Other·July 17, 2017

F000 INITIAL COMMENTS

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 an ABBREVIATED SURVEY for Complaint No. CA00533304 Inspection was limited to the specific complaint investigated and does not represent the findings of a full inspection of the facility. Representing the California Department of Public Health: Surveyors: 37726, HFEN and 33464, HFEN. THE DEPARTMENT WAS ABLE TO SUBSTANTIATE THE COMPLAINT ALLEGATION(S) AND FINDINGS WERE CITED AT F226 AND F314. IN ADDITION, DURING THE INVESTIGATION, THE DEPARTMENT DETERMINED THERE WERE VIOLATIONS OF THE REGULATIONS UNRELATED TO THE SPECIFIC COMPLAINT ALLEGATION(S) AND FINDINGS WERE CITED AT F250 AND F279. GLOSSARY OF ABBREVIATIONS AND BRIEF DESCRIPTIONS: ADLs - Activities of Daily Living ADON - Assistant Director of Nursing AM - morning Antecubital - (inner elbow) Blanchable - (skin redness which loses all redness when pressed) Braden Scale - (a tool to assess a resident's risk for developing a pressure ulcer) cm - centimeter(s) CNA - Certified Nursing Assistant Coccyx - (the bone at the base of the spinal column) Hemorrhage - (bleeding) 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: 1J0P11 Facility ID: CA060000765 If continuation sheet 1 of 32 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: _______________ 555286 (X3) DATE SURVEY COMPLETED 06/06/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE NEW ORANGE HILLS 5017 E Chapman Ave Orange, CA 92869 (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 Low Air Loss Mattress - (mattress used for prevention or treatment of skin breakdown) LVN - Licensed Vocational Nurse MAR - Medication Administration Record MDS - Minimum Data Set (a standardized assessment tool) Paraplegia - (paralysis of the legs and lower part of the body) PM - afternoon P&P - policy and procedure Right frontal and parietal lobe - (areas of the brain involved in behavior, processing language, and voluntary movement) RN - Registered Nurse SSD - Social Services Director Stage II pressure ulcer - (partial thickness loss of the skin presenting as a shallow open ulcer with a red pink wound bed) Stage IV pressure ulcer - (full thickness tissue loss with exposed bone, tendon, or muscle) Tunneling - (a passageway of tissue destruction under the skin surface that has an opening at the skin level from the edge of the wound)

F226 SS=D DEVELOP/IMPLMENT ABUSE/NEGLECT, ETC POLICIES CFR(s): 483.12(b)(1)-(3), 483.95(c)(1)-(3)

F226 483.12 (b) The facility must develop and implement written policies and procedures that: (1) Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property, (2) Establish policies and procedures to investigate any such allegations, and (3) Include training as required at paragraph §483.95, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 1J0P11 Facility ID: CA060000765 If continuation sheet 2 of 32 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: _______________ 555286 (X3) DATE SURVEY COMPLETED 06/06/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE NEW ORANGE HILLS 5017 E Chapman Ave Orange, CA 92869 (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 483.95 (c) Abuse, neglect, and exploitation. In addition to the freedom from abuse, neglect, and exploitation requirements in § 483.12, facilities must also provide training to their staff that at a minimum educates staff on(c)(1) Activities that constitute abuse, neglect, exploitation, and misappropriation of resident property as set forth at § 483.12. (c)(2) Procedures for reporting incidents of abuse, neglect, exploitation, or the misappropriation of resident property (c)(3) Dementia management and resident abuse prevention. This REQUIREMENT is not met as evidenced by: Based on interview and facility document review, the facility failed to thoroughly investigate a potential incident of verbal abuse as outlined in facility's P&P for one of two sampled residents (Resident 1). This posed the risk for the facility to not identify incidents of resident abuse. Findings: Review of the facility's P&P titled Recognizing Signs and Symptoms of Abuse dated 8/15/11, showed verbal abuse is defined as the use of oral language that willfully includes disparaging and derogatory terms to residents or families. Verbal abuse includes any use of disparaging or derogatory terms directed to or within the resident's hearing distance. Medical record review for Resident 1 was initiated on 5/10/17. Resident 1's medical record showed the resident was admitted to the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 1J0P11 Facility ID: CA060000765 If continuation sheet 3 of 32 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: _______________ 555286 (X3) DATE SURVEY COMPLETED 06/06/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE NEW ORANGE HILLS 5017 E Chapman Ave Orange, CA 92869 (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 facility on 2/22/17. Review of the MDS dated 3/3/17, showed Resident 1 was cognitively intact and able to clearly verbalize his needs. Resident 1 required extensive assistance from two or more persons for bed mobility. On 5/10/17 at 1042 hours, an interview was conducted with Resident 1. Resident 1 stated approximately two weeks ago while LVN 3 was performing his wound care, the LVN had requested assistance from CNA 9. Resident 1's significant other was visiting at the bedside during the time. CNA 9 entered Resident 1's room and threw away Resident 1's own cup in the trash. Resident 1 asked CNA 9 why she threw his own cup in the trash without asking his permission. CNA 9 stated she would replace the cup, to which Resident 1 had replied, "as long as it is not from the trash." CNA 9 stated she felt insulted as she would not pick up a cup from the trash. LVN 3 was standing by the door of the room, at which time CNA 9 walked out of the room and said, "I'm not going to be insulted, you can tell your patient to kiss my ass." After the incident had occurred, RN 3 entered the room and conducted an interview with Resident 1 and his significant other. The significant other documented the incident and submitted the documentation to RN 3. On 5/11/17 at 0800 hours, an interview was conducted with Resident 1. Resident 1 stated CNA 9's statement was directed at him, "she said it so I could hear it." Resident 1 stated he could not move and do anything and felt as if he could not defend himself. On 5/11/17 at 0944 hours, an interview was conducted with the ADON. The ADON stated she was informed of the incident between FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 1J0P11 Facility ID: CA060000765 If continuation sheet 4 of 32 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: _______________ 555286 (X3) DATE SURVEY COMPLETED 06/06/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE NEW ORANGE HILLS 5017 E Chapman Ave Orange, CA 92869 (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 1 and CNA 9 the following morning. The ADON stated she was the acting DON and Abuse Coordinator at the time of the incident. The ADON stated the statement made by CNA 9 was not directed toward the resident; therefore, it was not investigated as verbal abuse. The ADON was asked to provide documentation of the interviews RN 3 had conducted in regard to the incident. The ADON was unable to provide this information. On 5/11/17 at 1029 hours, an interview was conducted with the Human Resources Director. The Human Resources Director stated RN 3 had informed him of the incident. RN 3 showed him the statement written by Resident 1's significant other. The Human Resources Director was asked to provide documentation of the interviews RN 3 had conducted in regards to the verbal incident. The Human Resources Director was unable to provide this information. On 5/11/17 at 1239 hours, an interview was conducted with the Administrator. The Administrator stated the Human Resources Director had informed him of the verbal incident between Resident 1 and CNA 9. The Administrator stated he did not speak to Resident 1 in regards to the incident. The Administrator stated based on the significant other's statement, the comment made by CNA 9 was directed toward LVN 3. The Administrator stated CNA 9 was removed from providing resident care after the incident and has subsequently left the facility. The Administrator was asked to provide documentation of the interviews RN 3 had conducted in regards to the incident. The Administrator was unable to provide this information. On 5/11/17 at 1715 hours, an interview was FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 1J0P11 Facility ID: CA060000765 If continuation sheet 5 of 32 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: _______________ 555286 (X3) DATE SURVEY COMPLETED 06/06/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE NEW ORANGE HILLS 5017 E Chapman Ave Orange, CA 92869 (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 LVN 3. LVN 3 stated on the night shift of 4/26/17, she requested assistance from CNA 9 to place an incontinent brief on Resident 1. CNA 9 entered the room and threw Resident 1's own personal cup into the trash. Resident 1 asked CNA 9 for another cup. CNA 9 stated she would replace the resident's cup. Resident 1 told CNA 9 as long as she did not get the cup from the trash. Resident 1 told CNA 9 he was not trying to be disrespectful; he just did not want the cup from the trash. CNA 9 then walked out of the resident's room. As CNA 9 was walking out of Resident 1's room she said, "he can kiss my ass." LVN 3 stated Resident 1's significant other heard CNA 9's comment. LVN 3 stated CNA 9's comment was about Resident 1 and the comment was directed at LVN 3. LVN 3 stated she informed her supervisor, RN 3. LVN 3 stated Resident 1 seemed bothered by the CNA's statement and said "I do not understand why the CNA was so mad." On 5/15/17 at 0850 hours, a telephone interview was conducted with CNA 9. CNA 9 stated the LVN was performing wound care to Resident 1. CNA 9 did not want to interfere with the wound care, so she began to clean Resident 1's room. CNA 9 threw away a cup she believed to be trash and Resident 1 became upset. CNA 9 told Resident 1 she would replace his cup and Resident 1 told her he did not want a cup from the trash. CNA 9 told Resident 1 she would not get the cup from the trash. Resident 1 remained upset and made a derogatory comment to CNA 9. CNA 9 stated she left the room and while in the hallway she made a derogatory comment about Resident 1. On 5/25/17 at 1550 hours, an interview was conducted with RN 3. RN 3 stated on 4/26/17 at approximately 0430 hours, she was notified FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 1J0P11 Facility ID: CA060000765 If continuation sheet 6 of 32 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: _______________ 555286 (X3) DATE SURVEY COMPLETED 06/06/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE NEW ORANGE HILLS 5017 E Chapman Ave Orange, CA 92869 (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 by an LVN of a verbal incident that had occurred involving Resident 1 and CNA 9. RN 3 interviewed Resident 1 and his significant other. They told RN 3 the following: CNA 9 was called into Resident 1's room to change Resident 1's diaper and threw away Resident 1's own cup. Resident 1 told CNA 9 she should have asked permission before throwing away his cup. CNA 9 told Resident 1 she would replace his cup. Resident 1 told CNA 9 as long as the cup was not from the trash. CNA 9 said, "I'm not stupid, I would not get the cup from the trash." CNA 9 then walked out of the room and told an LVN who was in the room, "Your patient can kiss my ass." After the incident, RN 3 and RN 4 interviewed CNA 9. CNA 9 stated she was upset. RN 3 stated CNA 9 demonstrated a poor attitude towards RNs 3 and 4 during the interview. CNA 9 told RN 3 and RN 4 she needed to return to the floor to care for her residents. RN 3 stated she removed CNA 9 from caring for Resident 1 after the incident. RN 3 stated CNA 9 worked with three to four other residents after the incident and then left the facility. RN 3 stated she interviewed Resident 1, his significant other, CNA 9, and LVN 3. RN 3 stated she documented these interviews and submitted them along with the resident's significant other's written statement to the ADON. RN 3 stated she also informed the Human Resources Director about the incident. Review of CNA 9's Punch Detail Report dated 4/25/17, showed CNA 9 had worked the whole shift during the incident (from 2305 hours to 0619 hours). On 5/25/17 at 1613 hours, an interview was conducted with Resident 1's significant other. The significant other stated she heard CNA 9 state Resident 1 could "kiss her ass." The significant other stated she believed CNA 9 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 1J0P11 Facility ID: CA060000765 If continuation sheet 7 of 32 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: _______________ 555286 (X3) DATE SURVEY COMPLETED 06/06/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE NEW ORANGE HILLS 5017 E Chapman Ave Orange, CA 92869 (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 directed her comment toward Resident 1 and was talking about Resident 1. The significant other stated she was asked to write a statement documenting the incident, to which she complied and then submitted to the staff.

