Progress Report showed an entry dated 11/16/19, showing Resident 79 developed a Stage 1 pressure ulcer on the sacrococcyx measuring 8 cm (length) x 8 cm (width) x 0 cm (depth). An entry dated 11/26/19, showed the wound had developed into a deep tissue pressure injury measuring 5 cm x 5 cm x undetermined depth, described as a purplish skin discoloration. Review of the Interdisciplinary Team Conference Record dated 11/28/19, showed Resident 79 had been drinking poorly and eating less. The IDT recommended a wound consult and RD consult. Review of the Physician Orders showed an order dated 11/26/19, for a wound consult; and 11/27/19, for an RD consult. Further review of the Weekly Pressure Injury/Ulcer Progress Report showed an entry dated 12/5/19, showing the pressure ulcer had worsened to Unstageable measuring 5 cm x 5 cm x undetermined depth, described as 80% slough and 20% granulation (red pink wound bed), with minimal drainage/odor. Review of the medical record failed to show FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0LVL11 Facility ID: CA060000052 If continuation sheet 21 of 77 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 01/14/2020 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 documentation a wound consult was done. Review of the Nutritional Progress Note showed an entry by the RD dated 12/8/19. The RD addressed Resident 79's severe unplanned weight loss of 5.43% in one month, and 12.32% in six months. However, the documentation failed to show the RD had addressed Resident 79's pressure ulcer. Review of the Wound Assessment and Plan dated 12/12/19, showed the Wound Consultant's initial wound visit. The wound measured 3.8 cm x 3.3 cm x undetermined depth, described as 100% slough, with minimal drainage/odor. After performing a wound debridement (cutting away the dead tissue), the Wound Consultant evaluated the pressure ulcer as a Stage 4. Further review of the Nutritional Progress Note showed an entry by the RD dated 12/26/19, but failed to show the RD had addressed Resident 79's pressure ulcer. Review of the Wound Consultant's Wound Assessment and Plan dated 1/2/20, showed the wound had declined, measuring 6.1 cm x 3.8 cm x 1.2 cm (depth). The note showed, in addition to an increase in the size of the wound, there was persistent slough covering the wound bed with odor from the necrotic tissue. Resident 79 had poor oral intake. The Wound Consultant ordered weight loss protocol and nutritionist following. Review of the Nutritional Progress Note showed an entry by the RD dated 1/2/20, regarding her repeated dietary recommendations from 12/8/19, which were not acted upon. The RD failed to address Resident 79's pressure ulcer. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0LVL11 Facility ID: CA060000052 If continuation sheet 22 of 77 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 01/14/2020 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 On 1/10/20 at 0742 hours, an interview was conducted with LVN 6. LVN 6 stated the RD had not asked for a wound report of any of the residents in the facility. When asked if she had spoken with the RD regarding Resident 79's pressure ulcer, LVN 6 stated no. On 1/10/20 at 0955 hours, a wound care observation was conducted with LVN 6 and LVN 2. LVN 6 measured the wound at 6.1 cm x 3.5 cm x 1.7 cm with a 2 cm undermining at 10 o'clock. The wound edges were observed to be macerated (a result of prolonged exposure to moisture). On 1/10/20 at 1123 hours, an interview and concurrent medical record review was conducted with the RD. The RD was asked, when there is an order for an RD consult, does she check the medical record to see if the resident has any wounds. The RD stated no. The RD verified she had not addressed Resident 79's pressure ulcer in her assessments, however, had the facility carried out her dietary recommendations in a timely manner. The RD stated that could have helped prevent the development and worsening of Resident 79's pressure ulcer. The RD stated she had not informed Resident 79 had a facility-acquired Stage 4 pressure ulcer. Cross reference to F692, example #1. On 1/14/20 at 0820 hours, an interview and concurrent medical record review was conducted with the DON. The DON verified the above findings and stated he attended the IDT meetings to address Resident 79's pressure ulcer. The DON stated they discussed the progress of the wound during the meetings, however, there was no follow through of the previous recommendations or interventions.

F689 Free of Accident Hazards/Supervision/Devices F689 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0LVL11 02/14/2020 Facility ID: CA060000052 If continuation sheet 23 of 77 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 01/14/2020 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) SS=D CFR(s): 483.25(d)(1)(2) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE §483.25(d) Accidents. The facility must ensure that §483.25(d)(1) The resident environment 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, and medical record review, the facility failed to provide adequate supervision and a safe environment for two of 20 final sampled residents (Resident 68). * The facility failed to implement a speech therapy recommendation to supervise Resident 68 closely when eating. This failure placed Resident 68 at risk for choking and aspiration (the inhalation of food particle into the lungs resulting in difficulty breathing and possible pneumonia). Findings: On 1/8/20 at 0817 hours, during an initial tour of the facility, an observation was conducted of Resident 68. Pureed food items were observed on Resident 68's meal tray. There was no facility staff observed at the bedside assisting Resident 68 with eating. Medical record review for Resident 68 was initiated on 1/8/20. Resident 68 was readmitted to the facility on 7/16/19. Review of Resident 68's Physician Orders dated January 2020 showed an order dated FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0LVL11 Facility ID: CA060000052 If continuation sheet 24 of 77 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 01/14/2020 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 7/29/19, for Jevity 1.2 (nutritional formula) at 55 ml per hour for 20 hours to administer 1100 ml of nutritional formula. Another order dated 10/14/19, showed a puree texture diet with nectar thick liquids for oral gratification only. Review of Resident 68's Physician and Telephone Orders showed an order dated 10/23/19, for speech therapy evaluation and treatment with a diagnosis of dysphagia (difficulty swallowing). Review of Resident 68's Speech Therapy SLP (speech language pathology) Discharge Summary dated 11/15/19, showed the following: * Dates of service 10/24 - 11/15/19, for dysphagia therapy; * Skilled interventions addressing swallow dysfunction included therapeutic trial feedings to increase safety, diet texture, and liquid consistency to increase safe oral intake; * Recommendations included close supervision for oral intake. Review of Resident 68's care plan regarding speech therapy dated 10/24/19, showed the care plan problem addressed dysphagia; however, the plan of care was discontinued on 11/15/19. There was no other care plan problem developed to address supervising Resident 68 while eating. On 1/10/20 at 0959 hours, an interview was conducted with CNA 6. CNA 6 was asked to describe the care for Resident 68 while eating. CNA 6 stated the resident was able to eat independently. On 1/10/20 at 1035 hours, a concurrent interview and medical review was conducted with the Speech Therapist. The Speech FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0LVL11 Facility ID: CA060000052 If continuation sheet 25 of 77 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 01/14/2020 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 Therapist was asked why Resident 68 needed speech therapy services. The Speech Therapist stated it was to assess the resident for the safest and less restrictive diet due to difficulty swallowing. The Speech Therapist was asked about her assessment findings for Resident 68. The Speech Therapist stated Resident 68 had muscle weakness in the oropharynx (the part of the throat at the back of the mouth, including the soft palate, the base of the tongue, and the tonsils). The Speech Therapist explained Resident 68 had a risk for aspiration. The Speech Therapist was asked what her recommendations were when Resident 68 was discharged from speech therapy services. The Speech Therapist stated the discharge recommendations for Resident 68 included close supervision for oral intake. The Speech Therapist was asked to explain what close supervision for oral intake meant. The Speech Therapist stated close supervision for oral intake meant a staff member should be with the resident the entire time the resident was eating. The Speech Therapist explained close supervision of Resident 68 would ensure the resident was able to eat her food safely. On 1/10/20 at 1126 hours, a follow-up interview was conducted with CNA 6. CNA 6 was asked if she had assisted Resident 68 with eating. CNA 6 stated no. CNA 6 explained she delivered the meal tray to Resident 68 and left the resident to eat by herself. Cross reference to F656, example #2.

F690 SS=D Bowel/Bladder Incontinence, Catheter, UTI CFR(s): 483.25(e)(1)-(3)

