Average — CMS composite of the measures below.
The next survey window likely opens around December 2026
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 Orange Healthcare & Wellness Centre, Llc during CMS and state inspections, most recent first.
A resident with intact cognition repeatedly requested a copy of his entire medical record using the facility’s PHI access forms, but the records were not provided in accordance with the facility’s policy requiring release within two working days. The MRD forwarded the request to the corporate legal team, which later approved the release, yet the MRD did not provide the records even after approval. The DON confirmed the request and acknowledged that access was not granted until prompted by a surveyor, while the resident’s family member reported not being informed of any fees or signing any refusal, in contrast to the Administrator’s undocumented claim of verbal notification. These events led to a failure to provide timely access to the resident’s medical records.
Medication storage and labeling were not maintained as required. Pharmacy-delivered meds were left unattended at a nurse station, a medication refrigerator was found at 30 degrees F with insulin and other meds inside, and a treatment cart contained batteries, insulin syringes, and tools. Staff also found unlabeled loose meds in a med cart, dirt-like debris in storage bins, and white powder-like debris on the top of a medication refrigerator.
Kitchen Sanitation and Cooling Log Deficiencies: A stainless-steel blender was observed stored wet in the food prep area, and leftover cooked chicken was found at 43 F in the reach-in refrigerator without documentation on the cooling monitor log. The DSS verified the blender had not been air dried before storage and could not verify that the required cooling process had been followed for the chicken.
The facility failed to follow infection control practices in several areas. Its Legionella water management records did not document actual monthly pH/chlorine results or whether they were in range, and it could not produce monthly HVAC filter inspection documentation. In the laundry room, a clean linen cart had frayed edges, peeling duct tape, and a non-cleanable surface. During blood sugar checks on three residents, an LVN cleaned the glucometer with a 70% alcohol pad instead of using the disinfecting wipes identified by the facility and manufacturer.
A resident with cognitive impairment was observed with a loose tablet and an unlabeled bottle of mixed tablets at the bedside, and he stated he self-administered supplements brought in by his wife. The chart had no self-administration assessment or physician order, and staff could not identify the contents of the bottle when questioned by the LVN and DON.
Failure to provide an individualized activity program: A resident who could make his own decisions reported that activities were not meaningful to him and that activity staff did not come to his room. His activity eval showed interests in fishing, golf, music, trivia, movies, and reading, but the activity record documented only six 1:1 contacts over several weeks, mostly books/reading and trivia, with no refusals noted. The AD stated the resident rarely attended activities and that staff room visits were not being checked, while an Activity Asst said the resident should have been visited more often and was unsure what happened.
A resident with a PICC line was admitted with an order for weekly arm circumference and external catheter measurements, but the admission measurements were not documented. RN staff stated these measurements are obtained for newly admitted residents with PICC lines and help identify catheter issues, yet the record did not show the required admission PICC line measurements were completed.
A resident with an order for shift pain checks and NPI documentation had repeated MAR entries showing pain level 0 and NA for NPI, even though PRN Percocet was given multiple times for reported pain levels of 7 to 9. The DON confirmed nurses were supposed to chart the highest pain level for the shift and document all NPIs before PRN pain meds, and verified the entries were incorrect except for one evening shift.
A facility failed to provide adequate night-shift staffing and timely response to call lights, resulting in delayed assistance with toileting, transfers, incontinence care, and colostomy care for multiple residents. Cognitively intact residents reported waiting from more than 25 minutes to nearly 3 hours for help, while staff described being overwhelmed, having too many residents to care for, and not always answering call lights promptly.
A resident's ordered insulin was not available when needed after admission, and the DON verified it should have been available for the scheduled dose. In addition, an IV E-kit in Medication Room A was not replaced within the required timeframe after use, and an RN accessed the kit for a new admission but did not complete the pharmacy log, leaving the emergency medication supply inaccurately accounted for.
Menu items were not followed for two residents. One resident with a renal, CCHO diet and Type II DM was served a tray that included wheat rolls even though the menu indicated CCHO residents should not receive them. Another resident’s lunch tray did not include a green salad listed on the menu, and CNA 3 verified the salad was missing.
A resident receiving hospice services had missing hospice visit calendars in the chart, the facility plan of care did not incorporate the hospice care plan, and the hospice morphine order was not accurately reconciled. The hospice medication list ordered morphine concentrate 20 mg/mL at 5 mg q2h PRN for SOB and pain, but the facility order reflected a different concentration that would have delivered only 1 mg per 0.25 mL.
A CNA assigned to supervise two residents on high observation was found asleep in the room with her head down on a nightstand, while a privacy curtain blocked visual observation of one resident. The CNA stated she was asleep and could not maintain a visual of the resident with the curtain closed. RN and DON interviews confirmed staff watching residents on high observation were expected to keep both residents in view and not sleep while providing supervision; both residents had recent falls and were placed on high observation after admission.
Failure to Provide Transfer and Bed Hold Notices: A resident with capacity was transferred to an acute care hospital after confusion, agitation, tachycardia, AKI, UTI, and sepsis. The transfer/discharge notice identified the hospital and stated the resident's needs could not be met, but the record did not show a resident or rep signature, written notice to the resident or rep, or a copy sent to the Ombudsman. The facility also could not show that the bed hold policy was provided in writing at the time of transfer, despite a signed bed hold agreement on file.
A resident’s baseline care plan failed to include the removal of an indwelling urinary catheter and the ordered monitoring for urinary retention after catheter discontinuation. The resident had a physician order for 72-hour bladder monitoring, reported difficulty voiding after the catheter was removed, and the DON verified that staff were to monitor for retention, discomfort, and distention, but these interventions were not included in the baseline care plan.
A resident with a left arm AV shunt had a physician order for no BP checks on that arm, but the BP log repeatedly documented readings as taken from the left arm. The DON verified the order and the inaccurate documentation, and the resident stated nurses always used the right arm for BP checks.
Arbitration Agreement Not Properly Explained to Residents Without Capacity: Two residents with no capacity to understand and make decisions signed Arbitration Agreements that waived the right to a jury or court trial. The Admission Director verified the residents lacked capacity and stated staff should have contacted their representatives to explain the agreement; the Administrator and DON acknowledged the findings.
The facility failed to implement its QAPI plan and a prior POC for F694 related to PICC line care. The accepted POC required the DON to in-service RNs on measuring external PICC catheter length on admission, review residents with PICC lines for compliance, and report findings to the QA committee, but the QAPI binder did not show these interventions were completed, as verified by the Administrator.
A resident's pressure ulcer progressed from Stage 3 to Stage 4 with muscle exposure, and the physician was not notified of this significant change in condition as required by facility policy. The DON confirmed that the health record lacked documentation of physician notification regarding the change in the pressure ulcer's stage.
Two residents' call lights were not answered in a timely manner despite being audible at the nurses station and observed by staff, resulting in delays of up to 20 minutes before assistance was provided. Staff interviews confirmed awareness of the call lights and the expectation for prompt response, but the facility's policy was not followed.
Licensed nurses did not document their initials on the TARs after providing prescribed skin treatments to two residents, resulting in incomplete and inaccurate medical records as required by facility policy. The DON confirmed that documentation was missing for several dates on the evening shift.
Staff failed to follow infection control protocols, including an LVN not wearing a gown during wound care for a resident with a stage four pressure injury under Enhanced Barrier Precautions, and another LVN wearing PPE in the hallway after preparing to enter a COVID-19 isolation room. These actions were not in accordance with facility policy and were confirmed by facility leadership.
A resident reported physical abuse by a CNA, but instead of being suspended as required by facility policy, the CNA was reassigned to a different duty during the investigation. Staff interviews confirmed the CNA remained on duty, and the Administrator acknowledged the failure to follow protocol.
The facility failed to maintain infection control practices, as staff neglected hand hygiene during wound care. A nurse did not wash hands before treating a resident's wound, and another nurse and CNA failed to perform hand hygiene before applying barrier cream and accessing clean linens. Both staff members acknowledged their lapses, and the facility's IP and DON confirmed the importance of hand hygiene to prevent disease transmission.
A resident with dysphagia did not receive oral care every shift as ordered, with care only provided during day and evening shifts on specific dates. Observations confirmed the resident's mouth was dirty, and the lips were dry with white patches. The facility's LVN, RN, and DON acknowledged the failure to adhere to the three-shift oral care requirement.
The facility failed to prevent UTIs for two residents with urinary catheters by improperly positioning drainage bags on their beds, visible from public areas, and not covering them with dignity bags. Additionally, staff did not monitor one resident's urine color, which was dark yellow-brown, contrary to facility policy requiring regular assessment of urinary output. The DON and a treatment nurse confirmed these deficiencies.