F250 SS=D PROVISION OF MEDICALLY RELATED SOCIAL SERVICE CFR(s): 483.40(d)

F250 (d) The facility must provide medically-related social services to attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and medical record review, the facility failed to provide appropriate social services for discharge planning for one of two sampled residents (Resident 2). The SSD failed to document pertinent information regarding Resident 2's discharge plan in the resident's medical record. This had the potential for Resident 2 to not receive necessary services to meet the resident's continuing care needs upon discharge. Findings: On 5/10/17 at 0830 hours, Resident 2 was observed in bed watching television. Resident 2 was observed with no spontaneous movement and had a flat facial affect. When spoken to, Resident 2 slowly made eye contact and after a delay gave a one word response with difficulty (took several attempts to articulate a reply). The reply was appropriate; however, her speech was slow and slurred. Medical record review for Resident 2 was initiated on 5/10/17. Resident 2's medical FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 1J0P11 Facility ID: CA060000765 If continuation sheet 8 of 32 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: _______________ 555286 (X3) DATE SURVEY COMPLETED 06/06/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE NEW ORANGE HILLS 5017 E Chapman Ave Orange, CA 92869 (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 showed the resident was admitted to the facility on 4/4/17, with diagnoses including right frontal and parietal lobe hemorrhage. Review of Resident 2's MDS dated 4/13/17, showed the resident had short and long term memory problems, severe cognitive impairment, and no speech. The resident required an extensive physical assistance of two plus persons for bed mobility, total physical assistance of two plus persons for transfers and toilet use, and total physical assistance of one person for locomotion, dressing, eating, hygiene, and bathing. Review of Resident 2's Interdisciplinary Team Meeting/Care Conference Summary Sheet dated 4/10/17, showed the discharge plan was to return back home with help. The form did not specify what form of in home help was anticipated for Resident 2 upon discharge. Review of Resident 2's Social Service Progress Notes dated 4/10/17, showed a care planning meeting was held with the resident's family and care team on 4/10/17. The documentation also showed the discharge plan was for the resident to return home with help; however, there was no documentation of the type of help the resident would require at home or what resources for the provision of care were already in place (for example: caregiver, equipment, or home health services). There was not an initial social services assessment form completed for Resident 2 in the resident's medical record. On 5/10/17 at 1445 hours, an interview was conducted with the SSD regarding the discharge plan for Resident 2. The SSD verified the above medical record findings related to discharge planning for Resident 2. The SSD was asked to explain the resident's FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 1J0P11 Facility ID: CA060000765 If continuation sheet 9 of 32 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: _______________ 555286 (X3) DATE SURVEY COMPLETED 06/06/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE NEW ORANGE HILLS 5017 E Chapman Ave Orange, CA 92869 (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 discharge plan. The SSD stated the resident was at home prior to the hospitalization and placement in the facility. The SSD stated the plan was for the resident to return home. The SSD expressed concerns that the resident's current caregiver could not meet the resident's care needs at home due to the resident being dependent on all ADL care. The SSD stated the SSD had observed the caregiver with the resident in the facility and the caregiver provided no hands on care other than helping to feed the resident, and the caregiver was not interested in receiving caregiver training. According to the SSD, the caregiver stated her role was just to supervise the resident. When the SSD approached Resident 2's family member regarding caregiver training, the family member informed the SSD it was not the caregiver's job and the family member would be trained when it was time for the resident to be discharged. The SSD verified the above information was pertinent to plan the resident's discharge and should have been documented. The SSD agreed in the event the SSD was not available to complete the resident's discharge planning, no one would know of the SSD's concerns.

F279 SS=D DEVELOP COMPREHENSIVE CARE PLANS CFR(s): 483.20(d);483.21(b)(1)

F279 483.20 (d) Use. A facility must maintain all resident assessments completed within the previous 15 months in the resident’s active record and use the results of the assessments to develop, review and revise the resident’s comprehensive care plan. 483.21 (b) Comprehensive Care Plans FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 1J0P11 Facility ID: CA060000765 If continuation sheet 10 of 32 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: _______________ 555286 (X3) DATE SURVEY COMPLETED 06/06/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE NEW ORANGE HILLS 5017 E Chapman Ave Orange, CA 92869 (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 (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 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. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 1J0P11 Facility ID: CA060000765 If continuation sheet 11 of 32 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: _______________ 555286 (X3) DATE SURVEY COMPLETED 06/06/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE NEW ORANGE HILLS 5017 E Chapman Ave Orange, CA 92869 (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 (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 care plan problems in a timely manner to address the care needs of one of two sampled residents (Resident 2) related to the resident's high risk to develop pressure ulcers and discharge planning needs. This had the potential for Resident 2's care and services to not be anticipated to meet the care needs. Findings: On 5/10/17 at 0830 hours, Resident 2 was observed in bed watching television. Resident 2 was observed with no spontaneous movement and had a flat facial affect. When spoken to, Resident 2 slowly made eye contact and after a delay gave a one word response with difficulty (took several attempts to articulate a reply). The reply was appropriate; however, her speech was slow and slurred. Medical record review for Resident 2 was initiated on 5/10/17. Resident 2's medical record showed the resident was admitted to the facility on 4/4/17, with diagnoses including right frontal and parietal lobe hemorrhage. Review of the facility's P&P titled Patient Care Documentation revised 7/16/13, showed the admission plan of care was developed from the physician's orders and nursing admission assessment within 48 hours of the resident's admission. a. Review of the facility's P&P titled FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 1J0P11 Facility ID: CA060000765 If continuation sheet 12 of 32 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: _______________ 555286 (X3) DATE SURVEY COMPLETED 06/06/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE NEW ORANGE HILLS 5017 E Chapman Ave Orange, CA 92869 (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 Wound Care Suggestions and Documentation revised November 2011, showed resident's who are unable to independently turn will be repositioned at a minimum of every two hours. Review of Resident 2's physician's orders dated 4/4/17, showed an order to monitor the resident's skin integrity every day shift: I = intact, O = open area, B = bruises and to turn/reposition the resident every two hours: L = left, R = right, and circle and explain if the resident refused. Review of Resident 2's Resident Admission Form dated 4/4/17, showed the resident was alert, confused, and unable to move her extremities. The Skin Assessment section showed the resident had no documented skin integrity issues on the posterior of her body. Review of Resident 2's Braden Scale dated 4/4/17, showed a calculated score of 11. A score of less than 12 indicated the resident was at high risk for developing a pressure ulcer. Review of Resident 2's Body Assessment form dated 4/5/17, showed the resident had blanchable redness on the coccyx. Review of Resident 2's comprehensive care plan showed a problem titled Actual Skin Problem related to: coccyx redness dated 4/6/17; however, the approach plan failed to include the interventions to prevent pressure ulcers such as to turn/reposition the resident every two hours and document the resident's position or to monitor the resident's skin integrity every day shift as specified in the physician's orders. On 5/10/17 at 1515 hours, an interview and concurrent medical record review for Resident 2 was conducted with LVN 1. LVN 1 reviewed FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 1J0P11 Facility ID: CA060000765 If continuation sheet 13 of 32 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: _______________ 555286 (X3) DATE SURVEY COMPLETED 06/06/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE NEW ORANGE HILLS 5017 E Chapman Ave Orange, CA 92869 (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 comprehensive care plan and verified the above findings. Cross reference to F314. b. Review of Resident 2's comprehensive care plan showed a problem titled discharge planning (and a list of options) dated 4/4/17. The care plan problem failed to show the planned disposition of the resident. The approach plan showed four pre-printed options. There were two options chosen: to coordinate plans with the resident, family, and caregiver; and for the social services to visit and allow resident to discuss any concerns and feelings. The care plan problem did not show who had initiated the plan and no updates. There were no resident specific plans, goals, or interventions for Resident 2 in the care plan. On 5/10/17 at 1445 hours, an interview was conducted with the SSD. The SSD verified the above findings. Cross reference to F250.

