Below average — CMS composite of the measures below.
The next survey window likely opens around May 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Focused Care At Orange during CMS and state inspections, most recent first.
Expired medications were found on 3 of 3 med carts, and the facility failed to ensure pharmaceutical services met residents’ needs. Three residents reviewed had active medication needs, including meds for HTN, hypothyroidism, and Parkinsonism, while staff said nurses were responsible for removing expired meds but the items were overlooked, including overflow stock. The Administrator and ADONs stated the carts were supposed to be checked weekly, and the facility policy required outdated medications to be removed from inventory immediately.
Kitchen Food Safety and Sanitation Lapses: Staff were observed without paper towels at the handwashing station, with hair and beard restraints not fully worn, and with missed handwashing after entering the kitchen and after adjusting clothing. The walk-in coolers had debris and stains, ground beef was thawing in a sink without running water, and open drinks were left on a prep table near food and serving items.
Unsafe and unkempt furniture was observed on Hall 100 and in an occupied resident room. The living room had 2 stained fabric chairs and an end table with a leaning leg, and 2 overbed tables in the room were in poor repair, with loose trim on one and missing laminate on the other. The maintenance supervisor said the chairs needed cleaning and the tables needed replacement, and the Administrator said the furniture should have been free of stains and in good repair for a safe homelike environment.
A resident with COPD and other respiratory diagnoses had an order for continuous oxygen at 3 LPM via nasal cannula, but during observation the concentrator was found set at 5 LPM. An LPN checked the order, confirmed the correct setting, and noted the concentrator should not have been on 5 LPM; the resident said a nurse had turned the knob during the night, and the LPN documented an O2 saturation of 99%.
A resident with a documented Hydrocodone allergy was administered 10 doses of Hydrocodone-Acetaminophen by multiple LVNs, despite her allergy being clearly listed in her records and reported by family. The pharmacy consultant made no recommendations, and staff interviews confirmed the allergy was known but not acted upon. The resident was unaware of receiving the medication and reported mental disturbances, with no documented allergic reactions in the notes.
Three residents experienced improper installation and maintenance of bed rails, including a loose rail with a large gap and lack of adherence to manufacturer guidelines. Care plans did not address entrapment risks, and bed mobility assessments indicated rails were not recommended, yet they remained in use. Staff failed to report or document issues, and repeated falls occurred, placing residents at risk for entrapment and injury.
A resident with hemiplegia and contractures did not consistently receive a physician-ordered palmar cushion to the left hand to prevent further contractures and maintain ROM. Staff were unaware of the order, and the device was not applied as required, with the order missing from the MAR and no clear facility policy in place for contracture management.
Surveyors found that kitchen staff did not consistently wear hair restraints as required, with two staff members observed without proper coverings while working. Additionally, the deep fryer and its baskets were not cleaned after use, leaving food debris and particles from a previous meal. These actions did not comply with facility policies or FDA Food Code standards for kitchen sanitation and staff hygiene.
A CNA failed to follow proper perineal care technique for a female resident with a history of urinary tract infection by wiping from the rectal area towards the vaginal area during incontinent care, contrary to facility policy and infection control procedures. The resident required extensive assistance and was receiving antibiotics for a UTI at the time.
A medication cart was observed to contain a loose, unidentified pill and various debris, including powdery and sticky substances, in multiple drawers. An LVN using the cart was unaware of the contamination and did not remove the loose pill or clean the drawers. Interviews with the DON, ADONs, and Administrator confirmed that both ADONs and nurses are responsible for ensuring medication carts are clean, but the cart in question was possibly overlooked, resulting in noncompliance with facility policy.
A resident with multiple complex conditions was administered morphine at an incorrect frequency after a nurse misinterpreted a verbal hospice order, resulting in 9 doses given every 3 minutes instead of every 30 minutes. The error was not immediately recognized, and the resident's condition deteriorated, leading to death. Staff interviews revealed confusion about the order and a lack of intervention despite concerns about the dosing frequency.
A facility failed to coordinate assessments with the PASRR program, resulting in a delay in providing a customized manual wheelchair (CMWC) for a resident with intellectual disabilities. Despite the IDT's agreement on the need for a CMWC, errors and delays in the submission process through the LTC Online Portal led to a delay in approval and ordering of the equipment. The resident did not receive the necessary services within the expected timeframe.
A resident with severe cognitive impairment and multiple medical conditions was injured after a CNA provided care alone, contrary to the care plan requiring two staff members. The resident rolled off the bed, resulting in a hip fracture. Staff interviews revealed inconsistencies in understanding and implementing the care plan, highlighting systemic issues in communication and training.
A resident with severe cognitive impairment and physical disabilities fell out of bed and fractured her femur due to inadequate supervision and assistance. Despite her care plan requiring two-person assistance for ADLs, a CNA provided care alone, leading to the incident. Staff were reportedly trained to provide care without a second staff member, contrary to the care guide, resulting in an Immediate Jeopardy situation.
The facility failed to protect residents from abuse, as evidenced by incidents involving four residents. A resident with dementia slapped another with Alzheimer's, resulting in a bruise. Another incident involved a resident with spondylosis hitting and pushing a resident with Parkinson's, causing a fall and skin tear. The facility did not report these incidents as abuse, constituting a deficiency in ensuring residents' safety.
The facility failed to report two incidents of resident-to-resident abuse within the required 2-hour timeframe. In one case, a resident with dementia and bipolar disorder slapped another resident with Alzheimer's, resulting in a bruise. In another incident, a resident with cognitive impairment hit and pushed a resident with Parkinson's and Alzheimer's, causing a skin tear. The facility did not report these incidents promptly, citing a lack of serious injury and mutual altercation, contrary to their abuse policy.