Two residents' medical records were found incomplete due to missing documentation in the TAR for assessments and care related to urinary drainage and Foley catheter maintenance. These omissions occurred on multiple dates and were confirmed by a treatment nurse and the DON.
A facility failed to report the results of an investigation into possible financial abuse of a resident by a family member within the required five working days. Despite the facility's policy, the investigation remained incomplete beyond the mandated timeline, posing a risk of unaddressed abuse. The resident involved had severe cognitive impairment, and the delay in reporting was confirmed by the DON and Administrator.
A facility failed to develop a care plan for a resident at risk of financial abuse by a family member, despite being informed of an investigation. The resident had severe cognitive impairment and lacked decision-making capacity, yet no care plan was documented to address this risk. The DON confirmed the absence of a care plan during a review.
Two residents' rooms in the facility were found to have peeling paint above the headboards, compromising the homelike environment. Observations confirmed by an LVN and a CNA revealed the deficiency, which was acknowledged by the DON, who noted that maintenance should be notified to fix the issue.
The facility failed to follow its policy and procedures for bed rail use, affecting five residents. Staff did not attempt alternative measures, obtain informed consent, or complete necessary assessments and care plans. This oversight was confirmed through staff interviews and medical record reviews.
The facility failed to ensure proper medication storage and temperature control in three medication rooms. Syringes for a discharged resident were not discarded, and oral medications were improperly stored with external patches. Refrigerator temperatures were significantly above the required range, risking medication efficacy. Staff confirmed the issues, and temperature checks were not consistently logged.
The facility failed to follow food safety and sanitation guidelines, including a lack of backflow prevention in a food prep sink, unclean drying racks, and improper storage of perishable food in a resident's room. These issues were confirmed by staff and posed a risk of contamination for 83 residents consuming food from the kitchen.
The facility failed to maintain an accurate infection control surveillance program, only including residents prescribed antimicrobial medications. In the laundry room, personal items were found on a clean table, violating infection control practices. Additionally, an RN entered a COVID-19 isolation room without wearing an N95 mask, despite knowing the requirement. These deficiencies were acknowledged by staff.
The facility failed to inform physicians when residents were prescribed antibiotics without meeting McGeer's Criteria for a true infection. The Infection Preventionist did not document whether the criteria were met or notify physicians to reassess the need for antibiotics. Monthly reports showed cases of unnecessary antibiotic prescriptions, and the Director of Nursing acknowledged incomplete documentation.
The facility failed to conduct accurate entrapment assessments for residents using bed rails, as required by FDA guidelines. Six residents were observed with grab bars installed without proper documentation of entrapment assessments, potentially leading to serious injury or death. The Maintenance Director admitted to not measuring or documenting entrapment zones for grab bars, and the DON was informed of these findings.
A resident with an indwelling urinary catheter was observed with the collection bag not placed inside a privacy bag, compromising dignity. A CNA confirmed the oversight, and the DON acknowledged the expectation for privacy bags to be used for all catheter collection bags.
The facility failed to ensure call lights were within reach for five residents, as required by their policy. Observations showed call lights were inaccessible for several residents, with staff confirming these findings. The DON acknowledged the issue, but no corrective actions were mentioned.
The facility failed to provide and maintain documentation of advance directives for several residents, as required by policy. This included not obtaining copies of existing directives and not offering information on formulating directives to residents or their representatives. These deficiencies were identified through interviews and medical record reviews, highlighting a lack of systematic follow-up and documentation.
The facility failed to maintain proper IV access and medication labeling for two residents. One resident's PICC line measurement was not documented upon admission, and another resident's IV antibiotic bag was unlabeled. These oversights were confirmed by staff and violated the facility's policies.
The facility failed to provide appropriate respiratory care for several residents, including undated and improperly stored oxygen and nebulizer equipment. Observations revealed that oxygen tubing was left on the floor, nebulizer masks were not stored in setup bags, and CPAP equipment was improperly handled. These actions were contrary to the facility's policy, which requires proper labeling and storage of respiratory equipment. The Director of Nursing confirmed these expectations, highlighting deficiencies in respiratory care practices.
A resident receiving Norco for pain management was not monitored for side effects, and non-pharmacological interventions were not consistently provided. Despite the facility's policy, these interventions ceased after a reassessment, and no side effect monitoring was ordered or conducted.
The facility failed to ensure proper accounting and safeguarding of controlled medications, as evidenced by missing signatures from both incoming and outgoing licensed nurses on the controlled drugs count record for Medication Carts 1 and 3. This deficiency was confirmed by the DON and indicates non-compliance with the facility's protocols for medication accountability.
A facility failed to monitor a resident's orthostatic blood pressure as ordered by the physician for a resident on risperidone, an antipsychotic medication. The medical records showed inconsistent documentation of blood pressure readings, with some marked as 'NA' without explanation. Interviews with the LVN and DON confirmed that the readings should have been obtained and compared to prevent potential adverse complications.
A resident was served Brussels sprouts and low-fat milk despite documented preferences for nonfat milk and a dislike for Brussels sprouts. The discrepancy was confirmed by an MDS Coordinator, who took steps to rectify the situation. The DON acknowledged the failure to honor the resident's preferences.
The facility failed to educate staff and visitors on safe food handling practices for food brought from outside, risking residents' exposure to foodborne illnesses. Interviews revealed that staff, including an RN and the DON, were unaware of or had not received training on these practices, and the DSD confirmed no training had been conducted.
The facility failed to maintain essential kitchen equipment and a low air loss mattress in proper working condition. The ice machine was unclean, with a damaged rubber strip and residue, and the walk-in freezer floor was not cleanable. A resident's low air loss mattress pump malfunctioned with a muted alarm, unnoticed by staff. These issues highlight lapses in equipment maintenance and monitoring.
A facility failed to document a medication reconciliation for a resident upon discharge, as required by its policies. The resident's medical records lacked evidence of a completed reconciliation, which was confirmed by the MDS Coordinator during a review. This oversight risked discrepancies in medication orders, potentially impacting the resident's well-being.
The facility failed to maintain accurate and complete POLST forms for two residents. One resident's POLST was incomplete, lacking information on an advance directive or health care agent. Another resident's POLST was outdated, not reflecting an executed advance directive. The SSD acknowledged these issues, and the DON confirmed the need for immediate updates.
The facility failed to provide written notification of room changes to two residents, violating their rights. Despite the facility's policy requiring written notice, staff only informed residents verbally. One resident lacked the capacity to make decisions, and the other was not given written notice, highlighting a failure in adhering to established procedures.
Failure to Provide Timely Access to Requested Medical Records
Penalty
Summary
The facility failed to implement its policy to provide timely access to medical records for one of three sampled residents, resulting in a violation of the resident’s right to access his records. The facility’s policy, revised 11/1/15, required the HIPAA Privacy Officer to provide a copy of the medical record within two working days after receiving a written request. A cognitively intact resident, with a BIMS score of 13, submitted a written request on 1/29/26 for a copy of his entire chart, documented on a “Resident Request for Access to Protected Health Information” form as a second request. A corresponding “Resident Records Request Intake” form from the same date indicated that the resident’s family had raised concerns. The resident reported in interview that he had signed several request forms since 1/2026 and submitted them to the Medical Records Director (MRD), but had not received the requested records after several months. The MRD confirmed that the resident requested his whole chart on 1/29/26 and stated that facility practice was to provide requested records within 48 to 72 business hours. After receiving the 1/29/26 request, the MRD sent it to the corporate legal team for review, noting there was no defined timeframe for legal review. An email from the corporate legal team’s Health Information Specialist dated 3/31/26 showed the request was approved for release, but the MRD acknowledged that he still did not provide the records to the resident. The DON verified the resident’s request and stated that the facility could not deny residents access to their medical records, acknowledging that the records were not provided until the surveyor’s investigation. The resident’s family member reported not being informed of any required fees and not signing any form declining to pay such fees, while the Administrator stated she had verbally informed them of required fees but had no documentation of their refusal to pay. These actions and inactions resulted in the resident not receiving timely access to his requested medical records in accordance with facility policy.