F314 SS=G TREATMENT/SVCS TO PREVENT/HEAL PRESSURE SORES CFR(s): 483.25(b)(1)

F314 (b) Skin Integrity (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: 1J0P11 Facility ID: CA060000765 If continuation sheet 14 of 32 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: _______________ 555286 (X3) DATE SURVEY COMPLETED 06/06/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE NEW ORANGE HILLS 5017 E Chapman Ave Orange, CA 92869 (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, facility document review, and facility P&P review, the facility failed to ensure the necessary care and services were provided to prevent the development of a pressure ulcer for two of two sampled residents (Residents 1 and 2). Residents 1 and 2 were admitted to the facility without pressure ulcers but developed pressure ulcers after admission to the facility. * Resident 1 was admitted to the facility without a pressure ulcer. The facility failed to follow Resident 1's plan of care to turn the resident every 2 hours and administer a moisture barrier cream treatment as ordered by the physician. As a result, Resident 1 developed a Stage II pressure ulcer to his coccyx on 3/1/17, which deteriorated to a Stage IV pressure ulcer on 3/14/17. Resident 1 was confined to bed and his physical therapy was delayed as a result of the development of a Stage IV pressure ulcer while in the facility. Resident 1 stated he felt depressed as the wound was delaying his ability to be discharged home. * Resident 2 was admitted to the facility without a pressure ulcer. The facility failed to reposition Resident 2 and perform treatments as ordered for the skin redness to the coccyx discovered on 4/5/17. On 4/26/17, Resident 2's coccyx wound had worsened to a Stage II pressure ulcer. Findings: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 1J0P11 Facility ID: CA060000765 If continuation sheet 15 of 32 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: _______________ 555286 (X3) DATE SURVEY COMPLETED 06/06/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE NEW ORANGE HILLS 5017 E Chapman Ave Orange, CA 92869 (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 Wound Care Suggestions and Documentation dated September 2014, showed residents who are unable to independently turn will be repositioned at the minimum of every 2 hours. Preventative skin care program includes application of a moisture barrier ointment to protect the skin if indicated. All residents will have a complete skin assessment performed by licensed staff a minimum of weekly and charted on the weekly summary. The wounds should be measured and evaluated weekly for improvement or decline. 1. Medical record review for Resident 1 was initiated on 5/10/17. Resident 1 was admitted to the facility on 2/22/17, with a diagnosis of paraplegia of the bilateral lower extremities. Review of the MDS dated 3/3/17, showed Resident 1 had no cognitive impairment, could communicate his needs and required extensive assistance from two or more persons for bed mobility. Review of Resident 1's Resident Admission Skin Assessment Form dated 2/22/17, showed Resident 1's coccyx was within normal limits and without abnormalities (no skin breakdown or open areas). Review of Resident 1's care plan problem titled Skin Breakdown dated 2/22/17, showed a potential for skin breakdown related to decreased mobility. The care plan problem showed a goal for Resident 1 to be free from skin breakdown. Interventions included to turn Resident 1 every two hours while in bed. Review of the medical record showed no documented evidence the resident was consistently turned and repositioned every two FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 1J0P11 Facility ID: CA060000765 If continuation sheet 16 of 32 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: _______________ 555286 (X3) DATE SURVEY COMPLETED 06/06/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE NEW ORANGE HILLS 5017 E Chapman Ave Orange, CA 92869 (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 hours as care planned to prevent the pressure ulcer development. Review of the Interdisciplinary Wound Care Committee record dated 3/1/17, showed Resident 1 had developed a new in-house pressure ulcer to his coccyx. Documentation showed the pressure ulcer on Resident 1's coccyx was first identified on 3/1/17, as a Stage II pressure ulcer. There was no documentation of the size of the pressure ulcer. Review of Resident 1's physician's order dated 3/1/17, showed an order for a low air loss mattress for pressure ulcer and to apply moisture barrier cream every shift and as needed to the Stage II pressure ulcer on the coccyx. Review of Resident 1's Treatment Administration Record (TAR) for March 2017, showed an entry to apply moisture barrier cream to the Stage II pressure ulcer on the coccyx. Further review of the TAR for the month of March 2017 showed no documented evidence the moisture barrier cream was applied from 3/1/17 through 3/10/17, during the 7 PM to 7 AM shifts and on 3/8 and 3/9/17, during the 7 AM to 7 PM shifts; all of these dates were blank and with no nurses' initials documented to show the treatments had been performed as ordered. Review of a physician's order dated 3/11/17, showed Resident 1's Stage II pressure ulcer had deteriorated. The treatment order was changed to apply Santyl ointment. Santyl ointment contains an enzyme which breaks up dead skin and tissue. A physician's order dated 3/13/17 showed to "Please turn" resident every two hours and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 1J0P11 Facility ID: CA060000765 If continuation sheet 17 of 32 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: _______________ 555286 (X3) DATE SURVEY COMPLETED 06/06/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE NEW ORANGE HILLS 5017 E Chapman Ave Orange, CA 92869 (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 document it. However, review of the medical record showed no documented evidence the resident was consistently turned and repositioned every two hours as care planned and ordered to prevent further deterioration of the Stage II pressure ulcer on the coccyx. Review of Physician 1's progress note dated 3/14/17, showed Resident 1's Stage II pressure ulcer to his coccyx was first identified on 3/1/17, which was assessed to have deteriorated to a Stage IV on 3/14/17. Documentation showed the measurement of the Stage IV pressure ulcer on the coccyx was 3 cm (length) x 2.5 cm (width). Physician 1 documented the wound care nurse had notified her on 3/13/17, that Resident 1's Stage II coccyx pressure ulcer had deteriorated on 3/11/17, to an unstageable wound. Physician 1 documented it was unclear as to how the wound had rapidly deteriorate that quick, and was unfortunate set back as resident's therapy with slide board transfers was now delayed. The physician's progress note also showed Resident 1 had told Physician 1 he was not being turned every 2 hours and sometimes was