Above average — CMS composite of the measures below.
A standard survey is most likely before around July 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Orchards Skilled Nursing during CMS and state inspections, most recent first.
Surveyors found that kitchen utensils and cutting boards were in poor condition, including being chipped, cracked, frayed, discolored, and deeply grooved, making them difficult to clean and sanitize. The RD and Chef de Cuisine confirmed these items should have been replaced to meet infection control standards, as most residents consumed food prepared in the kitchen.
A resident's advance directive was not maintained in the medical record as required by facility policy. Although the family indicated an advance directive existed, it was neither present in the paper chart nor uploaded to the EMR. The SSD confirmed the document was missing and acknowledged it should have been obtained and readily available for staff reference.
A resident with heart failure used a personal heart monitor daily without staff assistance or oversight. Facility staff were unaware of the device, and there was no physician's order, care plan, or assessment documented for its use, contrary to facility policy requiring such measures for resident-owned equipment.
A resident with altered respiratory status did not receive oxygen therapy as ordered by the physician. The nasal cannula was not placed on the resident's nares, and the oxygen concentrator was set at 1 liter per minute instead of the ordered 2 liters per minute. Staff confirmed the concentrator was malfunctioning and acknowledged the physician's order was not followed.
Licensed nurses did not follow facility medication administration policies for three residents, including failing to notify a physician when a medication was unavailable, missing documentation for IV antibiotic administration, and not ensuring medication orders accurately reflected the route of administration for a resident with a feeding tube. These actions resulted in missed doses, incomplete records, and discrepancies between prescribed and actual care.
The facility's assessment did not include active participation from direct care staff, their representatives, residents, or family members, and lacked both a plan for recruitment and retention of direct care staff and a contingency plan for staffing needs. The Administrator confirmed these omissions and acknowledged the assessment was not updated per current CMS guidance.
A resident with Alzheimer's disease and no capacity for medical decision-making did not have hospice care properly coordinated, as the hospice calendar lacked complete documentation of skilled nursing and hospice aide visits per physician orders. Staff were unclear about visit frequencies and the identity of the hospice coordinator, leading to uncertainty about whether the resident received all necessary hospice services.
The facility did not ensure its infection surveillance logs and data collection forms were accurate and complete, resulting in mismatched and incomplete reporting of HAIs, CAIs, and infections not meeting McGeer's criteria. Several residents who received antibiotics for infections had incomplete documentation regarding infection classification, and both the IP and DON confirmed these discrepancies during review.
A laptop containing residents' medical information was left open and unattended on a medication cart in a hallway, allowing staff, residents, and visitors to view confidential data. An LVN acknowledged the privacy breach, and the DON confirmed the incident, which was not in accordance with facility policy requiring screens to be secured and logged off when unattended.
A resident's POLST form inaccurately indicated that an Advance Directive was not available, even though the document had been uploaded to the EMR. This discrepancy was confirmed during a review with the SSD, who acknowledged the POLST should have reflected the accurate status of the resident's Advance Directive.
The facility failed to ensure food safety and sanitary requirements in the kitchen, leading to multiple deficiencies. Observations revealed improper meat thawing, expired food not discarded, unmonitored TCS foods, unclean ice machines, lack of hair and beard restraints, poor condition of food preparation equipment, improper storage and labeling of food items, and dirty drying racks.
The facility failed to assess a resident for the capability to self-administer medications. An opened bottle of nasal spray was found on the resident's overbed table, and the resident admitted to using it daily without a physician's order. The resident's assessment indicated no interest in self-administration, and the LVN was unaware of the nasal spray at the bedside.
A facility failed to notify a resident's physician, responsible party, and RD of significant weight loss, as required by their policies and procedures. Despite the resident experiencing notable weight changes, the necessary notifications were not documented, as confirmed by interviews and medical record reviews.
An LVN failed to follow the facility's policy for taking a blood pressure reading by placing the stethoscope diaphragm over a resident's sweater instead of directly on the skin. This was confirmed by both the LVN and the DON.
The facility failed to ensure timely intervention for a resident experiencing significant weight loss. Despite the resident's weight loss being identified by the EHR system, there was no documentation of intervention by the nutritional services or RD. The process for addressing weight changes was disrupted due to the RD's vacation, leading to the resident's weight loss not being addressed in a timely manner.