Medication Storage and Labeling Deficiencies
Penalty
Summary
Medication storage practices were not followed at Nurse Station A when a pharmacy delivery containing 19 medication bubble packs, a large paper bag with a medication list, and three additional pharmacy bags was left on the nurse station counter unattended. RN 1 was observed leaving the area to assist a CNA while the medications remained unsecured, and a housekeeping staff member and a resident were nearby. LVN 4 later identified the items as the pharmacy delivery that had arrived earlier that morning, and RN 1 confirmed the medications should have been secured in the medication room until licensed staff could place them in the medication carts. Medication Room A’s refrigerator was found to be at 30 degrees Fahrenheit during two separate observations, which was below the facility’s stated acceptable range of 36 to 46 degrees Fahrenheit. The refrigerator contained Humulin R, insulin lispro, Lantus Solostar, and Veltassa powder, all of which had manufacturer-recommended storage temperatures of 36 to 46 degrees Fahrenheit. RN 2 confirmed the temperature was too low and verified the finding during both observations. Additional storage issues were identified with Treatment Cart A, Medication Cart A, Medication Refrigerator A, and Medication Cart B. Treatment Cart A contained batteries, insulin syringes, and miscellaneous tools in a storage bin, and staff stated those items belonged in central supply. Medication Cart A contained five cups of pre-poured loose medications that were unlabeled, and staff could not account for all of the medications. The same cart also had brownish dirt-like debris in a storage bin. Medication Refrigerator A had white powder-like debris on the top exterior surface, and Medication Cart B had dirt-like debris in a storage bin holding Coban and other items.
Kitchen Sanitation and Cooling Log Deficiencies
Penalty
Summary
The facility failed to ensure sanitary requirements were met in the kitchen when a stainless-steel blender was observed stored wet in the food preparation area. During the observation, the blender lid was opened and the blender was found to still contain moisture. The DSS verified the observation and stated the kitchen staff should have air dried the blender before storing it. The facility also failed to safely handle Time Temperature Control for Safety foods when leftover cooked chicken was found in the reach-in refrigerator at 43 F. The chicken had been dated the previous day, but the cooling monitor log did not document the cooling down process for that chicken. The DSS verified that the temperature should have been less than 41 F and could not verify that the required cooling process had been followed because no cooling documentation was available. The chicken was discarded, and the Administrator and DON were informed of the findings.
Infection Control Failures in Water Management, Laundry Equipment, and Glucometer Cleaning
Penalty
Summary
The facility failed to follow its infection prevention and control practices related to water management, laundry equipment, and blood glucose monitoring. The facility's Legionella Water Management Plan required monthly measurement of disinfectant residual and pH, and monthly inspection of HVAC filters, but the monthly pH/chlorine log only showed checkmarks and did not document the actual results or whether they were within an acceptable range. The facility's electronic maintenance logbook showed HVAC filters were changed quarterly, but documentation could not be located to show the filters were inspected monthly as required by the plan. In the laundry room, a wheeled clean linen cart used to transport clean dry linen from the dryer to the folding table had frayed edges, torn areas, and peeling layers of duct tape, and the Director of Maintenance verified the cart surface was not cleanable. For blood glucose monitoring, a medication administration observation showed an LVN cleaned the glucometer used on three residents with a 70% alcohol pad after use. The facility's policy required cleaning the device after each use per the manufacturer's instructions, and the manufacturer required cleaning and disinfection with validated wipes; the IP stated the glucometers must be cleaned and disinfected using Super Sani-Cloth wipes.
Unassessed Self-Administration of Unlabeled Medications
Penalty
Summary
The facility failed to ensure one resident was safe to self-administer medications. Resident 104 was observed in bed with one loose medication tablet and a white unlabeled medication bottle containing various medication tablets on the bedside table. The resident stated the medications in the bottle were supplements brought in by his wife and that he administered them himself. The facility’s policy required a resident to be assessed for self-administration, have physician approval documented, and have a written physician’s order before beginning self-administration, but no such assessment or order was found in the resident’s record. Resident 104’s medical record showed a history of cognitive impairment with no capacity to understand and make decisions. During interviews, LVN 3 stated she did not know where the loose tablet came from or what medications were in the unlabeled bottle, and she had been in the room earlier to administer medications without questioning the bottle. The DON later opened the unlabeled bottle and was unable to verify its contents, and stated the resident’s wife sometimes brought in supplements without notifying staff and that the facility had discussed this with her before.
Failure to Provide Individualized Activity Program
Penalty
Summary
The facility failed to provide an individualized and ongoing activity program to meet the needs and interests of one resident, Resident 20, in accordance with the comprehensive assessment and the resident’s physical, mental, and psychosocial well-being. The facility’s Activities Program policy stated that the activity program is designed to meet each resident’s needs, interests, and preferences and to support the highest attainable social, physical, and emotional functioning. During an initial tour, Resident 20 stated that activities were “a joke,” that music was offered only one to two times a week, that the music was not what he liked, and that activity staff did not come to his room. He also stated that the activity calendar posted in his room was likely only there to satisfy state guidelines. Medical record review showed Resident 20 was admitted to the facility and could make his own decisions. His activity evaluation documented preferences including fishing, golf, pop, country, and rock and roll music, news, sports, weather, talk shows, trivia and game shows, comedy movies, and reading non-fiction, fiction, and biology books. The quarterly activity progress note stated that activity staff would encourage, assist, and remind him to join group activities of interest and provide room rounds with activity materials and socialization as needed or tolerated. The activity look-back report showed only six documented activity contacts from 11/18/25 through 1/3/26, including 1:1 participation with books/reading materials and education/current topics/trivia, with no refusals documented. The Activity Director stated the resident hardly came to activities and was visited three times a week, but also stated she was not checking activity staff to ensure room visits were completed and was only hoping staff knew the resident’s plan of care. An Activity Assistant stated she conducted room visits on a set schedule and verified the look-back report, but said the resident should have been visited two to three times a week and was not sure what had happened.
PICC Line Admission Measurements Not Completed
Penalty
Summary
The facility failed to obtain the appropriate admission PICC line measurements for one resident who had a PICC line for IV access. The resident was admitted with an order to measure the arm circumference and PICC line external catheter lumens weekly, and the IV Administration Record showed a box for the measurements to be completed on the admission date, but that box was not completed. The medical record did not show that the resident’s arm circumference and external catheter length measurements were completed upon admission. During interview and concurrent record review, an RN stated that arm circumferences and PICC line external catheter length measurements were obtained for all newly admitted residents with PICC lines upon admission and weekly thereafter. Another RN stated that changes in these measurements help identify central line catheter issues, such as tubing migration. The RN verified that the resident’s medical record did not show the admission PICC line arm circumference and external catheter length measurements were obtained.
Inaccurate pain scoring and missing NPI documentation for PRN analgesic use
Penalty
Summary
The facility failed to provide appropriate pain management for Resident 11 by inaccurately documenting the resident’s pain level on the MAR and failing to document nonpharmacological interventions before administering PRN Percocet. The resident had a physician’s order dated 10/2/25 to have pain assessed every shift on a 0-10 scale and to document the NPI provided. Review of the January 2026 MAR showed repeated entries of pain level 0 with “NA” for NPI on multiple shifts, even though PRN Percocet 5-325 mg, two tablets at a time, was administered during those same shifts for reported pain levels ranging from 7 to 9. The record showed this pattern on day, evening, and night shifts from 1/1/26 through 1/7/26, with only one shift noted by the DON as having documentation that reflected NPI use prior to PRN administration. During the 1/7/26 interview and concurrent record review, the DON stated nurses should document the highest pain level for the entire shift and all NPIs implemented before giving PRN pain medication. The DON verified that the documented 0 pain levels and “NA” entries were incorrect and that the record did not show NPIs were implemented before the PRN Percocet was given, except for the evening shift on 1/2/26.
Delayed Night Shift Response to Call Lights and Resident Assistance
Penalty
Summary
The facility failed to ensure adequate staffing during the 2300 to 0700 shift to meet the physical and psychosocial needs of residents, including timely response to call lights and assistance with toileting and transfers. The report states that the facility did not ensure Resident 20’s call light was answered in a timely manner for assistance with toileting and transfers between the bed and bathroom during the early morning hours, and that Residents 43 and 81 also did not receive timely staff assistance during the night shift. The facility’s staffing policy stated that nursing personnel were to be available in sufficient numbers to meet resident needs and that scheduling would be done as needed to meet those needs. Resident 81, who was cognitively intact and required staff assistance with ADLs, reported that after admission he was left without assistance overnight and later experienced a delay of nearly three hours after pressing the call button for help changing a wet incontinence brief. Resident 43, who was cognitively intact and dependent on staff for ADLs, reported waiting more than an hour for nighttime assistance and described one incident in which a full colostomy bag caused pain while waiting more than 25 minutes for staff to respond. Resident 118, who had a recent indwelling urinary catheter removal and was being monitored for urinary retention, stated she had difficulty voiding and feared incontinence because staff took 15 to 20 minutes to respond to her call light for toileting assistance. Resident 20, who could make his needs known and make his own decisions, stated he used the call light for help in the bathroom but staff did not come, so he self-transferred back to bed. He also stated there was only one CNA available because the other was on break. CNA 4 later confirmed that Resident 20 had requested toileting assistance multiple times during the shift, and CNA 5 stated staff usually did not wait to answer call lights because the sound was annoying and they checked residents to see if the call light was on. RN 1 stated the facility had 88 residents for two LVNs, five CNAs, and two 1:1 sitters on the night shift, and that residents complained about call light response time.