F690 02/14/2020 §483.25(e) Incontinence. §483.25(e)(1) The facility must ensure that resident who is continent of bladder and bowel on admission receives services and assistance FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0LVL11 Facility ID: CA060000052 If continuation sheet 26 of 77 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 01/14/2020 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 to maintain continence unless his or her clinical condition is or becomes such that continence is not possible to maintain. §483.25(e)(2)For a resident with urinary incontinence, based on the resident's comprehensive assessment, the facility must ensure that(i) A resident who enters the facility without an indwelling catheter is not catheterized unless the resident's clinical condition demonstrates that catheterization was necessary; (ii) A resident who enters the facility with an indwelling catheter or subsequently receives one is assessed for removal of the catheter as soon as possible unless the resident's clinical condition demonstrates that catheterization is necessary; and (iii) A resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible. §483.25(e)(3) For a resident with fecal incontinence, based on the resident's comprehensive assessment, the facility must ensure that a resident who is incontinent of bowel receives appropriate treatment and services to restore as much normal bowel function as possible. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and medical record review, the facility failed to provide necessary services to restore as much bowel function as possible for one of 20 final sampled residents (Residents 54). * Resident 54 was not assessed accurately for bowel function. This posed the risk for further decline in the resident's bowel function. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0LVL11 Facility ID: CA060000052 If continuation sheet 27 of 77 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 01/14/2020 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 Findings: Review of the CMS 672 Resident Census and Conditions of Residents form completed by the DON and dated 1/7/20, showed 40 of the 98 residents in the facility were occasionally or frequently incontinent of bowel, and there were no residents on a bowel toileting program. On 6/10/19 at 0910 hours, during an initial tour of the facility, a concurrent interview and observation was conducted with Resident 54. Resident 54 was in bed and responded appropriately when greeted by his last name. Resident 54 was asked to describe his bladder and bowel pattern. Resident 54 stated he had been using incontinence briefs for bowel movements and had an indwelling catheter for urination. Review of Resident 54's medical record was initiated on 1/7/20. Resident 54 was admitted to the facility on 10/28/19, and readmitted on 11/12/19. Review of Resident 54's MDS dated 11/19/19, showed the resident had mild cognitive impairment, and was always continent of bowel. Review of Resident 54's care plan showed a care plan problem dated "11/12" (unidentifiable date format) addressing the resident's incontinence of bowel and the need of incontinence briefs and pads. Review of Resident 54's ADL Flowsheet dated November 2019 showed the resident had multiple episodes of bowel incontinence, For example, on the night shift of 11/12, 11/13, 11/14, 11/15, 11/16, 11/17, 11/18, and 11/19/19, bowel function was marked with the letter "I" on those dates. The flowsheet FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0LVL11 Facility ID: CA060000052 If continuation sheet 28 of 77 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 01/14/2020 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 showed the letter "I" meant incontinent. On 1/9/20 at 0843 hours, a follow-up interview was conducted with Resident 54. Resident 54 was asked if he could use the bathroom for urination and bowel movements. Resident 54 stated he could use the bathroom for bowel movements; however, the resident stated he was not able to go to the bathroom by himself. Resident 54 was asked if the staff had offered for him to use a bedpan to have bowel movements. Resident 54 stated the staff checked on him if he had a bowel movement; however, the staff had not offered for him to use a bedpan for bowel movements. Resident 54 explained he had no control with bowel movements and had been wearing incontinence pads for approximately one month. On 1/9/20 at 0920 hours, an interview was conducted with LVN 6. LVN 6 was asked to describe the bowel function of Resident 54. LVN 6 stated Resident 54 had always been incontinent of bowel since he was readmitted to the facility. On 1/9/20 at 0941 hours, an interview was conducted with CNA 4. CNA 4 was asked to describe Resident 54's bowel function. CNA 4 stated Resident 54 was incontinent of bowel and had been wearing incontinence briefs. CNA 4 explained the CNA from the previous shift reported to her Resident 54 was incontinent of bowel. On 1/9/20 at 1331 hours, a concurrent interview and medical record review was conducted with MDS Coordinator 2. MDS Coordinator 2 was asked the importance of assessing Resident 54's bowel function. MDS Coordinator 2 stated to identify appropriate interventions in maintaining and promoting FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0LVL11 Facility ID: CA060000052 If continuation sheet 29 of 77 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 01/14/2020 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 bowel continence. MDS Coordinator 2 was asked when Resident 54 was evaluated for a toileting program. MDS Coordinator 2 stated the bowel assessment for Resident 54 was performed on 11/19/19. MDS Coordinator 2 was asked what the findings were when the bowel assessment was performed. MDS Coordinator 2 stated the resident was assessed as continent of bowel. MDS Coordinator 2 was asked to describe how the bowel assessment was performed. MDS Coordinator 2 stated she performed the bowel assessment including interviews of the licensed nurses and CNAs and review of ADL Flowsheet completed by the CNAs. Review of Resident 54's ADL Flowsheet with MDS Coordinator 2 showed documentation Resident 54 had multiple episodes of bowel incontinence. MDS Coordinator 2 verified the findings. MDS Coordinator 2 acknowledged Resident 54 was assessed inaccurately for bowel function. MDS Coordinator 2 acknowledged the assessment of the bowel function for Resident 54 was not accurate, placed the resident at risk of not receiving appropriate care and worsening bowel function. MDS Coordinator 2 was asked if Resident 54 could have been a candidate for a bowel retraining program. MDS Coordinator 2 stated the resident could have benefited with a bowel retraining program. (Cross reference to F641, example 2)

F692 SS=G Nutrition/Hydration Status Maintenance CFR(s): 483.25(g)(1)-(3)