The facility failed to report an incident of resident-to-resident abuse to the State Survey Agency within the required timeframe. Two residents were involved in a physical altercation, but the Administrator did not report it as abuse due to the lack of serious injury. The facility's abuse policy mandates reporting such incidents, but this was not adhered to, resulting in a deficiency.
The facility failed to ensure a dietary staff member had a current Food Handler's Certificate while working in the kitchen. The staff member admitted to not realizing the expiration and was attempting to complete the training. The Dietary Manager and Administrator acknowledged the lapse, noting the DM was responsible for monitoring the certificates.
The facility failed to maintain sanitary conditions in the kitchen and did not properly monitor food temperatures before serving. Observations revealed significant buildup on cooking equipment, improper storage of shoes, and inconsistent temperature checks of food items.
The facility failed to maintain a working food scale in the kitchen, leading to inaccurate food portioning during meal service. The Dietary Manager acknowledged the issue and admitted there was no policy regarding food portions, potentially risking residents' nutritional intake.
The facility failed to ensure valid advance directives for three residents, resulting in the risk of CPR being performed against their wishes. The DNR orders were found to be invalid due to missing or incorrect physician details and witness signatures.
A facility failed to accurately code a resident's MDS assessment for bladder and bowel incontinence. The resident, with nephrostomy tubes and a colostomy, was incorrectly marked as always incontinent instead of not rated. This error was confirmed through record reviews and staff interviews, highlighting a deviation from the MDS RAI Manual guidelines.
The facility failed to ensure accurate PASRR screenings for two residents with mental illness and developmental disabilities, resulting in missed evaluations and necessary services. Both residents were admitted with negative PASRR Level 1 screenings despite having diagnoses that should have triggered further evaluations.
The facility failed to develop and implement comprehensive care plans for two residents, one with an anxiety disorder and another with a contracture of the right hand, leading to deficiencies in addressing their medical and psychosocial needs.
A resident with a cerebral vascular accident and right-hand contracture did not receive appropriate ROM interventions. The care plan did not address the contracture, and no hand splint was provided. Staff and therapy oversight led to the resident's condition being unaddressed, potentially worsening the contracture.
A resident with atrial fibrillation and shortness of breath did not receive oxygen therapy as ordered by the physician. The resident's oxygen was set at 3 liters instead of the prescribed 2 liters, which was confirmed by an LVN and acknowledged by the DON. This failure to follow the physician's order placed the resident at risk.
A resident with significant dental issues and severe cognitive impairment did not receive necessary dental services due to a lack of follow-up and coordination among staff. Despite being on a pureed diet and having obvious dental problems, no dental consult was arranged after an initial discussion with the family.
Expired Medications Left on Medication Carts
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of each resident because expired medications were found on 3 of 3 medication carts. Surveyors identified expired medications on the carts for Rooms 109-120, Rooms 217-220, and Rooms 205-216, and the report states that the facility failed to ensure expired medications were removed from the carts. The facility also failed to ensure accurate acquiring, receiving, dispensing, and administering of drugs and biologicals for 3 of 25 residents reviewed for pharmacy services. Resident #42 was a female with diagnoses including hypertension and hypothyroidism. Her quarterly MDS showed a BIMS score of 3, indicating severely impaired cognition. Her physician orders included amlodipine besylate 2.5 mg daily for hypertension and levothyroxine 50 mcg daily for low thyroid, and her care plan identified risks related to hypertension and hypothyroidism with interventions to administer medication as prescribed. Resident #61 was a male with Parkinsonism, had a BIMS score of 13 indicating intact cognition, and had an order for carbidopa/levodopa 25 mg/100 mg every 8 hours with care plan interventions to administer medication as prescribed. Resident #64 was a female with hypertension, had a BIMS score of 7 indicating severely impaired cognition, and her care plan included receiving medication as ordered. During the observation and interviews, staff identified that nurses giving medications from the carts were responsible for removing expired medications. The ADON and Administrator stated that expired medications had been overlooked and that staff did not check overflow medication for expiration dates. The Administrator also stated that the expectation was for medication carts to be checked weekly, including overflow medication, and for expired medications to be removed and destroyed timely. The facility policy titled, Storage of Medications, stated that outdated, contaminated, or deteriorated medications are immediately removed from inventory and disposed of according to medication disposal procedures.
Kitchen Food Safety and Sanitation Lapses
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional food safety standards in the kitchen. During observation, there were no paper towels at the handwashing station, the Dietary Manager’s hair was not fully contained in the hair restraint, Dishwasher A was not wearing a beard restraint, and [NAME] A’s beard restraint was not worn correctly. The Dietary Manager and [NAME] A entered the kitchen from outside without washing their hands, and [NAME] B lifted her shirt and pulled up her pants without washing her hands before touching kitchen seasonings. The kitchen also had sanitation and food handling issues during the same observation period. The floor and shelves of the walk-in coolers had green and brown debris and dark brown stains. Two log packs of ground beef were observed thawing in a sink without running water, and this was seen again later in the day. In addition, two open drinks belonging to [NAME] A were observed on the preparation table near serving plates and food. During interview, the Dietary Manager stated she should have washed her hands when she entered the kitchen and that all hair must be in the hair restraint while in the kitchen. [NAME] A stated he had gone outside to smoke and returned to finish cooking without washing his hands, and he acknowledged the drinks were his and should not have been on the preparation counter. Dishwasher A said he forgot to put on his beard restraint, and [NAME] B said she did not immediately wash her hands after adjusting her clothing. The Dietary Manager and Administrator both stated expectations for handwashing, hair restraints, clean coolers, proper thawing, and keeping drinks at the hydration station.