Medication Availability and IV E-kit Accounting Deficiencies
Penalty
Summary
The facility failed to ensure medications were available and administered as ordered for one resident. Resident 116 had a physician order dated 12/31/25 for Novolog to be given subcutaneously before meals and at bedtime per sliding scale. The resident was admitted at 1841 hours on 12/31/25, but the MAR showed a blood sugar of 200 mg/dl at 0630 hours on 1/1/26 with the entry coded as "9" for other/see progress notes. The progress note at 0646 hours on 1/1/26 showed the Novolog insulin was still pending delivery more than 11 hours after admission. The DON reviewed the record and verified the ordered insulin should have been available for the 0630 dose, and stated that if the ordered insulin was not available in the E-kits, the nurse should have contacted the physician for a temporary order for one of the available insulins until the pharmacy supply arrived. The facility also failed to manage the IV E-kit in Medication Room A according to policy and to accurately account for its use. Facility policy stated emergency medication kits were to be re-sealed after use and replaced within 72 hours of opening. On 1/8/26, the IV E-kit log showed the kit had been accessed on 1/2/26 and replaced by pharmacy on 1/6/26, which was beyond the 72-hour timeframe. The kit still had a yellow lock, and RN 2 stated that indicated it had been accessed and needed replacement. RN 2 and RN 1 determined RN 1 had accessed the kit on the previous shift to start an IV infusion for a new admission but did not complete the IV E-kit pharmacy log. The DON verified these findings.
Menu Items Not Followed for Two Residents
Penalty
Summary
The facility failed to ensure menus were followed for two residents receiving meals from the kitchen. For Resident 62, the facility's Winter Menus dated 1/7/26 showed that residents on a CCHO and renal diet were to receive oven crisp fish with tartar sauce, salt free french fries, ketchup, seasonal carrots, apple hill cake, and milk, and that residents on a CCHO diet were not to receive a wheat roll. Resident 62's diet ticket showed a renal, CCHO, regular texture diet, and also noted dislikes of cold cereal and fish. During tray line observation and concurrent interview with the DSS, the tray prepared for Resident 62 contained seasoned carrots, chicken, brown rice, apple hill cake, milk, and wheat rolls. The DSS verified the tray was ready to be served and confirmed that Resident 62 should not have received wheat rolls per the winter menus. Resident 62's medical record showed diagnoses including Type II Diabetes. For Resident 68, the January menu dated 1/6/26 listed lunch as pork chops with pear sauce, polenta, seasoned broccoli, a green salad with dressing, and a cranberry crunch bar. During observation and concurrent interview, Resident 68 was eating lunch in his room and his tray did not include a green salad. Resident 68 stated he was not sure what was on the lunch menu but would have liked a green salad. The resident's lunch tray ticket did not list the menu items but did include dislikes, which did not show salad. CNA 3 verified there was no green salad on the tray per the menu.
Hospice care plan and medication order reconciliation deficiencies
Penalty
Summary
The facility failed to provide the necessary care and services to ensure one of one final sampled resident receiving hospice services attained and maintained highest practicable well-being. Resident 100 was admitted to Hospice A under routine level of care and had physician orders for hospice-related care, including morphine sulfate for pain management. However, the resident's medical record did not contain the Hospice A visit calendar for December 2025 and January 2026, so the schedule of hospice visits was not available in the chart. The resident's plan of care also did not show that Hospice A's care plan had been incorporated into the facility plan of care, and the physician's orders were not accurately reconciled from the hospice medication list. The hospice medication list showed morphine concentrate 20 mg/mL with an order to administer 5 mg every two hours as needed for shortness of breath and pain, but the facility order reflected 20 mg per 5 mL, meaning 0.25 mL would provide only 1 mg instead of 5 mg. LVN 7 stated this discrepancy could lead to poor pain control for Resident 100. The Administrator and DON were informed and acknowledged the findings.
Inadequate Supervision for Two Residents on High Observation
Penalty
Summary
The facility failed to ensure adequate supervision for two residents who were on high observation after recent falls. During a tour, CNA 1 was observed inside the residents’ room with her head down on the nightstand next to one resident’s bed while the privacy curtain was closed, preventing visual observation of the other resident. The surveyor knocked on the wall to wake CNA 1 without success and then contacted RN 1, who entered the room and tapped CNA 1 on the arm before CNA 1 sat up and stood to speak with the surveyor. CNA 1 stated she was asleep and said she had been assigned to supervise the two residents because they were trying to get out of bed unassisted; she also stated she could not maintain a visual of one resident with the curtain closed. The medical record review showed one resident had been admitted with capacity to understand and make decisions and had been sent to the ER for evaluation after a fall, while the other resident was also able to make their own decisions and had a documented fall shortly after admission. RN 1 stated staff assigned to watch two residents on high observation should sit where both residents could be seen or keep the curtain open, and that they were not supposed to be sleeping while watching the residents. The DON and Administrator both stated the residents were on high observation because they had fallen on the day they were admitted, and that staff assigned to high observation should be doing frequent checks and should never be sleeping.
Failure to Provide Transfer, Bed Hold, and Ombudsman Notices
Penalty
Summary
The facility failed to provide required transfer and discharge documentation for Resident 7 when the resident was transferred to an acute care hospital. The resident was admitted to the facility and later readmitted, and the medical record showed the resident had capacity to understand and make decisions. A physician order dated 1/2/26 directed transfer to the hospital for confusion, agitation, and tachycardia, with a seven-day bed hold if admitted. Progress notes documented that the resident was transferred to the acute care hospital on 1/2/26 and was admitted there with acute kidney injury, urinary tract infection, and sepsis. The Notice of Proposed Transfer and Discharge form dated 1/2/26 identified the acute care hospital as the transfer location and stated the reason for transfer was that the resident's welfare and needs could not be met in the facility. However, the form did not show any resident or representative signature, and the medical record did not show that a written notice of transfer/discharge was provided to the resident or representative at the time of transfer. The record also did not show that a copy of the notice was sent to the Ombudsman. The facility also failed to document that the bed hold notice was provided in writing when the resident was transferred. The resident's bed hold agreement, signed by the representative on admission, stated the facility would hold the bed for up to seven days if the resident was transferred to a general acute care hospital or went on therapeutic leave, with certain notification and payment terms. During interview, RN 3 verified the resident was transferred to the hospital, confirmed the transfer/discharge notice lacked a resident or representative signature, and stated she could not find documentation showing the bed hold policy was provided in writing at transfer. The Medical Records Director verified the facility did not mail the written transfer/discharge notice or bed hold notice to the resident or representative, and the Administrator and DON acknowledged the findings.
Baseline Care Plan Missing Catheter Removal and Bladder Monitoring
Penalty
Summary
The facility failed to develop a baseline care plan for Resident 118 within 48 hours of admission. The baseline care plan did not include the resident’s indwelling urinary catheter removal or the interventions in place to monitor bladder function after the catheter was discontinued. Facility policy stated the baseline care plan must include the minimum information necessary to properly care for each resident, including resident-specific health and safety concerns, and the facility’s indwelling catheter policy stated the care plan would be updated as necessary after catheter removal. Resident 118 was admitted to the facility and had a physician’s order to monitor for signs and symptoms of urinary retention for 72 hours after indwelling urinary catheter removal. The baseline care plan reviewed for the resident did not address the catheter discontinuation or monitoring for urinary retention. During interview, the resident stated the catheter had been removed the previous morning and that she had a hard time voiding and had difficulty getting used to holding urine and rushing to the toilet when she felt the urge to void. The DON reviewed the record and verified that the catheter had been discontinued and that staff were to monitor for bladder retention, discomfort, and distention for 72 hours, and also verified that the baseline care plan failed to address these interventions.
Inaccurate Blood Pressure Documentation for Resident With Left Arm AV Shunt
Penalty
Summary
The facility failed to maintain an accurate medical record for one sampled resident who had dialysis-related care needs. Resident 5 had a physician order dated 11/28/25 for no blood pressure checks on the left arm because of a left arm AV shunt. However, the resident’s blood pressure log documented multiple blood pressure readings as being obtained from the left arm on 12/17/25, 12/18/25, 12/25/25 twice, 12/26/25, 1/1/26, and 1/5/26. During interview and record review, the DON verified that the resident had a left arm AV shunt and that blood pressure readings should not be checked on that arm. The resident stated that nurses always checked blood pressure on the right arm because the AV shunt was on the left arm.
