Below average — CMS composite of the measures below.
The next survey window likely opens around January 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 New Orange Hills during CMS and state inspections, most recent first.
The facility failed to develop and/or implement complete, person-centered care plans for several residents. One resident’s psychotropic medication care plan did not include all ordered meds or the targeted behaviors tied to anxiety, psychosis, and depression. Another resident’s bladder incontinence plan called for brief changes every 2 hours, but the task record did not show those changes were provided. Two residents who were cut while being shaved during showers had no care plan interventions for tremors or movement, and another resident had no care plan for long, discolored toenails despite podiatry findings of nail dystrophy, tinea unguium, and toe pain.
A facility failed to provide ordered respiratory care for multiple residents. One resident received oxygen at a higher rate than ordered, another hospice resident missed BiPAP therapy on multiple nights because of a missing mask piece and the chart did not show the hospice team or MD was notified, two residents had nasal cannulas stored unsafely or unsanitarily when not in use, and an RT left a resident unattended during an albuterol breathing treatment despite the resident’s ALS, chronic respiratory failure, trach, and ventilator dependence.
Kitchen sanitation and utensil storage deficiencies were identified during a kitchen tour. Surveyors observed a cutting board without a cleanable surface, dusty blender and storage container lids, dusty storage racks, scoops and a measuring cup stored with water residue, food particles in the 3-compartment sink drain, and utensils with melted handles and rust-like residue on a can opener. The facility’s policy required utensils and equipment to be clean, in good repair, and air-dried before storage.
The facility failed to carry out its infection surveillance program by limiting review to residents on antimicrobials or with an infection diagnosis, rather than evaluating residents with signs and symptoms using McGeer's Criteria. Staff also failed to keep the clean linen area sanitary, as personal items were left on the clean laundry counter and on a clean linen cart. In addition, a manager passed out a meal tray with hair hanging over the food, a vendor entered the kitchen without a beard restraint, a resident's urinary catheter drainage bag touched the floor mat, and multiple residents' personal belongings were stored on the floor.
A survey found medications and topical products at the bedside of three residents without the required physician orders, self-administration assessments, or care plans. One resident lacked capacity to make medical decisions, another had significant cognitive impairment from TBI, and a third resident said he used Debrox on his own; staff, including an LVN and the ADON, acknowledged the items should not have been at bedside without proper documentation.
Failure to Maintain Privacy During Care: Two residents were observed receiving care with the privacy curtain only partially closed. An LPN administered GT meds while one resident’s body was exposed, and an RT performed trach care and suctioning with the curtain not fully closed and the procedure visible from outside the room. Facility records showed both staff had been oriented on resident rights and privacy, and policy required privacy during treatment.
Homelike Environment Not Maintained: A resident’s window view showed stored mattresses, boxes, and other miscellaneous items, and another resident’s window view showed wooden boards and orange traffic cones; both residents said they did not like seeing the items. A third resident’s room had an insect, thick dust under and around the bed, dust on the baseboard and headboard, and trash and IV caps on the floor. The DON acknowledged the dust was more than one day of missed cleaning, and Housekeeping confirmed daily room cleaning duties included under the beds.
A resident had repeated PRN Ativan orders without a documented clinical rationale for continued use, and the targeted behaviors in the orders did not consistently match the behaviors being monitored. Monthly psychotropic behavior summaries were incomplete for olanzapine, bupropion HCl, and paroxetine HCl, and were missing for buspirone HCl and Ativan; the DON verified the incomplete and missing documentation during record review.
Failure to provide foot care was identified for a resident with cerebral palsy with quadriplegia, post status trach placement, and post status GT placement. The resident was observed in bed with a responsible party present, and the responsible party raised concern that the toenails had not been cared for. A focused body check found brown discoloration of the toenails and a first digit toenail extending about one half inch beyond the tip of the toe; an LVN verified the finding. An LVN believed the resident had seen podiatry the prior month, while the SSD stated the last podiatry visit was on 12/18/25 and that no one had informed her of the toenail concern.
Indwelling catheter care was not properly maintained for a resident with a catheter and drainage bag. Staff observed cloudy tubing with heavy sediment and a drainage bag with no change label, and the record did not show when the catheter had last been changed. An LVN, RN, and the DON verified the findings, despite an order for daily catheter care and bag changes as needed.
GT feeding orders were not followed for two residents, with one water flush pump and one enteral feeding pump set at rates different from the physician orders. For another resident, the HOB was observed below the ordered elevation while tube feeding was infusing, and the MAR did not document the exact gastric residual amount as required. Staff and the DON verified the mismatched pump settings, the inadequate HOB elevation, and the incomplete residual documentation.
A facility failed to ensure two CNAs were competent to shave residents who had spasms or sudden movement. One resident with cerebral palsy, seizures, ventilator dependence, and a GT was found with multiple superficial chin cuts after shaving, and another resident with diabetes, brain damage, and epilepsy had a horizontal chin cut with bleeding after shaving. The CNAs’ files did not show shaving skills checks for residents who move during the procedure, and the facility’s shaving competency form did not address shaving residents with spasms.
A resident’s scheduled baclofen dose was not available at the ordered time, and an LVN documented the dose as not given while waiting for pharmacy delivery. The MAR and nurses’ notes reflected the missed administration and physician notification, and another LVN acknowledged the medication should have been refilled ahead of time; acetaminophen was discussed as a temporary option even though it is not a muscle relaxant.
Failure to follow up on consultant pharmacist recommendation for PRN Ativan. The facility did not act on the pharmacist’s MRR note that the resident’s behavior description was too subjective and needed a specific, quantifiable behavior for the PRN Ativan order. The MAR/order history showed repeated PRN Ativan orders for increased agitation or anxiety manifested by increased agitation, and the DON verified the facility did not notify the physician to update the order.
Surveyors found improper medication and supply storage in a medication room and multiple carts, including dusty and stained storage areas, oral meds stored with non-oral meds, used syringes mixed with unused syringes, and expired items such as a COVID-19 testing kit, wound culture set, and reagent. Staff members verified the findings and acknowledged that some items were opened, expired, or stored incorrectly.
Cold Cole Slaw Served on Meal Trays: A resident council meeting revealed that two residents said the food was served cold and did not taste good. During tray observation with the Dietary Supervisor and RD, test trays for regular and pureed diets were found to have cole slaw with ice and clumps of ice formation, and the findings were verified by facility staff.
A resident with severe cognitive impairment had an insect observed crawling near the bed during a facility tour. Staff secured and removed the insect from the room. The Maintenance Director said pest control visited every two weeks but did not spray inside resident rooms, and the DON and Administrator acknowledged the resident was part of a vulnerable population and pests should not be present.
A resident with an arterial wound and two stage 2 pressure injuries was found on a LAL mattress that was not set according to the resident's weight. The mattress was observed set at 15 lbs, then later at 150 lbs, while an LVN confirmed the resident weighed 104 lbs and acknowledged the settings should have matched the resident's weight. The resident had an order for LAL mattress use for wound management and for settings to be checked every shift.
The facility failed to complete annual performance evaluations for two CNAs reviewed. CNA 4 and CNA 5 each had no annual evaluation based on job performance and competency, and the DSD verified the missing evaluations and stated he was behind on completing employee evaluations.
A resident’s medical record was inaccurate because a respiratory therapy note documented care and assessments after the resident had already been transferred to a GACH and did not return. The Medical Records Director confirmed the resident was out of the facility and that the note incorrectly showed humidified O2, tracheal suctioning/care, and respiratory assessments were performed after transfer; the entry was not identified as a late entry.
Two residents did not receive appropriate monitoring and documentation for diabetic care. One resident was not monitored for insulin side effects or signs of hyperglycemia, and another did not have daily glucose checks completed as ordered, with no documentation explaining the missed checks. Both the RN and DON confirmed these deficiencies in care and recordkeeping.
A resident's Fall Risk Evaluation was inaccurately completed by a licensed nurse, failing to document a recent fall despite facility policy and supporting documentation indicating the incident occurred. Both RN and DON confirmed the omission during record review and interviews.
A resident with severe cognitive impairment and a history of falls was found on the floor with multiple leg fractures after their bed, which was supposed to be kept in the lowest position per care plan and physician orders, was left elevated. Staff and family confirmed the bed was hip-high at the time of the incident, and required fall prevention interventions were not fully implemented.
A resident with end stage renal disease and hypertension did not have blood pressure monitored according to physician orders and preferences. Staff used a wrist blood pressure machine, which the resident reported as inaccurate, and took readings from the resident's left arm with a hemodialysis access site, despite orders not to do so. The DON confirmed that only approved equipment should be used and that staff should follow physician orders.
A resident with a dehisced surgical wound did not have Enhanced Barrier Precautions (EBP) implemented, despite physician orders for wound care and facility policy requiring EBP for such cases. Observations revealed no PPE set-up or EBP signage, and staff confirmed that EBP was not in place. The DON and Administrator verified the absence of EBP and related precautions for the resident.
