Average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Healthbridge Children's Hospital - Orange D/p Snf during CMS and state inspections, most recent first.
Two residents using LAL mattresses did not have the mattress settings managed in accordance with the documented orders. One resident with anoxic brain injury and total ADL dependence was observed on an Adapt Pro Elite mattress in static mode when it should have been alternating except during care, and another resident's mattress was set to firm without a physician order specifying the setting. Staff confirmed the settings and acknowledged the missing order.
Enteral feeding and GT medication administration failures were observed for multiple residents. An LPN, RN, and another LPN administered medications through GTs without verifying placement, and two residents receiving tube feedings were observed with HOB positioning below the required level, including one resident lying flat during continuous NGT feeding and another with HOB at 15 degrees during GT feeding. The residents had feeding tubes for swallowing problems or GT dependence, and facility policy required HOB elevation and tube placement checks during feeds and medication administration.
Failure to Verify GT Placement Before Med Administration: A facility failed to ensure licensed nurses verified GT placement before giving meds through feeding tubes. An LVN administered meds via GT to multiple residents without confirming placement, an RN gave sucralfate via GT without checking placement, and another LVN administered several meds via GT without verifying placement. The residents involved were GT dependent or had feeding tubes, and facility policy required placement checks before tube-med administration.
Unsanitary Kitchen Hood, Utensils, and Cutting Boards: Surveyors observed a greasy residue on the kitchen hood, multiple worn or damaged utensils and kitchenware with rust, residue, stains, and melted surfaces, and cutting boards that were heavily marred with deep grooves. The CDM verified the findings, and facility policy required the hood, utensils, and cutting boards to be maintained in sanitary condition. Two residents consumed food prepared in the kitchen.
Improperly Stored Garbage in Outside Dumpsters: The facility failed to ensure three outside garbage dumpsters were properly covered. Two dumpsters had lids propped open by garbage bags and cardboard boxes, and one dumpster was missing a lid and was fully open with garbage bags exposed. The CDM, Maintenance Director/Plant Operations Director, DON, and ADON were informed and acknowledged the findings.
Failure to Follow EBP and Hand Hygiene During Resident Care: An LVN administered GT medications to three residents on EBP without wearing a gown, and in one instance changed gloves without performing hand hygiene between glove use. An RN also took a resident’s vital signs in an EBP room without gloves. The residents involved had feeding tubes or were GT dependent and had orders for EBP during high-contact care.
Antibiotic stewardship was not properly monitored when three residents were prescribed antibiotics even though McGeer’s Criteria for true infection was not met. The IP stated an ATO was completed and the physician reviewed the signs and symptoms with the RN supervisor, but there was no physician progress note documenting the clinical rationale for continuing levofloxacin, Augmentin, or ciprofloxacin despite the residents not meeting criteria.
Uncovered urinary catheter drainage bags were observed for two residents with indwelling catheters. One resident had a suprapubic catheter and total ADL dependence, and staff stated the bag was kept at the side of the bed without a privacy cover. Another resident with an indwelling catheter and intermittent catheterization was observed with the bag uncovered near the room entrance, despite a care plan intervention to keep the bag and tubing below bladder level and away from the doorway. The ADON verified the bag should have been placed in a dignity bag.
A facility failed to follow its abuse policy after a resident reported that a CNA touched his private parts during showering. The resident had anoxic brain injury, lacked decision-making capacity, and required total assistance with ADLs, but the record showed no documented assessment, skin check, or monitoring after the allegation was reported; RN and ADON both verified the missing documentation.
A facility failed to develop care plans for two residents. One resident was receiving enoxaparin for DVT prophylaxis, but the care plan did not address anticoagulant use or monitoring for bleeding or other complications. Another resident with anoxic brain injury had bilateral side rails ordered for safety, but the care plan did not address the side rails. Staff and the DON/ADON acknowledged the missing care plan problems.
A resident with a seizure diagnosis had a physician order for padded side rails for seizure precautions, but staff observed the resident in bed with unpadded side rails on multiple occasions. An LPN stated the family had declined the padded side rails and that the refusal should have been documented, but later could not find any documentation showing the family declined them and acknowledged the physician order had been missed.
Unlabeled oxygen tubing for two residents with chronic respiratory failure was observed stored outside the setup bag and not dated. One resident's tubing was hanging on a wall hook, and the other resident's tubing was coiled around the oxygen regulator. The RT stated the tubing should be placed inside the labeled setup bag when not in use, and RN and ADON verified the findings.
A resident with orders for lubricating eye drops and eye ointment for dry eyes was observed receiving the eye drop, then the eye ointment only 2 to 4 minutes later instead of waiting the ordered 5 to 10 minutes between eye medications. The LVN verified the order and acknowledged the findings during interview and record review.
A resident’s chart contained behavior and side-effect monitoring for quetiapine even though there was no active physician order for the medication in the Order Summary Report or eMAR. RN 5 acknowledged the quetiapine order had been discontinued and that the related monitoring should also have been discontinued, and the DON and ADON were informed of the finding.
The facility failed to keep several residents' care plans aligned with current orders and care needs. A resident's hospitalization was not added to the care plan after transfer to an acute care hospital, a resident with seizures did not have padded side rails included in the seizure precaution plan, a resident using a low air loss mattress for skin breakdown prevention did not have that intervention listed, and another resident's care plan listed padded side rails even though the record showed an order for bilateral side rails instead.
A facility failed to report a sexual abuse allegation involving a resident to the appropriate State and Federal agencies in a timely manner. The resident's family member reported the incident to the CEO, who later confirmed awareness but did not retain documentation of the report or investigation. The CEO claimed the allegation was unsubstantiated, but no evidence of the investigation was kept, risking the allegation going unreported and uninvestigated.
A facility failed to follow its abuse P&P in investigating a sexual abuse allegation involving a resident. The resident's family reported the abuse, but the facility did not document a body assessment or conduct a comprehensive investigation, including interviews with family members or visitors. The CEO acknowledged the allegation but lacked documentation of staff interviews and did not retain the investigation report.
The facility failed to implement individualized care plans for three residents, leading to potential risks. A resident's family member was not educated on infection control measures, another resident was transferred with a mechanical lift by only one staff member instead of two, and a third resident's care plan did not address anticoagulant and antibiotic use. Staff interviews confirmed these deficiencies.
The facility failed to update care plans for two residents, one involving an abuse allegation and another regarding the use of bilateral AFOs. A resident's care plan was not revised to reflect an abuse allegation reported to the Administrator, while another resident's care plan lacked documentation for the use of AFOs as per a physician's order. These omissions were confirmed through interviews and medical record reviews.
A facility failed to ensure proper care for a resident with a GT feeding. The resident's head of bed was not positioned at the recommended 30 to 45 degrees, increasing the risk of aspiration. Additionally, the facility did not properly label the feeding formula, lacking a system to indicate when the formula was added. Staff confirmed these deficiencies, which were observed on multiple occasions.
The facility failed to date respiratory equipment for two residents, leading to potential infection risks. One resident's cool aerosol therapy bag was not changed weekly as required, and another resident's suction canister was not dated upon installation. Both residents had significant respiratory conditions, including chronic respiratory failure and tracheostomy status.
A facility failed to monitor a resident's behavior and side effects for alprazolam and sertraline, both prescribed for OMS. Staff interviews revealed that there was no specific behavior monitoring for sertraline, and alprazolam monitoring was inaccurate. The lack of specific physician orders for behavior monitoring was acknowledged by the staff.
The facility failed to properly store and label medications for two residents and had expired supplies in three medication carts. A resident had a tube of wound dressing on the bedside table, and another had ointment and wound dressing, both of which should have been secured. Additionally, expired supplies were found in three medication carts, including protective wipes, a pressure manometer, and feeding tube extension sets. Staff confirmed these findings and acknowledged the need for immediate removal of expired items.