Unsafe and Unkempt Furniture in Common Area and Resident Room
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment on Hall 100 and in one occupied room on that hall. During observation, the living room at the end of Hall 100 had 2 fabric chairs with discolored stained areas on the seat cushions, and an end table between the chairs had a front leg leaning to the left at the bottom of the leg. In the occupied room, 2 overbed tables were observed, one with loose trim and the other with areas of missing laminate. During interview, the maintenance supervisor stated the chairs needed to be cleaned, the end table and overbed tables needed to be replaced, and that the environment should be free of broken tables to promote safety and that overbed tables should have a smooth finish to allow the surface to be sanitized. He said the end table had likely been broken during the past weekend and had not been reported to him, and that he had attempted to reattach the trim on one overbed table but should have replaced both tables. The Administrator stated she expected the overbed tables and furniture to be free of stains and in good repair for a safe homelike environment, and that the furniture should have been reported to maintenance but was not reported. The Maintenance Service Policy stated maintenance service shall be provided to all areas of the building, grounds, and equipment, and that maintenance personnel are responsible for maintaining the building in a safe and operable manner at all times and keeping it in good repair and free from hazards.
Oxygen Concentrator Set Above Ordered Flow Rate
Penalty
Summary
The facility failed to ensure safe and appropriate respiratory care for Resident #5, who was admitted with diagnoses including COPD and high blood pressure. Physician orders dated May 2026 directed oxygen at 3 LPM via nasal cannula continuously, and the care plan identified oxygen therapy related to COPD, shortness of breath, hypoxia, respiratory failure, and pulmonary hypertension. During an observation on 06/02/2026 at 8:43 a.m., Resident #5 was in bed receiving oxygen, and the concentrator was set at 5 LPM instead of the ordered 3 LPM. During an interview and observation shortly afterward, the LVN checked the physician's orders, confirmed the ordered flow rate was 3 LPM, and stated the concentrator should not have been on 5 LPM. Resident #5 said a nurse had come in during the night and turned the knob, but she did not know who it was. The LVN checked the resident's O2 saturation, which was 99%, and stated she would report the incorrect concentrator setting to the physician, family, and DON.
Failure to Prevent Administration of Allergic Medication
Penalty
Summary
A facility failed to prevent a significant medication error involving a 78-year-old female resident with multiple documented allergies, including Hydrocodone. Despite clear documentation of the resident's Hydrocodone allergy on her face sheet, care plan, nurse report sheet, hospital discharge paperwork, and medication record, she was administered 10 doses of Hydrocodone-Acetaminophen over several days. The Hydrocodone was initially ordered by a hospital physician, but the facility's staff administered the medication without identifying or acting on the documented allergy. Multiple licensed vocational nurses (LVNs) administered the Hydrocodone doses, and the pharmacy consultant reviewed the resident's case without making any recommendations. Interviews with family members confirmed that the allergy was reported to staff upon admission, although the specific staff member was not recalled. The resident herself was unaware she had received Hydrocodone and did not recall being forced to take it, but reported mental disturbances associated with its administration, as relayed by her family. There were no documented notes of negative outcomes such as rashes or hives in the nurse's or progress notes during the period of administration. Interviews with facility staff, including the ADON, administrator, nurse practitioner, and pharmacist, confirmed that the resident's allergy to Hydrocodone was documented and that she should not have received the medication. The facility's policy required checking allergies before administering new medications, and in-service training on this topic had been conducted. Despite these protocols, the allergy was not identified or acted upon, resulting in the administration of a medication to which the resident was allergic.
Failure to Ensure Proper Bed Rail Installation, Assessment, and Maintenance
Penalty
Summary
The facility failed to ensure the correct installation, use, and maintenance of bed rails for three residents reviewed for bed rail use. Specifically, the facility did not have the manufacturers' recommendations and specifications available or follow them for installing and maintaining bed rails, resulting in a large gap in one resident's bed rail. Observations revealed that a bed rail was loose and had a gap of approximately 14 to 18 inches between the mattress and the rail, and staff reported that the issue had persisted for 2-3 months without being properly reported or addressed. The Director of Plant Operations was unaware of the issue until surveyor intervention and did not maintain documentation or a log of maintenance requests or repairs, nor did he have the manufacturer manuals for the beds or bed rails. Additionally, the facility failed to develop care plans that addressed the risk of entrapment and did not implement interventions to prevent entrapment for residents with a history of falling out of bed. Care plans for these residents did not include the risk of entrapment, and bed mobility assessments indicated that bed rails were not recommended for use, yet the rails remained in place. Multiple incident reports documented repeated falls from bed for these residents, and consent forms for bed rail use were present but not aligned with current assessments or care plans. The facility also did not provide maintenance and monitoring of bed rails according to manufacturer specifications or recommendations. There was no evidence of regular, documented inspections, and staff were not consistently trained on the proper procedures for reporting broken or malfunctioning bed rails. The lack of proper installation, assessment, and maintenance of bed rails placed residents at risk for entrapment, serious injury, or death, as directly stated in the report.
Removal Plan
- The Director of Plant Operations changed the bed for resident #70 with properly operating bed rails.
- The Charge Nurse reassessed resident #70 for bed mobility and the bed mobility assessment for resident #70 was updated. The use of side rails was recommended per assessment.
- The Charge Nurse reassessed resident #102 for bed mobility and the bed mobility assessment for resident #102 was updated. The use of side rails was not recommended per assessment.
- The Director of Plant Operations removed the assist bar for resident #102 per recommendations from assessment.