A resident with multiple complex diagnoses had severely abnormal lab results that were not properly addressed by nursing staff. An LVN reported the results to the physician without clarifying or highlighting the critical abnormalities, and no action was taken until another LVN later provided the lab values after the resident's condition worsened. Staff interviews revealed gaps in competency verification and understanding of lab value significance.
Two residents did not receive necessary care as ordered by their physicians: one was not taken to scheduled outpatient follow-up appointments due to transportation and insurance issues, and another received wound care involving betadine application without a physician's order. These failures were confirmed by facility staff, including the DON and an LVN.
A resident with anoxic brain damage and a stage 4 sacral pressure injury did not receive barrier cream as ordered, and wound assessments failed to document or address undermining. Nursing staff did not initially recognize the undermining or notify the physician, and the low air loss mattress was set incorrectly for the resident's weight, contrary to care plan and physician orders.
Surveyors found that a resident's clean isolation gown contained soiled gloves and that a soiled trach tie was not changed after wound care, despite facility policy and staff acknowledgment that soiled ties should be replaced. These lapses in infection control practices were confirmed through observation and staff interviews.
A resident's medical record showed that care tasks and medication administration were documented as completed after the resident had already been discharged. The MAR included check marks for daily heel protectors, apical pulse monitoring, pacemaker site checks, and potassium chloride ER administration, all recorded for a date following discharge. Both an LVN and the DON confirmed these inaccuracies during review.
The facility failed to provide necessary wound care for three residents, including incorrect treatment orders for a resident's wound, inappropriate mattress for another's pressure injury, and incorrect wound care sequence for a third resident. These deficiencies were confirmed by staff and involved miscommunication and failure to follow physician orders.
A facility failed to provide a resident with bilateral floor mats at the bedside as ordered by a physician, despite the resident being at high risk for falls. The absence of these mats was confirmed during an observation and interview with the ADON, and the DON verified the findings. The resident's care plan and medical records indicated the necessity of these mats following a previous fall.
The facility failed to follow physician's orders for GT feedings for two residents, starting the feedings two hours earlier than prescribed. Despite orders to begin at 1500 hours, the feedings were initiated at 1300 hours, as confirmed by LVNs and the DON. This discrepancy was acknowledged by the facility's administration.
The facility failed to maintain sanitary conditions in the kitchen, with utensils in poor condition, improper cleaning and storage of equipment, and inadequate maintenance of the ice machine and kitchen hood. These deficiencies, verified by the Dietary Manager, posed a risk of cross-contamination and foodborne illnesses for residents consuming food prepared in the facility.
The facility failed to ensure that call lights were within reach for four residents, potentially delaying care and impacting their well-being. Observations revealed call lights were out of reach for these residents, with staff only addressing the issue after verification. Two residents lacked decision-making capacity, highlighting the importance of accessible call lights. The DON acknowledged the need for staff to ensure call lights are within reach.
The facility failed to notify the physician timely about changes in two residents' conditions, leading to delayed interventions. One resident experienced difficulty swallowing, which was reported by family but not promptly communicated to the physician. Another resident had vomiting episodes and tube feeding was held without physician notification, despite low weight. The DON confirmed the need for timely physician notification.
A resident's right to a safe and comfortable environment was violated when staff searched their belongings without consent. The resident, who is legally blind but cognitively intact, was unaware of the intrusion until informed by their roommate. The DON confirmed that staff were instructed to check bedside areas but should have obtained permission first.
The facility failed to follow up on a dermatologist's recommendations for a resident's skin condition and did not monitor another resident's weight loss every shift for 72 hours as required. These oversights could have delayed necessary interventions.
A resident's new pressure ulcer was not reported or documented in a timely manner. CNA 1 observed the wound during a shower but delayed reporting it to Treatment Nurse 2 until after lunch. Treatment Nurse 1 was unaware of the wound, and CNA 2 had previously seen a callous but did not report it, assuming it was not new. This led to a delay in treatment and intervention.
A resident experienced another fall due to the facility's failure to implement the recommended two-person assistance for ADL care. Despite a previous fall and the Fall Committee's recommendation, a CNA provided bedside care alone, leading to the resident sliding off the bed. The DON confirmed the CNA's non-compliance with the two-person assistance directive.
A facility failed to prevent UTIs for a resident with an indwelling urinary catheter by positioning the urinary drainage bag above the bladder, contrary to policy. This was confirmed by a CNA and an LVN, despite the resident's care plan specifying the correct positioning to prevent complications.
A resident in an LTC facility was administered the incorrect enteral formula, receiving Vital 1.2 instead of the prescribed Vital 1.5. This error resulted in the resident receiving fewer calories than ordered, potentially impacting their well-being. The issue was identified during an observation and interview with an LVN, who noted the discrepancy after holding the feeding due to the resident vomiting.
The facility failed to provide necessary respiratory care for four residents, including not dating oxygen tubing for three residents and not administering oxygen as ordered for another. Observations and interviews confirmed these deficiencies, which did not adhere to the facility's policies, potentially putting residents at risk.
The facility failed to properly assess and document the use of side rails for three residents, leading to potential safety risks. One resident used side rails for positioning without documented alternatives being attempted. Another resident requested side rails for mobility, but the facility did not document any alternatives. A third resident had side rails despite being unable to self-position, making their use inappropriate. These deficiencies put residents at risk for entrapment and injuries.
The facility failed to ensure proper documentation and accounting of controlled medications. An inspection revealed discrepancies in the Narcotic Count Sheet and Medication Count Sheets for two residents, with missing or incorrect entries. LVN 3 admitted to errors in documentation, and the Administrator and DON acknowledged the findings.
A facility failed to accurately monitor orthostatic blood pressure for a resident on Zyprexa, as ordered by the physician. The medical records showed identical blood pressure readings for lying and sitting positions, indicating non-compliance with the procedure. Interviews with the DON and an LVN confirmed the readings should differ, and the LVN admitted to not following the correct procedure, potentially impacting the resident's treatment.
A facility's medication error rate was found to be 25%, exceeding the acceptable threshold. An LVN made eight errors by leaving residual medication in cups after administration to a resident. Additionally, the LVN incorrectly administered eye drops to another resident, applying them to only one eye instead of both as per the physician's order.
The facility failed to ensure proper storage and disposal of medications across multiple medication carts, leading to potential risks of unsafe administration and cross-contamination. Used syringes, topical creams, and various medications were improperly stored together, as confirmed by nursing staff. The Administrator and DON were informed and acknowledged these deficiencies.
A resident with intractable epilepsy had a low valproic acid level, but the facility failed to make repeated attempts to notify the physician. Despite a recommendation from the Consultant Pharmacist to clarify the medication's use and obtain a level, the medical record lacked evidence of follow-up actions. The DON stated that staff should make multiple attempts to contact the physician for abnormal lab values, but this was not documented.
The facility failed to maintain accurate medical records for four residents, leading to potential unmet care needs. A resident's IV fluid intake and weight refusal were not documented, another's MAR was incomplete, a third's hospice visitation log was missing entries, and a fourth's flu vaccination consent was improperly filed. These issues were confirmed by facility staff and acknowledged by administration.
Care plans failed to reflect medications, continence care, shaving safety, and toenail needs
Penalty
Summary
The facility failed to develop and/or implement comprehensive care plans for multiple residents. Review of the facility’s care planning policies showed the interdisciplinary team was expected to develop and implement person-centered care plans with measurable objectives to meet residents’ medical, nursing, mental, and psychosocial needs, and the psychotropic drug use policy stated an individualized, person-centered care plan would be initiated. For one resident, the care plan did not include all of the resident’s psychotropic medications or the specific targeted behaviors associated with those medications. The record showed orders for Ativan for anxiety manifested by increased agitation, olanzapine for psychosis manifested by angry outbursts as evidenced by resisting care, buspirone HCl for anxiety manifested by increased physical restlessness, bupropion HCl for depression manifested by verbalization of sadness, and paroxetine HCl for depression manifested by outbursts of crying. The care plan addressed some psychotropic medication use, but it did not include the targeted behaviors for Ativan or olanzapine, did not show the resident’s use of buspirone HCl, and did not address the targeted behaviors of verbalization of sadness and outbursts of crying for the antidepressants. For another resident, the care plan included bowel and bladder incontinence interventions, including disposable briefs and changing briefs every two hours and as needed, but the task record for bladder continence did not show that the brief changes every two hours were provided. For two residents who were observed with cuts to the chin during shaving, the records did not show care plan problems or interventions addressing tremors, movement, or being shaved during showers. One resident had multiple superficial cuts to the chin after shaving during a shower, and another resident had a horizontal superficial cut across the lower chin with blood present after jumping while being shaved in the shower. For a third resident, the care plan did not address toenail care even though the resident’s toenails were observed long and discolored, and podiatry documentation noted nail dystrophy, tinea unguium, and toe pain.