F692 02/14/2020 §483.25(g) Assisted nutrition and hydration. (Includes naso-gastric and gastrostomy tubes, both percutaneous endoscopic gastrostomy and percutaneous endoscopic jejunostomy, and enteral fluids). Based on a resident's comprehensive assessment, the facility must FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0LVL11 Facility ID: CA060000052 If continuation sheet 30 of 77 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 01/14/2020 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 ensure that a resident§483.25(g)(1) Maintains acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that this is not possible or resident preferences indicate otherwise; §483.25(g)(2) Is offered sufficient fluid intake to maintain proper hydration and health; §483.25(g)(3) Is offered a therapeutic diet when there is a nutritional problem and the health care provider orders a therapeutic diet. 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 three of 20 final sampled residents (Residents 11, 68, and 79) and one nonsampled resident (Resident 599) received the appropriate services to meet their nutritional needs and maintain desirable weights. * The facility failed to identify and address Resident 79's severe unplanned weight loss in a timely manner to prevent further weight loss. The facility failed to identify, implement, monitor, and modify the interventions specific to Resident 79's needs. These failures contributed to a continued weight loss and the development of a Stage 4 pressure ulcer. * The facility failed to provide timely nutritional assessments for Residents 599, 11, and 68. * The facility failed to timely follow the RD's recommendations for Resident 599. * The facility did not provide an RD consult for FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0LVL11 Facility ID: CA060000052 If continuation sheet 31 of 77 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 01/14/2020 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 Resident 11 as ordered by the physician. These failures had the potential for the residents not having their nutritional needs met and the facility not being able to evaluate if the planned interventions were effective. Findings: According to the facility's P&P titled Evaluation of Weight and Nutritional Status revised 1/2019, any resident who varies from previous reporting period by 5% in 30 days, 7.5% in 90 days, or 10% in 180 days, will be evaluated by the IDT - Nutrition and Weight Variance Committee to determine the cause of the weight loss and the interventions required. Once the weight loss is identified, the IDT Nutrition and Weight Variance Committee will: a. Identify and implement appropriate interventions; b. Update and revise the care plan, as appropriate; c. Notify the responsible party; d. Notify the Attending Physician; and e. Notify the RD. 1. On 1/8/20 at 0800 hours, Resident 79 was observed for breakfast in her room. Resident 79 was being spoon fed by the staff. Resident 79 was observed with eyes closed, however, would open her mouth and swallow every time she felt the spoon in her mouth. Resident 79 consumed 75% of her breakfast. Medical record review for Resident 79 was initiated on 1/8/20. Resident 79 was readmitted to the facility on 3/31/16. Review of the MDS dated 12/2/19, showed Resident 79 had severe cognitive impairment and required total assistance of one person for eating. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0LVL11 Facility ID: CA060000052 If continuation sheet 32 of 77 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 01/14/2020 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 the Individual Resident Weight History showed the following weights dated: - 1/6/19, 154.4 pounds; - 2/3/19, 150.4 pounds; - 3/3/19, 150 pounds; - 4/7/19, 145 pounds; - 5/5/19, 147 pounds; - 6/2/19, 138 pounds; - 7/7/19, 141.4 pounds; - 8/4/19, 137.4 pounds. Review of the Nutritional Assessment dated 8/12/19, showed Resident 79 was 62 inches in height and her usual body weight was 140 to 150 pounds. Resident 79's current weight was 137 pounds. The assessment showed a negative weight trend was identified. The RD recommended the following interventions: - four-ounce shake (protein supplement) three times a day; - four-ounce TwoCal HN (nutritional formula) two times a day with medication pass; - weekly weights times four; - check BMP (basic metabolic panel information about the body's fluid balance and levels of electrolytes like sodium and potassium), CBC (complete blood count), iron panel; and - mashed potatoes/ice cream at lunch and dinner. Review of the medical record failed to show documentation the above RD's recommendations were acted upon, nor the IDT - Nutrition and Weight Variance Committee had met and addressed the resident's negative weight trend. Further review of the Individual Resident Weight History showed the following recorded weights: - On 9/1/19, 132.4 pounds (11.73% weight loss in six months); FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0LVL11 Facility ID: CA060000052 If continuation sheet 33 of 77 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 01/14/2020 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 - On 10/6/19, 129.2 pounds (12.11% weight loss in six months); - On 11/3/19, 128.4 pounds (12.65% weight loss in six months) ; and - On 12/1/19, 121 pounds (5.43% weight loss in one month, 12.32% weight loss in six months). Review of the medical record failed to show documentation the RD had addressed Resident 79's severe unplanned weight loss in September, October, and November 2019. Review of the Weight Variance Committee Evaluations dated 9/20, 10/25, 11/26, and 12/24/19, failed to show the RD's involvement to address Resident 79's weight loss. The IDT meeting notes failed to show the committee had consulted with the RD regarding Resident 79's weight loss. Review of the plan of care showed a care plan problem was developed to address Resident 79's Nutrition and Hydration dated 8/12/19. The care plan failed to address Resident 79's continued, severe, unplanned weight loss. Cross reference to F657, example a. Review of the Nutritional Progress Note showed an entry by the RD dated 12/8/19. The RD recommended to increase the Prostat (nutritional supplement with protein and calorie content) to three times a day and add HPN (high protein nutrition, supplement) three times a day with meals. The note failed to show the RD observed Resident 79 for meals nor contacted the family for the resident's dietary preferences. Review of the medical record failed to show the above RD's recommendations were acted upon, nor documentation to show Resident 79's physician was informed of the above RD's recommendations. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0LVL11 Facility ID: CA060000052 If continuation sheet 34 of 77 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 01/14/2020 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 the Weight Variance Committee Evaluation dated 12/24/19, attended by LVN 1 and the DSS showed both staff met to address Resident 79's weight loss. However, there was no documentation why the RD's recommendations were not carried out. There were no new interventions added to address the resident's severe weight loss. Further review of the Nutritional Progress Note showed an entry by the RD dated 12/26/19. The RD documented her previous recommendations to increase the Prostat and HPN were not ordered and repeated the same recommendations. The RD documented there was no improvement in Resident 79's intake. However, the note failed to show the RD observed Resident 79 for meals nor contacted the family for the resident's dietary preferences. Review of the medical record failed to show the RD's repeated recommendations were acted upon, nor documentation to show Resident 79's physician was informed of the above RD recommendations. Further review of the Nutritional Progress Note showed an entry by the RD dated 1/2/20. The RD documented her previous recommendations for supplements were never carried out and Resident 79 remained at high nutritional risk and weight loss. The RD documented the recommendations to add the protein and calorie supplements were for the resident's benefit. Review of the medical record showed the above RD recommendations were not carried out until 1/7/20. Review of the laboratory results dated 11/21/19, showed Resident 79's albumin level FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0LVL11 Facility ID: CA060000052 If continuation sheet 35 of 77 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 01/14/2020 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 was at 2.6 g/dL (normal range: 3.5 - 5.7 g/dL; low albumin levels can also be seen in malnutrition and conditions where the body did not properly absorb and digest protein). Review of the laboratory results dated 12/17/19, showed Resident 79's pre-albumin level was 9 mg/dL (normal range: 17 - 34 mg/dL; an indicator of protein status, can be a sign of malnutrition). Review of the Weekly Pressure Injury/Ulcer Progress Reports showed Resident 79 developed an unstageable pressure ulcer to the sacrococcyx area (tailbone) on 12/5/19. The wound had progressed to a Stage 4 pressure ulcer by 12/12/19, and was increasing in size. Review of the RD's Nutritional Progress Notes dated 12/8, 12/26/19, and 1/2/20, failed to show documentation Resident 79's laboratory values and pressure ulcer were addressed by the RD in reference to her continued weight loss and poor meal intakes. On 1/9/20 at 0850 hours, an interview and concurrent medical record review was conducted with the RD. LVN 1, who introduced herself as the facility's Weight Variance Coordinator, joined the interview. The RD stated she assessed Resident 79 for severe unplanned weight loss on 12/8/19. The RD verified her recommendations were not acted upon in a timely manner and she had to make repeated recommendations. Her recommendations to increase the Prostat and HPN were not carried out until 1/7/20, a month after she had recommended them. The RD stated the recommendations were beneficial for Resident 79 because it could have addressed Resident 79's protein and caloric requirements. LVN 1 verified there was no documentation to FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0LVL11 Facility ID: CA060000052 If continuation sheet 36 of 77 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 01/14/2020 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 show why the RD's repeated recommendations were not addressed in a timely manner. LVN 1 stated the RD's recommendations should be carried out within 72 hours. On 1/10/20 at 0726 hours, an interview was conducted with CNA 3. CNA 3 stated Resident 79 needed assistance with meals and her appetite varied for breakfast and lunch. CNA 3 stated Resident 79 liked to drink the shake (HPN). CNA 3 stated Resident 79 used to only get the shake for lunch, now that she had it for breakfast, she would mix the shake with the cream of wheat and Resident 79 would eat it. CNA 3 stated the shake was not included in her documentation of meal intake because there was no area to document it. The area on the ADL flowsheet to document the nourishment referred to the snack (ice cream) which Resident 79 received at 1400 hours every day. On 1/10/20 at 1123 hours, a follow-up interview was conducted with the RD. The RD verified she had not addressed Resident 79's pressure ulcer in her assessments; however, had the facility carried out her recommendations in a timely manner, the RD stated that could have helped prevent the development and worsening of Resident 79's pressure ulcer. The RD reviewed her notes and verified she also failed to address Resident 79's abnormal laboratory values, specifically the pre-albumin level which was low. The RD stated she was not informed Resident 79 had a facility-acquired Stage 4 pressure ulcer. Cross reference to F686. On 1/14/20 at 0733 hours, a telephone interview was conducted with Resident 79's family member. The family member stated she was aware of Resident 79's weight loss and the family tried their best to come so they could assist in feeding Resident 79. The family member stated Resident 79 needed a lot of FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0LVL11 Facility ID: CA060000052 If continuation sheet 37 of 77 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 01/14/2020 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 cuing and time when eating, and she felt the facility staff did not have the time and patience to feed her. 2. Review of the facility's P&P titled Nutritional Assessment revised 2/1/14, showed the purpose of nutritional assessments is to ensure the residents are properly assessed for dietary needs. According to the P&P, the RD will complete the Nutritional Assessment within 14 days of admission. Medical record review for Resident 599 was initiated on 1/8/20. Resident 599 was admitted to the facility on 12/22/19. Review of Resident 599's Individual Resident Weight History showed the following weight entries: - 12/23/19, the resident weighed 120.6 pounds - 12/29/19, the resident weighed 114 pounds - 1/5/20, the resident weighed 110 pounds Review of Resident 599's Nutritional Assessment dated 1/6/20, showed Resident 599's first nutritional assessment was completed 15 days after admission. The assessment showed Resident 599 was 62 inches in height with a usual body weight of 120 +/- one to five pounds. Resident 599's current body weight was 114 pounds (Resident 599's weight on 1/5/20, was recorded on the Individual Resident Weight History as 110 pounds). The assessment showed Resident 599 experienced the weight loss and showed the RD's recommendation to add Prostat two times a day and snacks three times a day to the resident's diet. Review of Resident 599's Nutritional Assessment dated 1/8/20, showed a rerecommendation for Prostat twice a day and snacks three times a day. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0LVL11 Facility ID: CA060000052 If continuation sheet 38 of 77 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 01/14/2020 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 the medical record on 1/10/20 at 0900 hours, failed to show the above RD's recommendations were acted upon. On 1/10/20 at 0942 hours, an interview and concurrent medical record review was conducted with the RD. The RD stated she expected her recommendations to be completed within 72 hours. The RD stated since she was only at the facility two days a week, she checked the residents' medical records to see if the recommendations were implemented. The RD stated if the recommendation was not carried out, she rerecommended or verbalized her recommendation to a charge nurse. The RD stated the time frame she had to complete her first nutritional assessment on a resident was 14 days. The RD verified her nutritional assessment on Resident 599 was late and was completed after 15 days. The RD verified she was at the facility on 12/31/19, during the 14 days the resident was at the facility. The RD verified she did not attend the weight-variance committee meeting on 12/31/19, addressing Resident 599's significant weight loss. The RD verified the medical record failed to show her recommendations for Prostat and snacks. 3. Review of the facility's P&P titled Quarterly Nutritional Evaluation and Progress Notes revised 6/1/18, showed the purpose of quarterly nutritional evaluations is to ensure residents are properly evaluated for dietary needs on an ongoing basis. According to the facility's P&P, if a resident is receiving enteral (GT) feeding, the RD will complete a quarterly evaluation. Medical record review for Resident 11 was initiated on 1/8/20. Resident 11 was readmitted to the facility on 12/11/15. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0LVL11 Facility ID: CA060000052 If continuation sheet 39 of 77 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 01/14/2020 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 11's Physician Orders dated January 2020, showed an order dated 2/19/19, for Jevity 1.2 calories at 70 ml per hour for 20 hours to provide 1400 ml per 1680 calories in 24 hours. An additional physician's order dated 10/8/19, showed an order for an RD consult. On 1/10/20 at 0942 hours, an interview and concurrent medical record review was conducted with the RD. The RD stated tube feeding assessments should be completed on a quarterly basis. The RD verified Resident 11's last Quarterly Nutritional Assessment was completed on 2/26/19, and the last Nutrition Progress Note was completed on 6/6/19. The RD stated she made herself a calendar to help keep track of the quarterly assessments. The RD stated she did not have a facility document showing her by when the assessments should be completed. 4. Medical record review for Resident 68 was initiated on 1/8/20. Resident 68 was readmitted to the facility on 7/16/19. Review of Resident 68's Physician Orders dated January 2020 showed an order dated 7/29/19 for Jevity 1.2 calories at 55 ml per hour for 20 hours until 1100 ml infused to provide 1320 calories. Review of Resident 68's Nutritional Assessment dated 7/18/19, showed the resident's last nutritional assessment was completed on this date. On 1/10/20 at 0942 hours, an interview and concurrent medical record review was conducted with the RD. The RD verified Resident 68's last Nutritional Assessment was completed on 7/18/19. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0LVL11 Facility ID: CA060000052 If continuation sheet 40 of 77 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 01/14/2020 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

F693 Tube Feeding Mgmt/Restore Eating Skills CFR(s): 483.25(g)(4)(5)