- The Charge Nurse reassessed resident #87 for bed mobility and the bed mobility assessment for resident #87 was updated. The use of one bed rail for turning and repositioning recommended per assessment.
- The Director of Plant Operation removed the right bed rail from resident #102's bed.
- The Director of Plant Operations was educated according to Manufacturers Guidelines on proper installation of bed rails.
- The Director of Plant Operations conducted a Bed Rail Entrapment Assessment throughout the building to identify any bed rail posing a risk of entrapment.
- The Executive Director of Operation obtained the manufacturer's guidelines for each type of bedrail in the facility, and they are compatible for use with the beds that we have.
- Any non-compliant bed rail was either fixed or replaced to meet assessment standards and proper installation according to the manufactures guide.
- The Director of Plant Operations will complete the Bed Rail Entrapment Assessment.
- The Director of Clinical Operations and/or designee will conduct an audit of bed mobility assessments to ensure proper evaluation and documentation.
- If the bed mobility assessment indicated that bed rails were not needed, they were removed by the Director of Plant Operations.
- The Director of Clinical Operations and/or designee will lead training sessions to ensure team members understand proper procedures for identifying and addressing bed rail concerns.
- Team members must immediately report malfunctioning, broken, or non-working equipment to their Supervisor and the Director of Plant Operations via phone and on maintenance log.
- New team members will be educated regarding reporting any broken equipment during orientation.
- The Executive Director completed educational training with the Director of Plant of Operations regarding the completion of the Bed Rail Entrapment Assessment per company policy.
- Nursing staff and department managers educated on acceptable gaps for zone 1 and zone 3.
- Nursing staff will document on the licensed medication administration record the checks have been completed.
- Any gaps larger than 4-3/4 will be reported to the on-call phone and the maintenance log.
- Documentation will be completed on the company form for the assessment.
- The Executive Director of Operations completed educational training with the Director of Plant Operations on the manufacturer's guidelines on bed rails installation for the Medline (FCE1232RSRN) and Joerns beds (F14SC).
- Charge nurses must accurately complete bed rail assessments and determine if rails are suitable for resident use.
- Charge Nurses educated on how to accurately complete bed rail assessments.
- New charge nurses will be educated regarding completing an accurate bed rail assessment during orientation according to manufacturers' recommendation.
- If an assessment indicates bed rails are recommended, the team member must notify both the Director of Clinical Operations and the Director of Plant Operations immediately.
- New charge nurses will be educated regarding immediate notification to the Director of Clinical Operations and the Director of Plant Operations during orientation.
- The Director of Clinical Operation and/or Designee will complete training on accident/incident prevention, including types of interventions put into place to prevent any further fall.
- The Clinical Reimbursement Coordinator will conduct an audit of resident care plans, ensuring appropriate documentation of bed rail concerns.
- Care plans will be updated to specify bed rail risks and potential entrapment hazards.
- The Director of Clinical Operations notified the Medical Director of immediate jeopardy and reviewed bed rail policy and procedure.
- This practice will be reviewed with the QA Committee to ensure no changes are needed to the current policy.
- All actions outlined in this plan will be monitored for ongoing compliance, reinforcing our commitment to providing a safe environment for residents.
Failure to Provide Ordered Palmar Cushion for Resident with Contractures
Penalty
Summary
A resident with a history of hemiplegia, hemiparesis, and contractures following a cerebral infarction was not provided with appropriate treatment and services to maintain or improve range of motion (ROM) in accordance with physician orders. The resident had an order for a palmar cushion to be applied to the left hand at all times, except during hygiene, to prevent further contractures. Observations on multiple occasions revealed that the resident did not have the palmar cushion in place, and the resident reported not having had the cushion for weeks, despite feeling more comfortable with it. Nursing staff were unaware of the order and had not been applying the cushion, and the order was not reflected on the medication administration record (MAR) due to a lack of proper entry into the system. Interviews with staff indicated a lack of awareness and communication regarding the resident's need for the palmar cushion, with responsibility for its application being unclear between therapy and nursing. The care plan and physician orders specified the need for the cushion, but these were not consistently followed. Additionally, the facility did not have a current policy addressing the prevention and treatment of contractures, contributing to the failure to provide the required care and services to maintain the resident's ROM.
Failure to Maintain Kitchen Sanitation and Staff Hair Restraint Compliance
Penalty
Summary
Surveyors observed that the facility failed to maintain sanitary conditions in the kitchen, specifically regarding staff compliance with hair restraint policies and the cleanliness of cooking equipment. During an initial tour, one staff member was seen without a hair restraint while standing between the stove and counters, only putting it on after being observed. She admitted to removing it due to discomfort and forgetting to replace it, despite acknowledging the requirement to wear it at all times. Another staff member in the dishwashing area was also found without a hair restraint, stating she had forgotten to put it on, even though she was aware of the facility's policy. Both staff members confirmed they had been trained to always wear hair restraints to prevent hair from contaminating food or equipment. Additionally, the facility's deep fryer was found with baskets containing dried brown crusty substances and black particles on the side and front ledges, which were identified as leftover debris from a previous meal service. The Dietary Manager confirmed that the fryer baskets and ledges should have been cleaned after use and that failure to do so could result in cross contamination. The fryer was reportedly on a weekly cleaning schedule, but the observed debris was attributed to a meal served two days prior. Facility policies and FDA Food Code requirements for hair restraints and equipment cleanliness were reviewed, confirming that the observed practices did not meet established standards.