The facility failed to provide appropriate respiratory care for a resident by not labeling the oxygen tubing and allowing it to touch the floor, contrary to the facility's policy and procedure. The resident had physician's orders for oxygen therapy, which were not fully adhered to, as confirmed by an RN and the DON.
A resident's oxycodone-acetaminophen was not accurately reconciled, as the Controlled Drug Record showed medication removal without corresponding documentation in the electronic MAR. The discrepancy was confirmed by LVN 3 and acknowledged by the DON.
The facility failed to ensure proper disposal and storage of medications, with issues found in a medication cart, a medication room, and a resident's bedside cabinet. An LVN and the DON verified these findings.
The facility failed to ensure that the Food and Nutrition Services Director (FNSD) was competent in managing the day-to-day functions of the food services department. Multiple issues were found in the main kitchen, including improper thawing processes for meats, failure to discard expired food, and lack of monitoring of cooling for TCS foods. Interviews revealed gaps in the oversight and competency assessment of the kitchen staff.
The facility failed to follow the puree procedure for meat and vegetables, resulting in inconsistent products that may not meet the nutritional needs of residents on pureed diets. This was confirmed by the Administrator, FNSD, RD, and Chef.
A resident's food preference was not honored, leading to the continued serving of cranberry juice despite the resident's expressed dislike. The facility's process for updating dietary preferences was not effectively implemented, resulting in a failure to meet the resident's dietary needs.
The facility failed to communicate safe food handling guidelines to residents' family members and visitors who brought food from outside. Staff were trained on these guidelines, but the required 'Safe Food Handling Guide for Visitors and Staff' was not provided to visitors, as confirmed by the DON.
The facility failed to ensure complete and accurate medical records for three residents, as their POLST forms were found to be incomplete. The SSD left sections blank, hoping residents would eventually have capacity or waiting for family submissions, leading to potential risks in emergency situations. The DON confirmed these findings.
The facility failed to implement a water management program to prevent Legionella growth and did not ensure proper hand hygiene practices among staff. An LVN did not change gloves or perform hand hygiene before administering eye drops, and a CNA did not perform hand hygiene after touching a floor mat. The DON confirmed these lapses in infection control.
The facility failed to revise the comprehensive care plan for a resident to include non-pharmacological interventions for pain management as ordered by the physician. The LVN confirmed the omission during a medical record review, and the DON acknowledged the deficiency.
The facility failed to store trash in a sanitary manner, as evidenced by an uncovered green organic trash container and an open dumpster lid. The FNSD noted the trash container cover was broken, and the EVS Manager admitted staff often forget to close dumpster lids, contrary to facility policy and the US Food Code.
The facility failed to ensure the comprehensive care plan reflected the current care needs and interventions for a resident diagnosed with dementia. During a medical record review and interview with an LVN, it was found that the care plan did not address the specific care needs related to dementia, which was confirmed by the LVN.
Unsanitary Kitchen Utensils and Cutting Boards Identified
Penalty
Summary
The facility failed to maintain sanitary conditions in the kitchen, as evidenced by the presence of multiple kitchen utensils and cutting boards that were not in good repair or cleanable condition. During an initial kitchen tour, surveyors observed and verified with the Registered Dietitian (RD) and Chef de Cuisine that several utensils, including basting brushes, spatulas, ice cream scoops, and serving spoons, were discolored, frayed, chipped, cracked, peeling, melted, or otherwise worn out. These items did not meet the facility's own policies or the USDA Food Code requirements for food contact surfaces to be smooth, durable, and easily cleanable. Additionally, the facility's cutting boards were found to be heavily marred, fuzzy, and had deep grooves, making them difficult to clean and sanitize. The RD and Chef de Cuisine acknowledged that these cutting boards should have been replaced according to facility policy and food safety standards. These deficiencies were identified during a review of the kitchen where 38 of 40 residents consumed food prepared on-site, and the findings were confirmed through observation, interview, and review of facility policies and relevant food safety codes.
Failure to Maintain Advance Directive in Medical Record
Penalty
Summary
The facility failed to maintain a copy of an advance directive in the medical record for one resident reviewed for advance directives. According to the facility's policy and procedure, the Social Service Director (SSD) or designee is responsible for inquiring about the existence of any written advance directives upon admission and ensuring that information about the advance directive is prominently displayed in the medical record. For the resident in question, medical record review showed that although the family member stated an advance directive existed and would provide a copy, no such document was found in the resident's medical record or uploaded in the electronic medical record (EMR). Further review of the resident's records, including the POLST and H&P examination, did not reveal the presence of the advance directive. During an interview, the SSD confirmed that the advance directive was not present in the medical record and acknowledged that it should have been obtained and maintained. The Director of Nursing (DON) was informed and acknowledged these findings.