F693 SS=D PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 04/02/2020 §483.25(g)(4)-(5) Enteral Nutrition (Includes naso-gastric and gastrostomy tubes, both percutaneous endoscopic gastrostomy and percutaneous endoscopic jejunostomy, and enteral fluids). Based on a resident's comprehensive assessment, the facility must ensure that a resident§483.25(g)(4) A resident who has been able to eat enough alone or with assistance is not fed by enteral methods unless the resident's clinical condition demonstrates that enteral feeding was clinically indicated and consented to by the resident; and §483.25(g)(5) A resident who is fed by enteral means receives the appropriate treatment and services to restore, if possible, oral eating skills and to prevent complications of enteral feeding including but not limited to aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, and nasal-pharyngeal ulcers. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and medical record review, the facility failed to ensure two of 20 final sampled residents (Residents 87 and 36) received the volume of enteral feeding (nutrition delivered directly to the stomach using a tube) as ordered by the physician. This posed the risk of the residents' nutritional needs not being met. Findings: 1. On 1/8/20 at 0806 hours, Resident 87 was observed lying in bed. A tube feeding pump on FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0LVL11 Facility ID: CA060000052 If continuation sheet 41 of 77 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 01/14/2020 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 a pole was observed next to his bed. No tube feeding was being administered. Medical record review for Resident 87 was initiated on 1/8/20. Resident 87 was readmitted to the facility on 12/20/19. Review of the Physician Orders showed the following orders dated 12/21/19: - Jevity 1.5 (nutritional formula) to run at 75 ml per hour times 20 hours, providing 1500 ml/2250 calories, or until the total volume is infused; on at 1400 hours, and off at 1000 hours; and - phenytoin (antiseizure medication) 125 mg/5 ml suspension, give 200 mg via GT every 12 hours. Review of the Physician and Telephone Orders showed an order dated 1/7/20, to hold the enteral feeding one hour prior to and one hour after administering the phenytoin via GT. Review of the Medication Administration Record for January 2019 showed the phenytoin suspension was scheduled to be administered via GT, twice daily at 0900 and 2100 hours. On 1/9/19 at 0752 and 0936 hours, Resident 87 was observed lying in bed. A tube feeding pump on a pole was observed next to his bed. No tube feeding was being administered. On 1/9/20 at 0830 hours, an interview was conducted with CNA 5. CNA 5 stated Resident 87 was out of bed daily from around 1000 hours. Resident 87 liked to self-propel in his wheelchair inside the facility. On 1/9/20 at 1018, 1052 and 1320 hours, Resident 87 was observed self-propelling in his wheelchair in the hallways. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0LVL11 Facility ID: CA060000052 If continuation sheet 42 of 77 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 01/14/2020 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 On 1/9/20 at 1330 hours, an observation in Resident 87's room was conducted with the DSD. Resident 87 was lying in bed. No tube feeding was being administered. The DSD checked the pump and verified Resident 87 received 1202 ml of formula in the past 24 hours. On 1/9/20 at 1334 hours, an interview and concurrent medical record review was conducted with LVN 1 and the DSD. LVN 1 verified the enteral feeding was turned off for two hours in the morning and two hours in the evening when the phenytoin was being administered. Resident 87 missed four hours of enteral feeding, equivalent to 300 ml (450 calories) every day. When asked if the physician was informed Resident 87 did not receive the total volume of enteral feeding, LVN 1 stated no. The DSD stated the enteral feeding schedule needed to be clarified with the physician. 2. Medical record review for Resident 36 was initiated on 1/9/20. Resident 36 was readmitted to the facility on 10/8/19. Review of Resident 36's Admission Orders showed a physician's order dated 10/8/19, to administer phenytoin 100 mg via GT every 8 hours. Review of Resident 36's Nutritional Assessment dated 10/18/19, failed to list phenytoin as an ordered medication related to nutrition. The assessment did not address the drug nutrient interaction of phenytoin with the enteral formula or provide adjustments to the feeding to accommodate the order. Review of Resident 36's Physician Orders dated January 2020 showed a physician's order dated 10/8/19, to administer Jevity 1.5 (nutritional formula) to run at 60 ml per hour for FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0LVL11 Facility ID: CA060000052 If continuation sheet 43 of 77 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 01/14/2020 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 20 hours, providing 1200 ml/1800 calories per day from 1400 hours to 1000 hours or until dose limit is met. A clarified physician's order dated 12/31/19, showed to administer phenytoin oral suspension 125 mg/5 mL (100 mg) via GT every 8 hours and to turn off the tube feeding one hour before and one hour after administration of the phenytoin. Review of Resident 36's Medication Administration Record dated 1/20 showed the medication was administered as ordered at 0600, 1400 and 2200 hours on 1/1 - 1/9/20. The record showed the administrations at 0600 and 2200 hours were scheduled during the active GT feeding time. On 1/10/20 at 0942 hours, an interview and concurrent medical record review was conducted with the RD. The RD was asked if she was familiar with Resident 36. The RD stated she had not yet reviewed Resident 36's record. The RD stated she did not know how phenytoin related to the resident's nutrition. The RD verified, according to Resident 36's tube feeding order, the feeding would be off for four hours daily and phenytoin required feeding to be off one hour before and one hour after administration. The RD was asked if she was made aware of the above. The RD stated she did not know how medications and feeding orders were timed; in her scope of practice, she did not get involved with resident's medications. The RD was asked, since the medication required the tube feeding to be turned off for an additional four to six hours, depending on the administration times, would she look at the medications. The RD stated she had not looked at the medications and gone that in depth. The RD stated she expected nurses to notify her if the timing of the tube feeding needed to be changed. When asked if she would suggest a recommendation FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0LVL11 Facility ID: CA060000052 If continuation sheet 44 of 77 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 01/14/2020 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 to change the current order, the RD stated she would need to look at the tube feeding rate in order to decide. On 1/10/20 at 1617 hours, an interview and medical record review was conducted with LVN 5. LVN 5 reviewed Resident 36's Medication Administration Record and acknowledged Resident 36 received tube feeding for 20 hours a day with a phenytoin order to hold the tube feeding for an hour before and an hour after administration of the phenytoin three times a day. LVN 5 stated this was a concern since it showed Resident 36 had not been receiving enough of the nutritional formula, which could lead to malnutrition and dehydration. LVN 5 stated she needed to clarify the order with the RD to adjust the tube feeding.

F695 SS=D Respiratory/Tracheostomy Care and Suctioning F695 CFR(s): 483.25(i) 02/14/2020 § 483.25(i) Respiratory care, including tracheostomy care and tracheal suctioning. The facility must ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preferences, and 483.65 of this subpart. This REQUIREMENT is not met as evidenced by: Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and treatment for one of 20 final sampled residents (Resident 349) receiving respiratory therapy. * The facility failed to ensure Resident 349 received the necessary care for breathing treatment via the CPAP machine. This posed FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0LVL11 Facility ID: CA060000052 If continuation sheet 45 of 77 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 01/14/2020 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 the risk of the resident not receiving appropriate breathing treatments and negatively impact the resident's medical condition. Findings: Review of the facility's P&P titled BiPAP and CPAP revised 10/17/19, showed most residents will have their own BiPAP and CPAP machines. Verify settings for the machine with the physician and obtain a physician order. Care of the humidifier includes to fill the water chamber with distilled water to the line indicated on the water chamber. Humidification relieves the resident of dry sinuses and mouth. Cleaning instructions include: clean the hose by running through with mild soapy water then rinse with clear water daily; drip dry the hose; disassemble the CPAP mask by removing the head gear and cushion from the face; soak the head gear in warm mild soapy water; rinse the mask of all soap; dry the headgear. Documentation of the following will be charted daily unless otherwise specified by physician orders: pressure setting, type of mask and frequency of treatment, lung sounds, side effects, vital signs including oxygen saturation. On 1/7/20 at 1321 hours, an interview was conducted with Resident 349. Resident 349 was lying in bed. A CPAP machine was observed on top of her night stand. Resident 349 stated the CPAP was her personal machine. However, last night, the facility staff could not find distilled water to be used for her CPAP machine. Resident 349 stated she slept very late because she had to wait for them to find the distilled water to be used for her CPAP machine. Medical record review for Resident 349 was FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0LVL11 Facility ID: CA060000052 If continuation sheet 46 of 77 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 01/14/2020 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 initiated on 1/8/20. Resident 349 was admitted to the facility on 1/6/20. Review of the History and Physical Examination dated 1/7/20, showed Resident 349 had the capacity to understand and make decisions. Review of the Admission Orders dated 1/6/20, showed an order for CPAP at bed time for sleep apnea. The physician order did not include the settings of the machine. Review of the plan of care failed to show a baseline care plan was developed to address Resident 349's use of the CPAP machine. There were no interventions to include humidification and cleaning instructions. Review of the medical record failed to show documentation of the pressure setting, type of mask and frequency of treatment, lung sounds, side effects, vital signs, including oxygen saturation from the past two nights Resident 349 had used the CPAP machine in the facility. On 1/8/20 at 1449 hours, an interview and concurrent medical record review was conducted with LVN 8. LVN 8 stated he had not seen Resident 349 on her CPAP machine. LVN 8 stated when he came in the morning to administer Resident 349's medications, Resident 349 was not connected to the CPAP machine. When asked who and how the tubing and mask were cleaned, LVN 8 stated he did not know. LVN 8 could not find instructions in the medical record on how to care for the CPAP machine and tubing. LVN 8 verified the physician's order did not include the settings, and there was no documentation to show the order was clarified with the physician. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0LVL11 Facility ID: CA060000052 If continuation sheet 47 of 77 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 01/14/2020 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 On 1/8/20 at 1522 hours, an interview was conducted with LVN 9. LVN 9 stated Resident 349 used the CPAP from 2100 to 0900 hours daily. When asked how the CPAP machine and tubing were cleaned, LVN 9 stated she did not know. On 1/9/20 at 0738 hours, a follow-up interview was conducted with Resident 349. Resident 349 stated she cleaned and washed the mask and tubing daily when she was at home; however, the tubing and mask were not cleaned since she was admitted in the facility. Resident 349 stated no one from the facility had asked her about the cleaning and care of her CPAP machine.