Arbitration Agreement Not Properly Explained to Residents Without Capacity
Penalty
Summary
The facility failed to ensure the Arbitration Agreement was explained in a form, manner, and language understood by residents or their representatives for two residents reviewed. Resident 23's medical record showed an H&P dated 11/2/25 stating the resident had no mental capacity to understand and make decisions, and an MDS dated [DATE] showing severe cognitive impairment. Despite this, the Arbitration Agreement dated 8/12/25 contained Resident 23's signature and stated that by signing, the resident agreed to have claims decided by arbitration and gave up the right to a jury or court trial. Resident 72's medical record showed an H&P dated 10/12/25 stating the resident had no capacity to understand and make decisions, yet the Arbitration Agreement dated 10/24/25 contained Resident 72's signature and stated that by signing, the resident agreed to have any issue of medical malpractice decided by neutral arbitration and gave up the right to a jury or court trial. During an interview and concurrent document review on 1/9/26, the Admission Director verified that both residents had no capacity to understand and make decisions to sign the Arbitration Agreement and stated facility staff should have contacted the residents' representatives to explain the agreement. The Administrator and DON were later informed and acknowledged these findings.
Failure to Implement QAPI Plan and Prior PICC Line POC
Penalty
Summary
The facility failed to implement its QAPI plan and its prior Recertification Survey POC for F694. The accepted 2024 Recertification Survey POC required the DON to in-service RNs on measuring the external PICC line catheter length on admission, review residents with PICC lines to ensure RNs were measuring the external catheter length on admission, and report any findings related to PICC line care to the QA committee monthly for three months. During review of the facility’s QAPI binder with the Administrator, the binder did not show that these POC interventions had been completed, and the Administrator verified the findings.
Failure to Notify Physician of Pressure Ulcer Progression
Penalty
Summary
The facility failed to notify the attending physician of a significant change in a resident's condition, specifically when a pressure ulcer progressed from Stage 3 to Stage 4. According to the facility's policy, the physician must be notified of any significant change in a resident's condition, including changes in pressure ulcer staging that require medical assessment and potential changes in the treatment plan. Review of the resident's health record showed that the pressure ulcer on the right gluteus was documented as Stage 3 on one date and then as Stage 4 with muscle exposure on a subsequent date. The wound consultant performed debridement, and the ulcer was reclassified as Stage 4. Despite these changes, there was no documentation that the physician was notified of the progression from Stage 3 to Stage 4. During an interview and concurrent record review, the DON confirmed that the physician should have been notified of the change in the pressure ulcer's stage and verified that the health record did not show such notification. This failure to notify the physician was identified for one of five sampled residents.
Failure to Promptly Respond to Resident Call Lights
Penalty
Summary
The facility failed to provide reasonable accommodations to meet the care needs of two out of thirteen sampled residents by not ensuring that their call lights were answered in a timely manner. Observations revealed that for one resident with severe cognitive impairment who required substantial to maximum assistance with activities of daily living, the call light was activated and audible at the nurses station, but two staff members passed by the room without responding. The resident began screaming and was not assisted until 20 minutes later, when a CNA responded and confirmed the resident needed to be changed. In a separate incident, another resident activated the call light, which was also audible at the nurses station where two LVNs were present. An RNA passed by the room without responding, and the call light remained unanswered for 20 minutes until a CNA responded to remove the resident's lunch tray. Interviews with the involved staff confirmed they heard the call light but did not respond promptly, despite acknowledging that call lights should be answered right away. The facility's policy required prompt response to call lights, but this was not followed in these instances.
Failure to Document Treatments on TARs for Two Residents
Penalty
Summary
The facility failed to maintain accurate and complete medical records for two residents by not ensuring that licensed nurses documented their initials on the Treatment Administration Records (TARs) after providing prescribed treatments. For one resident, the TAR for July did not show documentation that the evening shift nurse performed the ordered sacrum cleansing and application of barrier cream on four specific dates. For another resident, the TAR lacked documentation for the cleansing and barrier cream application to the sacrococcyx and buttocks on two dates during the evening shift. These omissions were identified through medical record review and confirmed by the Director of Nursing (DON). The facility's policy and procedure required that medical records be completed and corrected in a standardized manner, with entries recorded promptly as events occur. The DON verified that after providing treatment, licensed nurses are expected to document the care provided in the resident's medical record. The absence of nurse initials on the TARs indicated that the required documentation was not completed as per facility policy, resulting in incomplete and potentially inaccurate medical records for the affected residents.
Failure to Follow Infection Control Practices During Wound Care and PPE Use
Penalty
Summary
The facility failed to ensure proper infection control practices were followed as outlined in its own policies and procedures. During wound care for a resident with a stage four pressure injury, an LVN did not wear a gown as required under Enhanced Barrier Precautions (EBP), despite signage and supplies being available at the resident's door. The LVN confirmed awareness that the resident was on EBP for a wound but still did not don the appropriate personal protective equipment (PPE) during the procedure. In a separate incident, another LVN was observed wearing PPE in the hallway after preparing to enter a resident's room under COVID-19 isolation but did not enter the room, instead proceeding to the medication room while still wearing PPE. Facility policy specifies that gowns and gloves should not be routinely worn in the hallway and should only be donned immediately before high-contact care tasks. Both the Infection Preventionist and the Administrator confirmed these observations and acknowledged that the correct infection control practices were not followed.
Failure to Suspend Staff Following Abuse Allegation
Penalty
Summary
The facility failed to follow its abuse protocol during the investigation of an alleged physical abuse incident involving a resident and a CNA. According to the facility's policy, any staff member accused of abuse must be suspended and removed from the premises during the investigation. However, after a resident reported an allegation of physical abuse by a CNA to an LVN during the night shift, the CNA was not suspended but was instead reassigned to a different assignment for the remainder of the shift. The facility's investigation documents did not show evidence that the CNA was suspended immediately after the allegation was made. Interviews with staff confirmed that the CNA continued to work in the facility after the allegation, although not directly with the resident who made the report. The LVN and RN involved in the incident acknowledged that the CNA was not suspended and that the Administrator was not informed immediately after the allegation. The resident involved had the capacity to make their own medical decisions, and an assessment following the report showed no injury. The Administrator later acknowledged the findings of the investigation.
Inadequate Hand Hygiene During Wound Care
Penalty
Summary
The facility failed to maintain proper infection control practices, as evidenced by multiple instances of staff neglecting to perform hand hygiene during wound care procedures. Treatment Nurse 1 was observed initiating wound care on a resident's left shin without washing hands before donning gloves. After cleaning the wound, the nurse removed the soiled gloves but did not perform hand hygiene before putting on a new pair of gloves to continue the treatment. This lapse in protocol was acknowledged by the nurse during an interview, who admitted the importance of hand hygiene in preventing infection spread. Similarly, Treatment Nurse 2 and a CNA were involved in another incident where hand hygiene was not performed before wound care. Treatment Nurse 2 applied barrier cream to a resident's buttock area without washing hands first. The CNA, after cleaning the resident's buttock area, attempted to access the clean linen cart with soiled gloves, only stopping when reminded to change gloves and perform hand hygiene. Both staff members acknowledged their failure to adhere to hand hygiene protocols during interviews. The facility's Infection Preventionist and Director of Nursing confirmed the expectation for staff to perform hand hygiene before and between tasks to prevent disease transmission.
Failure to Provide Consistent Oral Care for Resident
Penalty
Summary
The facility failed to provide oral care every shift for a resident diagnosed with dysphagia, as per the medical orders. The resident was admitted with an order dated 10/17/24, specifying that oral care should be provided every shift using a swab/suction as appropriate. However, a review of the resident's oral hygiene interventions for January 2025 revealed that oral care was only provided during the day and evening shifts on specific dates, and not consistently every shift as ordered. Observations and interviews conducted with the facility's LVN and RN confirmed that the resident's oral care was not provided every shift. During an observation on 1/8/25, the LVN noted that the resident's mouth was dirty, and the lips were dry with white patches, indicating a lack of oral care. The RN acknowledged the importance of oral care in preventing mouth infections and sores, and the DON confirmed that the facility's three-shift system was not adhered to in providing the required oral care for the resident.