Failure to Assess and Care Plan for Resident-Owned Heart Monitor
Penalty
Summary
A deficiency occurred when the facility failed to provide necessary services for a resident with a heart condition who brought a personal heart monitoring machine from home. Upon observation, the machine was found on the resident's bed, plugged in, and covered with a pillowcase. The resident reported using the machine daily to monitor her heart, but stated that facility staff did not assist with the care or functionality checks of the device. Review of the resident's medical records revealed no documentation of a physician's order for the heart monitor, no care plan addressing its use, and no assessment or documentation of the machine's presence or maintenance upon admission, despite the resident's diagnosis of heart failure. Interviews with facility staff, including an LVN and the DON, confirmed that they were unaware of the heart monitor at the bedside and acknowledged the absence of required documentation, orders, and care planning for the device. The facility's policy required adherence to manufacturer guidelines for resident-owned equipment, but this was not followed. The DON verified that a physician's order, care plan, and assessment should have been completed for the heart monitor when the resident was admitted.
Failure to Administer Oxygen Therapy as Ordered
Penalty
Summary
The facility failed to provide necessary respiratory care for a resident by not administering oxygen therapy as ordered by the physician. During an observation, the resident was found lying in bed with oxygen tubing labeled and dated, but the nasal cannula was not placed on the resident's nares. The oxygen concentrator was set at 1 liter per minute, which was inconsistent with the physician's order for 2 liters per minute via nasal cannula every shift to maintain oxygen saturation above 92%. The resident's care plan also specified the need for oxygen at 2 liters per minute due to altered respiratory status. Interviews with facility staff confirmed that the oxygen concentrator had been replaced due to malfunction, and the dial to set the oxygen flow was not working. Staff acknowledged that the physician's order for oxygen administration should have been followed, and the DON confirmed awareness of the findings. The resident was noted to have no capacity to make health care decisions but could express simple needs. The failure to follow the physician's order and ensure proper oxygen administration constituted a deficiency in providing safe and appropriate respiratory care.
Failure to Follow Medication Administration Policies and Procedures
Penalty
Summary
The facility failed to ensure that licensed nurses followed their policies and procedures for medication administration for three residents. For one resident with a history of cancer and dry mouth, the ordered Biotene medication was not available, resulting in missed doses over two days. Documentation showed that the medication was not administered, and there was incomplete progress note documentation explaining the missed doses. Although the facility's policy required notifying the physician when medications were unavailable, this was not consistently done, as confirmed by staff interviews and review of the medical record. Another resident, admitted with a urinary tract infection and ESBL resistance, had a physician's order for intravenous Ertapenem. The medication administration record (MAR) lacked documentation for four specific dates, and staff confirmed there was no evidence the medication was administered as ordered. The DON verified the missing documentation and acknowledged that what was not documented was considered not done, emphasizing the requirement for immediate documentation after medication administration. A third resident with an enteral feeding tube and a diagnosis of dysphagia was observed receiving all medications via gastrostomy tube (GT), despite physician orders specifying oral administration. The MAR reflected that medications were signed as given orally, not via GT, and staff confirmed that the orders should have accurately reflected the actual route of administration. The discrepancies between the physician's orders, the MAR, and the actual administration route were acknowledged by nursing staff and facility leadership.
Facility Assessment Lacks Required Stakeholder Involvement and Staffing Plans
Penalty
Summary
The facility failed to ensure its Facility Assessment was developed with the active involvement of required individuals, including direct care staff, their representatives, residents, residents' representatives, and residents' family members. Review of the assessment and interviews with the Administrator confirmed that these groups were not actively involved in the development process. Additionally, the assessment did not include a plan to maximize recruitment and retention of direct care staff, nor did it contain a contingency plan for staffing needs. These omissions were identified during a review of the facility's assessment and an interview with the Administrator, who verified the lack of involvement from key stakeholders and the absence of required plans. The Administrator also acknowledged that the Facility Assessment had not been updated to reflect the latest CMS guidance, as outlined in QSO-24-13-NH, which requires these elements to be addressed.