F697 SS=D Pain Management CFR(s): 483.25(k)

F697 02/14/2020 §483.25(k) Pain Management. The facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences. This REQUIREMENT is not met as evidenced by: Based on interview, medical record review, and facility P&P review, the facility failed to provide appropriate pain management for one of 20 final sampled residents (Resident 349). The facility failed to ensure Resident 349 was administered her pain medication as ordered by the physician and in a timely manner when she was having pain. This failure had the potential to cause the resident unnecessary pain and negatively affect the resident's wellbeing. Findings: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0LVL11 Facility ID: CA060000052 If continuation sheet 48 of 77 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 01/14/2020 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 the facility's P&P titled Pain Management revised 11/2016 showed a licensed nurse will assess each resident for pain upon admission, quarterly, when there is new onset of pain, or when there is a significant change in status. The licensed nurse will complete a Pain Assessment for residents identified as having pain. On 1/7/20 at 1321 hours, an interview was conducted with Resident 349. Resident 349 stated she had problems with her medications last night. Resident 349 stated she was in pain and was supposed to receive morphine (narcotic pain medication) and Dilaudid (narcotic pain medication), but, the nurse told her they only have morphine. Resident 349 stated she had to ask a family member for her Dilaudid from home so she could get medicated for pain. Resident 349 stated "...I have to give them my Dilaudid" and received the first dose at 0340 hours this morning. Resident 349 stated she was not able to sleep last night because of a combination of pain and chaos with her medications. Resident 349 stated her pain level started at a 7 which escalated to a 9 (on a pain scale of 0 to 10 with 0 = no pain to 10 = severe pain). Medical record review for Resident 349 was initiated on 1/8/20. Resident 349 was admitted to the facility on 1/6/20. Review of the History and Physical Examination dated 1/7/20, showed Resident 349 had the capacity to understand and make decisions. Review of the Resident Admission Assessment dated 1/6/20, showed Resident 349 arrived at the facility on 1/6/20 at 1650 hours. The form showed the assessment was not completed FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0LVL11 Facility ID: CA060000052 If continuation sheet 49 of 77 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 01/14/2020 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 and the area to assess the resident for pain was left blank. Review of the medical record showed Pain Assessment was not done on admission. The Pain Assessment form found in Resident 349's medical record was left blank. Review of the Admission Orders dated 1/6/20, showed the following orders: - morphine extended release 30 mg, give one tablet by mouth every 12 hours; - Dilaudid 4 mg, give one tablet by mouth, four times a day. Review of the Transfer Medication Reconciliation from the general acute care hospital dated 1/6/20, showed the last administered dose of morphine was at 1109 hours, and 1255 hours for the Dilaudid. Review of the Medication Administration Record for January 2020 showed the morphine 30 mg was scheduled to be administered daily at 0900 and 2100 hours; and the Dilaudid 4 mg was scheduled to be administered daily at 0900, 1300, 1700 and 2100 hours. However, there was no documentation Resident 349 was administered the morphine nor the Dilaudid at 2100 hours on 1/6/20. On 1/8/20 at 0753 hours, a follow-up interview was conducted with Resident 349. Resident 349 stated she had a problem getting her pain medication again this morning. Resident 349 stated at 0415 hours, she informed her CNA to call the nurse because she needed her Dilaudid. At 0445 hours, she pressed her call light and informed the CNA to call the nurse. Twenty minutes passed, Resident 349 stated she pressed her call light again, and the same thing happened. Resident 349 stated she did not receive her Dilaudid until 0600 hours this FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0LVL11 Facility ID: CA060000052 If continuation sheet 50 of 77 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 01/14/2020 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 morning. Resident 349 stated the nurse did not know she needed her pain medication. Resident 349 stated she was frustrated about the communication problem in the facility. "...my pain should be controlled." Resident 349 stated her pain level was at 7 and it was extremely difficult to move in bed because of the back pain. Resident 349 stated she had a lot of burning and nerve pain. Review of the Physician and Telephone Orders showed an order dated 1/7/20, showing the previous order for Dilaudid was discontinued, and a new order for Dilaudid 4 mg, give one tablet by mouth every six hours, PRN (as needed) for pain. Review of the Pain Assessment Flow Sheet showed Resident 349 was administered the Dilaudid 4 mg on 1/8/20 at 0600 hours, for a pain level of 8 out of 10. On 1/8/20 at 1414 and 1449 hours, interviews and concurrent medical record review was conducted with LVN 8. LVN 8 verified the above findings. LVN 8 verified there was no documentation Resident 349 received her pain medications on 1/6/20, and was not administered the PRN Dilaudid until 0600 hours this morning. On 1/8/20 at 1532 hours, an interview and concurrent medical record review was conducted with LVN 9. LVN 9 verified the above findings and stated she only gave Resident 349 the morphine which she got from their emergency medication kit because the rest of Resident 349's medications were not yet delivered by the pharmacy. LVN 9 stated she forgot to sign the Medication Administration Record that she administered the morphine to Resident 349. When asked why she did not take the Dilaudid from the emergency FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0LVL11 Facility ID: CA060000052 If continuation sheet 51 of 77 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 01/14/2020 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 medication kit when Resident 349 had been complaining of pain, LVN 9 had no answer. (Cross reference to F755)

F755 SS=D Pharmacy Srvcs/Procedures/Pharmacist/Records CFR(s): 483.45(a)(b)(1)-(3)

F755 02/14/2020 §483.45 Pharmacy Services The facility must provide routine and emergency drugs and biologicals to its residents, or obtain them under an agreement described in §483.70(g). The facility may permit unlicensed personnel to administer drugs if State law permits, but only under the general supervision of a licensed nurse. §483.45(a) Procedures. A facility must provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident. §483.45(b) Service Consultation. The facility must employ or obtain the services of a licensed pharmacist who§483.45(b)(1) Provides consultation on all aspects of the provision of pharmacy services in the facility. §483.45(b)(2) Establishes a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation; and §483.45(b)(3) Determines that drug records are in order and that an account of all controlled drugs is maintained and periodically reconciled. This REQUIREMENT is not met as evidenced by: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0LVL11 Facility ID: CA060000052 If continuation sheet 52 of 77 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 01/14/2020 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 Based on observation, interview, and record review, the facility failed to provide pharmaceutical services for two of 20 final sampled residents (Residents 87 and 349), and two nonsampled residents (Residents 449 and 450). * The facility failed to follow the manufacturer's specifications in the administration of Milk of Magnesia (a medication to relieve constipation) to Resident 87. This failure posed the risk of the resident not receiving the prescribed medication and negatively impact the resident's well-being. * The facility failed to ensure an accurate reconciliation and documentation of controlled medications. This failure resulted in a lack of accountability for the medications and presented a potential for the diversion of the controlled substance. * The facility failed to utilize their emergency medication supply to ensure Resident 349 received pain medication to manage her severe pain. Resident 349 had to ask a family member to bring the pain medication from home because they were not available in the facility. Findings: 1. On 1/9/20 at 0739 hours, a medication administration observation for Resident 87 was conducted with LVN 7. LVN 7 stated Resident 87's medications were administered via GT. LVN 7 was observed preparing Resident 87's medications including Milk of Magnesia. Review of the label on the bottle of Milk of Magnesia showed to provide a full glass, 8 ounces, of liquid with each dose. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0LVL11 Facility ID: CA060000052 If continuation sheet 53 of 77 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 01/14/2020 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 LVN 7 was observed administering the medications to Resident 87 via the GT, and flushing the tube with water in between administration of each medication. LVN 7 was asked the amount of water being flushed through the GT of Resident 87 in between administration of each medication. LVN 7 stated she flushed Resident 87's GT with approximately 5 ml of water in between each medication. After LVN 7 completed the medication administration for Resident 87, the LVN was asked the total amount of water flushed through the resident's GT after administering the medications to the resident. LVN 7 stated the total amount of water flushed through Resident 87's GT was 120 ml (120 ml equals 4.05 ounces). On 1/9/20 at 0837 hours, an interview was conducted with LVN 7. LVN 7 acknowledged she did not administer 8 ounces of liquid when the Milk of Magnesia was administered to Resident 87. 2. On 1/10/20 at 0718 hours, a concurrent interview, pharmacy record review, and medical record review was conducted with the DON. a. Review of Resident 450's Narcotic and Hypnotic Record for lorazepam (controlled antianxiety medication), showed the dispensed amount was 2 ml. on the lower section of the record showed the following; "10 ml," "10/9/19," and illegible handwriting. There was no documentation showing a dose of the medication was signed out. The DON explained the "10 ml" was the amount of the medication destroyed, "10/9/19" was the date when the medication was destroyed, and the illegible handwriting was the signatures of the pharmacist and himself who FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0LVL11 Facility ID: CA060000052 If continuation sheet 54 of 77 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 01/14/2020 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 performed the destruction of the medication. The DON acknowledged the Disposition of Unused Portion of Drug section of the Narcotic and Hypnotic Record was not completed appropriately. The DON verified there was no dose of lorazepam signed out from the record, and the destroyed amount of the drug did not equal the amount dispensed by the pharmacy. b. Review of Resident 449's Narcotic and Hypnotic Record for oxycodone (controlled pain medication), showed the following; * Dispensed quantity was eight tablets. * Three doses (dose numbers 6, 7, and 8) of the medication were signed out and the dates were illegible, two (6 and 7) of the three doses signed out were marked off with a line, and "error" was written next to dose number 6. * On the lower section of the record showed "6," "10/9/19," and illegible handwriting. The DON verified the above findings. On 1/10/20 1336 hours a follow-up interview was conducted with the DON. DON was asked to explain what it meant when doses number 6 and 7 were marked off with a line. The DON stated the doses marked off with a line meant the entries on the record were canceled. The DON was asked about the entries on the lower section of the record. The DON stated the "6" was the amount of the medication destroyed, the "10/9/19" was the date when the medication was destroyed, and the illegible handwriting was the signatures of the pharmacist and himself who performed the destruction of the medication. The DON acknowledged Resident 449's Narcotic and Hypnotic Record for oxycodone did not reflect accurate documentation how the medication was signed out. 3. On 1/7/20 at 1321 hours, an interview was FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0LVL11 Facility ID: CA060000052 If continuation sheet 55 of 77 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 01/14/2020 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 conducted with Resident 349. Resident 349 stated she had problems with her medications last night. Resident 349 stated she was in pain and was supposed to receive morphine (narcotic pain medication) and Dilaudid (narcotic pain medication), but the nurse told her they only had morphine. Resident 349 stated she had to ask a family member for her Dilaudid from home so she could get medicated for pain. Medical record review for Resident 349 was initiated on 1/8/2020. Resident 349 was admitted to the facility on 1/6/20. Review of the Admission Orders dated 1/6/20, showed the following orders: - morphine extended release 30 mg, give one tablet by mouth every 12 hours; - Dilaudid 4 mg, give one tablet by mouth, four times a day. Review of the Transfer Medication Reconciliation from the general acute care hospital dated 1/6/20, showed the last administered dose for the morphine was at 1109 hours, and 1255 hours for the Dilaudid. Review of the list of medications available in the emergency medications kit showed morphine 30 mg and Dilaudid 4 mg were available. On 1/8/20 at 1432 hours, an interview was conducted with the DON. The DON verified both the morphine and Dilaudid tablets were available in the facility's emergency medications kit. On 1/8/2020 at 1532 hours, an interview and concurrent medical record review was conducted with LVN 9. LVN 9 verified the above findings and stated she only gave FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0LVL11 Facility ID: CA060000052 If continuation sheet 56 of 77 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 01/14/2020 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 Resident 349 the morphine which she got from their emergency medication kit. When asked why she did not take the Dilaudid from the emergency medication kit when Resident 349 had been complaining of pain, LVN 9 had no answer. Review of the C-II E-Kit Record provided by the facility on 1/14/20, showed morphine 30 mg was taken from the emergency medication kit on 1/6/20 at 1900 hours. There was no documentation Dilaudid 4 mg was taken from the emergency medication kit.