The facility failed to submit accurate staffing data to CMS, resulting in a One-Star Staffing Rating. While RN and LVN hours met requirements, CNA hours were below the minimum on several days. The CEO submitted the PBJ in the wrong format, leading to its rejection, and was unable to resubmit due to lack of contact information and documentation.
The facility failed to maintain safe operating conditions for resident care equipment. A mechanical lift stopped working mid-transfer due to a dead battery, requiring manual intervention to return a resident to bed. Additionally, ice buildup was observed in the refrigerator used for storing enteral feedings, posing potential risks for equipment hazards.
A resident with severe brain injury and difficulty swallowing was not assisted with meals in a timely manner, as observed on multiple occasions. Despite physician orders for CNA assistance with feeding, the resident's breakfast and lunch trays were left covered and untouched for extended periods, potentially affecting meal enjoyment.
A resident's room in the facility was found to have a supply cabinet drawer that was difficult to open and had thin wood material protruding, along with chipped blue paint on the wall near the call light system. These issues were confirmed by an LVN and a family member, who expressed concern about the broken state of the cabinet. The CEO acknowledged the findings.
A facility failed to send a Notice of Transfer/Discharge to the LTC Ombudsman for a resident transferred to an acute care facility. The resident, unable to make decisions, was transferred without the required notification. The Case Manager confirmed the oversight, attributing it to the resident's short stay, and acknowledged the error.
A facility failed to report an abuse allegation involving a resident to the CDPH L&C Program, as required by their policy and procedure. The incident involved a resident allegedly abused by an unknown provider, reported by the resident's family to a hospital social worker. Despite documentation by the SS/CM, the facility did not notify the CDPH L&C Program, and the CEO and SS/CM could not provide evidence of notification during an interview.
A facility failed to investigate an alleged abuse incident involving a resident, as required by its policy. Despite a complaint received by the CDPH, the facility's CEO could not provide documentation of an internal investigation. The facility's SS/CM claimed the allegation was vetted multiple times with no evidence found, but the required thorough investigation was not documented.
The facility failed to establish and maintain an infection prevention and control program, specifically lacking a proper water management plan to prevent the growth and spread of Legionella and other pathogens. Interviews revealed that the Director of Maintenance and a CNA were not following comprehensive water management protocols, increasing the risk of infection spread.
The facility failed to complete bed entrapment assessments for six residents, missing critical measurements for Zones 5, 6, and 7. Observations and interviews confirmed the use of side rails, and the Maintenance Director admitted to incomplete assessments. The CEO verified the findings.
The facility failed to ensure a resident was free from physical restraints without proper assessment and consent. The resident was subjected to a hand mitten and abdominal binder without the necessary documentation, assessment, or informed consent, contrary to the facility's policies. Staff interviews and medical record reviews confirmed these deficiencies.
The facility failed to develop comprehensive care plans for four residents, including the use of a lap tray, tobramycin medication, side rails, and restraints, despite physician's orders. Interviews and medical record reviews confirmed these omissions, posing a risk to individualized care.
The facility failed to prevent accidents and ensure safety measures for four residents. One resident did not receive immediate vital signs or neurological assessment after a fall, and the care plan was delayed. Another resident was not monitored in a stroller as required, and two residents did not have the necessary padded side rails for safety and seizure precautions.
The facility failed to document the external catheter measurements and develop a care plan for a resident with a CVAD, potentially delaying the identification of catheter-related complications. This was confirmed through observations, interviews, and medical record reviews.
The facility failed to label and date the mechanical ventilation tubing setup bag for a resident with a tracheostomy tube, as required by its policies and procedures. The respiratory therapist confirmed the setup bag should be changed weekly and labeled, but this was not done.
The facility failed to ensure the least restrictive alternatives were attempted before using side rails for a resident. The resident was observed with bilateral full padded side rails elevated, and the medical record did not show any evidence of less restrictive measures being tried. Interviews with staff confirmed the omission.
The facility failed to act on the Pharmacy Consultant's recommendations for two residents. One resident did not have blood pressure monitoring added to their Diuril medication order, and another resident's Culturelle medication order was not evaluated for chronic use as recommended. The CEO confirmed these recommendations were not addressed.
A facility failed to ensure a resident was free from unnecessary psychotropic medications by not monitoring episodes of crying inconsolably for Risperdal use, not documenting non-pharmacological interventions, and having inaccurate side effects monitoring for both Risperdal and diazepam.
The facility failed to properly store, label, and dispose of medications. Discontinued medications were found in the medication refrigerator, and oral medications were stored with externally used medications in a medication cart. Staff verified these findings, indicating a failure to follow the facility's policies.
The facility failed to meet sanitary requirements in the kitchen, including the presence of expired and moldy food items, improperly stored frozen food, and wet and damaged cutting boards. These deficiencies were verified by the CDM and pose a risk of foodborne illness to residents.
The facility failed to implement an accurate antibiotic stewardship program by excluding residents on long-term antibiotic therapy from the surveillance listing. Two residents on long-term antibiotics were not tracked, and the Infection Preventionist confirmed that the Quality Assurance and Performance Improvement report was based on this incomplete listing. The duration of antibiotic therapy was not reviewed, and the pharmacist did not review the antibiotic usage data, leading to potential inappropriate antibiotic use.
The facility failed to complete a comprehensive discharge assessment for a resident who was transferred to another facility. The CEO confirmed that the MDS for discharge was not completed.
The facility failed to update a resident's care plan to include the use of padded side rails for seizure/safety precautions, despite a physician's order. This oversight was confirmed through observation, interviews, and medical record reviews.
Improper LAL Mattress Settings and Missing Order Specifications
Penalty
Summary
The facility failed to ensure the necessary care and services were provided to prevent the risk and development of pressure injuries for two residents who were using low air loss (LAL) mattresses. The report states that Resident 19 had an anoxic brain injury, no decision-making capacity, and required total assistance for all ADLs. Resident 19 was observed lying on an Adapt Pro Elite LAL mattress that was set to static mode with a weight setting of 110 pounds, even though the physician's order directed the mattress to be used every shift for skin breakdown prevention, with pressure settings adjusted according to weight and switched to static only while care was being provided and returned to alternating mode when finished. Resident 23 was also observed in bed on a low air loss mattress, with the pump set at a 400 lbs firm setting. The resident's order included use of a low air loss mattress every shift for skin breakdown prevention, but the order summary did not include a physician's order specifying the mattress setting. During interviews, nursing staff verified the mattress was set to firm based on the machine indicator and stated they adjusted the setting based on the resident's weight, while also confirming there was no physician order for the specific setting. Facility staff and the DON/ADON were informed of the findings. The facility's policy required LAL mattresses to be used in accordance with physician orders and manufacturer guidelines, with nursing staff responsible for verifying the order and setting the mattress appropriately. The mattress manual stated the pump settings should be adjusted to the patient's weight and comfort, but the observations and record review showed the settings for both residents were not aligned with the documented orders and, for Resident 23, no specific setting order was present.