Respiratory Care Not Provided as Ordered and Equipment Stored Improperly
Penalty
Summary
The facility failed to provide ordered respiratory care for a resident who was prescribed continuous oxygen at 2 liters per minute via nasal cannula. During observations, the resident was seen receiving oxygen at 2.5 liters per minute instead of the ordered rate, and an RN verified that the resident should only have been receiving 2 liters per minute as ordered by the physician. The facility also failed to ensure that a resident receiving hospice care and diagnosed with COPD and obstructive sleep apnea was provided BiPAP therapy as ordered at bedtime. Respiratory therapy progress notes documented multiple nights when the resident was not placed on the BiPAP machine because a piece of the BiPAP mask was missing. The notes also showed licensed nurses were aware the resident was not on the BiPAP on multiple occasions, but the record did not show that the hospice care team or physician was notified when the BiPAP was not provided. In addition, the facility failed to store nasal cannulas in a sanitary condition for two residents. One resident’s nasal cannula was observed hanging on a hook attached to an over-the-bed table when not in use, and another resident’s nasal cannula was observed on the floor during a meal observation and again during follow-up. The facility also failed to ensure a resident receiving albuterol breathing treatments was not left unattended during administration; the RT was observed leaving the room while the treatment was still running, and the resident stated staff sometimes left him during treatments. The resident had ALS, chronic respiratory failure with tracheostomy and ventilator dependence, and was ordered albuterol via ventilator and tracheostomy for wheezing and shortness of breath.
Kitchen sanitation and utensil storage deficiencies
Penalty
Summary
The facility failed to ensure sanitary requirements were met in the kitchen during an initial kitchen tour and concurrent interview with the DSS. Surveyors observed one yellow cutting board used for cooked meat, poultry, and fish that did not have a cleanable surface, the plastic lid for a heavy-duty blender stored upside down and coated in dust, multiple storage racks in the dry storage area coated in dust, and the lid for a dry storage container for sugar coated in dust. They also observed one stainless steel scoop and one stainless steel measuring cup stored with dry watermarks and food residue, and the floor drain for the three-compartment sink contained food particles with dried brown water residue around the edges. The facility’s kitchen utensils were also observed in poor condition. Surveyors found one stainless steel pizza cutter with a melted black handle, two stainless steel spatulas with melted cream handles, and one hand-held can opener with rust-like residue on the edges. The facility’s policy stated that utensils, counters, shelves, and equipment are to be kept clean, maintained in good repair, and free from breaks, corrosion, cracks, and chipped areas. The DSS acknowledged the findings and stated the damaged items would be disposed of. The report also noted that cleaned equipment and utensils were not being stored in a dry condition. Three stainless steel scoops were observed stored with water inside the scoops, despite the facility’s dishwashing policy stating that dishes are to be air dried in racks before stacking and storing. The DSS verified the observation and stated the items were supposed to be air-dried. The report identified 88 residents receiving food prepared from the facility’s kitchen.
Infection Control and Sanitary Storage Failures
Penalty
Summary
The facility failed to implement its infection prevention and control surveillance program for the months of July 2025 through January 2026. The infection preventionist stated that resident infection surveillance was initiated only when a resident was prescribed antimicrobial medications or diagnosed with an infection, and that McGeer's Criteria was used to determine whether a resident had a true infection. Review of the surveillance logs showed residents were classified as HAI, CAI, or DNMC only when antimicrobial medications were prescribed, and the logs did not show any residents who exhibited signs or symptoms of infection but were not prescribed antimicrobials or diagnosed with an infection. The infection preventionist stated the facility did not initiate McGeer's Criteria forms for residents who had signs and symptoms of infection but were not prescribed antimicrobials or diagnosed with an infection. The facility also failed to maintain sanitary conditions in the laundry area. During observation of the clean laundry sorting counter, facility communication devices, a personal water bottle, and a personal cellphone were present on the counter. A clean linen cart positioned next to the counter had clean linens on the top shelf, but a portable speaker was also observed on the same shelf. Housekeeping staff and the Maintenance Director verified these findings, and the DON later acknowledged them. Additional infection control failures were observed throughout the facility. While meal trays were being passed out, the Business Office Manager held Resident 15's tray close to her body and allowed her hair to hang over the milk cartons. A vendor employee entered the kitchen without the required beard restraint and crossed the yellow food and safety line after being directed there by the receptionist. Resident 14's indwelling urinary catheter drainage bag was observed touching the floor mat, and staff including a CNA and LVN verified the observation. The facility also failed to store Residents 21, 44, and 137's personal belongings in a sanitary manner, as bags of clothing and personal items were observed on the floor or touching the floor in their rooms, and staff verified those observations.
Medications Kept at Bedside Without Required Orders or Assessments
Penalty
Summary
The facility failed to ensure that residents who had medications at bedside were assessed, had a care plan, and had a physician order to self-administer those medications. Facility policy stated that residents may self-administer medications only when the interdisciplinary team determines it is clinically appropriate and safe, and that medications to be self-administered must be specifically ordered and monitored by nursing staff. During the survey, ketoconazole cream was observed on top of one resident’s bedside drawer. The resident’s record showed a physician order for ketoconazole cream to be applied daily, but there was no documented order for bedside storage or self-administration and no self-administration assessment in the record. The resident’s physician progress note stated the resident did not have capacity to make medical decisions. An LVN stated the resident’s parents wanted to treat him themselves and acknowledged there was no order or assessment for self-administration. Hydrogen peroxide topical solution and Desitin paste were observed on another resident’s nightstand. That resident’s record showed significant cognitive impairment secondary to traumatic brain injury and no orders for those products, and staff stated the family brought and used their own products. Debrox earwax removal aid was also observed on a third resident’s nightstand; that resident stated he bought it himself and used it independently, but the record contained no physician order, assessment, or care plan for self-administration. Staff members and the ADON acknowledged that medications should not have been at bedside without the required documentation.
Failure to Maintain Privacy During Resident Care
Penalty
Summary
The facility failed to maintain privacy for two residents during care by not fully closing the privacy curtain. During a medication administration observation, an LVN administered medications via gastrostomy tube to one resident while the curtain was only partially closed, leaving the resident’s abdominal area exposed and allowing a staff member to walk by to the roommate’s side of the room. When questioned, the LVN stated the curtain should have covered the resident completely and that it was forgotten. In a separate observation, a respiratory therapist provided tracheostomy care and suctioning to another resident while the privacy curtain was not completely closed, and the procedure could be seen from outside the room. The resident was documented as alert, oriented to time, place, and persons, and able to communicate verbally with clear speech. The respiratory therapist stated they did not know the curtain had to be fully closed. Facility records showed both the LVN and respiratory therapist had received orientation on resident rights and privacy, and the facility’s policies stated residents shall be examined and treated in a manner that maintains privacy and that a closed door or drawn curtain shields the resident from passers-by.
Homelike Environment Not Maintained
Penalty
Summary
The facility failed to provide a homelike environment for two sampled residents and one nonsampled resident. Outside Resident 55’s room, a stack of mattresses, boxes, and other miscellaneous items was stored where it could be seen from the resident’s window and from the hallway. Resident 55 was observed looking out the window toward the items and responded with a gesture indicating dislike when asked about them. Resident 55 was bedbound, had ALS, functional quadriplegia, chronic respiratory failure, and a tracheostomy with ventilator dependency, and his social preference was to remain in his room. Outside Resident 79’s room, a pile of wooden boards and orange traffic cones was visible from the resident’s window and from the hallway. Resident 79, who had respiratory failure, asthma, and anxiety and did not have cognitive impairment, was observed in her wheelchair facing the window. She stated she did not like seeing the boards and cones outside her window and said she liked staying in her room and sketching inside her room. The Maintenance Director verified the items were stored outside her window and stated he did not know how long they had been there. Resident 132’s room was observed during the initial tour to have an insect crawling near the bed, thick dust under and around the bed, dust on the baseboard behind the bed, and crumpled trash and IV caps on the floor. LVN 15 and Consultant 3 verified the dust under the bed and on the headboard and the trash on the floor. Resident 132 was severely impaired and never or rarely made decisions. The DON stated the amount of dust under the bed was more than just one day of missed cleaning, and Housekeeper 2 verified that daily sweeping and mopping, including under the beds, was part of the housekeeping responsibility.
Unnecessary Psychotropic Medication Monitoring Failure
Penalty
Summary
The facility failed to ensure one resident was free from unnecessary medications when Resident 118 had repeated PRN Ativan orders without a documented clinical rationale for continued use. The record showed multiple Ativan orders over time for anxiety or agitation, including orders tied to behaviors such as agitation, physical restlessness, and anxiousness, but the medical record did not contain the prescriber’s rationale for continuing PRN Ativan. The DON reviewed the record and verified that the targeted behavior of increased agitation was not an appropriate specific targeted behavior and should have been clarified to a more quantifiable behavior. The resident’s psychotropic medication behavior monitoring was also incomplete. Monthly behavior data sheets for olanzapine, bupropion HCl, and paroxetine HCl were missing January 2026 data, and there were no monthly behavior data sheets for buspirone HCl or Ativan. The record also showed that the behavior being monitored for buspirone and Ativan did not match the behaviors targeted in the orders, including monitoring for anxiousness while the order targeted increased agitation or physical restlessness. The DON verified the incomplete and missing behavior monitoring during the record review.