F756 SS=D Drug Regimen Review, Report Irregular, Act On CFR(s): 483.45(c)(1)(2)(4)(5)

F756 02/14/2020 §483.45(c) Drug Regimen Review. §483.45(c)(1) The drug regimen of each resident must be reviewed at least once a month by a licensed pharmacist. §483.45(c)(2) This review must include a review of the resident's medical chart. §483.45(c)(4) The pharmacist must report any irregularities to the attending physician and the facility's medical director and director of nursing, and these reports must be acted upon. (i) Irregularities include, but are not limited to, any drug that meets the criteria set forth in paragraph (d) of this section for an unnecessary drug. (ii) Any irregularities noted by the pharmacist during this review must be documented on a separate, written report that is sent to the attending physician and the facility's medical director and director of nursing and lists, at a minimum, the resident's name, the relevant drug, and the irregularity the pharmacist identified. (iii) The attending physician must document in FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0LVL11 Facility ID: CA060000052 If continuation sheet 57 of 77 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 01/14/2020 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 the resident's medical record that the identified irregularity has been reviewed and what, if any, action has been taken to address it. If there is to be no change in the medication, the attending physician should document his or her rationale in the resident's medical record. §483.45(c)(5) The facility must develop and maintain policies and procedures for the monthly drug regimen review that include, but are not limited to, time frames for the different steps in the process and steps the pharmacist must take when he or she identifies an irregularity that requires urgent action to protect the resident. This REQUIREMENT is not met as evidenced by: Based on interview, medical record review, and facility document review, the facility failed to ensure the Pharmacy Consultant's identified drug irregularity and medication recommendation was addressed for one of 20 final sampled residents (Resident 41). * The facility failed to ensure the Pharmacy Consultant's recommendation to clarify the blood pressure parameters for Resident 41's use of midodrine (a medication used to treat low blood pressure). This failure had the potential for the resident to experience an adverse drug reaction. Findings: Medical record review for Resident 41 was initiated on 1/7/20. Resident 41 was readmitted to the facility on 12/30/19. Review of the Admission Orders dated 12/30/19, showed a physician's order for midodrine 5 mg before hemodialysis (a method of removing toxins from the blood) avoid dosing FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0LVL11 Facility ID: CA060000052 If continuation sheet 58 of 77 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 01/14/2020 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 after the evening meal or within four hours of bedtime. Review of the New Admission Medication Regimen Review (MRR) dated 12/31/19, showed the Pharmacy Consultant recommended clarifying hold parameters for midodrine. Further review of the bottom of the page where the facility was to document the follow up with the physician failed to show any documentation if the physician was contacted, the nurse's name, or a date and time of notification. Review of the Medication Sheets, one undated and one dated for January 2020, showed Resident 41 received midodrine on 12/31/19, 1/1, 1/4, 1/7, and 1/8/20. On 1/9/19 at 1630 hours, an interview and concurrent medical record review was conducted with the DON. The DON stated he and LVN 1 were responsible to review and notify the physician when the Pharmacy Consultant made recommendations regarding the resident's medications. The DON stated if the physician agreed with the recommendations they would clarify or update the order immediately to reflect the Pharmacy Consultant's recommendations. The DON reviewed Resident 41's medical record and was unable to find documentation the pharmacist's recommendation was addressed with the physician and the physician's response.

F758 SS=D Free from Unnec Psychotropic Meds/PRN Use F758 CFR(s): 483.45(c)(3)(e)(1)-(5) 02/14/2020 §483.45(e) Psychotropic Drugs. §483.45(c)(3) A psychotropic drug is any drug that affects brain activities associated with mental processes and behavior. These drugs FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0LVL11 Facility ID: CA060000052 If continuation sheet 59 of 77 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 01/14/2020 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 include, but are not limited to, drugs in the following categories: (i) Anti-psychotic; (ii) Anti-depressant; (iii) Anti-anxiety; and (iv) Hypnotic Based on a comprehensive assessment of a resident, the facility must ensure that--§483.45(e)(1) Residents who have not used psychotropic drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record; §483.45(e)(2) Residents who use psychotropic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs; §483.45(e)(3) Residents do not receive psychotropic drugs pursuant to a PRN order unless that medication is necessary to treat a diagnosed specific condition that is documented in the clinical record; and §483.45(e)(4) PRN orders for psychotropic drugs are limited to 14 days. Except as provided in §483.45(e)(5), if the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she should document their rationale in the resident's medical record and indicate the duration for the PRN order. §483.45(e)(5) PRN orders for anti-psychotic drugs are limited to 14 days and cannot be renewed unless the attending physician or prescribing practitioner evaluates the resident for the appropriateness of that medication. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0LVL11 Facility ID: CA060000052 If continuation sheet 60 of 77 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 01/14/2020 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 This REQUIREMENT is not met as evidenced by: Based on interview and medical record review, the facility failed to ensure one of 20 final sampled residents (Resident 79) was free from unnecessary psychotropic medications. Resident 79 was receiving Remeron (antidepressant medication) for depression manifested by poor appetite. The facility failed to accurately monitor Resident 79's meal intake. This posed the risk of Resident 79's physician not having the necessary information to determine the effectiveness of the Remeron. Findings: Medical record review for Resident 79 was initiated on 1/8/20. Resident 79 was readmitted to the facility on 3/31/16. Review of the Physician Orders showed an order dated 11/26/19, for Remeron 15 mg by mouth at bed time for poor oral intake of less than 50%. Review of the Medication Administration Record and CNAs documentation of meal intake for January 2019 showed multiple inconsistencies in the monitoring of Resident 79's meal intake. For example, on 1/1 and 1/2/20, the CNAs' documentation showed Resident 79 consumed 30% of dinner on both dates; however, the licensed nurses documented meal intake of 50% on 1/1 and 80% on 1/2/20. On 1/10/20 at 0901 hours, an interview and concurrent medical record review was conducted with LVN 1. LVN 1 reviewed the Medication Administration Record and the CNAs' documentation of meal intake and verified the above findings. LVN 1 stated the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0LVL11 Facility ID: CA060000052 If continuation sheet 61 of 77 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 01/14/2020 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 licensed nurses' monitoring should match the CNAs' monitoring because they were the ones assisting Resident 79 with meals.

F760 SS=D Residents are Free of Significant Med Errors CFR(s): 483.45(f)(2)