Failure in Catheter Care and Monitoring
Penalty
Summary
The facility failed to provide appropriate care and services to prevent urinary tract infections (UTIs) for two residents with indwelling urinary catheters. Observations revealed that the urinary drainage bags for both residents were improperly positioned on top of their beds, visible from the hallway and patio, and not covered with dignity bags. This improper positioning risked urine flowing back into the bladder, increasing the risk of catheter-associated urinary tract infections (CAUTIs). Additionally, the facility's policy required that catheter bags be kept below the bladder level and away from entrance doors, which was not adhered to in these cases. Furthermore, the staff failed to monitor and assess the urinary output of one resident, whose urine was observed to be dark yellow-brown, indicating a potential issue. The facility's policy mandated that nursing staff assess urinary drainage for signs of infection, including color, cloudiness, and other factors, every shift. However, this was not done, as evidenced by the lack of monitoring of the resident's urine color. The Director of Nursing (DON) and a treatment nurse acknowledged these deficiencies during interviews, confirming the failure to follow the facility's policies and procedures for catheter care.
Incomplete Documentation in Resident Medical Records
Penalty
Summary
The facility failed to ensure complete and accurate documentation in the Treatment Administration Records (TAR) for two residents. For the first resident, there were missing entries regarding the assessment of urinary drainage for signs of infection and the provision of Foley catheter care on multiple dates in November 2024. These assessments and care were required every shift as per the physician's order dated October 4, 2024. The specific dates of missing documentation included November 3rd, 4th, 15th, and 28th, during various shifts. Similarly, for the second resident, the TAR lacked documentation for the assessment of urinary drainage, Foley catheter care, and monitoring for signs and symptoms of a urinary tract infection (UTI) on November 7th and 15th, 2024. These tasks were mandated by physician orders dated May 8, 2024, and July 23, 2024, to be performed every shift. The absence of these records was confirmed during interviews with Treatment Nurse 2 and the Director of Nursing (DON), who acknowledged the deficiencies in the residents' medical records.
Failure to Timely Report Financial Abuse Investigation
Penalty
Summary
The facility failed to provide a thorough investigation and report the results of an investigation regarding an allegation of possible financial abuse involving a resident's family member. The facility's policy and procedure on abuse reporting and investigations, revised in March 2018, requires that the results of all abuse investigations be reported to the California Department of Public Health (CDPH) Licensing and Certification Program within five working days of the reported allegation. However, the facility did not comply with this requirement for one of the two sampled residents, identified as Resident 2, who was involved in an allegation of financial abuse. Resident 2, who was admitted to the facility with severe cognitive impairment, was the subject of an open investigation for possible financial abuse by a family member, as informed by a Court Investigator. Despite the facility's Social Services Director completing a Report of Suspected Dependent Adult/Elder Abuse form on the date of the incident, the Director of Nursing (DON) confirmed during an interview that the facility's internal investigation was still ongoing beyond the five-day reporting requirement. The Administrator verified that the investigation had not been completed, indicating a failure to meet the mandated timeline for reporting the investigation results to the CDPH, thus posing a risk for potential abuse to remain unidentified and for the resident to go unprotected.
Failure to Address Financial Abuse Risk in Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for a resident who was at risk of financial abuse by a family member. Despite being informed by a Court Investigator about an open investigation into possible financial abuse, the facility did not create a care plan to address this risk. The facility's policy requires that care plans be updated to reflect new problems or changes in a resident's condition, but this was not done in this case. The resident in question had severe cognitive impairment, as indicated by a BIMS score of 1, and lacked the capacity to understand and make decisions. Despite these vulnerabilities, the facility did not document any care plan addressing the risk of financial abuse. The Director of Nursing confirmed the absence of such a care plan during a record review and interview, acknowledging the oversight.
Failure to Maintain Homelike Environment Due to Peeling Paint
Penalty
Summary
The facility failed to maintain a homelike environment for two residents, as observed during a survey. Resident 3's room was found to have chipped paint on the wall above the headboard during an observation conducted on October 2, 2024. This observation was verified by LVN 2, who confirmed the presence of chipped paint in Resident 3's room. The facility's policy and procedure on Resident Rights Personal Property, revised in January 2012, emphasizes ensuring the quality of life for all residents by allowing them to create a homelike environment. Similarly, Resident B's room was observed to have peeling paint above the headboard. This was confirmed through interviews and observations with CNA 2 and LVN 3. The Director of Nursing (DON) was informed of these findings and acknowledged that peeling paint does not constitute a homelike environment. The DON stated that the process would involve notifying the maintenance department to address the issue.
Failure to Follow Bed Rail Policy and Procedures
Penalty
Summary
The facility failed to adhere to its policy and procedures regarding the use of bed rails, which are intended to be used as mobility enablers. The policy requires that before bed rails are used, staff must attempt appropriate alternatives, assess the resident for safety risks, obtain a physician's order, and secure informed consent from the resident or their representative. Additionally, a care plan should be initiated to address the use of bed rails. However, the facility did not complete these steps for five of the six residents reviewed for side rail use, potentially putting them at risk for serious injuries. For Resident 64, the facility did not document any attempts to use alternative measures before installing bilateral grab bars. There was no physician's order, informed consent, or care plan addressing the use of these grab bars, despite the resident using them for repositioning and turning. Similarly, Resident 45 had a physician's order and a care plan for the use of grab bars, but the facility failed to obtain informed consent. Resident 47 had a physician's order for grab bars, but the assessment did not indicate a need for them, and there was no care plan or informed consent documented. Resident 78 had a physician's order and a care plan for a left-side grab bar, but informed consent was not obtained. Lastly, Resident 601 had a physician's order for bilateral grab bars, but the assessment did not support their use, and there was no care plan or informed consent documented. These deficiencies were verified through interviews and medical record reviews with various staff members, including LVNs and the DON, who acknowledged the findings.
Medication Storage and Temperature Control Deficiencies
Penalty
Summary
The facility failed to ensure proper medication storage in three medication storage rooms, leading to potential risks for residents. During an inspection, it was observed that syringes with needles labeled for a discharged resident were not discarded and remained on the medication room shelf. Additionally, oral lactulose solution was improperly stored next to lidocaine patches, violating the facility's policy of separating orally administered medications from externally used ones. The inspection also revealed that the temperatures of the medication refrigerators in all three medication rooms were out of the required range. In one room, the refrigerator temperature was recorded at 64 degrees Fahrenheit, while in another, it was 55 degrees Fahrenheit, and in the third, it was 50 degrees Fahrenheit. These temperatures were significantly higher than the required range of 36 to 46 degrees Fahrenheit for most medications stored, including insulin, antibiotics, and other injectable medications. The discrepancies in temperature logs and actual readings indicated a failure in monitoring and maintaining appropriate storage conditions. Interviews with staff, including the Infection Preventionist, Registered Nurses, and Licensed Vocational Nurses, confirmed the findings. The staff acknowledged the improper storage and temperature issues but were unable to provide explanations for the discrepancies. The facility's policy required regular checks and logging of refrigerator temperatures, but it was noted that the Pharmacy Nurse Consultant's checks were not logged, contributing to the oversight.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to adhere to food safety and sanitation guidelines, as evidenced by three specific deficiencies. Firstly, a food preparation sink located near the DSS's office was found to lack backflow prevention, which is a requirement according to the USDA Food Code 2022. The Maintenance Assistant confirmed that the backflow prevention device had been removed, posing a risk of contamination. Secondly, a rack used for drying plate covers was observed to have a greasy residue and food debris, which violates the USDA Food Code's requirement for nonfood contact surfaces to be free of dirt and debris. The DSS acknowledged this finding during the inspection. Additionally, the facility did not comply with its own policy regarding perishable food brought in by visitors. A resident's room was found to contain perishable food items, such as a block of cheese, that were not stored in a refrigerator as required. The resident confirmed that the cheese needed refrigeration, and both LVN 1 and MDS Coordinator 2 acknowledged the oversight. These deficiencies posed a risk of cross-contamination and potential food poisoning for the 83 residents who consumed food from the facility's kitchen.
Infection Control Deficiencies in Surveillance, Laundry, and PPE Use
Penalty
Summary
The facility failed to maintain an accurate infection control surveillance program from January 2024 through August 2024. The surveillance was only conducted on residents who exhibited signs and symptoms of an infection and were prescribed antimicrobial medications. Residents who showed signs and symptoms of infection but were not prescribed antimicrobial medications were not included in the facility's infection control surveillance log. The Surveillance Data Collection Form was incomplete and inaccurate, failing to determine whether the resident's infection met the McGeer's criteria for true infection. The facility also failed to implement proper infection control practices in the laundry room. During an inspection, personal items such as eyeglasses and an employee phone were found on the clean table area where clean clothes or linens were folded. This was verified by Laundry Services Personnel 1, who acknowledged that these items should not be on the table used for folding clean laundry. Additionally, the facility did not ensure that RN 2 wore the appropriate PPE when entering a COVID-19 isolation room for a resident. RN 2 entered the room without wearing an N95 mask, despite knowing the requirement to do so. The resident was on COVID-19 isolation, and the required PPE included an N95 mask, face shield, goggles, gown, and gloves. This oversight was acknowledged by RN 2 and confirmed by IP 1.