Improper Perineal Care Technique During Incontinent Care
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) failed to provide appropriate perineal care to a female resident who was always incontinent of bowel and bladder and had a recent urinary tract infection. During observed incontinent care, the CNA cleaned the resident's perineal area by wiping towards the rectum, but then cleaned the rectal area and wiped towards the vaginal area once, contrary to proper infection control procedures. The resident's care plan required extensive assistance for personal hygiene and noted she was receiving antibiotics for a urinary tract infection at the time of the incident. The CNA acknowledged during an interview that she had been trained to wipe from clean to dirty and recognized she should have wiped from front to back. The Director of Nursing confirmed that the facility's policy and expectations were for staff to wipe from front to back to prevent infections. The facility's written procedure also specified cleaning from front to back using a separate section of the wipe for each stroke.
Medication Cart Found Unclean with Loose Pill and Debris
Penalty
Summary
A deficiency was identified when a medication cart serving rooms 109-120 was found to contain a loose, unidentified pill and scattered debris, including powdery and sticky substances, in multiple drawers. During observation, an LVN using the cart was unaware of the loose pill and did not remove it or clean the debris. The LVN acknowledged that the cart should be clean and free of loose pills, and stated that while maintenance sometimes pressure washes the carts, nurses are responsible for wiping down bottles and keeping the cart clean. The LVN believed that resident medications were not at risk because the medications were sealed, but agreed the cart should be wiped down. Interviews with the DON, ADONs, and Administrator revealed that responsibility for ensuring medication carts are clean and free of expired or loose medications is shared among ADONs, who are to check and clean the carts weekly, and the nurses who use the carts, who serve as a backup. The dirty medication cart was attributed to being possibly overlooked. The facility's policy requires that medication storage areas be kept clean, but the observed condition of the cart did not meet this standard.
Significant Medication Error: Incorrect Morphine Dosing and Transcription
Penalty
Summary
A significant medication error occurred when a resident with multiple complex diagnoses, including Alzheimer's disease, COPD, epilepsy, diabetes with neuropathy, paranoid schizophrenia, and pain, was administered morphine at an incorrect frequency and dosage. The resident, who was severely cognitively impaired and dependent on staff for all care, was ordered morphine sulfate 100mg/5ml, 1ml by mouth every 2 hours as needed. However, following a pain crisis, a new verbal order was received from hospice to administer 1ml every 30 minutes until the resident was comfortable, then every 2 hours. The nurse on duty misinterpreted and transcribed the order as 1ml every 3 minutes, resulting in the administration of 9 doses (180mg) over a 24-minute period. The error was not immediately identified, and the nurse continued to administer morphine according to the incorrect transcription. The nurse stated she clarified the order multiple times with the hospice RN, but still proceeded with the erroneous frequency. The hospice RN, upon arrival later in the day, discovered the error during a review of the narcotic count sheet and nurse's documentation. The hospice RN and physician were notified, and the resident's responsible party was offered Narcan or transfer to the ER, but these interventions were declined. The resident was closely monitored for changes in condition, and her respiratory status declined over the following hours. Interviews with staff revealed that the nurse who administered the morphine was not familiar with the hospice provider and believed the dosing was a new pain management protocol. Other staff present at the time expressed concern about the frequency but did not intervene. The error was ultimately reported to facility leadership and the consulting pharmacist, who confirmed the dosage was outside standard prescribing guidelines. The resident's condition deteriorated, and she passed away within hours of the overdose. The facility's policy required evaluation of new medication orders for appropriate dose, route, and frequency, but this was not followed in this instance.
Failure to Coordinate PASRR Assessments and Services
Penalty
Summary
The facility failed to coordinate assessments with the PASRR program and incorporate the recommendations from the PASRR evaluation report into a resident's care planning. Specifically, the facility did not provide and arrange for a specialized customized manual wheelchair (CMWC) for a resident as recommended and agreed upon by the interdisciplinary team (IDT) within the timeframe set by PASRR. This deficiency was identified for one of two residents reviewed for PASRR assessments. The resident involved was a male with multiple diagnoses, including moderate intellectual disabilities, developmental disorder of speech and language, hypertension, hypertensive chronic kidney disease, chronic kidney disease, and benign prostatic hyperplasia. The resident was PASRR positive for intellectual disability and required specialized services, including a CMWC. Despite the IDT's agreement on the need for a CMWC during a quarterly meeting, the facility did not ensure timely coordination and delivery of the wheelchair. The Clinical Reimbursement Coordinator was responsible for submitting the request for the CMWC through the LTC Online Portal. However, there were delays and errors in the submission process, which led to a delay in the approval and ordering of the CMWC. The DME company did not receive the approval until several weeks after the initial request, resulting in the resident not receiving the necessary equipment within the expected timeframe. Interviews with facility staff revealed a lack of awareness of the specific timelines required for PASRR-related processes, contributing to the deficiency.
Failure to Implement Care Plan Leads to Resident Injury
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident, which resulted in a serious injury. The resident, a female with severe cognitive impairment and multiple medical conditions, was dependent on staff for all activities of daily living (ADLs). Despite the care plan indicating that two staff members were required for her care, a certified nursing assistant (CNA) provided care alone, leading to the resident rolling off the bed and sustaining a hip fracture. The incident occurred when the CNA was providing toileting care without a second staff member, contrary to the care plan's requirements. The CNA was unaware of the care guide's instructions and had been trained to provide care without a second staff member. This lack of adherence to the care plan resulted in the resident falling from the bed and later requiring surgical repair for a hip fracture. Interviews with various staff members revealed inconsistencies in the understanding and implementation of the care plan. Some staff believed the resident required only one staff member for assistance, while others were unaware of the care guide's requirements. The Director of Nursing (DON) and other staff members acknowledged the risk of injury when care plans were not followed accurately, highlighting a systemic issue in the facility's communication and training processes.