Failure to Coordinate and Document Hospice Services
Penalty
Summary
The facility failed to coordinate hospice care for one resident, resulting in incomplete documentation and uncertainty regarding the provision of required hospice services. Specifically, the hospice calendar did not accurately reflect the scheduled and completed skilled nursing (SN) and hospice aide (HA) visits as ordered by the physician. Staff interviews revealed a lack of clarity about the frequency of these visits, with the LVN unable to confirm how often the HA visited the resident and acknowledging that the hospice calendar was not properly marked. This incomplete documentation made it unclear whether the resident received the necessary hospice care as outlined in the care plan. Additionally, there was confusion among staff regarding the identity of the facility's hospice designee or coordinator. The LVN incorrectly identified the DON as the hospice coordinator, while facility documents indicated that the Social Services Director (SSD) held this role. The DON later confirmed that the SSD was the designated hospice coordinator. The resident involved had a primary hospice diagnosis of Alzheimer's disease, lacked capacity to make health care decisions, and required routine hospice care as per physician orders.
Inaccurate Infection Surveillance Documentation and Incomplete Data Collection
Penalty
Summary
The facility failed to implement its infection prevention and control program as required, specifically by not ensuring the accuracy and completeness of its monthly Infection Prevention and Control Surveillance Log and Surveillance Data Collection Forms. For the months of January and February 2025, the numbers recorded on the surveillance logs did not match the infection control monthly summary reports, resulting in inaccurate reporting of healthcare-associated infections (HAIs), community-acquired infections (CAIs), and infections not meeting McGeer's criteria. This discrepancy was confirmed by both the Infection Preventionist (IP) and the Director of Nursing (DON) during interviews and document reviews. Additionally, the Surveillance Data Collection Forms for several residents who received antibiotics for infections were incomplete, as they failed to indicate whether the infections were classified as HAI or CAI, despite documentation of antibiotic administration and McGeer's criteria assessment. The IP acknowledged that these forms were incomplete and that the infection data should have matched across all reports to ensure accurate infection control information. The DON also verified and acknowledged these findings during the review.
Failure to Safeguard Electronic Medical Records
Penalty
Summary
The facility failed to safeguard residents' medical records and protect confidential health information as required by its own policies and procedures. During an initial tour, a laptop containing residents' information was observed left open and unattended on top of a medication cart in a hallway near Nurses' Station A. The cart and laptop were unattended, with no licensed nurse present, while other staff, residents, and visitors passed by, making the information visible and accessible to unauthorized individuals. When questioned, an LVN acknowledged the laptop was left open and confirmed that the computer screen should have been closed to maintain privacy. The Director of Nursing (DON) was also informed of the incident and verified the findings. The facility's policy requires that workstation screens be positioned to limit public view and that staff log off when leaving terminals, but these procedures were not followed in this instance.
Inaccurate POLST Documentation of Advance Directive
Penalty
Summary
The facility failed to ensure the accuracy of a resident's medical record, specifically regarding the documentation of the resident's Advance Directive on the POLST form. During a review of the medical record for one resident, it was found that the POLST form indicated the Advance Directive was not available, despite the fact that the document had been uploaded into the electronic medical record several days after the POLST was completed. This discrepancy was confirmed during an interview and concurrent record review with the Social Services Director, who acknowledged that the POLST form should have reflected the presence and review of the Advance Directive in the resident's current medical record. The facility's policy requires that all entries in the medical record be accurate, but this was not followed in the case of the resident's POLST documentation.
Multiple Food Safety and Sanitary Deficiencies in Kitchen
Penalty
Summary
The facility failed to ensure food safety and sanitary requirements in the kitchen, leading to multiple deficiencies. Observations revealed that the meat thawing process was not followed, with various meat items lacking use-by dates or freezer pull dates. Additionally, expired food was not discarded, and Time/Temperature Control for Safety (TCS) foods were not monitored to ensure proper cooling. These lapses were confirmed by the Food and Nutrition Services Director (FNSD) and the Chef during interviews and inspections of the walk-in refrigerator and cook's preparation refrigerator. The facility also failed to maintain cleanliness and proper hygiene in the kitchen. Two ice machines were found to be unclean, with slimy and crusty residues observed on the ice machine deflector and chute. Dietary personnel did not wear appropriate hair and beard restraints, exposing food to potential contamination. Furthermore, food preparation equipment, including frying pans, muffin pans, and cutting boards, were found to be in poor condition with thick residue buildup and heavy knife marks. These issues were verified by the FNSD and the Plants Operation Manager. Additional deficiencies included improper storage and labeling of food items. A storage container was found with a scoop left inside, and a dry food storage container was not properly sealed. Food preparation equipment was not air-dried before storage, and opened food in the freezer was not properly labeled and dated. The drying rack was also observed to be dirty with yellow and black debris. These findings were confirmed by the FNSD and the Chef during the kitchen tour and interviews.