Enteral Feeding and GT Medication Administration Failures
Penalty
Summary
The facility failed to provide appropriate care for residents receiving enteral feeding and medication administration through feeding tubes. Surveyors found that licensed nurses did not verify GT placement before administering medications to Residents 1, 6, 10, and 17. In each of those observations, staff administered medications and water through the GT without first confirming placement by the methods described in the facility’s policy, and staff acknowledged during interview that placement should have been checked before medication administration. The facility also failed to maintain the required head-of-bed elevation during tube feedings for Residents 11 and 22. Resident 11 was observed receiving continuous NGT feeding while lying flat in bed, despite a care plan intervention calling for HOB elevation during continuous feeding. Resident 22 was observed receiving GT feeding with the HOB elevated only to 15 degrees, even though the physician’s order required elevation to 30 degrees during feeds and for 30 minutes afterward. The record also showed a care plan directing staff to elevate the HOB during and after tube feeding and to check tube placement and gastric contents per facility protocol. Resident-specific records showed that the affected residents were dependent on enteral feeding or had swallowing problems requiring feeding tubes. Resident 1 and Resident 17 had GTs and care plans that included checking GT placement and gastric contents/residual volume per facility protocol. Resident 6 was GT dependent and had a care plan with the same intervention. Resident 10 was observed receiving multiple medications through the GT without placement verification. Facility staff and the IP acknowledged the findings during interviews, and the facility’s policies required HOB elevation and tube placement verification during enteral feeding and medication administration.
Failure to Verify GT Placement Before Medication Administration
Penalty
Summary
The facility failed to ensure that licensed nurses demonstrated competency in verifying GT placement before administering medications to residents who were dependent on enteral feeding. During medication administration observations, LVN 3, RN 3, and LVN 4 administered medications through GTs without first verifying placement as described in the facility’s medication administration policy and lesson plan. The report states that three of four licensed nurses observed for medication administration did not demonstrate the required competency for GT medication administration. For Resident 22, who had a feeding tube and a care plan addressing NPO status and enteral feeding dependency, LVN 3 administered multiple medications and water through the GT without verifying placement by aspirating gastric contents or injecting 20 ml of air. For Resident 1, who also had a feeding tube and a care plan requiring GT placement and gastric residual checks, LVN 3 administered medications and water through the GT after checking residuals but did not inject 20 ml of air prior to medication administration. For Resident 17, who had a GT and a care plan requiring placement and gastric content checks, LVN 3 administered water and simethicone through the GT without aspirating gastric contents or injecting 20 ml of air before giving the medication. For Resident 6, who was GT dependent and had a care plan requiring GT placement checks, RN 3 administered sucralfate suspension via GT without verifying placement. For Resident 10, who had a GT and was receiving medications through the tube, LVN 4 administered erythromycin oral solution, sodium chloride oral solution, and tizanidine via GT without verifying placement. During interviews, LVN 3 stated he did not check residuals or GT placement for Residents 17 and 22 because licensed staff checked the tube every shift, and RN 3 and LVN 4 acknowledged they did not verify GT placement before medication administration.
Unsanitary Kitchen Hood, Utensils, and Cutting Boards
Penalty
Summary
The facility failed to maintain sanitary conditions in the kitchen during survey observations and interviews. The kitchen hood over the stove had yellowish, greasy residue, and the CDM acknowledged that dietary staff cleaned the hood once a week while it was also serviced by an outside company. The hood’s service sticker showed it was last serviced on 2/11/26. Facility policy stated the Ansul hood system must remain in safe working condition, be regularly inspected, and be free of grease accumulation, and that dietary staff must ensure the hood, filters, and surrounding surfaces are free of visible grease. The facility also failed to ensure kitchen utensils and food-contact items were in good repair and clean. During the kitchen tour, the CDM verified that one red peeler with a black handle was discolored and worn out, one light blue rubber basting brush had yellowish stains at the base, one stainless steel can opener had orange discoloration consistent with rust, and three white rubber spatulas with red handles were partially melted, with one showing peeling rubber edges and discoloration. In addition, several stainless steel scoops and a stainless steel spatula were observed with fuzzy film, watermarks, orange residue, or dry crusted residue, and a stainless steel scissor with a black handle was dirty with dry crusted residue. The facility further failed to maintain cutting boards in a sanitary condition with smooth, cleanable surfaces. The green, red, and yellow cutting boards were observed to be fuzzy, heavily marred, and to have deep grooves. Facility policy required cutting boards to be cleaned and sanitized after each use, inspected regularly, and discarded or resurfaced if deeply scratched, cracked, or worn. The CDM verified the findings and stated the thin cutting boards were replaced every six months. The DON and ADON were later informed and acknowledged the findings. The report also states that two of 21 residents consumed food prepared in the kitchen.
Improperly Stored Garbage in Outside Dumpsters
Penalty
Summary
The facility failed to ensure garbage was properly stored in three of three outside garbage dumpsters. Review of the facility's Non-Medical Waste Management policy showed that non-biomedical waste must be disposed of in designated dumpsters, trash bags must be securely tied before disposal, and dumpster lids must remain closed to prevent pests and odors. The 2022 FDA Food Code was also cited as requiring outside garbage receptacles to have tight-fitting lids or covers to prevent scattering of garbage or refuse, breeding of flies, or entry of rodents. During observation with the CDM, two of the three dumpsters were found with lids partially propped open because of garbage bags and cardboard boxes, preventing full closure. The third dumpster was observed without a lid and fully open with garbage bags exposed. The Maintenance Director/Plant Operations Director reviewed a photograph of the dumpsters and verified the findings, stating the dumpster lids should be fully closed to prevent trash from coming out of the containers. The CDM later verified that the dumpsters should have lids and that the lids should be closed to prevent items from entering or exiting the trash containers and to maintain infection control.
Failure to Follow EBP and Hand Hygiene During Resident Care
Penalty
Summary
The facility failed to implement infection control practices during medication administration and resident care for four residents who were on enhanced barrier precautions (EBP). Resident 1 had a feeding tube and an order for enhanced standard precautions every shift. During medication administration, the LVN performed hand hygiene and donned gloves, but was not observed wearing a gown. After administering medications via the GT, the LVN removed gloves and put on a new pair without performing hand hygiene before giving a topical medication. Similar EBP lapses were observed for two other residents with feeding tubes. For Resident 17, who had a GT and an order for EBP every shift, the LVN performed hand hygiene and donned gloves before entering the room to administer medication via GT, but was not observed wearing a gown. For Resident 22, who used a feeding tube and also had an order for EBP every shift, the LVN again performed hand hygiene and donned gloves before entering the room to administer multiple medications, but was not observed wearing a gown. For Resident 18, who was GT dependent and had an order for enhanced barrier precautions during high-contact care, an RN took vital signs inside the room while the resident was on EBP precautions but was not wearing gloves. During interview, the RN stated there was no need to wear gloves when taking vital signs or turning off feeding pumps because she was not actually rendering care or touching other lines. The LVN later acknowledged not wearing a gown for Residents 1, 17, and 22 and not performing hand hygiene between glove use for Resident 1, and the DON and ADON were informed and acknowledged the findings.
Antibiotic Stewardship Program Not Properly Monitored
Penalty
Summary
The facility failed to ensure its antibiotic stewardship program was monitored and that antibiotic use was addressed for two sampled residents and one nonsampled resident. Review of the facility’s infection prevention and antibiotic stewardship policies showed that the facility used McGeer’s Criteria to monitor infections and that the Infection Preventionist was to review infections, monitor antibiotic usage patterns, and include a report on residents receiving antibiotics who did not meet criteria for active infection. The facility’s Subacute Surveillance Line Listing for March 2026 showed that Resident 3 was prescribed levofloxacin 250 mg, Resident 19 was prescribed Augmentin 500 mg, and Resident 9 was prescribed ciprofloxacin 500 mg, even though McGeer’s Criteria for true infection was not met for each resident. Review of the Revised McGeer Criteria for Surveillance Checklist for Residents 3, 9, and 19 showed that each resident had signs and symptoms of infection, but did not meet the criteria for true infection. During interview, the Infection Preventionist stated the facility completed an antibiotic time-out for residents who did not meet criteria and that the physician reviewed the resident’s signs and symptoms with the RN supervisor to determine whether antibiotic therapy should continue. Documentation of the antibiotic time-out was shown for Residents 3, 9, and 19, but there was no physician progress note documenting the clinical rationale for continuing the antibiotics despite the residents not meeting criteria. The ADON reviewed the findings and verified them.