Failure to Inform Physician of Unnecessary Antibiotic Use
Penalty
Summary
The facility failed to inform the physician of residents prescribed antibiotics when their signs and symptoms did not meet McGeer's Criteria for a true infection. This deficiency was identified for one of the 19 final sampled residents and three non-sampled residents. The Infection Preventionist (IP) was responsible for conducting surveillance and completing a Surveillance Data Collection Form for each resident with signs and symptoms of an infection. However, the IP did not document whether the residents' conditions met McGeer's Criteria, and there was no evidence that the physician was notified to reassess the need for antibiotics. The facility's Monthly Antibiotic Stewardship Reports for June and July 2024 showed cases where residents were prescribed antibiotics without meeting the criteria for a true infection. Specifically, Residents 77, 87, and 603 were prescribed antibiotics without meeting the criteria, and there was no documentation of physician notification. Additionally, Resident 87's Surveillance Data Collection Form indicated that a urine culture was not obtained. The Director of Nursing (DON) acknowledged the findings and the incomplete and inaccurate documentation in the facility's Infection Control Surveillance Form.
Failure to Conduct Accurate Entrapment Assessments for Bed Rails
Penalty
Summary
The facility failed to ensure accurate and complete entrapment assessments for residents using bed rails, as required by the FDA's Hospital Bed System Dimensional and Assessment Guidance. The report highlights that six residents were observed with grab bars installed on their beds without proper documentation of entrapment assessments. This oversight could potentially lead to entrapment, serious injury, or death, especially for vulnerable populations such as the elderly or those with uncontrolled body movements. For Resident 64, the medical record review showed no physician's order for the use of bilateral bed grab bars, and the bed rail assessment indicated no siderail or assist bars were needed. However, observations confirmed the presence of grab bars, and the Maintenance Director admitted to not measuring or documenting entrapment zones for grab bars. Similar issues were found with Residents 45, 47, 63, 78, and 601, where either the entrapment assessments were missing or the residents' preferences and needs were not accurately documented. The Maintenance Director acknowledged the lack of documentation for grab bar measurements, and the Director of Nursing (DON) was informed of these findings. The facility's policy requires annual bed measurement inspections to document entrapment areas, but this was not adhered to, leading to the deficiencies noted in the report.
Failure to Maintain Resident Dignity with Catheter Privacy
Penalty
Summary
The facility failed to ensure care was provided in a manner that promoted dignity and respect for a resident who was using an indwelling urinary catheter. During an initial tour of the facility, the resident was observed lying in bed with a urinary catheter draining into a collection bag that was not placed inside a privacy bag. This oversight was confirmed by a Certified Nursing Assistant (CNA), who acknowledged that the collection bag should have been inside the privacy bag to maintain the resident's privacy. The resident, who was unable to make his own decisions, had a physician's order for a 16 Fr indwelling/suprapubic catheter due to benign prostatic hyperplasia. The Director of Nursing (DON) stated that it was expected for all catheter collection bags to be inside privacy bags to provide dignity to residents. The DON was informed of the findings and acknowledged the deficiency.
Call Light Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that the call lights were within reach for five residents, which could potentially impact their psychosocial well-being or delay the provision of care. The facility's policy and procedure (P&P) on the communication-call system, revised on January 1, 2012, mandates that call cords be placed within the resident's reach. However, observations and interviews revealed that the call lights for Residents 16, 38, 76, 39, and 61 were not accessible. Resident 16's call light was clipped on the edge of the head of the bed, out of reach. Resident 38's call light was found underneath the pillow, making it inaccessible. Resident 76's call light was placed on top of the bedside drawer, not within reach, despite the resident's need for dependent assistance for bed mobility. Further observations showed that Resident 39's call light button was on top of the bedside drawer, out of reach, and Resident 61's call light cord was clipped to the wall at the head of the bed, with the button hanging and inaccessible. Interviews with staff, including LVN 7, CNA 2, MDS Coordinator 3, and CNA 5, confirmed these findings. The Director of Nursing (DON) acknowledged the deficiencies, stating that call lights should be within residents' reach, but the report does not mention any corrective actions taken to address these issues.
Failure to Document and Maintain Advance Directives
Penalty
Summary
The facility failed to provide written information regarding advance directives and did not obtain or maintain copies of these directives in the medical records for five residents. This deficiency was identified through interviews, medical record reviews, and a review of the facility's policies and procedures. The facility's policy required that upon admission, residents be informed of their rights to make medical decisions, including the formulation of advance directives. However, the facility did not adhere to this policy, resulting in incomplete documentation and follow-up regarding residents' advance directives. For Resident 17, the facility did not maintain a copy of the advance directive in the medical record, despite acknowledging its existence and requesting it. Similarly, Resident 76's records lacked documentation of whether the resident or their representative was offered information on formulating an advance directive. Resident 45's records showed an undated acknowledgment form indicating a request for more information on advance directives, but there was no evidence of follow-up or provision of the requested information. Resident 601's records indicated an advance directive was in place, but the facility failed to maintain a copy in the medical record. Additionally, Resident 351's records did not document whether an advance directive was offered to the resident's representative, despite the resident's severe cognitive impairment. These failures highlight the facility's lack of a systematic approach to ensuring residents' advance directives are documented and honored, potentially impacting the residents' healthcare decisions.
Deficiencies in IV Access and Medication Labeling
Penalty
Summary
The facility failed to provide necessary care and services for maintaining intravenous (IV) access for two residents. For Resident 600, the facility did not document the measurement of the peripherally inserted central catheter (PICC) line's external catheter length upon admission, as required by the facility's policy and procedure (P&P) for PICC dressing changes. This oversight was confirmed during an interview with RN 2, who acknowledged the absence of the required documentation in Resident 600's medical record. Resident 600 had orders for total parenteral nutrition (TPN) via the PICC line and weekly measurements of the arm circumference and external lumen catheter, but the initial measurement was not recorded. For Resident 89, the facility failed to properly label the IV antibiotic medication bag. During an observation, it was noted that Resident 89 was receiving an IV antibiotic at a specified rate, but the medication bag was neither labeled nor dated, contrary to the facility's P&P for administering intermittent infusions. RN 2 admitted to forgetting to label the medication bag. Resident 89 had a physician's order for cefoxitin sodium to be administered intravenously for an infection of the spine, but the lack of labeling was confirmed during a review with the Director of Nursing (DON).
Deficiencies in Respiratory Care Practices
Penalty
Summary
The facility failed to provide appropriate respiratory care for several residents, as observed during a survey. Resident 58's oxygen nasal cannula tubing was found undated, unlabeled, and not stored in a setup bag when not in use, contrary to the facility's policy. Additionally, the oxygen machine was left on while the resident was not in the room, with the nasal cannula left on the bed. Resident 351's nebulizer mask and tubing were also not stored in a setup bag, and there was no care plan in place for the use of nebulizer therapy, despite a physician's order for breathing treatment medication. Resident 352's oxygen tubing was observed touching the floor, which was verified by RN 2, who then replaced it with new tubing. Resident 75's nebulizer mask and tubing were undated and left on top of the nebulizer machine, with no physician's orders for medications requiring nebulizer use. Resident 69's CPAP mask was found touching the bedside table, and the tubing was undated, which was confirmed by the MDS Coordinator and the Director of Central Supply, who stated that the CPAP tubing should be dated and stored in a plastic bag. The facility's policy on oxygen therapy, revised in November 2017, requires that oxygen supplies be dated and stored safely. The Director of Nursing confirmed the expectation that all respiratory equipment should be labeled and stored properly when not in use. These deficiencies in respiratory care practices had the potential to affect the respiratory health and well-being of the residents.
Inadequate Pain Management for a Resident
Penalty
Summary
The facility failed to provide adequate and appropriate pain management for a resident, identified as Resident 600, who was receiving narcotic pain medication. The facility did not monitor Resident 600 for side effects related to the use of Norco, a narcotic medication prescribed for moderate to severe pain. Additionally, the facility did not consistently implement non-pharmacological interventions for pain management, as required by their policy and procedure. These interventions were only provided until 9/3/24, despite the resident continuing to receive Norco on subsequent dates. During an interview and medical record review, RN 2 confirmed that non-pharmacological interventions should have been continued alongside the narcotic medication. However, these interventions were not reinstated after a 14-day reassessment of the resident's pain management. Furthermore, there was no physician's order to monitor for side effects of the Norco medication, nor was any monitoring completed. This oversight in pain management practices was identified as a deficiency by the surveyors.