sitting in stool. On 5/10/17 at 1629 hours, an interview and concurrent record review was conducted with the ADON (acting DON as of 4/1/17). The ADON was asked if Resident 1 reported to her that he was not being turned. The ADON stated Resident 1 informed her on 4/20/17, two CNAs on the night shift were giving Resident 1 an attitude about being turned. The ADON was asked if she had investigated Resident 1's concern. The ADON stated she conducted an interview with CNA 6 and CNA 7, as she felt based on the time frame provided to her by Resident 1. The ADON stated CNA 6 and CNA FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 1J0P11 Facility ID: CA060000765 If continuation sheet 18 of 32 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: _______________ 555286 (X3) DATE SURVEY COMPLETED 06/06/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE NEW ORANGE HILLS 5017 E Chapman Ave Orange, CA 92869 (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 told her they turned Resident 1 as per his turning schedule. The ADON stated she also spoke with six or seven additional CNAs, and they denied failing to turn the resident. The ADON was asked if she documented any of her interviews with these CNAs. The ADON stated, "I wrote some notes on a census sheet." The ADON provided a copy of the census sheet notes. The census sheet dated 4/20/17, showed the following documentation, "c/o turning PM shift (sometime day) CNA 6 and CNA 7 - attitude." The ADON stated there was no additional documentation in regards to this. Review of Resident 1's Nursing Assistant Daily Flow Sheets (used by the CNAs to document turning the residents every two hours) for the months of February, March, and April 2017 showed the following documentation for the bed mobility/position every two hours: a. Blank areas with no charting were noted on the following dates: - Night Shift: 2/24, 3/28, 3/29, 4/2, 4/4, 4/6, 4/16, 4/19, 4/21, 4/22, 4/23, and 4/26/17. - AM Shift: 3/29, 4/1, 4/5, 4/7, and 4/10/17. - PM Shift: 4/9, 4/15, and 4/16/17. b. "N" ("No" according to the charting code) on the following dates: - Night shift: 3/3 through 3/7/17 and 3/9 through 3/27/17. c. "S" (supervision/cueing according to the charting code) on the following dates: - AM Shift: 3/1 through 3/9/17. On 5/10/17 at 1629 hours, an interview and concurrent record review was conducted with FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 1J0P11 Facility ID: CA060000765 If continuation sheet 19 of 32 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: _______________ 555286 (X3) DATE SURVEY COMPLETED 06/06/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE NEW ORANGE HILLS 5017 E Chapman Ave Orange, CA 92869 (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 ADON. The ADON verified on 3/1 through 3/9/17 (the time frame in which the pressure ulcer deteriorated from a Stage II to a Stage IV), the AM shift documentation showed Resident 1 was given supervision/cueing with repositioning. The ADON acknowledged the resident could not reposition himself and required staff assistance with turning and repositioning. The ADON verified on 3/3/17 through 3/14/17 (the time frame in which the pressure ulcer deteriorated from a Stage II to a Stage IV) the night shift had documented Resident 1 was not being turned. The ADON stated "N" as per the document charting code indicated "No," the resident was not being turned. The ADON stated she was unable to determine if Resident 1 was being turned on the dates and shifts listed above due to the the lack of documentation. On 5/11/17 at 0800 hours, an interview was conducted with Resident 1. Resident 1 stated he was admitted to the facility with no pressure ulcers. Resident 1 stated staff on all shifts failed to turn him, with an increased incidence on the night shift. Resident 1 stated he had told approximately six different facility licensed nurses and CNAs since his admission that he was not being turned. Resident 1 stated after the development of the coccyx pressure ulcer, he was confined to bed for several weeks. Resident 1 stated he felt depressed because the wound prevented him from attaining his goal of being discharged home. Resident 1 stated, "I know I could have been home if was not for this wound. I can not even get onto my own chair. This has prevented me from being independent and caring for myself, instead of enjoying time out of bed and learning how to live and move after my accident." The resident was asked at what time barrier cream was applied to his coccyx. Resident 1 stated the barrier cream was applied during the day shift. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 1J0P11 Facility ID: CA060000765 If continuation sheet 20 of 32 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: _______________ 555286 (X3) DATE SURVEY COMPLETED 06/06/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE NEW ORANGE HILLS 5017 E Chapman Ave Orange, CA 92869 (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 An observation of Resident 1's pressure ulcer and interview was conducted with Treatment Nurse 1 on 5/11/17 at 0905 hours. Resident 1 was observed with full thickness tissue loss to his coccyx, measuring 4 cm (length) x 3 cm (width) x 3.5 cm (depth). Treatment Nurse 1 assessed the resident's pressure ulcer and stated the measurement of the tunneling was 4.8 cm at 9 o'clock. Treatment Nurse 1 stated Resident 1's coccyx area was clear and without skin breakdown or tissue injury on admission to the facility. Treatment Nurse 1 stated the redness on the resident's coccyx area developed and was treated with a moisture barrier cream. Treatment Nurse 1 stated Resident 1 had developed a Stage II pressure ulcer and was placed on a low air loss mattress. Resident 1's wound then deteriorated to a Stage IV pressure ulcer. Treatment Nurse 1 stated Resident 1 was bed bound for two weeks when he developed a Stage IV pressure ulcer. Treatment Nurse 1 stated the resident had told her he was very sick of being in bed. Treatment Nurse 1 stated before the Stage IV pressure ulcer was developed, Resident 1 spent approximately three hours a day in his wheel chair. On 5/16/17 at 0831 hours, an interview and concurrent record review was conducted with CNA 5. CNA 5 had cared for Resident 1 during the night shift on 3/3, 3/4, and 3/6/17 (the time frame the Stage II had deteriorated to Stage IV pressure ulcer). CNA 5 verified he charted "N" on these dates. CNA 5 stated "N" meant "no," Resident 1 was not turned and he could not turn himself. CNA 5 was asked if Resident 1 had ever refused to be turned. CNA 5 stated Resident 1 refused to be turned a handful of days he worked. CNA 5 stated he was uncertain of the exact dates, stating sometime between the end of February 2017 and early FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 1J0P11 Facility ID: CA060000765 If continuation sheet 21 of 32 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: _______________ 555286 (X3) DATE SURVEY COMPLETED 