Uncovered urinary catheter drainage bags
Penalty
Summary
The facility failed to maintain the dignity of two residents with indwelling urinary catheters by leaving their catheter drainage bags uncovered. Resident 23 was observed in bed with a suprapubic urinary catheter drainage bag placed at the side of the bed and uncovered on two separate observations. Resident 23’s record showed the resident had an indwelling urinary catheter and required total assistance from staff for all ADL care. During interview, RN 2 confirmed the resident had a suprapubic catheter and stated the drainage bag needed to remain below bladder level for drainage, but also stated the facility staff placed the bag at the side of the bed without any covering and denied use of privacy or dignity covers. Resident 3 was also observed in bed with an indwelling urinary catheter drainage bag placed at the side of the bed near the room entrance and uncovered. Resident 3’s quarterly MDS showed an indwelling urinary catheter with intermittent catheterization and dependence on staff for ADLs. The care plan included an intervention to position the catheter bag and tubing below bladder level and away from the room entrance door. When shown a photograph of the uncovered drainage bag, the ADON verified the observation and stated the bag should have been placed inside a dignity bag to protect the resident’s dignity. The DON was informed and acknowledged the findings.
Failure to Assess and Monitor Resident After Abuse Allegation
Penalty
Summary
The facility failed to implement its abuse policy for Resident 19 after the resident reported that a CNA touched his private parts while he was in the shower. The facility’s abuse policy required a licensed nurse to assess the individual and document findings, including an injury assessment, and required staff to monitor residents who had been abused at least once per shift for a minimum of 72 hours or until the resident’s medical condition, mood, and function stabilized. Review of Resident 19’s medical record showed no documentation that the resident was assessed after the allegation was reported and no documentation that the resident was monitored after the report. Resident 19 was admitted to the facility with a diagnosis of anoxic brain injury and had no decision-making capacity. The quarterly MDS showed the resident required total assistance from staff for all ADL care. During interview and record review, RN 5 verified there was no change of condition assessment and no skin assessment documented after the allegation of abuse was reported. The ADON also verified that the change of condition assessment, skin assessment, and resident monitoring were not completed when the abuse allegation was reported, and the DON was informed of and acknowledged these findings.
Failure to Care Plan Anticoagulant Use and Bilateral Side Rails
Penalty
Summary
The facility failed to develop care plans for two sampled residents. Resident 5 had no decision-making capacity, was receiving enoxaparin sodium 30 mg/0.3 ml subcutaneously in the evening for DVT prophylaxis, and the medical record did not show a physician order for monitoring for side effects or adverse reactions related to anticoagulant therapy. The plan of care did not include a problem or interventions addressing the resident’s anticoagulant use, including monitoring for signs and symptoms of bleeding or other complications associated with anticoagulant therapy. Resident 19 had an anoxic brain injury, had no decision-making capacity, and required total assistance from staff for all ADL care. The physician’s order summary showed bilateral side rails up for safety, but the plan of care did not include a care plan problem addressing the resident’s use of bilateral side rails. During interviews, RN 1 and RN 5 acknowledged that care plans should have been developed for these issues, and the DON and ADON were informed and acknowledged the findings.
Failure to Provide Ordered Padded Side Rails for Seizure Precautions
Penalty
Summary
The facility failed to provide the necessary care and services to ensure one resident was free from accident hazards when padded side rails ordered for seizure precautions were not in place. Resident 17 had a diagnosis of seizure, and the resident's side rail assessment form noted seizure precautions as the reason for using side rails. A physician's order dated 4/24/26 directed the use of padded side rails for seizure precautions, but the resident was observed in bed with side rails that were not padded on multiple occasions. During interview, an LVN verified that the side rails were not padded and stated the resident's family had declined the padded side rails, adding that the refusal should have been documented in the medical record. On follow-up, the LVN observed padded side rails in place but was unable to locate documentation showing the family had declined them and acknowledged the physician's order had been missed. The DON and ADON were informed and acknowledged the findings.
Unlabeled Oxygen Tubing Not Stored Properly
Penalty
Summary
The facility failed to provide necessary respiratory care services for two residents who were receiving oxygen therapy. Resident 4 had a diagnosis of chronic respiratory failure and an order to receive cool aerosol during nights with FLO2 to keep oxygen saturation above 92%. Resident 10 also had chronic respiratory failure and an order to titrate FLO2 to keep oxygen saturation above 92%. Facility policy stated oxygen masks and cannulas were to be changed weekly and as needed, and respiratory disposable treatment equipment was to be dated when changed weekly. During observation, Resident 4's oxygen tubing was seen hanging on a wall hook, unlabeled, undated, and not stored inside the clear plastic setup bag. Resident 10's oxygen tubing was observed coiled around the oxygen regulator at the wall, also unlabeled, undated, and not stored inside the clear plastic setup bag. The respiratory therapist stated the setup bags should be labeled with the resident's name and date and that oxygen tubing should be placed inside the labeled setup bag when not in use. RN 1 and the ADON were informed of the observations and verified the findings.
Eye Medication Administration Did Not Follow Ordered Interval
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of one resident during a medication administration observation. Resident 22 had physician's orders for dextran 70-hypromellose ophthalmic solution to both eyes every two hours while awake for dry eyes, with instructions to wait five to ten minutes between eye drop medications, and for Refresh P.M. ophthalmic ointment to both eyes every six hours for eye dryness. The resident was observed receiving the dextran ophthalmic solution at 0620 hours. LVN 3 then administered the nighttime relief lubricant eye ointment to the resident's right eye at 0622 hours and to the left eye at 0624 hours, which did not follow the ordered five to ten minute interval between eye medications. During the concurrent interview and medical record review, LVN 3 verified the physician's order required waiting five to ten minutes between administering eye drops and acknowledged the findings. The DON and ADON were later informed and acknowledged the findings.
Inaccurate Medication Monitoring Documentation
Penalty
Summary
The facility failed to ensure the accuracy of the medical record for Resident 18. The resident’s chart contained behavior monitoring and side-effect monitoring documentation for quetiapine, an antipsychotic medication, even though there was no physician’s order for quetiapine in the Order Summary Report or the eMAR. The facility’s charting and documentation policy required resident services, progress, and changes in condition to be documented in the medical record in an objective, complete, and accurate manner. During medical record review, the Order Summary Report showed physician’s orders for side-effect monitoring for quetiapine and behavior monitoring for quetiapine, but no order for the medication itself. RN 5 acknowledged that the quetiapine order had been discontinued in January 2026 and stated the behavior and side-effect monitoring should have been discontinued as well. The DON and ADON were informed of and acknowledged the findings.
Care Plans Not Updated to Match Current Orders and Care Needs
Penalty
Summary
The facility failed to ensure the comprehensive plan of care was revised to reflect current care needs and interventions for four residents. The report states that the comprehensive care plan was to be prepared, reviewed, and revised by a team of health professionals, and that care plans were to be revised as resident information and conditions changed. Surveyors found that the care plans for Residents 11, 17, 23, and 3 did not match current orders or documented care needs. Resident 11 was transferred to an acute care hospital because of an uncontrolled nosebleed, and physician orders were entered for the transfer and for no NGT placement to the nostril for two weeks due to a deviated septum. However, the care plan did not include the hospitalization on 3/9/26. Resident 17 had a diagnosis of seizures, and although a physician order dated 4/24/26 directed padded side rails for seizure precautions, the care plan problem for seizure precautions did not include padded side rails. Staff observed the resident in bed with padded side rails, and RN 1 verified the intervention was missing from the care plan. Resident 23 was observed in bed on a low air loss mattress, and a physician order directed use of the mattress every shift for skin breakdown prevention. The care plan addressed the resident's pressure ulcer but did not include the low air loss mattress. Resident 3 was observed in bed with bilateral side rails elevated, and the record showed an order for bilateral side rails up at all times for safety per the resident's mother's preference. The care plan, however, listed padded side rails up per a physician order even though the medical record did not include an order for padded side rails. The ADON and DON were informed of these findings and acknowledged them.