Failure to Assess Resident for Self-Administration of Medication
Penalty
Summary
The facility failed to ensure that Resident 33 was accurately assessed for the capability to self-administer medications. An opened bottle of oxymetazoline hydrochloride nasal spray was found on Resident 33's overbed table, and the resident admitted to using it daily to relieve a stuffy nose. However, there was no physician's order for the nasal spray, and the resident's assessment for self-administration of medications indicated no interest in self-administration. Additionally, the resident had a BIMS score of 9, indicating moderate cognitive impairment. During an interview and concurrent medical record review, LVN 4 confirmed that they were unaware of the nasal spray at the bedside and that Resident 33 had not been assessed for self-administration of the medication. No care plan was developed for the administration of the nasal spray, and there was no physician's order for its use. This oversight had the potential for unsafe medication administration for Resident 33.
Failure to Notify Physician and Family of Significant Weight Loss
Penalty
Summary
The facility failed to ensure the notification of change for a resident reviewed for weight loss. Specifically, the facility did not communicate Resident 14's significant weight loss to the resident's physician, responsible party, and registered dietitian (RD). This failure was identified through interviews, medical record reviews, and a review of the facility's policies and procedures (P&P). The resident experienced a weight loss of 5.4% and 7.6 lbs. from 2/28/24 to 3/29/24, and a further weight loss of 6.5% and 9.2 lbs. from 3/7/24 to 4/3/24. Despite these significant changes, there was no documentation showing that the necessary notifications were made. During interviews, both RN 1 and the Director of Nursing (DON) confirmed that the resident's weight loss should have triggered notifications to the physician, RD, and responsible party. The DON stated that the charge nurse or clinical nurse supervisor is responsible for making these notifications once a significant weight change is identified. However, a review of Resident 14's medical record confirmed that these notifications were not made, which is a clear deviation from the facility's P&P and the guidelines outlined in the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual.
Improper Blood Pressure Measurement
Penalty
Summary
The facility failed to ensure services provided met professional standards of care when an LVN improperly took a blood pressure reading for a nonsampled resident. The LVN wrapped the blood pressure cuff on the resident's left upper arm and placed the diaphragm of the stethoscope on the left brachial artery over the resident's sweater, contrary to the facility's policy, which requires the diaphragm to be placed directly on the skin. This was confirmed during an interview with the LVN and the Director of Nursing (DON), who both acknowledged that the correct procedure was not followed.
Failure to Address Significant Weight Loss in a Resident
Penalty
Summary
The facility failed to ensure timely intervention for a resident experiencing significant weight loss. Resident 14, who was readmitted to the facility after a hospital stay, showed a weight loss of 5.4% and 7.6 lbs from 2/28/24 to 3/29/24, and a further weight loss of 6.5% and 9.2 lbs from 3/7/24 to 4/3/24. Despite these significant weight changes, there was no documentation of intervention by the nutritional services or the Registered Dietician (RD). The facility's policy required a referral to dietary services and an assessment by the Nutritional Services Director or RD upon identification of significant weight loss, but this was not followed for Resident 14. Interviews with facility staff revealed that the process for addressing weight changes involved weekly Nutritional At Risk (NAR) meetings, which were disrupted due to the RD's vacation. The resident's weight loss was identified by the electronic health record (EHR) system, but there was no documentation showing that the weight loss was reported or addressed. The Director of Nursing (DON) confirmed that the resident's weight loss should have been addressed within the week, but the covering RD did not review Resident 14 during the RD's absence. This lack of timely intervention had the potential to result in continued nutritional decline for the resident.