Failure to Provide Foot Care
Penalty
Summary
Provide appropriate foot care was not provided for Resident 35. On 2/13/26 at 1533 hours, Resident 35 was observed in bed with the responsible party at bedside, and the responsible party voiced concern that the resident's toenails had not been cared for. During the observation, Resident 35's first digit toenail was seen extending beyond the tip of the toe. The responsible party gave permission for a focused body check, and at 1545 hours the body check was completed with LVN 14 and CNA 6 present. Resident 35's toenails were observed with brown discoloration, and the first digit toenail was extended approximately one half inch beyond the tip of the toe; LVN 14 verified the finding. During interview, LVN 14 stated she thought Resident 35 had been seen by the podiatrist the prior month. Medical record review showed Resident 35 had diagnoses including cerebral palsy with quadriplegia, post status tracheostomy placement, and post status GT placement. The SSD stated Resident 35's last podiatry visit was on 12/18/25, that insurance covered podiatry visits every 90 days and as needed, and that no one informed her of the concern with Resident 35's toenails so she could arrange an appointment.
Indwelling Catheter Care Not Properly Documented or Maintained
Penalty
Summary
The facility failed to provide appropriate care and services for the use of an indwelling urinary catheter for one of three sampled residents reviewed for catheter care. Resident 15 had an indwelling urinary catheter connected to a urinary drainage bag at the side of the bed, and the catheter tubing was observed to be cloudy with a lot of sediment. The drainage bag also had no label showing when it was last changed. The resident had a physician's order for daily indwelling urinary catheter care for maintenance, urinary drainage bag change as needed, and catheter change as needed for soiled, clogged, leaking, or dislodged catheters. The care plan addressed monitoring the catheter for signs and symptoms of infection. Review of the medical record did not show documentation of when the indwelling urinary catheter was changed. During interview and record review, LVN 7 verified the tubing had whitish streaks, the urine was brownish to dark brown with a lot of sediment and cloudy, and the drainage bag lacked a change label. RN 2 and the DON also verified there was no documentation showing when the catheter had been changed.
GT Feeding Orders Not Followed and Residual Monitoring Not Properly Documented
Penalty
Summary
Necessary care and services related to GT feeding were not provided for Residents 2, 30, and 144. Resident 2 had a physician order for 500 cc water via PEG tube at 25 cc/hr for 20 hours, but during the initial tour the water flush pump was observed set at 30 cc/hr. Resident 2's H&P stated the resident did not have the capacity to make needs known or make medical decisions. Resident 30 had a physician order for 1200 cc of Diabetisource AC via PEG tube at 60 cc/hr for 20 hours, but during the initial tour the GT feeding pump was observed set at 65 cc/hr. Resident 30's H&P stated the resident did not have the capacity to understand and make decisions. During interview and record review, an LVN and the DON verified that the water flush rate for Resident 2 and the GT feeding rate for Resident 30 did not match the physician's orders. Resident 144 was GT feed dependent and had orders to receive Fibersource HN at 50 ml/hr via GT, elevate the HOB 30 to 45 degrees during and one hour after feeding, and check residuals and hold feeding if residuals were above 150 ml. While the feeding was infusing, the resident was observed lying in bed with the HOB only slightly elevated and not at least 30 degrees. Review of the MAR showed residuals were to be monitored every shift, but there was no specific amount of gastric residual documented. Staff interviews confirmed the HOB was not elevated to the ordered level and that the residual monitoring did not document the exact amount obtained.
Inadequate CNA competency for shaving residents with spasms or sudden movement
Penalty
Summary
The facility failed to ensure CNAs 7 and 8 were competent to shave residents who had episodes of spasms or sudden movement. Resident 4, who had cerebral palsy, a seizure disorder, chronic respiratory failure with ventilator dependence, and a gastrostomy tube, was observed with multiple superficial cuts to the chin. LVN 14 stated the cuts occurred while the resident was being shaved, and the resident’s progress notes documented scabs after shaving. CNA 7 stated she showered Resident 4 and thought the cuts were already present, but the employee file did not show a skills check for shaving residents, including residents who move around while being shaved. Resident 124, who had diabetes, brain damage, and epilepsy, was observed with a horizontal superficial cut across the lower chin with an open area at the left corner and blood running down the chin. CNA 8 stated the cut occurred while she was shaving the resident in the shower and that the resident jumped while she was shaving his chin. Review of CNA 8’s employee file also failed to show a skills check for shaving residents, including residents with episodes of moving around while shaving. The DSD reviewed the facility’s shaving competency document, which listed steps for shaving and a satisfactory/unsatisfactory section, but it did not address how to shave residents who move around or have spasms during shaving.
Missed Scheduled Baclofen Dose
Penalty
Summary
The facility failed to provide necessary pharmaceutical services for one of six nonsampled residents, Resident 56, by not ensuring baclofen was administered according to the physician’s order. Facility policy stated routinely scheduled medications were to be given at the times specified in the standard medication schedule, and twice-daily medications were to be administered at 0900 and 1700 hours. Resident 56 was admitted to the facility and had an H&P noting the resident did not have the capacity to understand and make decisions. The physician’s order dated 10/6/25 directed baclofen oral suspension 25 mg/5 ml, 2 ml via GT two times a day. During a medication administration observation, LVN 9 stated the baclofen could not be given at the scheduled 0900 time because it was not available and was expected to be delivered soon. The MAR for February 2026 showed an initial and code 7 entry for the baclofen dose at 0900, and the nurses’ notes documented physician notification and that the medication was pending pharmacy delivery. Later, LVN 9 stated the baclofen had still not been delivered and that the desk nurse had called the pharmacy and notified the physician. LVN 11 stated that if the medication was unavailable, acetaminophen could be given in the meantime, and acknowledged that acetaminophen is not a muscle relaxant and that the baclofen should have been refilled ahead of time.
Failure to Follow Up on Consultant Pharmacist Recommendation for PRN Ativan
Penalty
Summary
The facility failed to follow up on the consultant pharmacist’s recommendation for Resident 118’s PRN Ativan use. The facility’s Medication Regimen Review policy stated that the consultant pharmacist would review residents’ medical records monthly, document irregularities, and provide them to the facility within seven working days, with the report to be acted upon and nursing personnel to provide a written response. In the consultant pharmacist’s December 2025 review, the pharmacist noted that “agitation or restlessness” was too subjective to use as a diagnosis or behavior and requested that the resident’s PRN Ativan order be updated with a specific and quantifiable behavior based on the resident’s words or actions, such as striking out, resisting care, or continuous yelling/screaming. Medical record review showed multiple physician orders for Ativan 1 mg every six hours PRN, variously for increased agitation or anxiety manifested by increased agitation, from December 2025 through February 2026. The record did not show that the facility followed up on the pharmacist’s recommendation or notified the physician to update the order with a specific and quantifiable behavior for anxiety. During an interview and concurrent record review, the DON verified that the facility failed to follow up on the consultant pharmacist’s recommendation to update the behaviors for the PRN Ativan use.
Medication Storage and Expired Supply Deficiencies
Penalty
Summary
The facility failed to ensure proper storage and disposal of medications and biologicals in one medication storage room and in three of five medication and treatment carts inspected. In Medication Storage Room A, surveyors observed dusty and stained storage surfaces, an expired COVID-19 testing kit, oral medications stored with non-oral medications, and stained medication packaging, including a yellowish stained vitamin C bottle label and naloxone spray package. The room also had dusty, sticky stains on the e-kit cabinet door and medication refrigerator handle, along with dark stains in the treatment supplies closet. RN 2 verified these findings and stated nurses and housekeeping staff clean the room, with housekeeping unable to enter unless a nurse stayed during cleaning. In Medication Cart A, surveyors observed brownish-black stains in bins used for glucometer strips, lancets, and syringes, as well as used plastic-like oral syringes stored with unused syringes. LVN 17 and the IP verified the findings and stated the bins should have been clean and the used syringes should not have been stored with unused syringes. In Treatment Cart A, surveyors found an opened single-use suture removal tray, an opened package of gauze, and an expired wound culture set; LVN 4 and RN 2 verified the items were expired or improperly opened and stored. In Treatment Cart B, a COVID-19 reagent was found expired, and RN 1 stated it should have been discarded. The Administrator was informed and acknowledged the findings.
Cold Cole Slaw Served on Meal Trays
Penalty
Summary
The facility failed to ensure food served was palatable, attractive, and at a safe and appetizing temperature for 88 of 88 residents who received meals prepared in the kitchen. During a resident council meeting, Residents 1 and 2 stated the food was served cold and did not taste good. During an observation of meal tray service with the Dietary Supervisor, kitchen staff were preparing beef stew and corn cole slaw. Later, two test trays were observed with the Dietary Supervisor and the RD: the regular diet tray’s cole slaw contained small pieces of ice, and the pureed diet tray’s cole slaw had clumps of ice formation. These findings were verified by the Dietary Supervisor and the RD.