Failure to Report Sexual Abuse Allegation Timely
Penalty
Summary
The facility failed to implement its abuse policy and procedures (P&P) for reporting a reasonable suspicion of a crime, specifically regarding a sexual abuse allegation involving a resident. The facility did not report the allegation to the local State and Federal agencies in a timely manner, as required by section 1150 B of the Social Security Act. The incident involved a nonsampled resident, referred to as Resident 12, who was reportedly afraid of a Certified Nursing Assistant (CNA 2). The resident's family member reported the abuse allegation to the facility's CEO in April 2024, but the CEO claimed to have only been informed of the allegation in May 2024 by the local police department. During an interview, the CEO confirmed awareness of the allegation but failed to provide documented evidence of reporting the incident to the local State agency. The CEO stated that a report was hand-delivered to the agency, but no copies of the documents were retained. Additionally, the CEO mentioned that an investigation was conducted, and the allegation was found to be unsubstantiated, yet no documentation of the investigation was maintained. This lack of documentation and timely reporting posed a risk of the abuse allegation going unreported and uninvestigated.
Failure to Investigate Sexual Abuse Allegation
Penalty
Summary
The facility failed to implement its abuse policy and procedure (P&P) related to the investigation of a sexual abuse allegation involving a nonsampled resident, referred to as Resident 12. The facility's P&P required documentation of all allegations, injury assessments by a licensed nurse, and interviews with family members, visitors, other residents, and staff from different shifts. However, the facility did not adhere to these procedures. Family Member 1 reported that Resident 12 was sexually abused by CNA 2, and expressed concerns about the facility's attempt to discharge Resident 12 prematurely. Family Member 1 observed Resident 12's distress when hearing CNA 2's voice and reported the abuse to the CEO in April 2024. Despite this, the medical record for Resident 12 lacked documentation of a body assessment related to the alleged abuse. The CEO confirmed awareness of the sexual abuse allegation, which was also reported by the local police department in May 2024. However, the CEO's investigation was incomplete, as it only involved interviews with night shift staff and lacked documented evidence of staff statements or a list of interviewed staff. Additionally, the CEO did not interview Resident 12's family members or visitors regarding the allegation. The CEO deemed the allegation unsubstantiated but failed to retain a copy of the investigation. Consequently, the facility did not provide documented evidence to demonstrate a thorough investigation of the sexual abuse allegation.
Failure to Implement Individualized Care Plans
Penalty
Summary
The facility failed to develop and implement individualized care plans for three residents, leading to potential risks. For Resident 4, the facility did not create a care plan to educate the resident's family member on the use of gown and gloves during high-contact interactions, despite the resident being on enhanced-based precautions for infection prevention. This oversight was observed when the family member entered the room without proper protective equipment and performed suctioning on the resident. Staff interviews confirmed the lack of documentation and education provided to the family member. Resident 12's care plan included the requirement for two staff members to assist with transfers using a mechanical lift, as per the facility's policy. However, an observation revealed that only one staff member conducted the transfer, contrary to the care plan and policy, posing a risk of injury or fall. Additionally, Resident 19's care plan did not address the use of anticoagulant and antibiotic medications, despite physician orders for these treatments. Staff interviews confirmed the absence of care plan problems for monitoring these medications, acknowledging it as a mistake.
Failure to Revise Care Plans for Abuse Allegation and AFO Use
Penalty
Summary
The facility failed to revise the care plans for two residents, which posed a risk of not providing appropriate care. For Resident 12, the care plan was not updated to reflect an abuse allegation reported by the resident to a family member, who then informed the Administrator in April 2024. Despite the Administrator's awareness of the allegation, the care plan did not address this issue, as confirmed during an interview with the Administrator and a review of the resident's medical records. For Resident 17, the care plan was not revised to include the use of bilateral ankle-foot orthoses (AFOs) as ordered by a physician. The order, dated November 15, 2024, specified the use of AFOs for two hours on and two hours off from 0800 to 2200 hours, along with instructions for maintaining ankle alignment, performing passive range of motion exercises, and monitoring skin integrity. During an interview and medical record review, RN 1 acknowledged the absence of documentation in the care plan regarding the AFOs and confirmed the need for revision.
Failure to Ensure Proper GT Feeding Protocols
Penalty
Summary
The facility failed to ensure that a resident with a gastrostomy tube (GT) feeding received appropriate treatment and services to prevent complications. Specifically, the head of the bed (HOB) for the resident was not positioned at the recommended 30 to 45 degrees during GT feeding, which is necessary to reduce the risk of aspiration. Multiple staff members, including a respiratory therapist, registered nurse, licensed vocational nurse, and certified nursing assistant, confirmed that the HOB should be at least 30 degrees. However, observations revealed that the HOB was only at 20 degrees, which was verified by staff as incorrect. This improper positioning was observed on multiple occasions, and staff acknowledged the error and adjusted the HOB accordingly. Additionally, the facility did not properly label the tube feeding formula. The facility's policy required that the enteral feeding formula label include the initials, date, and time the formula was hung or administered. However, observations showed that the feeding formula and water flush bags were labeled only with the date and time when the bags were changed, not when the formula was added. Staff confirmed that there was no system in place to label the GT feeding bags with the date and time of formula addition, which could lead to confusion and potential complications for the resident.
Failure to Date Respiratory Equipment
Penalty
Summary
The facility failed to provide necessary respiratory care and services for two residents, leading to potential increased risk of infection. For one resident, the facility did not ensure that the cool aerosol therapy plastic bag was dated according to the facility's policy and procedure (P&P). The bag was observed to be dated 2/6/25, and it should have been changed on 2/13/25, as per the weekly change requirement. This resident had a medical history of chronic respiratory failure, tracheostomy status, and multiple congenital heart malformations. For another resident, the facility failed to date the suction canister when it was installed and connected to the suction machine. The canister was observed with 60-70 ml of whitish secretions and was not dated, which was verified by the LVN. This resident had a medical history of acute and chronic respiratory failure with hypoxia, tracheostomy status, and dependence on ventilator status. The CEO was made aware of these findings and acknowledged the deficiencies.
Failure to Monitor Psychotropic Medication Effects
Penalty
Summary
The facility failed to ensure that a resident was free from unnecessary psychotropic medications. Specifically, the facility did not monitor the episodes of OMS as a behavior manifestation and side effect for the medications alprazolam and sertraline, both prescribed for the same indication. This lack of monitoring could lead to inaccurate assessments of behavior and side effects, potentially affecting the physician's ability to determine the effectiveness of the medications for the resident. During interviews and medical record reviews, it was revealed that there was no specific behavior monitoring for the use of sertraline, and the behavior monitoring for alprazolam was not accurately documented. Both RN 4 and LVN 6 acknowledged that the physician's orders did not specify which behaviors to monitor for these medications, and there was no side effect monitoring in place. This oversight in monitoring and documentation was verified by the staff involved.