Removal Plan
- Physical Therapy evaluated Resident #5 to ensure appropriate staff assist to prevent further accidents.
- The Director of Clinical Operations implemented floor mats for Resident #5.
- The MDS nurse updated the level of assist to 1-2 person for ADL's for Resident #5 to prevent further injuries.
- Physical Therapy determines the level of assistance required.
- The MDS Nurse implemented scoop mattress for Resident #5 to prevent further injuries.
- The above change in care is discussed in the morning clinical meeting with the update being added to the Kardex to keep staff informed.
- The MDS Nurse is responsible for making the update on a quarterly basis, or as needed if a change occurs, after the IDT has discussed the resident.
- The IDT determines the number of staff (increase/decrease) that is needed for ADL's.
- The EDO had the therapist go re-evaluate Resident #5 for ADL care.
- The evaluation showed that Resident #5 was a 1 person assist for bed mobility.
- The IDT met and are in agreeance will make the change on the care plan effective.
- The Director of Clinical Services will perform an in-service education to the staff immediately on the level of care during of this assessment of Resident #5.
- The MDS Nurse and/or designee will review fall care plans on all residents to ensure that they are appropriate and will help prevent injuries by ensuring the appropriate level of assistance needed for ADL's by team members.
- All care plans will be reviewed to ensure the appropriate level of assistance for ADL's by staff is accurate by the MDS Nurse and/or designee.
- The care plan will update the Kardex to show the level of assistance needed to all nursing staff.
- All incidents/accidents will be reviewed in the morning clinical meeting by the Director of Clinical of Operations and/or designee to ensure that care plan is updated to reflect any changes in level of care and appropriate interventions are in place after each fall.
- In-service Education will be provided to all nursing staff by the Director of Clinical Services and/or designee.
- Staff will not be allowed to work until in-service education has been provided which includes: How to use the Kardex to determine the level of staff assistance needed to care for the residents.
- The change in level of assistance will be communicated in the morning clinical meeting and the Kardex is updated at that time.
- The Director of Clinical Services and/or the Assistant Director of Clinical Services will randomly monitor two nurse aides weekly to ensure that they are utilizing the Kardex for resident care.
- Any aide that is not utilizing the Kardex system will be re-trained immediately.
- The Regional Clinical Reimbursement Coordinator will perform in-service education with the MDS Nurses on personalizing the care plan for falls with interventions and level of care provided by team members.
- The Director of Clinical Services and/or the Assistant Director of Clinical Services will monitor during the morning clinical meeting, during the review of incidents/accidents, that the interventions and level of care provided by team members are being reviewed and care plan changed as needed.
- The incident/accident care plans will be monitored by the Director of Clinical Services and/or by the Assistant Director of Clinical Services in the morning clinical meeting with the IDT to ensure appropriate fall interventions are in place for the resident's care plan.
- The fall interventions will be monitored for 72 hours by the Director of Clinical Operation and/or designee to ensure that the intervention is effective.
- If the fall intervention is not effective the IDT will make other recommendations for a new approach and the care plan will be updated.
Failure to Provide Adequate Supervision and Assistance Leads to Resident Injury
Penalty
Summary
The facility failed to provide adequate supervision and assistance devices to prevent accidents for a resident who was dependent on staff for all activities of daily living (ADLs). The resident, who had severe cognitive impairment and multiple physical disabilities, required two-person assistance for bed mobility, toileting, and bed baths as per her care plan. However, on the day of the incident, a CNA provided care without a second staff member, resulting in the resident falling out of bed and sustaining a fractured left femur. The resident's care plan and care guide clearly indicated the need for two-person assistance, but the CNA was reportedly trained to provide care without a second staff member. This discrepancy between the care plan and the training provided to staff led to the resident not receiving the required level of care. Interviews with various staff members revealed a lack of awareness and adherence to the care guide, with some staff believing that the resident could assist with repositioning by holding the side rail, despite her severe cognitive and physical impairments. The incident was further compounded by the initial x-ray not showing a fracture, delaying the identification and treatment of the injury. It was only after the resident exhibited pain during therapy that a repeat x-ray was conducted, revealing the fracture. The facility's failure to ensure that staff followed the care guide and provided the necessary level of assistance placed the resident at risk of harm, resulting in an Immediate Jeopardy situation.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect residents from abuse and neglect, as evidenced by incidents involving four residents. Resident #3, diagnosed with dementia, COPD, anxiety, and bipolar disorder, was involved in an altercation with Resident #4, who has Alzheimer's. On October 5, 2024, Resident #3 slapped Resident #4, resulting in a bruise on Resident #4's face. The incident was confirmed by the facility's investigation, and it was reported to the Health and Human Services (HHS) the following day. Despite the facility's actions to separate the residents and adjust medications, the initial failure to prevent the altercation constituted a deficiency. Another incident involved Resident #1, who has spondylosis and acute kidney failure, and Resident #2, diagnosed with Parkinson's and Alzheimer's. On November 11, 2024, Resident #1 hit and pushed Resident #2, resulting in Resident #2 falling and sustaining a skin tear. The facility did not report this incident as resident-to-resident abuse, as the Administrator believed it was a mutual altercation without serious injury. However, the failure to report and prevent the incident was a deficiency in ensuring residents' safety and protection from abuse. The facility's noncompliance with abuse prevention policies was identified as a deficiency, with the incidents occurring between October 5, 2024, and November 11, 2024. The facility's abuse policy, revised in January 2020, mandates that residents be free from abuse, neglect, and exploitation. The facility's failure to adhere to this policy and promptly report and address incidents of resident-to-resident abuse led to the identified deficiency.