Failure to Provide Appropriate Respiratory Care
Penalty
Summary
The facility failed to ensure that Resident 26 received appropriate respiratory care. Specifically, the oxygen tubing used by Resident 26 was not labeled and was observed touching the floor on multiple occasions. The facility's policy and procedure (P&P) for oxygen management, revised on 5/31/21, requires that nasal cannulas, masks, and tubing be changed every seven days, dated, timed, and initialed. However, during observations on 4/2/24 and 4/3/24, the oxygen tubing for Resident 26 was found to be non-compliant with these guidelines. Resident 26, who was admitted to the facility on an unspecified date, had a physician's order to administer oxygen at one to three liters per minute via nasal cannula to maintain oxygen saturation levels above 92%. Another order required the oxygen nasal cannula to be changed every Sunday night or as needed. During an interview on 4/3/24, RN 1 confirmed that the oxygen tubing was not labeled and was touching the floor, which was against the facility's P&P. The Director of Nursing (DON) was informed of these findings on 4/4/24 and verified the observations.
Failure to Accurately Reconcile Controlled Medication
Penalty
Summary
The facility failed to ensure that Resident 13's oxycodone-acetaminophen, a narcotic pain medication, was accurately reconciled. The Controlled Drug Record indicated that the medication was signed out on two occasions, but the electronic Medication Administration Record (MAR) did not show documented evidence of administration for these instances. This discrepancy was verified by LVN 3 during a controlled medication reconciliation. The facility's policy requires each dose of controlled drugs to be signed, dated, and timed out on the proof of count sheet prior to administration, and the medication nurse must sign out the dose, not just initial it. However, this procedure was not followed in the case of Resident 13's medication administration on the specified dates. Resident 13 was admitted to the facility and had the capacity to understand and make decisions, as noted in the Internal Medicine H&P examination. A physician's order was in place for the administration of oxycodone-acetaminophen for moderate to severe pain. Despite this, the medication bubble pack showed the correct number of remaining tablets, indicating that the medication was removed but not properly documented as administered. The Director of Nursing (DON) acknowledged the findings and confirmed that licensed nurses are required to sign both the Controlled Drug Record and the MAR, which was not done in this case.
Improper Disposal and Storage of Medications
Penalty
Summary
The facility failed to ensure the proper disposal and storage of medications. In Medication Cart A, two open boxes of Restasis eye drops were stored next to three boxes of levalbuterol inhalation solution. This was verified by an LVN during an observation and interview. In Medication Room A, a waste disposal bin with multiple whole tablets inside was observed, and various medications were improperly stored together. An LVN confirmed these findings and stated that the facility did not use any liquid to dissolve the tablets, contrary to the facility's policy. The DON acknowledged that non-narcotic medications should be dissolved using the Drug Disposal System Rx Destroyer solution and disposed of daily or weekly as necessary. During an initial tour, a resident was found with a bottle of Theraworx Muscle Cramps foam on top of their bedside cabinet, which had been brought in by a family member but not used at the facility. The resident was cognitively intact, and an LVN verified the finding, stating it was the first time seeing the medication. The DON was informed and acknowledged this finding as well.
Incompetence in Food and Nutrition Services Management
Penalty
Summary
The facility failed to ensure that the Food and Nutrition Services Director (FNSD) was competent in managing the day-to-day functions of the food services department. The FNSD's personnel file lacked documentation of food service training, such as a certification from the American National Standards Institute-Conference for Food Protection, to show training in food service safety and sanitation guidelines. During the annual recertification survey, multiple issues were found in the main kitchen, including improper thawing processes for meats, failure to discard expired food, lack of monitoring of cooling for TCS foods, inadequate hair and facial hair covering, and improper storage of food and refuse. These deficiencies were observed despite the FNSD's claims of conducting kitchen walk-throughs and in-servicing staff. Interviews with the FNSD and the Administrator revealed gaps in the oversight and competency assessment of the kitchen staff. The FNSD stated that employee competency was evaluated once a year and that the Chef was responsible for overseeing back-of-the-house activities. However, the FNSD could not provide written documentation of kitchen inspections. The Administrator mentioned that department heads' competency was assessed based on their experience, knowledge of policies and procedures, and oversight by a consultant Dietitian. Despite these measures, the facility failed to ensure that the FNSD and kitchen staff were adequately trained and competent, leading to multiple deficiencies in the food services department.