Improper Storage and Expired Supplies in Medication Carts
Penalty
Summary
The facility failed to ensure proper storage and labeling of medications and biologicals for two residents and three medication carts. Resident 4 had a tube of Triad hydrophilic wound dressing on the bedside table, which was brought in upon admission and should have been stored in the medication treatment cart. Similarly, Resident 273 had a tube of mupirocin ointment and a tube of Venelex wound dressing on the bedside table, which were also brought in upon admission and should have been secured in the medication treatment cart. Both instances were verified by the respective nursing staff, who acknowledged that the medications should have been stored securely. Additionally, three medication carts contained expired supplies. Medication Cart 2 had eight packets of SurePrep protective wipes past their expiration date. Medication Cart 4 contained an expired AG Cuffill pressure manometer. Medication Cart 6 had expired GT feeding tube extension sets with Enfit connectors and 42 packets of SurePrep protective wipes. The nursing and respiratory staff confirmed the presence of expired supplies and acknowledged that they should be removed immediately, as expired supplies could be less effective.
Failure to Submit Accurate Staffing Data to CMS
Penalty
Summary
The facility failed to submit complete and accurate direct care staffing information to CMS, which resulted in a One-Star Staffing Rating. The review of the CMS CASPER reports indicated that the facility did not submit data for the quarter from July 1, 2024, to September 20, 2024. The Pediatric Monthly Subacute Staffing Report revealed that while RN and LVN hours met the requirements, CNA hours were below the minimum on several days across multiple months, totaling significant hours below the required minimum. Despite the negative variances in CNA hours, excess nursing hours were reported, suggesting that nursing staff assisted with resident care. During an interview and document review with the CEO, it was revealed that the PBJ was submitted electronically in October 2024 but not in the required XML format, leading to its rejection. The CEO did not initially notice the rejection and was unable to resubmit the PBJ due to a lack of available options and contact information for CMS. The CEO also failed to provide documentation of the rejection notice, as she was unable to print it from the CMS PBJ website.
Equipment Maintenance Deficiencies
Penalty
Summary
The facility failed to maintain resident care equipment in safe operating condition, as evidenced by two specific incidents. In the first incident, a mechanical lift used to transfer a resident from bed to wheelchair stopped working mid-transfer due to a dead battery. This occurred when the resident was approximately one and a half feet above the wheelchair, necessitating manual intervention by the CNA to return the resident to bed. The facility's policy required the lift to be charged daily for a minimum of eight hours, and the Maintenance Director confirmed that staff were expected to replace the lift's battery with a charged one after each use. In the second incident, ice buildup was observed in the refrigerator designated for enteral feedings, which were stored alongside food items brought from outside the facility. This was confirmed during an observation and interview with an RN, who verified the presence of ice buildup along the back side of the refrigerator. These deficiencies posed risks for equipment hazards or unsafe practices that could affect the residents' well-being.
Failure to Assist Resident with Timely Meal Consumption
Penalty
Summary
The facility failed to ensure that a resident, identified as Resident 12, was assisted with her meals in a timely manner, which could potentially affect the enjoyment of her meals at an appetizing temperature. On the morning of February 19, 2025, Resident 12's breakfast tray was delivered at 0800 hours but was observed still covered and untouched at 0940 hours, with the overbed table positioned about one foot away from the foot of her bed. At 1000 hours, a CNA was observed feeding Resident 12 oatmeal. Later, at 1146 hours, the CNA placed Resident 12's lunch tray on the overbed table and left the room without assisting her. By 1205 hours, the lunch tray remained covered and untouched. Resident 12's medical records indicate she was admitted to the facility with severe brain injury, multiple back and rib fractures, chronic lung disease, and difficulty swallowing. A physician's order dated February 18, 2025, specified that Resident 12 was to be on a soft and bite-sized texture diet and required assistance from CNAs for feeding. Despite these orders, the CNA failed to assist Resident 12 promptly with her meals, as verified during an interview with the CNA, who could not explain the delay in providing assistance.
Facility Fails to Maintain Safe and Homelike Environment
Penalty
Summary
The facility failed to provide a safe, clean, and homelike environment for a resident residing in Room A. Observations revealed that the supply cabinet drawer in the room was difficult to open, with thin wood material protruding from the face of the drawer, and the drawer rails were not aligned. Additionally, the wall near the call light system had chipped blue paint. These issues were confirmed during an observation and interview with an LVN, who was unaware of how long these conditions had existed. A family member of the resident also noted the broken condition of the supply cabinet drawer, expressing concern that it might fall if pulled open, and mentioned the peeling paint on the wall. The family member chose not to use the cabinet due to its broken state. The CEO of the facility acknowledged these findings and indicated that a job order had been sent to the maintenance department for repair.
Failure to Notify LTC Ombudsman of Resident Transfer
Penalty
Summary
The facility failed to ensure that a copy of the Notice of Transfer/Discharge was sent to the LTC Ombudsman for a resident who was transferred to an acute care facility for a higher level of care. The resident, who lacked the capacity to understand and make decisions, was admitted to the facility and later transferred without the required notification being sent to the Ombudsman. This oversight was confirmed during an interview with the Case Manager, who acknowledged that the notice was not sent due to the short duration of the resident's stay at the facility. The Case Manager admitted that this procedure was incorrect and recognized the necessity of sending the notice regardless of the resident's length of stay.
Failure to Report Alleged Abuse
Penalty
Summary
The facility failed to adhere to its policy and procedure (P&P) for reporting a reasonable suspicion of a crime, specifically an allegation of abuse, in accordance with section 1150B of the Act. This deficiency was identified when the facility did not report an abuse allegation involving a resident to the California Department of Public Health (CDPH), Licensing and Certification (L&C) Program. The facility's P&P, revised in January 2024, mandates that all alleged violations and substantiated incidents be reported to the state department of health and other relevant agencies within two hours by telephone and within twenty-four hours in writing. However, the facility did not comply with this requirement in the case of the abuse allegation concerning the resident. The incident involved a resident who was allegedly physically abused by an unknown provider, as reported by the resident's family member to a social worker at an acute care hospital. This information was documented in the resident's progress notes on September 13, 2024, by the Social Services/Case Manager (SS/CM). Despite this documentation, the facility did not notify the CDPH L&C Program of the alleged abuse. During an interview conducted on October 17, 2024, the Chief Executive Officer (CEO) and the SS/CM were unable to provide evidence that the required notification had been made, highlighting the facility's failure to report the abuse allegation as per their established P&P.
Failure to Investigate Alleged Abuse
Penalty
Summary
The facility failed to thoroughly investigate an allegation of abuse involving a resident who was allegedly abused by an unknown staff member. The facility's policy and procedure (P&P) on abuse, revised in January 2024, mandates a timely and thorough investigation of any incident or allegation of abuse, neglect, mistreatment, or misappropriation of a resident's property. This includes reviewing the resident's medical record, interviewing the person(s) reporting the incident, any witnesses, and staff members who had contact with the resident, and reviewing all events leading up to the alleged incident. However, the facility did not adhere to these procedures. The deficiency was identified when the California Department of Public Health Licensing and Certification Program received a complaint on October 16, 2024, alleging that a resident was physically abused by an unknown provider on September 11, 2024. A review of the resident's progress notes revealed that a social worker from an acute care hospital informed the facility of the abuse allegation reported by the resident's family member. The facility's social services/case manager (SS/CM) claimed that the allegation had been thoroughly vetted by the facility and CalOptima three times with no evidence found. However, during an interview on October 22, 2024, the CEO was unable to provide documentation of an internal investigation, despite stating that a meeting was held with the night shift staff regarding the alleged abuse.