Insect Found in Resident Room
Penalty
Summary
The facility failed to maintain an effective pest control program to prevent the presence of an insect in Resident 132's room. Resident 132 was admitted to the facility and, according to the MDS assessment, was severely impaired and never or rarely made decisions. During the initial tour of the facility, an insect was observed crawling near Resident 132's bed. The insect crawled under the bed, and LVN 15 and Consultant 1 were able to secure and remove it from the room. During interview, the Maintenance Director stated the facility had a pest control company that came every two weeks, but the company did not spray inside resident rooms because of the risks of the chemicals being used. The Maintenance Director said the pest control company sprayed the inside and outside perimeter of the facility. The DON and Administrator both acknowledged that Resident 132 was part of a vulnerable population and that the facility should not have pests that could potentially jump into residents' beds or get into their mouths.
Incorrect LAL Mattress Settings for Resident With Pressure Injuries
Penalty
Summary
Provide appropriate pressure ulcer care and prevent new ulcers from developing was not ensured for one resident who had an arterial wound to the right foot, a stage 2 pressure injury to the left buttock area, and a stage 2 pressure injury to the left gluteal fold. The resident was observed in bed on a low air loss mattress, and the mattress settings were not aligned with the resident's weight. On 2/11/26, the mattress was set to 15 pounds even though the resident appeared to weigh more than that. On 2/17/26, the mattress was observed set to 150 pounds, and LVN 14 confirmed the resident weighed 104 pounds and acknowledged the mattress should have been set according to the resident's weight. The resident had an order dated 2/10/26 to use the LAL mattress for wound management and to check placement and settings every shift.
Missing Annual CNA Performance Evaluations
Penalty
Summary
The facility failed to ensure annual performance evaluations were completed for two of three CNA employee files reviewed, identified as CNA 4 and CNA 5. During an employee file review and concurrent interview with the DSD on 2/12/26 at 0928 hours, it was noted that CNA 4 was hired on 7/2/24 and had no annual performance evaluation completed based on job performance and competency. CNA 5 was hired on 8/13/24 and also had no annual performance evaluation completed based on job performance and competency. The DSD verified these findings and stated he was behind on completing employee evaluations.
Inaccurate Medical Record Entry After Resident Transfer
Penalty
Summary
The facility failed to ensure that one closed medical record was complete and accurate for Resident 12. The resident’s record contained a respiratory therapy note dated 2/3/26 documenting humidified oxygen, treatments per physician orders, routine tracheal tube suctioning and care, tracheal tube site assessment, and no signs of respiratory distress or increased respiratory effort, even though the resident had been transferred to a GACH on 2/2/26 and did not return to the facility. The facility’s Documentation policy stated the medical record should be a concise and accurate account of treatment, care, response to care, signs, symptoms, and progress. During record review, the Medical Records Director confirmed the resident was transferred out on 2/2/26 and verified the respiratory note incorrectly showed care and assessments were performed the day after the resident left the facility. The director also stated late entries should be documented as late entries, but the note in question was not identified that way.
Failure to Monitor and Document Diabetic Care and Glucose Checks
Penalty
Summary
The facility failed to provide quality care and services for two residents by not ensuring proper monitoring and documentation related to diabetic management. For one resident with Type 2 diabetes and no decision-making capacity, the facility did not document monitoring for side effects or effectiveness of prescribed insulin, nor did they monitor or document for signs and symptoms of hyperglycemia as outlined in the resident's care plan. Both the RN and DON confirmed that there was no evidence of such monitoring or documentation in the medical record, and that clarification with the physician regarding blood sugar monitoring was not obtained. For another resident, the facility did not complete physician-ordered daily glucose monitoring on several specified dates, as evidenced by missing documentation in the medication administration records. The RN verified the omissions and acknowledged that reasons for missed glucose checks were not documented. The DON also confirmed these findings, stating that refusals or other reasons should have been recorded to ensure proper tracking of the resident's blood sugar status.
Inaccurate Fall Risk Evaluation Documentation
Penalty
Summary
The facility failed to ensure the accuracy of a resident's medical record, specifically regarding the Fall Risk Evaluation for one resident. The resident, who lacked decision-making capacity, experienced a fall as documented in the SBAR Communication Form. However, the Fall Risk Evaluation completed on the same day did not reflect this incident, instead indicating that the resident had no falls in the past three months. This discrepancy was confirmed during interviews and record reviews with both a registered nurse and the Director of Nursing, who acknowledged that the fall should have been included in the evaluation. Facility policies required that post-fall assessments and care plan changes be completed for all residents who experienced a fall, and that medical records provide a concise and accurate account of care and resident condition. The licensed nurse responsible for the Fall Risk Evaluation did not document the recent fall, resulting in an inaccurate record. This inaccuracy was verified by facility staff during the survey process.
Failure to Maintain Bed in Low Position Resulting in Resident Fall and Fracture
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a resident's bed was maintained in the low position as required by the resident's care plan. The resident, who had a diagnosis of Alzheimer's dementia, a history of falls, severe cognitive impairment, and was dependent on staff for all activities of daily living, was identified as being at high risk for falls. The care plan and physician orders specified the use of bilateral bolster pillows, floor mats, and keeping the bed in the lowest position to minimize injury risk. Despite these interventions, the bed was found elevated at the time of the incident. On the day of the event, a family member visiting the resident observed that the bed was elevated and subsequently found the resident on the floor, in pain, and with visible injuries. Multiple staff members, including CNAs and LVNs, confirmed that the bed was elevated to hip height when they responded to the incident. The resident sustained fractures to the left lower leg, as confirmed by hospital records, and required transfer to an acute care hospital for treatment. Facility documentation, interviews, and medical record reviews all indicated that the required fall prevention interventions were not fully implemented, specifically the failure to keep the bed in the low position. The facility's own policies and procedures mandated that residents at risk for falls have appropriate interventions in place, including maintaining the bed in the lowest position, but this was not adhered to at the time of the incident.
Failure to Follow Physician Orders and Use Approved Equipment for Blood Pressure Monitoring
Penalty
Summary
The facility failed to provide necessary care and services by not monitoring a resident's blood pressure according to physician orders and resident preferences. Specifically, staff used a wrist blood pressure machine, which the resident reported as inaccurate, and repeatedly obtained low systolic readings. The resident expressed concerns about the accuracy of the device and stated that nurses often had to retake his blood pressure multiple times to get an accurate reading. Additionally, the resident reported that staff were obtaining blood pressure readings from his left arm, which contained a hemodialysis access site, despite a physician order prohibiting blood pressure measurements from that site. Medical record review confirmed the resident had diagnoses of end stage renal disease on hemodialysis, hypertension, and a history of diabetes. Physician orders included instructions to hold antihypertensive medication if systolic blood pressure was below a certain threshold and a specific order not to obtain blood pressure readings from the left arm with the hemodialysis access. During interviews, a nurse admitted to using a wrist blood pressure machine and to taking readings from whichever arm the resident offered, while the DON confirmed that only facility-approved machines should be used and that staff should follow physician orders regarding blood pressure monitoring.
Failure to Implement Enhanced Barrier Precautions for Resident with Surgical Wound
Penalty
Summary
The facility failed to implement and maintain effective infection prevention and control practices for a resident with a surgical wound. The resident, who had a history of cranioplasty and a slowly healing, dehisced surgical wound, was admitted and readmitted to the facility. Physician orders were in place for daily wound care, including cleansing and dressing changes for both the scalp and left temple wounds. However, there was no physician order for Enhanced Barrier Precautions (EBP), which are required for residents with wounds at high risk for colonization with multidrug-resistant organisms (MDROs). During observations, the resident was found in bed with wound dressings but without any PPE set-up or EBP signage outside the room. Interviews with the LVN and Infection Preventionist (IP) confirmed that EBP was not implemented, despite both acknowledging that EBP should have been in place due to the resident's surgical wound. The IP also verified the absence of a physician's order for EBP and the lack of necessary precautions. Further review and interviews with the Director of Nursing (DON) and the Administrator confirmed that the resident had a surgical wound and that EBP, including PPE set-up and signage, was not implemented as required. The facility's failure to follow its own infection prevention and control policies and procedures resulted in the deficiency, as the necessary precautions to prevent the transmission of communicable diseases or organisms were not in place for the resident.