Failure to Follow Puree Procedure for Meat and Vegetables
Penalty
Summary
The facility failed to ensure the resident menu was followed correctly during the preparation of pureed meals, specifically for meat and vegetables. During an observation of lunch meal preparation, Cook 3 did not adhere to the facility's recipe for pureed vegetables and meat. For the pureed green beans, Cook 3 added more thickener than specified in the recipe after initially finding the mixture too runny. Similarly, for the pureed pork, Cook 3 used incorrect measurements and added extra broth and thickener to achieve the desired consistency. These deviations from the recipe resulted in an inconsistent product that may not meet the nutritional needs of the residents on pureed diets. The issue was confirmed during a discussion with the Administrator, Food and Nutrition Services Director (FNSD), Registered Dietitian (RD), and Chef, who acknowledged that the puree procedure was not followed correctly. This failure posed a risk to the nutritional adequacy of the meals provided to the five residents who received pureed diets, as the consistency and nutritional content of the food could be compromised by not following the established recipes and procedures.
Failure to Honor Resident's Food Preference
Penalty
Summary
The facility failed to honor the food preference for one of the sampled residents, Resident 17, which had the potential for inadequate nutrition. The facility's policy and procedure (P&P) required obtaining food preferences, allergies, or intolerances and noting them on the dietary interview/pre-screen form and tray card. Despite Resident 17's expressed dislike for cranberry juice, which she communicated to the staff, she continued to be served cranberry juice for breakfast on multiple occasions. This was observed during concurrent observations and interviews with Resident 17 on two consecutive days. The Licensed Vocational Nurse (LVN) 4 acknowledged the resident's preference and noted it on her diet card, but the diet order was not updated accordingly, resulting in the resident being served cranberry juice again the following day. Further interviews revealed that the facility's process for updating food preferences was not followed correctly. LVN 4 confirmed that despite noting the resident's preference, the diet card still listed cranberry juice as the beverage. The Food and Nutrition Services Director (FNSD) stated that the nurse could communicate changes to the kitchen staff either verbally or through a slip, but this process was not effectively implemented in this case. As a result, Resident 17's food preference was not honored, indicating a failure in the facility's system to ensure residents' dietary needs and preferences are met as per their policy.
Failure to Communicate Safe Food Handling Guidelines to Visitors
Penalty
Summary
The facility failed to ensure the safe food handling guidelines were communicated to the residents' family members and visitors who brought food from outside. The facility's policy and procedure (P&P) titled 'Food from Outside Sources' required the community to help visitors understand safe food handling practices as summarized in the 'Safe Food Handling Guide for Visitors and Staff (DOC 403)'. However, during an interview, an LVN stated that she only educated family members and visitors about the resident's diet and not on safe food handling. Additionally, the Director of Nursing (DON) confirmed that while staff received in-service training on outside food and safe food handling, the facility had not provided the Safe Food Handling Guide to family members and visitors, citing that it was overwhelming for them to read the document.
Incomplete POLST Forms for Three Residents
Penalty
Summary
The facility failed to ensure complete and accurate medical records for three residents reviewed for advanced directives. Specifically, the POLST forms for Residents 14, 26, and 35 were found to be incomplete. For Resident 14, the POLST form was missing information in Section D regarding the presence and review of an advance directive. The SSD admitted to leaving this section blank, hoping the resident would eventually have capacity to make decisions. Similarly, Resident 35's POLST form also had an incomplete Section D, with the SSD again leaving it blank to avoid having to complete a new POLST if the resident later formulated an advance directive. Resident 26's POLST form was incomplete as well, with the SSD waiting for the resident's family to submit the advance directive, which was pending at the time of the review. Interviews and concurrent medical record reviews with the SSD and DON confirmed these deficiencies. The SSD acknowledged the incomplete sections and provided reasons for leaving them blank, while the DON verified the findings and stated that the expectation was for all resident documents to be completed. These actions and inactions led to the potential risk of the residents' advanced directive statuses not being communicated to healthcare staff in the event of an emergency.