Inadequate Water Management Program
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program designed to provide a safe and sanitary environment to help prevent the transmission of communicable diseases and infections. Specifically, the facility did not ensure that their water management program was properly established and implemented. The program lacked an assessment of the facility water systems to identify where Legionella and other opportunistic pathogens could grow and spread. Additionally, there were no measures in place to prevent the growth of these pathogens, nor was there a monitoring system to ensure the effectiveness of any control measures. This deficiency was confirmed during an interview and document review with the Infection Control Preventionist, who was unable to provide the necessary documentation, including a flow diagram of the building's water system and identification of areas where water may stagnate. Further interviews revealed that the Director of Maintenance was only checking water temperatures for resident comfort and to prevent scalding, not as part of a comprehensive water management plan. A CNA also confirmed that the water was used for all residents for showering and handwashing, indicating a potential risk for the spread of infection due to the lack of proper water management protocols. The facility's failure to implement a thorough water management plan increased the risk of spreading infections among residents.
Incomplete Bed Entrapment Assessments
Penalty
Summary
The facility failed to ensure the residents' entrapment assessments were complete and the measurements were recorded during the bed inspection when identifying areas of possible entrapment with the use of side rails for six of 12 final sampled residents. This deficiency was observed through a combination of observation, interview, medical record review, and facility document review. The residents involved were found to have incomplete bed entrapment assessments, specifically missing measurements for Zones 5, 6, and 7, which are critical areas for potential entrapment according to the Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment. For instance, Resident 9 was observed multiple times with bilateral full padded side rails elevated. The medical record review showed a physician's order for padded side rails due to seizure and safety precautions. However, the Bed System Measurement Device Test Results Worksheet for Resident 9 did not include assessments for Zones 6 and 7. Similar deficiencies were found for Residents 1, 7, 10, 17, and 22, where the bed entrapment assessments were incomplete, missing measurements for critical zones that could pose a risk of entrapment. Interviews with the facility staff, including Licensed Vocational Nurses (LVNs), Certified Nursing Assistants (CNAs), and the Maintenance Director, confirmed the use of side rails for the residents and the responsibility of the Maintenance Director for conducting the bed inspections. The Maintenance Director admitted to using a Bionix safety measuring device but verified that the assessments for Zones 5, 6, and 7 were incomplete. The CEO of the facility was also informed and verified the findings, acknowledging the incomplete bed entrapment assessments for the residents involved.
Failure to Ensure Proper Use of Physical Restraints
Penalty
Summary
The facility failed to ensure that Resident 21 was free from the use of physical restraints without proper assessment and consent. Specifically, the facility did not conduct an assessment or implement the least restrictive measures before applying a mitten to Resident 21's hand and an abdominal binder. Additionally, the facility did not obtain informed consent from the responsible party for the use of these restraints. These actions were contrary to the facility's policy and procedures, which require a written order from a physician, an initial assessment of the resident's mental, behavioral, and physical status, and informed consent before applying restraints. The medical record review for Resident 21 showed no documentation of the required assessment, consent, or monitoring for the use of the hand mitten and abdominal binder. Observations and interviews with facility staff confirmed the use of the mittens and abdominal binder on Resident 21 without the necessary documentation and assessments. The resident's medical record indicated that the mittens were used on a specific date, but there was no evidence of when the mittens were released or any skin assessment for circulation during their use. Interviews with the LVN, RN, and CEO verified the lack of consent, assessment, and monitoring for the restraints applied to Resident 21. The facility's failure to follow its own policies and procedures posed a risk to the resident's independence and psychosocial well-being.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop comprehensive person-focused care plans for four of twelve sampled residents, leading to deficiencies in individualized care. Resident 1 was observed using a lap tray attached to their wheelchair for positioning, but the care plan did not address this use despite a physician's order. Similarly, Resident 8 was prescribed tobramycin inhalation nebulization solution, but the care plan failed to include this medication. Resident 10 was observed with all four side rails elevated in bed, yet the care plan did not document the use of side rails for protection, even though there was a physician's order for one side rail to secure ventilator tubing. Resident 21 was observed with an abdominal binder and mittens to prevent pulling out a GT, but the care plan did not address these restraints despite physician's orders for their use. Interviews and concurrent medical record reviews with registered nurses confirmed the lack of care plans for these specific needs. The CEO was also informed and verified the findings. These omissions in the care plans posed a risk of not providing appropriate, consistent, and individualized care for the residents, as the care plans did not reflect the necessary interventions and supports required for their conditions.
Failure to Prevent Accidents and Ensure Safety Measures
Penalty
Summary
The facility failed to provide the necessary care and services to prevent accidents for four residents. Resident 11 experienced a fall incident, but the facility did not take vital signs or complete a neurological assessment immediately after the fall. The care plan problem was only initiated nine days later, and there was no documentation of addressing the causative factors of the fall or consulting the pharmacist and physical therapist as per the care plan. Additionally, there was no IDT review conducted as per the facility's policy and procedures on falls. Resident 4 was observed in a stroller that was not strapped to the crib as per the physician's order. There was no documentation showing that Resident 4 was monitored while in the stroller, and the facility failed to develop a care plan problem related to the use of the stroller. The CEO confirmed that if the stroller was not strapped to the crib, a staff member should be with the resident, and Resident 4 should be watched the most. Resident 7 was observed in bed with four side rails elevated but without the required padded side rails as per the physician's order and care plan. The facility did not document when the resident's family member removed the paddings or any education provided to the family member. Similarly, Resident 22 was observed with side rails elevated but without the required padded side rails for seizure precautions. The facility failed to ensure the side rail paddings were properly placed as per the physician's order and care plan intervention.
Failure to Document CVAD Care and Develop Care Plan
Penalty
Summary
The facility failed to ensure the proper administration and documentation of care for a Central Venous Access Device (CVAD) for one resident. Specifically, the facility did not complete and document the external catheter measurements in the medical record for the resident, nor did it develop a care plan for the use of the CVAD. These omissions were identified through observation, interviews, and medical record reviews, which revealed that the necessary measurements and assessments were not documented, and there was no specific care plan addressing the CVAD. The resident in question had a PICC line tunneled on the right upper chest, with dressing changes scheduled weekly and as needed. However, the medical record lacked documentation of the external catheter measurements and a care plan for the CVAD. The RN and CEO both verified these findings during interviews, confirming that the required documentation and care planning were not in place, potentially delaying the identification of catheter-related complications for the resident.
Failure to Label and Date Respiratory Equipment
Penalty
Summary
The facility failed to ensure the mechanical ventilation tubing setup bag for one resident was labeled in accordance with the facility's policies and procedures (P&P). This was observed on multiple occasions, where the setup bag was found unlabeled and undated. The facility's P&P required that all respiratory disposable treatment equipment be dated when changed, and the setup bag for mechanical ventilation tubing should be labeled with the resident's initials and room number. The respiratory therapist (RT) confirmed that the setup bag should be changed weekly and labeled accordingly, but this was not done for the resident in question. The resident involved had a tracheostomy tube and was connected to a mechanical ventilator. The medical record review showed that the resident had specific physician's orders for mechanical ventilation and the administration of dornase alfa inhalation solution. Despite these orders, the facility did not adhere to its own P&P regarding the labeling and dating of respiratory equipment. The RT Director also confirmed that the close suction system should be changed three times a week and that the respiratory setup bags should be labeled and dated, which was not done in this case.
Failure to Attempt Least Restrictive Alternatives Before Using Side Rails
Penalty
Summary
The facility failed to ensure the least restrictive alternatives were attempted prior to the use of side rails for one of the sampled residents. Resident 9 was observed on multiple occasions lying in bed with bilateral full padded side rails elevated. The medical record review for Resident 9 showed a physician's order to apply the padded side rails every shift for seizure and safety precautions. However, the Side Rail Use Assessment Form dated 1/18/22, which should document the least restrictive measures attempted, was left blank. Further review of the medical record did not show any evidence that less restrictive alternatives were attempted before the use of side rails. During interviews and concurrent medical record reviews with LVN 3 and RN 2, it was verified that Resident 9's medical record did not show the least restrictive alternatives were attempted prior to the use of side rails. Both LVN 3 and RN 2 confirmed that the side rail assessment form was the only form used to document the least restrictive measures, and it was left blank for Resident 9. This failure had the potential to put the resident at risk for entrapment and serious injury.