Failure to Ensure Proper Accounting of Controlled Medications
Penalty
Summary
The facility failed to ensure proper accounting and safeguarding of controlled medications, as evidenced by missing signatures from both incoming and outgoing licensed nurses on the controlled drugs count record. This deficiency was observed during a medication cart inspection of Medication Carts 1 and 3. Specifically, the controlled drugs count record for Medication Cart 3 had missing signatures on several dates, including 8/21, 8/22, 9/1, and 9/7. Similarly, Medication Cart 1 had missing signatures on 8/6, 8/18, 8/22, 8/24, 8/31, and 9/1. These findings were verified by the respective LVNs during the inspection. The facility's policy and procedure, as well as the Narcotic Book Guide, require that a physical inventory of all controlled medications be conducted by two licensed nurses at each shift change, with both nurses signing the controlled drugs count record. However, the failure to consistently follow this procedure was confirmed by the Director of Nursing (DON) during an interview and document review. The absence of signatures indicates a lack of compliance with the facility's established protocols for medication accountability, potentially leading to drug diversion.
Failure to Monitor Orthostatic Blood Pressure for Resident on Antipsychotic Medication
Penalty
Summary
The facility failed to ensure that a resident was free from unnecessary psychotropic drugs by not monitoring the resident's orthostatic blood pressure as ordered by the physician. The resident was prescribed risperidone, an antipsychotic medication, and the physician had ordered weekly monitoring of the resident's orthostatic blood pressure in lying, sitting, and standing positions. However, the medical records showed that the blood pressure readings were not consistently documented, with some readings marked as 'NA' without explanation. Interviews with the LVN and the DON confirmed that the blood pressure readings should not have been documented as 'NA' and should have been obtained and compared as per the physician's order. The facility's policy required monitoring for orthostatic hypotension, especially for residents on antipsychotic medications, to prevent adverse complications. The failure to monitor the resident's orthostatic blood pressure as ordered had the potential to result in adverse complications from the medication.
Failure to Honor Resident's Food Preferences
Penalty
Summary
The facility failed to honor the food preferences of a resident, identified as Resident 30, which is a violation of their dietary policy. Resident 30, who has the capacity to understand and make decisions, was served Brussels sprouts and low-fat milk for lunch, despite having documented preferences for nonfat milk and a dislike for Brussels sprouts. This discrepancy was observed during a lunch observation in Resident 30's room, where the meal tray did not align with the resident's stated preferences as indicated on the meal ticket. The issue was confirmed by MDS Coordinator 2, who acknowledged that Resident 30 should have been provided with an alternative vegetable. The MDS Coordinator took immediate steps to rectify the situation by asking Resident 30 for her choice of an alternative vegetable and providing her with nonfat milk. The Director of Nursing (DON) was later informed of the findings and acknowledged that the resident's food preferences and dislikes should have been honored, as per the facility's policy.
Lack of Safe Food Handling Education for Staff and Visitors
Penalty
Summary
The facility failed to ensure that both employees and visitors bringing food from outside were educated on safe food handling practices, posing a risk of foodborne illness to residents. The facility's policy titled 'Food Brought by Visitors,' revised in June 2018, included guidelines for safe food handling, reheating, and storage. However, interviews with staff revealed a lack of awareness and training on these practices. RN 2 was unable to confirm receiving any education on safe food handling and was unsure if visitors were informed about these practices. The Director of Staff Development (DSD) confirmed that no training had been provided to staff during her two-month tenure. Further interviews with the Director of Nursing (DON) and the DSD highlighted the absence of a structured approach to ensure compliance with the facility's policy. The DON could only specify that food should be clean and in a sealed container but could not elaborate on how safe food handling was enforced. The DSD verified that no training records existed for educating staff on safe food handling practices. This lack of education and enforcement of the policy created a potential risk for residents consuming food brought in by visitors.
Deficiencies in Equipment Maintenance and Monitoring
Penalty
Summary
The facility failed to maintain essential kitchen equipment in proper working condition, as observed during a survey. The ice machine in the kitchen was found to be unclean, with a rubber strip on the harvester curtain not intact and covered in a white residue identified as dried glue. The ice machine chute also had a grayish, white residue. The Maintenance Assistant, who cleaned the ice machine monthly, admitted to not following the manufacturer's cleaning instructions due to a language barrier and used an incorrect cleaning solution. Consequently, the ice machine was taken out of service. Additionally, the walk-in freezer floor was not in a cleanable condition. The floor had black anti-slip tape that was not intact, exposing a metal floor with a hard, thick brown residue resembling rust. The linoleum floor beyond the ramp was cracked and not intact, with a brown residue. The Maintenance Director was unaware of the condition of the freezer floor, indicating a lack of communication or oversight in maintenance procedures. The facility also failed to ensure the proper functioning of a low air loss mattress for a resident. The mattress pump had a red light blinking, indicating a malfunction, and the alarm was muted. Despite daily checks by an LVN, the malfunction went unnoticed until it was observed by the MDS Coordinator. The LVN was unaware of any issues with the mattress pump or muted alarms, suggesting a gap in monitoring and reporting procedures for essential medical equipment.
Failure to Document Medication Reconciliation at Discharge
Penalty
Summary
The facility failed to ensure a thorough and documented medication reconciliation for Resident 99 upon discharge. Resident 99 was admitted to the facility and later discharged home. A review of the facility's policies and procedures indicated that the discharge summary should include a comprehensive medication reconciliation, detailing the resident's drug therapy and any changes from pre-discharge to post-discharge medication regimens. However, upon reviewing Resident 99's medical records, there was no documented evidence that such a reconciliation had been completed at the time of discharge. During an interview and concurrent medical record review with the MDS Coordinator, it was confirmed that the discharge nurse was responsible for completing and documenting the medication reconciliation. Despite this responsibility, the records for Resident 99 did not reflect any such documentation, indicating a lapse in following the facility's discharge procedures. This oversight posed a risk of not identifying discrepancies in medication orders, potentially affecting the resident's well-being.
Incomplete and Outdated POLST Forms for Two Residents
Penalty
Summary
The facility failed to ensure the medical records for two residents were accurate and complete, specifically regarding their Physician Orders for Life-Sustaining Treatment (POLST) forms. For Resident 64, the POLST form was incomplete as it did not indicate whether the resident had an advance directive or a health care agent. This was acknowledged by the Social Services Director (SSD) during an interview and concurrent medical record review. For Resident 63, the POLST form was outdated and did not reflect the resident's advance directive, which had been executed and documented in the resident's progress notes. The SSD admitted that the nursing staff completed the POLST form and that she failed to inform them of the advance directive update or update the POLST herself. The Director of Nursing (DON) confirmed that the facility should have updated the POLST immediately upon obtaining the advance directive.
Failure to Provide Written Notification of Room Changes
Penalty
Summary
The facility failed to provide written notification of room changes to two residents, violating their rights. According to the facility's policy, residents and their representatives should receive timely advance written notice of any room or roommate changes, including the reasons for such changes. However, for two residents, this procedure was not followed. Resident 7, who was nonverbal and lacked the mental capacity to make decisions, did not have documentation showing that their representative was notified of the room change. Similarly, Resident 8, who had the mental capacity to make decisions, was not provided with written notice of the room change. Interviews with facility staff, including the Social Services Director (SSD) and the Admissions Director, revealed that the facility's practice was to inform residents and their families of room changes verbally, without providing written documentation. The SSD confirmed that there was no room change form used to document these changes, and the Admissions Director acknowledged that written notifications were not provided. This lack of adherence to the facility's policy resulted in the failure to properly notify Residents 7 and 8 of their room changes in writing.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 4,076 citations issued within 25 miles in the last 12 months — including the 9 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Orange
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Town & Country | 0.5 mi | ★★★★★ | 27 | 0 |
| Mainplace Post Acute | 0.6 mi | ★★★★★ | 29 | 0 |
| Healthbridge Children's Hospital - Orange D/p Snf | 1.2 mi | ★★★★★ | 18 | 0 |
| The Hills Post Acute | 1.6 mi | ★★★★★ | 29 | 0 |
| French Park Care Center | 1.7 mi | ★★★★★ | 51 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Orange Healthcare & Wellness Centre, Llc.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.