Plan Of Correction
F0880 signage, orders and care plans were in place. What measures will be put into place or what systemic changes the facility will make to ensure that the deficient practice does not recur. Infection Preventionist/Designee conducted an in-service from 8/5/25 - 8/12/25 to licensed nurses regarding EBP practices and the criteria that would require implementation. Infection Preventionist will make daily rounds and audit new admissions and current residents on EBP, Monday - Friday x 3 months to ensure proper implementation of EBP on the floor that includes signage, orders and care plans are in place. DON/Designee will conduct audit for at least 3-5 residents a week x 4 weeks x 3 months to ensure Enhance Barrier Precautions have been implemented and care planned. How the facility plans to monitor its performance to make sure that solutions are sustained. The Infection Preventionist/Designee will track, trend, and report findings to the QAA/QAPI Committee monthly for 3 months or until substantial compliance is achieved. Completed Date: 8/13/2025 DON/Designee will conduct audit for at least 3-5 residents a week x 4 weeks x 3 months to ensure Enhance Barrier Precautions have been implemented and care planned. How the facility plans to monitor its performance to make sure that solutions are sustained. The Infection Preventionist/Designee will track, trend, and report findings to the QAA/QAPI Committee monthly for 3 months or until substantial compliance is achieved. Completed Date: 8/13/2025
Failure to Ensure Nursing Staff Competency in Interpreting and Reporting Critical Lab Values
Penalty
Summary
The facility failed to ensure that licensed nurses demonstrated the necessary competencies and skill sets to care for a resident with complex medical needs. A resident with chronic respiratory failure, tracheostomy, ventilator dependence, and anemia of chronic disease was admitted and had laboratory tests ordered. The results showed severely abnormal values, including a high WBC, low hemoglobin, and low hematocrit. The LVN on duty sent a picture of the lab results to the resident's physician via text but did not clarify or address the abnormal findings beyond reporting the results and responding to a question about water flushes. The physician's response only addressed fluid status, and no further clarification or action was taken regarding the critical lab abnormalities at that time. Later, another LVN contacted the physician due to the resident's low blood pressure and, after some confusion about the resident's identity, provided the lab values when prompted by the physician. Only then did the physician order additional diagnostic tests and treatments, including blood cultures, a urine test, chest x-ray, antibiotics, and IV fluids. The resident's condition continued to deteriorate, leading to a transfer to an acute care hospital. Interviews with facility staff revealed that the LVN responsible for initially reporting the lab results did not express concern about the abnormal values and stated she was just following orders. Other nursing staff indicated that proper procedure would have included assessing the resident, highlighting significant lab results, and ensuring the physician was aware of the critical findings. The Director of Nursing and the Director of Staff Development both acknowledged that nurses are expected to question unclear orders and have a basic understanding of lab values, but orientation only included a brief review of lab values without specific competency verification.
Plan Of Correction
How the facility plans to monitor its performance to make sure that solutions are sustained. The DON/Designee will track, trend, and report findings to the QAA/QAPI Committee monthly for 3 months or until substantial compliance is achieved. Completed Date: 7/30/25
Failure to Ensure Physician-Ordered Appointments and Wound Care
Penalty
Summary
The facility failed to provide necessary care and services for two residents, resulting in deficiencies related to physician-ordered follow-up and wound care. For one resident with acute and chronic respiratory failure, tracheostomy, and congenital malformation of the skull and facial bones, the facility did not ensure attendance at scheduled outpatient appointments for a speech evaluation and a plastic surgeon. Documentation showed that transportation for the appointments could not be arranged due to insurance issues, and the resident ultimately did not attend either appointment, despite physician orders and acknowledgment from the Director of Nursing (DON) that follow-up should have occurred. For another resident, the facility did not follow physician orders regarding wound care after surgery. The resident's order specified removal of a Prevena dressing, but during the procedure, betadine was applied to the surgical incision without a physician's order. This was confirmed by both a Licensed Vocational Nurse (LVN) and the DON, who acknowledged that betadine application required a physician's order. The Administrator and DON confirmed these findings during the survey.
Failure to Provide Proper Pressure Ulcer Care and Mattress Settings
Penalty
Summary
The facility failed to provide necessary care and services to prevent the development or worsening of pressure injuries for one resident. During wound care, licensed vocational nurses did not apply barrier cream to the resident's sacrum as ordered by the physician. Additionally, the wound care assessment did not document the presence of undermining in the sacrococcyx pressure injury, despite direct observation of undermining from 8 o'clock to 12 o'clock. The nurses involved did not initially recognize or document the undermining, and the physician was not notified of this change in the wound's condition at the time of assessment. The resident, who had a diagnosis of anoxic brain damage and was non-verbal, was dependent for mobility and had a documented stage 4 pressure injury to the sacrum. Medical records and care plans indicated the need for regular assessment, documentation, and communication regarding the wound's status, including the presence of undermining. However, the initial admission record lacked measurements and staging of the pressure injury, and subsequent skin evaluations did not address the undermining observed during wound care. Furthermore, the facility did not ensure that the low air loss mattress (LALM) settings were correctly adjusted according to the resident's weight. The mattress was set for a weight of 180 pounds, while the resident weighed 116 pounds. This discrepancy was confirmed by both nursing staff and the Director of Nursing, who acknowledged that the mattress settings should correspond to the resident's actual weight as part of wound management interventions.
Infection Control Deficiencies in Linen Handling and Tracheostomy Care
Penalty
Summary
Surveyors identified deficiencies in infection prevention and control practices for one of eight sampled residents. During an observation of wound care for a resident with a tracheostomy and a neck wound, a clean isolation gown was found to contain soiled gloves inside the sleeve. This was verified by the LVN present. Interviews with the infection prevention (IP) nurse and Maintenance Director revealed that gowns should be checked for foreign objects before being placed in clean linen storage, but gloves sometimes remained inside gowns after laundering, with the Maintenance Director acknowledging that gloves could melt during washing if not removed. Additionally, the same resident had a physician's order for daily tracheostomy care and wound management. During wound care, the LVN was observed moving a visibly soiled trach tie to access the wound, but did not change the tie after completing the wound care. The soiled trach tie, which had visible discoloration and debris, was only changed after the surveyor's observation and verification by staff. Interviews with the respiratory therapist, IP nurse, and DON confirmed that trach ties should be changed if soiled, regardless of the regular schedule. The facility's policies required staff to minimize the spread of infection, handle linens properly, and change trach ties as needed if soiled. The observed failures to ensure clean linens and to change a soiled trach tie after wound care did not align with these policies, resulting in a deficiency related to infection control practices.
Inaccurate Medical Record Documentation After Resident Discharge
Penalty
Summary
The facility failed to maintain accurate medical records for one of eight sampled residents. Specifically, a review of the closed medical record for a resident who had been discharged revealed that multiple care tasks and medication administrations were documented as completed on the medication administration record (MAR) for a date after the resident had already left the facility. These tasks included daily use of heel protectors, monitoring of apical pulse and pacemaker site, observation for pacemaker malfunction, and administration of potassium chloride ER tablets. Both the LVN and the DON confirmed that the MAR indicated these tasks as completed after the resident's discharge, and the facility's policy required clinical records to be a concise and accurate account of care and treatment provided.
Deficiencies in Wound Care and Treatment Orders
Penalty
Summary
The facility failed to provide necessary wound care and services for three residents, leading to deficiencies in their treatment. For Resident 2, there was a lack of communication and clarification between two physicians providing different wound care orders. The resident's treatment plan was not updated in the electronic health record (EHR) to reflect the wound specialist's recommendations, resulting in the discontinuation of mupirocin ointment without proper clarification. This oversight was confirmed by both the Licensed Vocational Nurse (LVN) and the Director of Nursing (DON), who acknowledged the failure to follow the correct treatment plan. Resident 3 did not receive the appropriate bed mattress to promote healing of a pressure injury. Despite a physician's order for a Low Air Loss (LAL) mattress, the resident was observed lying on a different type of mattress. This discrepancy was verified by the DON during an observation and interview, indicating a failure to adhere to the prescribed treatment for pressure injury management. For Resident 5, the facility did not follow the correct sequence of wound care treatment as ordered by the physician. The LVN applied the xeroform dressing before the collagen sheet, contrary to the physician's instructions to apply the collagen sheet first. This error in the wound care procedure was acknowledged by the LVN and confirmed by the DON, highlighting a failure to execute the physician's orders accurately.
Failure to Provide Safety Mats for High-Risk Resident
Penalty
Summary
The facility failed to ensure that a resident remained free from accident hazards by not providing the bilateral floor mats at the resident's bedside as ordered by the physician. This deficiency was identified during an observation and interview with the Assistant Director of Nursing (ADON), where it was confirmed that the resident, who was at high risk for falls, did not have the required safety mats in place. The resident's medical records indicated a physician's order for the mats dated 6/26/24, and the care plan initiated on 6/21/24 also included this intervention following an actual fall on that date. The resident's Quarterly Fall Risk Evaluation dated 12/19/24, classified them as high risk for falls, underscoring the necessity of the mats for safety. Despite these documented orders and care plans, the mats were not present during the observation on 2/26/25. The Director of Nursing (DON) was informed of these findings and verified the absence of the mats, confirming the facility's failure to adhere to the prescribed safety measures for the resident.