Failure to Timely Report Resident-to-Resident Abuse Incidents
Penalty
Summary
The facility failed to report allegations of abuse within the required 2-hour timeframe for four residents involved in two separate incidents. In the first incident, Resident #3 slapped Resident #4 in the face after an altercation, resulting in a bruise on Resident #4's face. The facility did not report this incident to the appropriate authorities until the following day, exceeding the mandated reporting period. Resident #3 had a history of dementia, COPD, anxiety, and bipolar disorder, while Resident #4 had Alzheimer's and was known to be potentially physically aggressive. In the second incident, Resident #1 hit and pushed Resident #2, leading to a skin tear on Resident #2's left forearm and elbow. This incident was also not reported within the required timeframe. Resident #1 had moderate cognitive impairment and a history of behavioral symptoms, while Resident #2 had Parkinson's and Alzheimer's, with a care plan indicating verbal aggression. Despite the altercation, the facility did not report the incident as resident-to-resident abuse, citing the lack of serious injury and the nature of the altercation as mutual. The facility's failure to report these incidents promptly could place residents at risk of further abuse, physical harm, mental anguish, and emotional distress. The facility's abuse policy mandates immediate reporting of any allegations of abuse or suspicious serious bodily injury, which was not adhered to in these cases. Interviews with the Director of Nursing and the Administrator revealed a misunderstanding of the reporting requirements, contributing to the delay in notifying the appropriate authorities.
Failure to Report Resident-to-Resident Abuse
Penalty
Summary
The facility failed to investigate and report an incident of resident-to-resident abuse to the State Survey Agency within the required 5 working days. This incident involved two residents, where one resident hit and pushed another. The facility did not submit the findings of their investigation within the stipulated timeframe, which is a requirement for such incidents. The Director of Nursing (DON) was aware of the incident and notified the Administrator, who is the abuse coordinator. However, the Administrator did not report the incident as abuse because he perceived it as a mutual altercation without serious injury. Resident #1, who was involved in the incident, had moderate cognitive impairment and a history of behavioral symptoms directed at others. His care plan did not include any behavioral interventions. Resident #2, the other resident involved, was cognitively intact but had a history of verbal aggression. Following the incident, Resident #1 was moved to another room, and both residents were separated. Despite these actions, the facility did not fulfill its obligation to report the incident to the state, as required by their abuse policy and state regulations.
Expired Food Handler's Certificate for Dietary Staff
Penalty
Summary
The facility failed to employ staff with the appropriate competencies and skill sets to carry out the functions of the food and nutrition service. Specifically, one dietary staff member (DA J) did not have a current Food Handler's Certificate while working in the facility's kitchen. Record review indicated that DA J's certificate had expired, and during an interview, DA J admitted to not realizing the expiration and was attempting to complete the training. The Dietary Manager (DM) and the Administrator acknowledged the lapse, with the Administrator noting that the DM, who had recently started, was responsible for monitoring the certificates. This deficiency could place residents at risk of foodborne illness due to being served by improperly trained staff.
Sanitary Conditions and Food Temperature Monitoring Deficiencies
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food under sanitary conditions in the preparation kitchen. Observations revealed that baking sheets, steam table pans, muffin pans, and skillets had brown and/or black baked-on buildup. Additionally, staff did not leave their shoes in the kitchen, and food temperatures were not properly checked before serving. Specifically, during the initial tour of the kitchen, multiple baking sheets, muffin pans, and a skillet were found with significant buildup. The Dietary Manager (DM) acknowledged the issue but mentioned she had only been working at the facility for two weeks and had not addressed the buildup yet. During the lunch meal service, slide shoes were found under the prep table, and the DM acknowledged they should not be there. Cook G pulled turkey breast roasts from the oven and checked their temperature, but the DM did not check the food temperatures before serving. When prompted by the surveyor, the DM checked the temperature of the turkey slices, which had dropped to 154 degrees, and then checked the other foods on the steam table, which were above the required holding temperature. The DM and Cook G admitted that food temperatures should be checked when taken out of the oven and before serving, but this was not done consistently.
Failure to Maintain Essential Kitchen Equipment
Penalty
Summary
The facility failed to maintain essential equipment in safe operating condition, specifically a food scale in the kitchen. During the lunch meal service, it was observed that the food scale was not functioning, preventing accurate measurement of food portions. Cook G sliced turkey roasts without pre-cutting them to the required portion size and attempted to use the food scale, which did not work. The Dietary Manager (DM) acknowledged the issue and admitted that without a working scale, the accuracy of the meat portions could not be determined. The DM also mentioned that there was no policy regarding the food scale or food portions and that they were supposed to follow the menu spreadsheet for portion amounts. This deficiency could potentially lead to residents not receiving the correct amount of food, which may result in weight loss and decreased quality of life.
Failure to Ensure Valid Advance Directives
Penalty
Summary
The facility failed to ensure the right to formulate an advance directive was provided for three residents. Resident #26, an elderly male with chronic obstructive pulmonary disease, hypertension, and peripheral vascular disease, had a DNR order that was not valid due to missing physician details and incorrect witness signatures. The Director of Nursing (DON) acknowledged the invalidity of the DNR and the potential for CPR to be initiated against the resident's wishes. Resident #91, an elderly female with cerebral infarction, respiratory failure, kidney failure, and peripheral vascular disease, also had a DNR order that was not valid. The physician's signature was in the wrong section, lacked a date, and did not include the physician's printed name or license number. The DON confirmed the invalidity of the DNR and the risk of CPR being performed against the resident's wishes. Resident #216, an elderly male with cerebral infarction, hypertension, and heart failure, had a DNR order that was incomplete. The form lacked identification of the person initiating the DNR and the physician's signature in the required section. The DON admitted the DNR was not valid, which could result in CPR being administered contrary to the resident's preferences.