06/06/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE NEW ORANGE HILLS 5017 E Chapman Ave Orange, CA 92869 (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 March 2017. CNA 5 stated when a resident refused to be turned he circled his entry on the Bed Mobility/Position form and documented the refusal on the back of the page. CNA 5 stated he was also required to inform the LVN charge nurse of the refusal who would then then cosign his documentation. CNA 5 stated he did not document Resident 1's refusals because he was told by the LVN charge nurse, the LVN would document the refusals on the MAR. CNA 5 stated he did not verify if the LVN charge nurse documented Resident 1's refusals. CNA 5 was asked if Resident 1 had reported to him that he (Resident 1) was not being turned. CNA 5 stated the resident told him the AM and PM shifts failed to turn him because they were too busy. CNA 5 stated he reported the resident's complaint about not being turned to his supervisor, LVN 3. Review of Resident 1's MARs for the months of February and March of 2017, did not show documentation Resident 1 was refusing to be turned. The MAR for March 2017, failed to show documentation Resident 1 was being turned and repositioned every two hours from 3/1/17 through 3/12/17 and 3/13/17 through 3/31/17. In addition, there were 23 times where there was nothing documented. On 5/22/17 at 0832 hours, an interview and concurrent record review was conducted with CNA 8. CNA 8 cared for Resident 1 during the night shift on 3/7, 3/12, 3/13 (time frame Stage II deteriorated to Stage IV) 3/24, and on 3/26/17. Review of the Nursing Assistant Daily Flow Sheet (bed mobility/position every 2 hours section) for March 2017, showed CNA 8 documented "N" ("N" indicated no, the resident was not turned every 2 hours) on 3/7, 3/12, 3/13, 3/24, and 3/26/17. CNA 8 stated, "Y" indicated yes, the resident was turned every 2 hours. CNA 8 stated Resident 1 did not refuse FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 1J0P11 Facility ID: CA060000765 If continuation sheet 22 of 32 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: _______________ 555286 (X3) DATE SURVEY COMPLETED 06/06/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE NEW ORANGE HILLS 5017 E Chapman Ave Orange, CA 92869 (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 be turned during the times she cared for him. Review of the Interdisciplinary Team Conference Record - Wound dated 5/24/17, showed Resident 1 had developed an avoidable pressure ulcer on his coccyx based on the National Pressure Ulcer Advisory Panel guidelines. On 5/24/17 at 1100 hours, an interview and concurrent record review was conducted with Physician 1. Physician 1 stated she informed the DON on 3/14/17, of Resident 1's complaint of facility staff not turning every two hours and that he was sometimes left sitting in stool. The DON had informed Physician 1 an action plan would be developed and the DON would speak to the nurses. Physician 1 stated she was not informed Resident 1's treatment was not administered on 3/1/17 through 3/10/17 during the 7 PM - 7 AM shifts, and 3/8 and 3/9/17 during the 7 AM - 7 PM shifts. Physician 1 stated failing to carry out the treatment order could have contributed to development/worsening of Resident 1's pressure ulcer on his coccyx. On 5/24/17 at 1232 hours, an interview and concurrent record review was conducted with Treatment Nurse 1. Treatment Nurse 1 was asked if Resident 1 reported to her that he was not being turned. Treatment Nurse 1 stated Resident 1 had told her a CNA on night shift, sometime last week, had failed to turn or reposition him and let him sleep. Treatment Nurse 1 stated she reported the resident's complaint to her supervisor, RN 1. Treatment Nurse 1 verified there was no documentation as to why the treatments were not done from 3/1/17 through 3/10/17 during the 7 PM to 7 AM shifts and on 3/8 and 3/9/17 during the 7 AM to 7 PM shifts. Treatment Nurse 1 unable FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 1J0P11 Facility ID: CA060000765 If continuation sheet 23 of 32 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: _______________ 555286 (X3) DATE SURVEY COMPLETED 06/06/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE NEW ORANGE HILLS 5017 E Chapman Ave Orange, CA 92869 (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 determine if the treatment was administered on these dates. On 5/24/17 at 1635 hours, an interview was conducted with RN 1. RN 1 stated Treatment Nurse 1 did not report to her last week or at any time Resident 1 was not being turned by a CNA on the night shift. RN 1 stated if it had been reported to her Resident 1 was not being turned, she would have conducted interviews with Resident 1, CNAs, nurses, and followed up with the Quality Assurance Committee inquiring as to any reports of residents failing to be turned. RN 1 stated she had not conduct interviews or follow up with Quality Assurance because Treatment Nurse 1 did not report to her Resident 1 was not being turned. On 5/25/17 at 1603 hours, an interview was conducted with LVN 3. LVN 3 was asked if Resident 1 or any staff had reported to her that Resident 1 was not being turned every two hours. LVN 3 stated Resident 1 told her that sometime during the month of March 2017, that the AM shift staff did not turn the resident every two hours while he was in bed. LVN 3 stated she reported the resident's complaint about not being turned to the AM shift nurse; however, she could not remember who the nurse was. LVN 3 stated aside from Resident 1, she was never informed by anyone else the resident was not being turned. Review of Resident 1's Pressure Skin Condition Record dated 3/1/17, showed Treatment Nurse 1 was the first to identify the Resident 1's coccyx pressure ulcer on 3/1/17. There was no documentation of the stage of the pressure ulcer. On 5/24/17 at 1232 hours, an interview and concurrent record review was conducted with Treatment Nurse 1. Treatment Nurse 1 confirmed she did not document the stage of Resident 1's coccyx pressure ulcer on FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 1J0P11 Facility ID: CA060000765 If continuation sheet 24 of 32 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: _______________ 555286 (X3) DATE SURVEY COMPLETED 06/06/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE NEW ORANGE HILLS 5017 E Chapman Ave Orange, CA 92869 (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 3/1/17. Review of Resident 1's Pressure Skin Condition Record dated 4/15/17, showed Resident 1 had a Stage IV pressure ulcer to his coccyx which measured 4.7 cm (length) x 4.0 cm (width) x 3.3 cm (depth) with tunneling of 4 cm at 9 o'clock. The Pressure Skin Condition Record dated 4/21/17, showed the Stage IV coccyx pressure ulcer was increasing in size, it now measured 5.0 cm (length) x 4.0 cm (width) x 3.3 cm (depth). The documentation did not show the measurement for tunneling. On 5/24/17 at 1232 