Failure to Follow Physician's Orders for GT Feedings
Penalty
Summary
The facility failed to adhere to physician's orders regarding the administration of gastrostomy tube (GT) feedings for two residents, identified as Residents 3 and 5. According to the medical records, Resident 3 was supposed to receive enteral feeding starting at 1500 hours daily, delivering 1100 cc of Jevity 1.5 formula at a rate of 55 cc/hr for 20 hours. However, an observation on December 20th revealed that the feeding had commenced prematurely, with 39 ml already infused before the scheduled time. Similarly, Resident 5's orders indicated that enteral feeding should begin at 1500 hours, providing 1200 cc of water at 60 cc/hr for 20 hours. Despite this, the feedings for both residents were initiated at 1300 hours, two hours earlier than prescribed. Interviews with Licensed Vocational Nurses (LVNs) 1 and 3 confirmed the early administration of the feedings, with LVN 3 admitting to starting the GT feedings around 1300 hours. LVN 1 acknowledged that the feedings were ordered to start at 1500 hours, with a permissible window of one hour before and after the scheduled time. The Director of Nursing (DON) verified the discrepancy and stated that the licensed nurses should have followed the physician's orders. The facility's Administrator and DON acknowledged these findings, indicating a failure to provide necessary care and services as per the physician's directives.
Sanitation Deficiencies in Kitchen
Penalty
Summary
The facility failed to maintain sanitary conditions in the kitchen, as evidenced by several observations during a kitchen tour. The kitchen utensils, including spatulas, whisks, and scoops, were found to be in poor condition, with chipped edges, discoloration, and residues. These conditions were verified by the Dietary Manager, who acknowledged that such utensils should not be used as they can harbor bacteria. Additionally, the cutting board was heavily marred, discolored, and peeling, making it difficult to clean and sanitize, which could lead to the accumulation of pathogenic microorganisms. The facility also failed to ensure that equipment and utensils were properly cleaned and stored. During the kitchen tour, it was observed that some utensils were stored wet and dirty, and the heavy-duty blender was not air-dried before storage. The microwave used for warming food was found to have dry, crusted food residue, and the kitchen hood had black, greasy residue, indicating inadequate cleaning. The ice machine, used by residents and staff, had ice buildup, which was acknowledged by the Maintenance Supervisor, who stated that the machine was under warranty and required maintenance by an outside company. These deficiencies in maintaining sanitary conditions in the kitchen had the potential for cross-contamination and foodborne illnesses among the residents consuming the food prepared in the facility. The Dietary Manager and Maintenance Supervisor acknowledged the findings and the need for proper cleaning and maintenance of kitchen equipment and utensils to prevent bacterial growth and ensure food safety.
Failure to Ensure Call Lights Within Residents' Reach
Penalty
Summary
The facility failed to provide reasonable accommodations for the call lights of four residents, which were not within their reach, potentially impacting their psychosocial well-being or delaying care. For Resident 96, the call light was found hanging at the back of the bed, out of reach, and was only placed within reach after verification by LVN 11. Similarly, Resident 108's call light was found underneath the pillow, out of reach, and was acknowledged by LVN 7 as needing to be accessible. Resident 775's call light was observed on the floor during two separate observations, both times out of reach, and was only placed within reach after CNA 2 verified the situation. Resident 775 was noted to lack the capacity to understand and make decisions, emphasizing the importance of having the call light accessible. Resident 78's call light was initially observed on the resident's right shoulder, not within reach, despite the resident having the ability to use the call light and movement in both hands. LVN 13 confirmed the call light's position and moved it under the resident's right hand. The Director of Nursing (DON) acknowledged that most residents in the Subacute Unit used call lights and emphasized the need for staff to place them within reach. The Administrator and DON were informed of these findings and acknowledged the deficiencies.
Failure to Timely Notify Physician of Resident Condition Changes
Penalty
Summary
The facility failed to notify the physician in a timely manner regarding changes in the condition of two residents, leading to a delay in intervention and potential adverse outcomes. For Resident 51, the physician was not promptly informed about a change in the resident's swallowing status. The resident's family member had reported difficulty in swallowing liquids to the Social Services Department, which was supposed to notify the nursing staff. However, the physician was only notified several days later, after the Speech Therapist conducted a screening and recommended a swallow study. For Resident 56, the physician was not notified about the resident's episodes of vomiting and the decision to hold the resident's tube feeding. The resident had a history of vomiting, and the tube feeding was held without obtaining a physician's order, despite the resident's low weight. The nursing staff failed to communicate these changes to the physician, resulting in the resident receiving significantly less formula than ordered. The Director of Nursing confirmed that the physician should have been notified of these changes.
Unauthorized Search of Resident's Belongings
Penalty
Summary
The facility failed to honor a resident's right to a safe and comfortable environment by allowing staff to go through a resident's personal belongings without consent. This incident involved a resident who was legally blind but cognitively intact, as confirmed by their medical records. The resident was unaware of the intrusion until informed by their roommate, who witnessed the event. The roommate observed two individuals dressed like staff entering the room early in the morning, using a flashlight to search through the resident's belongings on the tray table, bedside table, and drawer while the resident was asleep. The Director of Nursing (DON) later confirmed that staff had been instructed to check residents' bedside areas for proper labeling and food expiration dates. However, the DON acknowledged that staff should have obtained permission from the resident before inspecting their belongings. This oversight led to the resident feeling upset upon learning about the unauthorized search, highlighting a breach in maintaining a homelike and respectful environment for the resident.
Failure to Follow Up on Consult Recommendations and Monitor Weight Loss
Penalty
Summary
The facility failed to provide necessary care and services to two residents, resulting in potential delays in identifying changes in their conditions and implementing appropriate interventions. For one resident, the facility did not follow up timely on skin and wound consult recommendations. The dermatologist had recommended a specific skin care regimen, including the use of fragrance-free products and avoiding harsh soaps. However, the medical record did not show that the physician was notified of these recommendations, and the resident continued to experience severe itchiness. Another resident was not monitored every shift for at least 72 hours following a noted weight loss, as required by the facility's policy. The medical record review revealed that the resident was not monitored on specific shifts, which was confirmed by the ADON and RN. This lack of monitoring could have delayed the identification of changes in the resident's condition and the implementation of necessary interventions.
Failure to Timely Report and Address Pressure Ulcer
Penalty
Summary
The facility failed to ensure timely reporting and addressing of a new pressure ulcer for Resident 51, which was observed during a transfer to a wheelchair after a shower. The resident had an open area of approximately 2 cm on the right heel, which was not documented in the medical record. Treatment Nurse 1 was unaware of the wound, indicating a lack of communication and documentation regarding the resident's condition. CNA 1, who was assigned to Resident 51 for the first time, observed the wound during the morning shower and reported it to Treatment Nurse 2 only after lunch, which the DON acknowledged as untimely. Additionally, CNA 2, who had been assigned to the resident earlier in the week, noticed a callous on the right heel but did not report it, assuming it was not a new issue. This series of inactions and miscommunications led to a delay in treatment and intervention for the resident's pressure ulcer.
Failure to Implement Two-Person Assistance for ADL Care
Penalty
Summary
The facility failed to implement the recommended two-person assistance for Activities of Daily Living (ADL) care for a resident, which resulted in the resident experiencing another fall. The medical record review revealed that the resident had previously sustained a fall when a Certified Nursing Assistant (CNA) attempted to roll the resident in bed to place a mechanical lift sling, causing the resident to slide off the bed. Following this incident, the Fall Committee's Interdisciplinary Team (IDT) recommended two-person assistance for ADL care. Despite this recommendation, another fall occurred when a CNA was providing bedside care without assistance, and the resident began to slide off the bed. During an interview and concurrent medical record review with the Director of Nursing (DON), it was confirmed that the CNA was performing ADL care alone, contrary to the IDT's recommendation for two-person assistance.
Improper Positioning of Urinary Catheter Drainage Bag
Penalty
Summary
The facility failed to provide appropriate care and services to prevent urinary tract infections (UTIs) for a resident with an indwelling urinary catheter. During an observation, it was noted that the urinary drainage bag and tubing for the resident were positioned above the bladder, contrary to the facility's policy and procedure, which requires the drainage bag to be below the bladder to prevent UTIs and other complications. This improper positioning was confirmed by both a Certified Nursing Assistant (CNA) and a Licensed Vocational Nurse (LVN), who acknowledged that the drainage bag should be lower than the bladder. The resident in question had a care plan addressing the use of an indwelling urinary catheter for neurogenic bladder, which included specific interventions to position the catheter drainage bag and tubing below the bladder. Despite this, the drainage bag was observed to be incorrectly positioned, posing a risk for the development of UTIs. The facility's policy, revised in November 2019, clearly outlines the correct procedure for catheter drainage bag positioning, which was not adhered to in this instance.
Incorrect Enteral Formula Administered to Resident
Penalty
Summary
The facility failed to administer the correct enteral formula to a resident, identified as Resident 56, who was receiving tube feeding. The medical record review revealed a physician's order for Vital 1.5 formula to be administered at a specific rate and volume. However, during an observation and interview with an LVN, it was discovered that the resident was receiving Vital 1.2 instead of the prescribed Vital 1.5. The LVN reported that the tube feeding was held due to the resident vomiting, and upon checking, it was found that the resident had received less than the ordered calories due to the incorrect formula being used. This discrepancy had the potential to negatively impact the resident's well-being.
