Healthcare Center of Orange County

In the surveyor’s words

From the most serious findings on record at Healthcare Center of Orange County, in the surveyor’s own words.

• Actual harm, isolatedF689Oct 9, 2025

  Based on interview, medical record review, facility document review, and facility P&P review, the facility failed to provide the necessary care and services to ensure one of three sampled residents (Resident 1) was free from accident hazards. * Resident 1 had an unwitnessed fall incident on 9/18/25. The facility failed to investigate Resident 1's family member's grievance regarding Resident 1's position near the edge of the bed on 9/16/25. Resident 1's fall risk assessment was inaccurate resulting in an incorrect fall risk score status. In addition, the facility failed to update Resident 1's care plan addressing the resident's risk for fall and his behavior of dangling his legs off the bed prior to his fall incident. […]

• Actual harm, isolatedF684Mar 30, 2022

  Based on observation, interview, medical record review, and facility document review, the facility failed to provide the necessary care and services to ensure one of two sampled residents (Resident 1) attained or maintained their highest practicable physical well-being. * Resident 1 was found with a deep laceration to her left hand which was covered with a dressing. CNA 1, who was providing care to Resident 1 when the laceration was sustained, covered the laceration with a dressing and failed to report the incident to the licensed nurses. This failure resulted in Resident 1's transfer to the acute care hospital and required sutures to repair the left-hand laceration. Findings: Medical record review for Resident 1 was initiated on 2/28/22. […]

• Actual harm, isolatedF684Jun 1, 2021

  Based on interview and medical record review, the facility failed to provide the necessary care and services to ensure one of two sampled residents (Resident 1) attained and/or maintained their highest practicable physical well-being. The facility failed to ensure the daily wound care treatment was provided to Resident 1's right heel diabetic ulcer as ordered by the physician. In addition, the facility failed to obtain a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . […]

• No harm, potential for more than minimal, patternF686Aug 13, 2026

  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 risk and development of pressure injuries for two of three final sampled residents (Residents 4 and 7) reviewed for pressure injuries. * The facility failed to ensure the low air loss mattress (LAL) setting was on alternating mode for Residents 4 and 7. This failure had potential for Residents 4 and 7 not receiving full treatment to prevent the worsening of pressure injuries.Findings: 1. According to KMS Alternating Pressure Pump and Mattress User Manual for ProtekTM Aire 6000, undated, on the operation section showed a firm surface will make it easier for the patient to transfer or reposition. […]

• No harm, potential for more than minimal, patternF695Aug 13, 2026

  Based on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure five of six final sampled residents (Residents 1, 3, 5, 8, and 38) and one nonsampled resident (Resident 69) reviewed for respiratory care were provided the appropriate respiratory care. * The facility failed to ensure Resident 1's BIPAP (Bilevel Positive Airway Pressure, a machine used to provide pressurized air into the airways while asleep) mask was properly stored when not in use. * The facility failed to ensure the manufacturer's recommendation for cleaning and disinfecting of the ventilator machines was followed for Residents 3, 8, and 38. […]