Infection Control and Hand Hygiene Deficiencies
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program designed to provide a safe and sanitary environment to help prevent the transmission of communicable diseases and infections. Specifically, the facility did not implement a water management program to prevent the growth of Legionella and other opportunistic pathogens. The Plant Operation Manager was unable to provide documentation of control measures, corrective actions, or contingency response plans, and incorrectly believed that ongoing testing and control measures were unnecessary if there was no standing water. The Infection Preventionist was also unaware of the implementation and oversight responsibilities for Legionella monitoring, as outlined in the facility's policy and CDC guidelines. Additionally, the facility failed to ensure proper hand hygiene practices among staff. During a medication pass, an LVN did not change gloves or perform hand hygiene after touching a bedside table before administering eye drops to a resident. The LVN also used the same tissue for both eyes, contrary to the facility's hand hygiene policy. The DON confirmed that the gloves should have been changed and separate tissues should have been used for each eye. Furthermore, a CNA did not perform hand hygiene after touching a floor mat with bare hands before delivering a meal tray to another room. The CNA acknowledged the lapse in hand hygiene and admitted to not knowing if hand hygiene was necessary in that situation, despite having received prior training. The DON was informed and acknowledged these findings, which indicate a failure to adhere to the facility's hand hygiene policy.
Failure to Revise Comprehensive Care Plan for Pain Management
Penalty
Summary
The facility failed to ensure the comprehensive plan of care for Resident 639 was revised to address the resident's specific care needs and interventions. The facility's policy and procedure (P&P) required the Interdisciplinary Team to develop and implement a comprehensive person-centered care plan for each resident within seven days after the completion of the comprehensive assessment and after each Minimum Data Set (MDS) assessment, except the discharge assessment. The care plan should be reviewed and revised as the resident's conditions change. However, the care plan for Resident 639, who was admitted to the facility on an unspecified date, was not updated to include non-pharmacological interventions for pain management as ordered by the physician on 3/17/24. These interventions included repositioning, dim light/quiet environment, hot/cold applications, relaxation, distraction, music, massage, aromatherapy, and other methods documented in progress notes. On 4/3/24, during an interview and concurrent medical record review, LVN 1 confirmed that Resident 639's plan of care did not include the non-pharmacological interventions for pain as ordered by the physician. LVN 1 stated that she documented the non-pharmacological interventions provided on the Medication Administration Record (MAR) under the resident's behavior. On 4/4/24, the Director of Nursing (DON) was informed of the findings and acknowledged the deficiency. This failure posed a risk for Resident 639 to not receive the care and services required to attain or maintain their highest level of physical and mental well-being.
Improper Trash Storage
Penalty
Summary
The facility failed to store trash in a sanitary manner, as evidenced by the improper covering of a green organic trash container and one of three dumpsters. During an initial tour of the kitchen, a green organic trash container with raw vegetables inside was observed without a cover, which the Food and Nutrition Services Director (FNSD) stated was broken. Later, an observation of the trash disposal area revealed that the lid of one of the dumpsters was fully open. The Environmental Services (EVS) Manager acknowledged that staff had forgotten to close the dumpster cover and admitted to having ongoing issues with employees not closing the dumpster lids. The facility's policy and procedure (P&P) on garbage and trashcans, revised on 5/20/20, mandates that all food waste must be placed in covered garbage and trashcans, and that dumpster lids must be closed to prevent pest harboring, in accordance with the US Food Code 2022, Section 5-501.113.
Failure to Address Dementia Care Needs in Comprehensive Care Plan
Penalty
Summary
The facility failed to ensure the comprehensive care plan reflected the current care needs and interventions for one resident diagnosed with dementia. The facility's policy required the Interdisciplinary Team to develop and implement a comprehensive person-centered care plan with measurable objectives and time frames within seven days after the completion of the comprehensive assessments. However, during a medical record review and interview with an LVN, it was found that the care plan for the resident did not address the specific care needs related to dementia. The LVN confirmed the absence of documentation for the resident's care plan problem specific to dementia, verifying the deficiency.
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.
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What surveyors actually found near you
We read the 914 citations issued within 25 miles in the last 12 months — 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.
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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.
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Rancho Mission Viejo
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| San Juan Hills Healthcare Center | 3.8 mi | ★★★★★ | 18 | 0 |
| Palm Terrace Healthcare & Rehabilitation Center | 3.8 mi | ★★★★★ | 27 | 0 |
| Villa Valencia Healthcare Center | 4.2 mi | ★★★★★ | 7 | 0 |
| Laguna Hills Health And Rehabilitation Center | 4.3 mi | ★★★★★ | 46 | 0 |
| Freedom Village Healthcare Center | 5 mi | ★★★★★ | 19 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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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 June 2026) and official state health department websites.