Failure to Provide Proper Respiratory Care
Penalty
Summary
The facility failed to provide necessary respiratory care and services for four residents, as observed during a survey. For three residents, the facility did not ensure that oxygen tubing was dated, which is a requirement according to the facility's policy. This oversight was confirmed through observations and interviews with staff, including Licensed Vocational Nurses (LVNs) and the Director of Nursing (DON). The facility's policy mandates that oxygen tubing should be replaced and dated every seven days, but this was not adhered to for Residents 83, 725, and 726. Additionally, the facility did not administer oxygen as ordered by the physician for Resident 65. The resident was observed receiving oxygen at a rate of 4 liters per minute, contrary to the physician's order of 3 liters per minute. This discrepancy was verified through an interview with an LVN, who confirmed that the oxygen administration did not match the physician's order. The resident's care plan also indicated the need for humidified oxygen as prescribed, which was not followed. These deficiencies were identified through a combination of observations, interviews, and medical record reviews. The facility's failure to date oxygen tubing and administer oxygen as ordered by the physician had the potential to put residents at risk for adverse effects due to inaccurate administration of oxygen and improper care of oxygen equipment. The facility's policies were not followed, as confirmed by multiple staff members, including the DON and respiratory therapists.
Inadequate Assessment and Documentation of Side Rail Use
Penalty
Summary
The facility failed to ensure accurate and complete assessments and evaluations for the use of side rails for three residents, leading to potential safety risks. Resident 18 was observed using 1/4 side rails for positioning, but the medical record did not show any measures or interventions attempted before implementing the side rails. The Assistant Director of Nursing (ADON) confirmed that the least restrictive measures were not evaluated, and the necessary documentation was incomplete. For Resident 41, the facility did not document evidence of the least restrictive alternatives implemented before the use of side rails. The resident requested side rails to assist with bed mobility, but the Director of Nursing (DON) verified that the facility did not offer or document any alternatives before implementing the side rails. The DON acknowledged that the interventions on the evaluation form were not appropriate for the resident, and the facility failed to implement the least restrictive alternatives. Resident 56 had an order for bilateral padded 1/4 side rails for positioning and mobility, but the resident did not respond to verbal stimulation and had no purposeful movement. The DON confirmed that the use of side rails was inappropriate for this resident, as they were unable to self-position. These failures in assessment and documentation put the residents at risk for entrapment and serious injuries.
Failure to Document and Account for Controlled Medications
Penalty
Summary
The facility failed to provide necessary pharmaceutical services by not ensuring all controlled medications were accounted for and documented properly. During an inspection of Medication Cart A, it was found that the Narcotic Count Sheet for a specific date had entries crossed out, indicating that a controlled substances count was not performed. LVN 3 admitted to filling out the row in error and confirmed that the documentation did not show that licensed staff performed the required count on that day. Additionally, there were discrepancies in the documentation of controlled medication administration for two residents. For one resident, the Medication Count Sheet showed an incomplete entry, with the time column left blank, as LVN 3 had started filling it out in anticipation of the next dose. For another resident, the count of lorazepam tablets did not match the physical count, as a dose was administered but not documented on the Medication Count Sheet. LVN 3 acknowledged these discrepancies and confirmed that documentation should be completed at the time of administration to ensure accurate counts and prevent drug diversion. The Administrator and DON were informed and acknowledged these findings.
Failure to Accurately Monitor Orthostatic Blood Pressure
Penalty
Summary
The facility failed to accurately monitor orthostatic blood pressure for a resident prescribed Zyprexa, an antipsychotic medication, for schizophrenia. The physician had ordered orthostatic blood pressure monitoring to be conducted while the resident was lying and sitting every Monday. However, the medical administration records from August to November showed identical blood pressure readings for both positions on multiple occasions, indicating that the procedure for taking orthostatic blood pressure was not followed correctly. Interviews with the Director of Nursing (DON) and a Licensed Vocational Nurse (LVN) confirmed that the orthostatic blood pressure readings should differ between lying and sitting positions. The DON acknowledged that the readings were not accurately monitored, and the LVN admitted to taking the blood pressure readings immediately after the resident changed positions, which is contrary to the facility's policy that requires a waiting period between position changes. This inaccuracy in monitoring had the potential to affect the resident's treatment and medication adjustments.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, with a reported rate of 25% due to nine medication errors out of 36 observations. During a medication pass observation, an LVN was seen administering eight medications to a resident by crushing them and mixing them with applesauce. After administration, residual medication was found in each of the eight cups, resulting in eight medication errors. Additionally, the same LVN administered dorzolamide eye drops to another resident, applying the drops only to the right eye despite the physician's order to administer them to both eyes. The LVN acknowledged the discrepancy but stated the resident preferred drops only in the right eye. However, the resident expressed a preference for drops in both eyes, leading to another medication error.
Improper Medication Storage and Disposal in Facility
Penalty
Summary
The facility failed to ensure proper storage and disposal of medications and biologicals across multiple medication carts, leading to potential risks of unsafe medication administration and cross-contamination. During an inspection of Medication Cart E, a used syringe of saline was found stored with unopened injection sites, and hydrocortisone cream was stored with safety needles. These findings were verified by RN 1, who acknowledged that the syringe should have been discarded and the cream should not have been stored with needles. In Medication Cart D, nitroglycerin sublingual tablets were improperly stored with lubricant jelly, which was confirmed by RN 1, who removed the medication from the cart. Medication Cart A had several issues, including a sharps container filled above the full line and various medications stored together despite different routes of administration. LVN 3 confirmed these findings, noting that such storage practices could lead to cross-contamination. Medication Cart C contained topical gel stored with pre-filled syringes and vials, and transdermal patches stored with oral supplements, with the latter observed in an unclean condition. LVN 5 verified these issues. Similarly, Medication Cart B had lubricant eye gel stored with heparin vials, and various medications with different administration routes stored together. These findings were confirmed by LVN 6 and the ADON. The Administrator and DON were informed of all these deficiencies and acknowledged them.
Failure to Follow Up on Abnormal Lab Results for Seizure Medication
Penalty
Summary
The facility failed to follow up with the physician regarding abnormal laboratory results for a resident with intractable epilepsy. The resident, who was readmitted to the facility, had a physician's order for divalproex sodium to manage seizure activity. A review of the resident's laboratory results showed a valproic acid level of 37 mcg/ml, which was below the reference range of 50-100 mcg/ml, and flagged as low. Despite this, the medical record did not show repeated attempts to notify the physician about the low laboratory results. The Consultant Pharmacist had previously recommended clarifying the use of valproic acid for seizures and obtaining a valproic acid level. A nursing note indicated that the nurse communicated with the physician about the low valproic acid level and recommended increasing the dose, but they were awaiting a response. During an interview, the Director of Nursing stated that the expectation for abnormal laboratory values was to make two to three attempts to notify the physician and, if unsuccessful, to contact the medical director. However, the facility's records did not reflect these actions.
Incomplete Medical Records and Documentation Failures
Penalty
Summary
The facility failed to maintain accurate medical records for four residents, leading to potential unmet care needs due to incomplete documentation. For Resident 33, there was no documentation of intravenous fluid intake every shift, despite orders to monitor intake and output. Additionally, Resident 33's refusal to be weighed was not documented, as the RNA did not know how to record the refusal in the PointClickCare system. This lack of documentation was verified by both RN 3 and the DON, who acknowledged the oversight. Resident 49's medication administration record (MAR) was incomplete, missing documentation for insulin administration, Prevacid, artificial tears, and the use of a left-hand mitten. LVN 15 confirmed the missing entries for two consecutive days, and the DON explained the process for medication administration and the importance of daily audits to capture missing documentation. The charge nurse was responsible for completing audits within 72 hours, but the missing entries were not addressed in a timely manner. For Resident 105, the hospice visitation log was incomplete, missing signatures and dates for visits by hospice staff. The DSD confirmed the missing entries and had contacted the hospice provider to address the issue. Additionally, Resident 41's updated flu vaccination consent was not filed in the appropriate medical records folder. The IP and DON both acknowledged that the consent should have been stored in the resident's medical record, but it was instead kept in a separate binder. These documentation failures were acknowledged by the facility's administration.
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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.
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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 | 1.7 mi | ★★★★★ | 21 | 0 |
| Healthbridge Children's Hospital - Orange D/p Snf | 2.3 mi | ★★★★★ | 18 | 0 |
| The Hills Post Acute | 2.8 mi | ★★★★★ | 29 | 0 |
| Orange Healthcare & Wellness Centre, Llc | 3.5 mi | ★★★★★ | 27 | 0 |
| Town & Country | 3.6 mi | ★★★★★ | 27 | 0 |
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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.