F760 02/14/2020 The facility must ensure that its§483.45(f)(2) Residents are free of any significant medication errors. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and medical record review, the facility failed to ensure two of 20 final sampled residents (Resident 36 and 87) were free of significant medication errors. * The facility failed to ensure the discharge instructions from the general acute care hospital were carried out when an order to administer Resident 87's midodrine hydrochloride (blood pressure medication) to be administered routinely was not included in the admission orders. * The facility failed to ensure Resident 36 was administer phenytoin (a medication used to treat and prevent seizures) as ordered by the physician. This had the potential for Resident 36 to have increased episodes of seizures. These failures had the potential to negatively impact the residents' well-being. Findings: 1. Medical record review for Resident 87 was initiated on 1/8/20. Resident 87 was readmitted to the facility on 11/8/19. Resident 87 was transferred to the general acute care hospital on 12/18/19, and was readmitted to the facility on 12/21/19. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0LVL11 Facility ID: CA060000052 If continuation sheet 62 of 77 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 01/14/2020 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 the Physician Orders showed an order dated 12/21/19, for midodrine hydrochloride 5 mg, give two tablets via GT, three times a day for hypotension. Review of the Medication Administration Record for January 2020 showed the midodrine hydrochloride two tablets three times a day was not administered as ordered. The Medication Administration Record showed the medication was to be administered PRN (as needed); however, there was no parameter when to give the medication. There was no documentation to show Resident 87's blood pressure was monitored. Review of the discharge instructions from the general acute care hospital dated 12/21/19, showed the medications to be continued after discharge included midodrine hydrochloride 5 mg, give one tablet via GT three times a day and midodrine hydrochloride 5 mg, give two tablets three times a day as needed for blood pressure - (left blank). Review of the Admission Orders dated 12/21/19, showed an order for midodrine 5 mg, two tablets via GT three times a day, PRN for hypotension. Hold if the SBP (systolic blood pressure - the top number of the blood pressure) was greater than 130. On 1/10/20 at 1037 hours, an interview and concurrent medical record review was conducted with LVN 7. LVN 7 stated the midodrine was to be administered PRN. LVN 7 verified there was no parameter when to administer and there was no documentation the blood pressure was monitored. LVN 7 reviewed the discharge instructions from the general acute care hospital and stated the midodrine one tablet was to be administered FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0LVL11 Facility ID: CA060000052 If continuation sheet 63 of 77 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 01/14/2020 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 three times a day, but was not included in the admission orders. LVN 7 stated Resident 87 used to receive the midodrine 5 mg three times a day before he was transferred to the hospital and the discharge instructions from the hospital showed to continue the midodrine as it was previously ordered. Review of the Medication Sheet from 12/1 to 12/18/19, showed midodrine 5 mg was administered three times a day at 0900, 1300, and 1700 hours, and to hold if the SBP was greater than 130. Resident 87's SBP at 0900 hours ranged from 90 to 110. On 1/10/20 at 1147 hours, the DON was informed and acknowledged the findings. 2. According to Lexi-Comp (a pharmacy resource for healthcare professionals), tube feedings decrease phenytoin (Dilantin) absorption. To avoid decreased serum levels hold feedings for one to two hours prior to and one to two hours after phenytoin administration. Review of Resident 36's Physician Orders dated January 2020 showed an order dated 10/8/19, to administer phenytoin 100 mg via GT every 8 hours. Review of the Consultant Pharmacists Recommendations dated 10/9/19, showed a recommendation to turn off Resident 36's tube feeding one prior to and one hour after the administration of phenytoin. Review of a laboratory result for phenytoin dated 10/10/19, showed Resident 36's phenytoin level was 8.6 (normal range 10 - 20). Review of the Physician and Telephone Orders showed a physician's order was obtained on FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0LVL11 Facility ID: CA060000052 If continuation sheet 64 of 77 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 01/14/2020 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 12/31/19, to administer phenytoin oral suspension 125 mg/5 ml (100 mg) every 8 hours via GT and to turn off the tube feeding one hour before and one hour after administration. Review of Resident 36's Medication Administration Record dated January 2020 showed to administer phenytoin at 0600, 1400, and 2200 hours via GT and to turn off the tube feeding one hour before and one hour after administration. On 1/9/20 at 1404 hours, an interview and concurrent review of Resident 36's Physician Orders and Medication Administration Records was conducted with LVN 3. LVN 3 stated Resident 36 had phenytoin ordered for seizures. LVN 3 stated she turned off the resident's tube feeding an hour before she administered the medication and turned it back on immediately after administration of the phenytoin. LVN 3 stated the medication was more effective when taken on an empty stomach and the absorption of the drug was increased. LVN 3 stated today she administered the phenytoin to Resident 36 at 1330 hours. LVN 3 stated she turned the tube feeding back on at 1400 hours today. LVN 3 verified the physician's orders for Resident 36 required the tube feeding to be off for an hour before and one hour after administration. LVN 3 acknowledged she should have waited an hour after administration to turn the feeding back on. On 1/9/20 at 1420 hours, an observation of Resident 36's tube feeding showed 25 ml's of Jevity 1.5 Cal (nutritional formula) had been administered to the resident at a rate of 60 ml per hour. On 1/10/20 at 0755 hours, an observation of FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0LVL11 Facility ID: CA060000052 If continuation sheet 65 of 77 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 01/14/2020 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 Resident 36's tube feeding, review of Resident 36's Physician Orders and Medication Administration Records and concurrent interview was conducted with LVN 4. LVN 4 stated she worked the 2300 to 0700 shift this morning. LVN 4 verified on 1/10/20 at 0800 hours, the current feeding volume administered to the resident was 1,003 ml at a rate of 60 ml per hour. LVN 4 stated Resident 36's tube feeding was started on 1/9/20 at 1400 hours. LVN 4 stated she administered phenytoin this morning to Resident 36 at 0600 hours. LVN 4 stated she did not turn off the tube feeding for Resident 36 during her shift. LVN 4 was asked if there were any special instructions regarding the administration of phenytoin. LVN 4 stated, for a seizure medication such as Dilantin, she would stop the tube feeding one hour before and one hour after medication administration, but phenytoin did not require to stop the tube feeding with administration. LVN 4 was asked to explain the process she used to administer medications. LVN 4 stated she used the Medication Administration Record to check what medications she was giving at that time. LVN 4 stated she did not look at the physician's orders before administering medications unless she needed clarification on an order. LVN 4 was asked what she would do if she was not familiar with a medication. LVN 4 stated she would check the physician's orders, talk to her supervisor or call the pharmacy. LVN 4 verified Resident 36's physician's orders and Medication Administration Record showed to turn off the tube feeding one hour before and one hour after medication administration. LVN 4 stated she should have held the tube feedings one hour before and one hour after she administered the phenytoin. On 1/10/20 at 1617 hours, review of Resident 36's Physician Orders and Medication Administration Records and concurrent FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0LVL11 Facility ID: CA060000052 If continuation sheet 66 of 77 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 01/14/2020 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 interview was conducted with LVN 5. LVN 5 stated she had been administering Resident 36's phenytoin without stopping the tube feedings one hour before and one after administration. LVN 5 stated she reviewed the physician's orders and the Medication Administration Record before administering medications to residents. LVN 5 verified Resident 36's physician orders required the tube feeding to be stopped one hour before and one hour after administration. LVN 5 verified she should have held the tube feedings one hour before and one hour after she administered the phenytoin. On 1/10/20 at 1630 hours, an interview and concurrent medical record review was conducted with the DSD. The DSD stated she expected nurses to read both the physician's orders and the Medication Administration Record before administering medications. The DSD verified the nurses should have turned off the tube feedings an hour before and one hour after the phenytoin administration according to the physician's orders. (Cross reference to

F693)

F808 SS=D Therapeutic Diet Prescribed by Physician CFR(s): 483.60(e)(1)(2)

F808 02/14/2020 §483.60(e) Therapeutic Diets §483.60(e)(1) Therapeutic diets must be prescribed by the attending physician. §483.60(e)(2) The attending physician may delegate to a registered or licensed dietitian the task of prescribing a resident's diet, including a therapeutic diet, to the extent allowed by State law. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and medical FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0LVL11 Facility ID: CA060000052 If continuation sheet 67 of 77 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 01/14/2020 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 record review, the facility failed to ensure one nonsampled resident (Resident 599) was provided the therapeutic diet ordered by the physician. This had the potential of the resident not having her nutritional needs met. Findings: On 1/8/20 at 0746 hours, Resident 599 was observed in her room sitting with her breakfast tray in front of her. No meal ticket was observed on the tray. The resident's tray included scrambled eggs, toast, butter, one glass of what appeared to be milk and one glass of what appeared to be juice. Resident 599 stated she was waiting for someone to bring her milk and cold cereal. Medical record review for Resident 599 was initiated on 1/8/20. Resident 599 was admitted to the facility on 12/22/19. Review of the Resident Recent Weight Report dated 1/7/20, showed Resident 599's diet order was regular, renal, CCHO (concentrated carbohydrate). Review of Resident 599's Physician Orders dated January 2020 showed an order dated 12/22/19, to administer a regular renal diet. Review of Resident 599's Physician Progress Note dated 1/6/20, showed the resident lost an additional four pounds on 1/5/20, and listed a plan to change the resident's diet to CCHO. Review of Resident 599's Physician and Telephone Orders showed a physician's order dated 1/6/20, to change the resident's diet to CCHO. Review of Resident 599's Medication Administration Record dated January 2020 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0LVL11 Facility ID: CA060000052 If continuation sheet 68 of 77 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 01/14/2020 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 showed an entry dated 1/6/20, to discontinue the resident's regular renal diet. An additional entry dated 1/6/20, showed to administer a regular CCHO diet. Review of Resident 599's Dietary Communication diet change ticket dated, "1/6/19," showed the new diet order as CCHO. On 1/14/20 at 0940 hours, the assistant Dietary Manager verified the meal ticket was for the month of January 2020 not 2019. Review of Resident 599's Nutritional Assessment dated 1/6/20, completed and signed by the RD, showed Resident 599's diet order as a regular renal diet changed to CCHO. Review of Resident 599's Nutritional Assessment note dated 1/8/20, completed and signed by the RD, showed Resident 599 remained on a regular renal diet with CCHO therapeutic modification. Review of Resident 599's meal ticket dated 1/9/20, showed the resident was to receive a regular, renal, CCHO diet for breakfast, lunch, and dinner. On 1/10/20 at 0942 hours, an interview and concurrent medical record review was conducted with the RD. The RD was asked if she knew why the physician changed Resident 599's diet order on 1/6/20. The RD stated she did not speak to the physician and only spoke to the dietary supervisor regarding this order. The RD stated her interpretation of the physician's order was that he added an additional therapeutic diet to Resident 599's renal diet order. The RD stated she talked to Resident 599 on 1/9/20, after the Dietary Manager stated the resident was complaining about the CCHO addition on her diet. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0LVL11 Facility ID: CA060000052 If continuation sheet 69 of 77 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 01/14/2020 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

F812 Food Procurement,Store/Prepare/ServeSanitary CFR(s): 483.60(i)(1)(2)