hours, an interview and concurrent record review was conducted with Treatment Nurse 1. Treatment Nurse 1 stated she was unsure why she had not documented the measurement for tunneling. Treatment Nurse 1 stated documentation of tunneling was necessary to determine if wound was improving or worsening. On 5/24/17 at 1310 hours, an interview was conducted with Treatment Nurse. Treatment Nurse 1 stated photographs of Resident 1's coccyx pressure ulcer were taken on admission and when there was a change in the condition of his pressure ulcer. She said the photographs were taken when the Stage II pressure ulcer was identified, and when it deteriorated to a Stage IV. Treatment Nurse 1 stated she recalled taking the photographs of Resident 1's Stage II pressure ulcer as she was the first to identify the wound. The treatment nurse stated Resident 1's wound photographs were printed from the facility's camera, placed in the resident's medical record under the progress note section, and then the photographs were deleted from the camera. There were no photographs of Resident 1's wound in his medical record. The treatment FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 1J0P11 Facility ID: CA060000765 If continuation sheet 25 of 32 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: _______________ 555286 (X3) DATE SURVEY COMPLETED 06/06/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE NEW ORANGE HILLS 5017 E Chapman Ave Orange, CA 92869 (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 nurse was unable to locate the photographs in the medical record or on the facility's camera. On 5/24/17 at 1310 hours, a request was made to the ADON to review any and all photographs of Resident 1's pressure ulcer. No photographs were ever provided. On 5/24/17 at 1350 hours, an interview was conducted with Resident 1. Resident 1 confirmed facility staff had photographed the wound to his coccyx on several occasions. On 5/24/17 at 1436 hours, an interview was conducted with the Administrator. The Administrator stated the facility does not have a P&P for taking photographs of resident wounds. The Administrator stated the facility practice was to take photographs on admission and when requested by a physician. 2. On 5/10/17 at 0830 hours, Resident 2 was observed on her back in bed with the head of bed elevated watching television. On 5/10/17, the additional observations were made and showed the following: - At 0945 hours, Resident 2 was observed in the standing frame in the physical therapy department. - At 1045 hours, Resident 2 was sitting in her room in a wheelchair. - At 1145 hours, Resident 2 was sitting in her room in a wheelchair. - At 1415 hours, Resident 2 was lying in bed on her back with a private caregiver at her bedside. - At 1525 hours, a concurrent observation was made with LVN 1; Resident 2 was lying in bed on her back. At no time during the above observations was Resident 2 observed to have spontaneous or purposeful movements to reposition herself. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 1J0P11 Facility ID: CA060000765 If continuation sheet 26 of 32 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: _______________ 555286 (X3) DATE SURVEY COMPLETED 06/06/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE NEW ORANGE HILLS 5017 E Chapman Ave Orange, CA 92869 (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 Medical record review for Resident 2 was initiated on 5/10/17. Resident 2 was admitted to the facility on 4/4/17. Review of Resident 2's Resident Admission Assessment form dated 4/4/17, showed the resident was alert but confused and was unable to move her extremities. The skin assessment section showed the skin was within normal limits other than a bruise on the left antecubital area. Review of Resident 2's Braden Scale (skin assessment form) dated 4/4/17, showed Resident 2 was confined to bed, had limited ability to respond to pressure-related discomfort, and was unable to make even slight changes in body or limb position without staffs' assistance. Resident 2's calculated Braden Scale score was 11. A score of 12 or less represented High Risk to develop a pressure ulcer. Review of Resident 2's physician's orders dated 4/4/17, showed an order to monitor the resident's skin integrity daily upon admission and every day shift and document: I = intact, O = open area, B = bruises. Another physician's order dated 4/4/16, showed to turn/reposition Resident 2 every two hours as follows: L = left, R = right, B = back and to circle and document on the back of the form if the resident refused to be repositioned. Review of Resident 2's Body Assessment form dated 4/5/17, showed the resident had blanchable redness to the coccyx (no documented measurement). The redness to Resident 2's coccyx was documented on 4/9, 4/16, and 4/23/17. A physician's order dated 4/6/17, showed the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 1J0P11 Facility ID: CA060000765 If continuation sheet 27 of 32 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: _______________ 555286 (X3) DATE SURVEY COMPLETED 06/06/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE NEW ORANGE HILLS 5017 E Chapman Ave Orange, CA 92869 (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 following wound care order for Resident 2's coccyx redness: apply moisture barrier cream to the affected area every shift and as needed. Review of Resident 2's MDS dated 4/13/17, showed the resident had short and long-term memory problems, severe cognitive impairment, and unable to speak. The resident required extensive physical assistance of two plus persons for bed mobility and total physical assistance of two plus persons to transfer to and from the bed. Review of Resident 2's Body Assessment form dated 4/26/17, showed the resident had a Stage II pressure ulcer on the coccyx, measuring 0.6 cm (length) by 1.2 cm (width) with superficial depth. A physician's order dated 4/26/17, showed the following wound care order for Resident 2's Stage II coccyx pressure ulcer showed to cleanse the area with normal saline, pat dry, and apply a Mepilex (a specialized wound covering) dressing every day. Review of Resident 1's Treatment Administration Record for April 2017, showed the physician's order to apply the moisture barrier cream to the coccyx redness every shift. However, this order was not carried out for the AM shift on 4/17, 4/18, 4/19 and 4/20/17, and not carried out on the PM shift for the entire month of April 2017. Review of the CNA notes for the month of April 2017, in the section for Bed mobility/Position every two hours for the AM and PM shifts, showed the resident was totally dependent/required full staff performance for bed mobility. The documentation from the night shift for the section Bed Mobility/Position FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 1J0P11 Facility ID: CA060000765 If continuation sheet 28 of 32 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: _______________ 555286 (X3) DATE SURVEY COMPLETED 06/06/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE NEW ORANGE HILLS 5017 E Chapman Ave Orange, CA 92869 (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 every two hours showed 19 nights with entry "N." According to the Codes at the bottom of the page of the CNA note, an "N" meant "No." The dates between Resident 1's admission and 4/26/17, when the resident's Stage II pressure ulcer was identified, "N" was documented 15 times for Bed Mobility/Position every two hours on the night shift. On 5/10/17 at 1415 hours, an interview was conducted with Resident 2's Private Caregiver about the resident's activities for the day. The Private Caregiver stated the resident remained up in the wheelchair until 1330 hours after the resident had finished her lunch. The Private Caregiver stated the resident was then transferred back to bed by two CNAs using a mechanical lift, positioned on her back at the time. The Private Caregiver stated the resident was supposed to be repositioned every two hours because of her pressure ulcer. On 5/10/17 at 1515 hours, an interview and concurrent medical record review was conducted with LVN 1 regarding Resident 2's pressure ulcer. LVN 1 stated Resident 2 was unable to move or turn herself, and she was supposed to be repositioned every two hours. LVN 1 stated she documented on the MAR to identify the resident had been turned every two hours during her shift; however, LVN 1 stated she did not observe Resident 2 had been turned and did not document which position the resident was in every two hours. LVN 1 stated she asked the CNA to reposition the resident every two hours, and relied on the CNA to follow the instructions. LVN 1 verified the physician's orders regarding repositioning the resident and documenting the resident's position when turned. On 5/10/17 at 1525 hours, a concurrent observation was made of Resident 2 with LVN FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 1J0P11 Facility ID: CA060000765 If continuation sheet 29 of 32 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: _______________ 555286 (X3) DATE SURVEY COMPLETED 06/06/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE NEW ORANGE HILLS 5017 E Chapman Ave Orange, CA 92869 (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 1. Resident 2 remained positioned on her back. It had been over two hours since Resident 2 had been returned to bed from sitting in her wheelchair and placed on her back. LVN 1 was informed Resident 2 had been observed throughout the day either sitting in a wheelchair or lying on her back without any off-loaded her coccyx area. LVN 1 stated she was unaware the resident had not been repositioned. A concurrent review of Resident 2's CNA Notes for April 2017 was made with LVN 1. LVN 1 verified for 19 of the 30 day, an "N" was documented for "Bed mobility/Reposition every two hours" on the night shift. LVN 1 stated an "N" meant "No," and indicated the resident had not been turned. On 5/11/17 at 1145 hours, an interview was conducted with CNA 1 regarding Resident 2's pressure ulcer. CNA 1 stated during their initial rounds of Resident 2 on 4/16/17, the resident was on her back and "soaking wet." CNA 1 stated it looked like the resident had not been changed or turned for a long time based on how soaked the resident's incontinent brief was with urine. CNA 1 stated when she wiped Resident 2's skin over the coccyx her skin appeared bright pink as though the top layer of skin had peeled off. CNA 1 said she immediately called the treatment nurse to assess the resident. On 5/19/17 at 1128 hours, an interview and concurrent medical record review was conducted with Treatment Nurse 2 regarding Resident 2's skin and the facility's pressure ulcer assessments. Treatment Nurse 2 stated a treatment nurse always assessed a resident's skin within 12 hours of admission if possible, though the facility's P&P was within 24 hours. If a skin problem was observed the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 1J0P11 Facility ID: CA060000765 If continuation sheet 30 of 32 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: _______________ 555286 (X3) DATE SURVEY COMPLETED 06/06/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE NEW ORANGE HILLS 5017 E Chapman Ave Orange, CA 92869 (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 treatment nurse notified the resident's case manager and DON or ADON, measured the area, obtained physician orders for treatment, initiated a care plan problem to address the skin issue, with interventions which may include pressure relief devices, repositioning every two hours, medications, and limiting time up in a wheelchair. Treatment Nurse 2 stated the definition of a Stage I pressure ulcer was non-blanchable redness, or blanchable redness which did not refill within three seconds. She stated she would press the reddened area with two fingers and if the area turned white it was blanchable. If the reddened area did not resolve with relief of pressure to the area she would classify it as a Stage I pressure ulcer. Treatment Nurse 2 stated she assessed Resident 2's skin on 4/5/17. The treatment nurse stated the resident had blanchable redness to her coccyx which did not resolve with pressure relief to the area. Treatment Nurse 2 stated she did not measure the reddened area, or document how long the area stayed blanched, and did not classify the area as a Stage I pressure ulcer. Treatment Nurse 2 stated for a Stage I pressure ulcer she would usually obtain an order for a hydrocolloid patch (a specialized wound dressing); she verified the treatment order she obtained was to apply a moisture barrier cream to be applied every shift and as needed. Treatment Nurse 2 stated in retrospect, she should have classified and obtained treatment orders for Resident 2's reddened area as a Stage I pressure ulcer. According to the Northwest Regional Spinal Cord Injury System, Department of Medicine at the University of Washington, a pressure sore has begun if the pressure is removed from a reddened area for 10 to 30 minutes and the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 1J0P11 Facility ID: CA060000765 If continuation sheet 31 of 32 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: _______________ 555286 (X3) DATE SURVEY COMPLETED 06/06/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE NEW ORANGE HILLS 5017 E Chapman Ave Orange, CA 92869 (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 skin color does not return to normal. A person should stay off the area and treat the area as a Stage I pressure ulcer. To test for blanching, press a finger into the pink, red, or darkened area, the area should become white, when the pressure is removed the area should return to pink, red or darkened within a few seconds. If the area stays white, blood flow is impaired and damage has begun. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 1J0P11 Facility ID: CA060000765 If continuation sheet 32 of 32