Failure to Act on Pharmacy Consultant's Recommendations
Penalty
Summary
The facility failed to ensure that the Pharmacy Consultant's recommendations from the drug regimen review were acted upon for two residents. For Resident 11, the Pharmacy Consultant recommended adding blood pressure monitoring to the Diuril medication order in the MAR. However, this recommendation was not implemented, and the resident's blood pressure was not monitored and documented prior to administering the medication from 3/1 to 3/14/24. The medical record showed no evidence that the Pharmacy Consultant's recommendations were addressed. For Resident 4, the Pharmacy Consultant recommended discussing with the primary care physician the need for the continuation of the Culturelle medication and to add the word 'for chronic use' to the medication order if it was for chronic use. This recommendation was also not acted upon, and there was no documented evidence that the Culturelle medication was discussed with the primary care physician or that the medication order was updated. During an interview, the CEO confirmed that the Pharmacy Consultant's recommendations for both residents were not addressed.
Failure to Monitor Psychotropic Medication Use and Side Effects
Penalty
Summary
The facility failed to ensure that a resident was free from unnecessary psychotropic medications. Specifically, the facility did not monitor episodes of crying inconsolably as one of the behavior manifestations for Risperdal medication for the resident. Additionally, the facility did not ensure that the monthly behavior summary and side effects monitoring were accurate related to the use of Risperdal. Furthermore, the facility did not document the implementation of non-pharmacological interventions prior to the use of Risperdal medication and failed to ensure there was a monthly summary of side effects monitoring related to the use of diazepam medication. The medical record review showed that the resident was administered diazepam and Risperdal medications without proper documentation of non-pharmacological interventions and accurate side effects monitoring. The resident's Medication Administration Records (MAR) and Treatment Administration Records (TAR) for January, February, and March 2024 revealed inconsistencies and inaccuracies in documenting behavior manifestations and side effects. For instance, there was no monitoring for episodes of crying inconsolably related to Risperdal use, and the monthly summaries for side effects monitoring were either missing or inaccurate. An interview with a registered nurse confirmed these findings, indicating that the resident should have been monitored for emotional lability and crying inconsolably instead of emotional lability and toning for Risperdal use. The nurse also acknowledged that the monthly behavior summary for toning should have been documented under emotional lability. These failures had the potential to result in inaccurate behavior and side effects monitoring, thereby preventing the physician from having the necessary information to determine the effectiveness of the medication for the resident.
Improper Medication Storage and Disposal
Penalty
Summary
The facility failed to ensure the proper storage, labeling, and disposal of medications, leading to potential safety risks. In Medication Room A, a Ziplock bag containing several foil packets of Tobramycin for a resident was found inside the medication refrigerator, despite a physician's order to discontinue the medication months earlier. Both RN 5 and RT 2 verified the findings and acknowledged that discontinued medications should be removed and given to the RT Director. This oversight indicates a failure to follow the facility's policy on medication storage and disposal. Additionally, an inspection of Medication Cart A revealed that medications administered orally were not stored separately from externally used medications. Various medications, including nasal sprays, eye drops, and suppositories, were found stored together with oral medications like antispasmodics, anticholinergics, and analgesics. LVN 4 and the CEO confirmed these findings, with the CEO noting that dividers should be used to ensure proper separation. These lapses in medication management could lead to unsafe medication administration and cross-contamination.
Sanitary Deficiencies in Kitchen
Penalty
Summary
The facility failed to meet sanitary requirements in the kitchen, as evidenced by several observations during an inspection. Expired and moldy food items were found in the refrigerator, including a container of mozzarella cheese and strawberries with visible mold. Additionally, a bag of beef patties with freezer burns and an improperly stored bag of sausage patties were observed. These findings were verified by the Certified Dietary Manager (CDM) during the inspection. The facility's failure to discard expired and moldy food items and properly store frozen food items poses a risk of foodborne illness to residents receiving food prepared in the kitchen. Further inspection revealed that the facility did not adhere to proper air-drying procedures for kitchen equipment. Four cutting boards were found wet and stored on shelves, ready for use, which the CDM confirmed. Additionally, two cutting boards were heavily marred with knife marks, making them difficult to clean and sanitize effectively. The facility's policy and procedure on sanitation require all utensils and equipment to be kept clean and in good repair, free from breaks and cracks. The failure to air-dry cutting boards and replace damaged ones compromises the sanitary condition of the kitchen and the safety of the food prepared there.
Failure to Implement Accurate Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement an accurate antibiotic stewardship program, as evidenced by the exclusion of residents on long-term antibiotic therapy from the surveillance listing. Specifically, two residents were not included in the surveillance line listing despite being on long-term antibiotic therapy. Resident 1 had orders for gentamicin sulfate and Tobramycin for infection prophylaxis, and Resident 8 had an order for Tobramycin inhalation nebulization solution for pneumonia prophylaxis. These residents were not tracked in the facility's surveillance line listing for antibiotic use, which only included residents on short-term antibiotic therapy. The Infection Preventionist (IP) confirmed that the residents on long-term antibiotic therapy were not included in the surveillance line listing and that the Quality Assurance and Performance Improvement (QAPI) report on antibiotic stewardship was based on this incomplete listing. The IP also verified that the duration of antibiotic therapy was not reviewed, and the pharmacist did not review the antibiotic usage data, including the duration or days of therapy. Consequently, the facility's antibiotic stewardship program did not accurately reflect the number of residents prescribed antibiotics, leading to potential inappropriate antibiotic use and failure to meet the program's objectives.
Failure to Complete Comprehensive Discharge Assessment
Penalty
Summary
The facility failed to complete a comprehensive assessment for discharge for one nonsampled resident. Resident 14 was admitted to the facility and later discharged to another facility. Upon review of the medical records and an interview with the CEO, it was confirmed that the Minimum Data Set (MDS) for discharge was not completed for Resident 14. This oversight was verified by the CEO during the interview and concurrent medical record review.
Failure to Update Care Plan for Padded Side Rails
Penalty
Summary
The facility failed to ensure the comprehensive plan of care for Resident 21 was revised to reflect the resident's current care needs and interventions. Specifically, the care plan was not updated to address the use of padded side rails, which were ordered by the physician for seizure/safety precautions. This oversight was identified through observation, interview, and medical record review, revealing that the care plan problem for the resident's seizure disorder did not include the necessary intervention of padded side rails, despite a physician's order dated 11/25/23 for their use every shift. During an interview and concurrent medical record review, RN 1 confirmed the use of padded side rails for Resident 21's safety and acknowledged that the care plan should have been updated to reflect this intervention. The CEO also verified these findings. The facility's policy and procedure for care planning, dated 5/2023, mandates that care plans be individualized and regularly reviewed and revised to reflect the reassessment of the resident's needs, which was not adhered to in this case.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 4,099 citations issued within 25 miles in the last 12 months — including the 9 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Orange
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Chapman Global Medical Center D/p Snf | 0.7 mi | ★★★★★ | 21 | 0 |
| Orange Healthcare & Wellness Centre, Llc | 1.2 mi | ★★★★★ | 27 | 0 |
| Town & Country | 1.3 mi | ★★★★★ | 27 | 0 |
| The Hills Post Acute | 1.3 mi | ★★★★★ | 29 | 0 |
| Mainplace Post Acute | 1.7 mi | ★★★★★ | 29 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Healthbridge Children's Hospital - Orange D/p Snf.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.