F812 SS=F PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 02/14/2020 §483.60(i) Food safety requirements. The facility must §483.60(i)(1) - Procure food from sources approved or considered satisfactory by federal, state or local authorities. (i) This may include food items obtained directly from local producers, subject to applicable State and local laws or regulations. (ii) This provision does not prohibit or prevent facilities from using produce grown in facility gardens, subject to compliance with applicable safe growing and food-handling practices. (iii) This provision does not preclude residents from consuming foods not procured by the facility. §483.60(i)(2) - Store, prepare, distribute and serve food in accordance with professional standards for food service safety. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and facility P&P review, the facility failed to ensure the sanitary requirements were met in the kitchen. * White residue was observed in the ice chute and the ice storage area of the ice machine. * The facility failed to ensure the water temperature of the three compartment sink was at least 110 degrees F. * The facility failed to ensure the microwave used to heat food brought to the residents from the outside was clean and in good working condition. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0LVL11 Facility ID: CA060000052 If continuation sheet 70 of 77 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 01/14/2020 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 * The facility failed to ensure the refrigerator used to store food brought to residents from the outside was clean and free of ice buildup. These failures had the potential to cause foodborne illnesses in a medically vulnerable resident population who consumed food prepared in the kitchen. Findings: Review of the CMS 672 Resident Census and Conditions of Residents dated 1/7/20, and signed by the DON, showed 94 of the 98 residents residing in the facility received food prepared in the kitchen. 1. Review of the facility's P&P titled Ice Machine - Operation and Cleaning dated 10/1/14, showed dietary staff will follow the manufacturer's guidelines for operation and cleaning of the ice machine. Review of the manufacturer's guidelines titled C0322 through C1030 D Series Air and Water Cooled User Manual Cleaning, Sanitation and Maintenance, dated 10/14 showed the ice machine's water system should be cleaned and sanitized a minimum of twice per year. The manual also showed quality of the water supplied to the ice machine would have an impact on the time between cleanings. On 1/7/20 at 1355 hours, an inspection of the facility's ice machine was conducted with the Maintenance Supervisor and Dietary Manager present. The inside of the ice machine storage bin was observed with white residue in the ice chute; the area ice is dispensed into the ice storage bin. White residue was also noted inside the ice machine bin where ice is stored. The Maintenance Supervisor stated the white build up was from the hard water present in the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0LVL11 Facility ID: CA060000052 If continuation sheet 71 of 77 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 01/14/2020 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 area and the residue in the ice machine was normal and could not be removed. The Maintenance Supervisor stated the ice machine was descaled every six months. The maintenance Supervisor stated the last time the ice machine was descaled and sanitized was 6/15/19. The Maintenance Supervisor acknowledged the ice machine should have been descaled and sanitized one month ago. Upon observation of the descaling procedure of the ice machine with the Maintenance Supervisor on 1/8/20 at 1415 hours, the white residue was removed from the ice chute, the ice storage bin and the cover of the ice storage bin. Review of Preventive Maintenance Task Sheet (undated) showed the last time the Maintenance Supervisor cleaned and sanitized the ice machine was 6/15/19. 2. According to the USDA Food Code 2017, Section 4-501, Manual Warewashing Equipment, Wash Solution Temperature, the temperature of the wash solution shall be maintained at not less than 110 degrees F. Review of the facility's P&P titled Pot and Pan Cleaning dated 10/1/14, showed to fill the first and second compartments of the sink twothirds full with water between 110 to 120 degrees F. Scrub pots and pans in the first compartment, transfer the washed pots to the rinse sink (second compartment) to make sure they are free of detergent, and transfer the rinsed pots to the sanitizing compartment (third compartment) and allow them to remain in the solution for a minimum of one minute. On 1/8/20 at 1247 hours, an observation of the manual dishwashing process was conducted with Dietary Cook 2. Dietary Cook 2 was FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0LVL11 Facility ID: CA060000052 If continuation sheet 72 of 77 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 01/14/2020 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 observed scrubbing dishes in the first compartment, rinsing them in the second compartment and finally placing them in the third sanitizing compartment. Dietary Cook 2 was asked to take the temperature of the water in the first washing compartment. The temperature of the water in the first compartment was 102 degrees F. On 1/8/20 at 1252 hours, an interview was conducted with the Assistant Dietary Manager. When asked if the water temperature of 100 degrees F was acceptable in the three compartment sink, the Assistant Dietary Manager stated the water temperature in the manual dishwashing sink compartments should have been 100 degrees F or above. On 1/8/20 at 1445 hours, an interview was conducted with the Dietary Manager. The Dietary Manager was asked if there was a water temperature washing requirement for the first compartment of the three compartment sink. The Dietary Manager stated he believed there was no requirement. The Dietary Manager was asked if a temperature of 102 degrees F was acceptable for the first compartment. The Dietary Manager stated any temperature above 100 degrees F was acceptable. 3. On 1/8/20 at 0855 hours, the inside of a microwave in the utility room on Station 1 was observed with black and brown residue and plastic peeling on three sides. CNA 1 verified the above and stated the microwave was used to heat resident food brought in from the outside of the facility. On 1/8/20 at 0910 hours, an interview was conducted with the Maintenance Supervisor. The Maintenance Supervisor verified the above and stated the microwave was not acceptable FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0LVL11 Facility ID: CA060000052 If continuation sheet 73 of 77 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 01/14/2020 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 for use in its current condition. The Maintenance Supervisor stated it appeared someone could have placed an item in the microwave that should not have been microwaved. The Maintenance Supervisor stated there was no documentation when this microwave was last cleaned. 4. On 1/8/20 at 0845 hours, a concurrent interview and observation was conducted with the DON of the refrigerator used for storing residents' food brought from the outside. The refrigerator was observed with a two inch thick buildup of ice in the freezer. An orange residue and food particles were observed inside the bottom of the refrigerator. The DON verified the above. When asked who was responsible for cleaning the refrigerator, the DON stated he assigned a nurse to do it when needed.

F838 SS=D Facility Assessment CFR(s): 483.70(e)(1)-(3)

F838 02/14/2020 §483.70(e) Facility assessment. The facility must conduct and document a facility-wide assessment to determine what resources are necessary to care for its residents competently during both day-to-day operations and emergencies. The facility must review and update that assessment, as necessary, and at least annually. The facility must also review and update this assessment whenever there is, or the facility plans for, any change that would require a substantial modification to any part of this assessment. The facility assessment must address or include: §483.70(e)(1) The facility's resident population, including, but not limited to, (i) Both the number of residents and the facility's resident capacity; (ii) The care required by the resident population FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0LVL11 Facility ID: CA060000052 If continuation sheet 74 of 77 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 01/14/2020 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 considering the types of diseases, conditions, physical and cognitive disabilities, overall acuity, and other pertinent facts that are present within that population; (iii) The staff competencies that are necessary to provide the level and types of care needed for the resident population; (iv) The physical environment, equipment, services, and other physical plant considerations that are necessary to care for this population; and (v) Any ethnic, cultural, or religious factors that may potentially affect the care provided by the facility, including, but not limited to, activities and food and nutrition services. §483.70(e)(2) The facility's resources, including but not limited to, (i) All buildings and/or other physical structures and vehicles; (ii) Equipment (medical and non- medical); (iii) Services provided, such as physical therapy, pharmacy, and specific rehabilitation therapies; (iv) All personnel, including managers, staff (both employees and those who provide services under contract), and volunteers, as well as their education and/or training and any competencies related to resident care; (v) Contracts, memorandums of understanding, or other agreements with third parties to provide services or equipment to the facility during both normal operations and emergencies; and (vi) Health information technology resources, such as systems for electronically managing patient records and electronically sharing information with other organizations. §483.70(e)(3) A facility-based and communitybased risk assessment, utilizing an all-hazards approach. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0LVL11 Facility ID: CA060000052 If continuation sheet 75 of 77 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 01/14/2020 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 This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to update the facility wide assessment necessary to identify the facility needs of the RD when the facility did not assess the adequacy of RD hours necessary to meet the nutritional needs of the residents of the facility. This failure placed the residents of the facility at risk for compromised nutritional status. Findings: Review of the Facility Assessment Tool dated 11/19 showed the facility assessment was completed from 11/11/19 to 11/25/19. Section 3.1 Staff Type showed staff included Orange Healthcare staff members and contracted positions. The RD was not listed in section 3.5 Staffing Plan showing the facility's dietician needs. On 1/10/20 at 0935 hours, an interview was conducted with the RD. The RD stated she covered three facilities totaling 324 beds for the organization. The RD stated she worked two eight hour days for the facility. When asked how the RD prioritized her time, the RD stated initial nutritional assessments, weekly and monthly weight changes, RD consults, and weight variance meetings were her priority followed by quarterly assessments of enterally fed residents, monthly kitchen audits and quarterly in-services for kitchen staff. The RD stated she frequently worked extra hours to accommodate the work load. On 1/10/20 at 1450 hours, an interview and concurrent record review was conducted with the Administrator. The Administrator verified the RD was listed in the facility assessment under section 3.1 Staff Type but not listed in FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0LVL11 Facility ID: CA060000052 If continuation sheet 76 of 77 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 01/14/2020 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 section 3.5 Staffing Plan. The Administrator stated the RD was not listed because she was contracted and not an Orange Healthcare staff member. The Administrator stated the purpose of the facility assessment was to account for services offered and make sure each resident's needs are met. On 1/10/20 at 1536 hours, a follow-up interview was conducted with the Administrator. The Administrator stated the RD was currently at the facility one and a half to two days a week. The Administrator was asked how they decided on that number. The Administrator stated that was the number of days that was provided to him when he joined the facility. The Administrator stated he was not sure how they decided on that number or who came up with it. Cross reference to F692. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0LVL11 Facility ID: CA060000052 If continuation sheet 77 of 77