Inaccurate MDS Assessment for Continence
Penalty
Summary
The facility failed to ensure an accurate MDS assessment for a resident reviewed for MDS assessment accuracy. Specifically, the facility did not accurately code the resident's MDS assessment for bladder and bowel incontinence. The resident, a female with diagnoses including malignant neoplasm of the cervix and quadriplegia, had nephrostomy tubes and a colostomy. Despite this, the resident's MDS assessment was incorrectly coded as always incontinent of bowel and bladder, rather than not rated, as required by the MDS RAI Manual. This discrepancy was confirmed through record reviews and interviews with facility staff, including the MDS Nurse and the DON, who acknowledged the error and its potential negative outcomes, such as the resident not receiving appropriate care and incorrect information being reported to CMS. The resident's care plan and physician orders indicated the presence of nephrostomy tubes and a colostomy, which should have led to the MDS assessment being marked as not rated for both bladder and bowel continence. Observations confirmed the presence of these medical devices. The MDS Nurse admitted that the assessment should have been marked not rated, and the DON confirmed that the facility followed the MDS RAI manual for accuracy. The incorrect coding of the MDS assessment was a clear deviation from the manual's guidelines, which specify that residents with ostomies or nephrostomy tubes should be coded as not rated for continence.
Failure to Ensure Accurate PASRR Screenings
Penalty
Summary
The facility failed to ensure preadmission screening for individuals identified with mental illness (MI), developmental disability (DD), or intellectual disability (ID) were evaluated for services for two residents. Resident #50, a male with diagnoses including recurrent depressive disorders, major depressive disorder, and anxiety disorder, was admitted without an accurate PASRR Level 1 screening. Despite having physician orders for antidepressants and anxiety medication, his PASRR Level 1 screening was negative, and no further evaluation was conducted. The MDS nurse acknowledged that a positive PASRR Level 1 should have triggered a further evaluation, but this was not done due to the initial negative screening result. The Regional Nurse confirmed that the resident should have had a positive PASRR Level 1 and a corrected screening should be sent to the Local Mental Health Authority (LMHA). Similarly, Resident #69, a female with diagnoses of Huntington's disease, dementia, and anxiety disorder, was admitted without an accurate PASRR Level 1 screening. Her admission MDS indicated severely impaired cognition and an altered level of consciousness, yet her PASRR Level 1 screening was negative. The MDS nurse responsible for her screening admitted to being unaware that Huntington's disease was a PASRR positive diagnosis. The Director of Nursing (DON) and the Regional Nurse both acknowledged that the incorrect PASRR Level 1 screening could result in the resident missing out on necessary PASRR services. The Regional Nurse admitted to overlooking the screening and stated that reeducation for the MDS nurses would be provided. The facility's policy, revised in November 2023, mandates that PASRR screenings be completed timely and accurately. However, the failure to adhere to this policy resulted in both residents not receiving the necessary evaluations and services. The October 2023 Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual specifies that all individuals admitted to a Medicaid-certified nursing facility must have a Level 1 PASRR completed to screen for possible MI, ID, or DD. The facility did not comply with these requirements, leading to the deficiencies noted in the report.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for two residents, leading to deficiencies in addressing their medical and psychosocial needs. Resident #50, a male with an anxiety disorder, did not have a care plan for his anxiety or the medication buspirone, despite having an active diagnosis and physician orders for the medication. This oversight was acknowledged by the MDS nurse, who admitted that the lack of a care plan could result in the resident not receiving appropriate care. The deficiency was identified through record reviews and interviews with staff, who confirmed the absence of the necessary care plan for the resident's anxiety disorder and medication management. Similarly, the facility did not develop a care plan for Resident #55's contracture of the right hand, despite the resident having a diagnosis of cerebral vascular accident and limited range of motion (ROM) in both upper and lower extremities. Observations revealed that the resident's fingers and thumb were stiff and contracted, yet the care plan did not address these issues. Interviews with the DON and MDS nurse confirmed that the care plan was not updated to reflect the resident's condition, which could lead to the resident not receiving the required care. The facility's policy on comprehensive care plans mandates regular updates, but this was not adhered to in these cases.
Failure to Provide Appropriate ROM Interventions
Penalty
Summary
The facility failed to ensure a resident with limited range of motion (ROM) received appropriate treatment and services to prevent further decrease in ROM. Resident #55, who had a diagnosis of cerebral vascular accident, exhibited contractures in her right hand. Despite this, there were no physician orders for a hand splint, and the resident's care plan did not address her limited ROM. Physical therapy notes indicated that the resident received therapy for her lower extremities but did not document any interventions for her right-hand contracture. Observations confirmed that the resident's fingers and thumb were stiff and contracted, and she did not have a hand splint in place during multiple checks by staff and interviews with the resident and staff members. Interviews with staff revealed that the resident had not been provided with a hand splint, and there was a lack of communication and oversight regarding the resident's need for ROM interventions. The physical therapist admitted that the contracture of the resident's right hand was overlooked during therapy sessions, which focused on other issues such as tardive dyskinesia and gross motor skills. The therapist acknowledged that interventions like a palm guard could have been implemented to prevent further contracture. The Director of Nursing (DON) confirmed that there was no specific policy for ROM or contracture management in place. The lack of appropriate interventions and oversight led to the resident's condition being unaddressed, potentially resulting in further contractures and skin integrity issues. Staff members, including CNAs and LVNs, were unaware of the need for a hand splint and had not been instructed to provide one, highlighting a systemic issue in the facility's care planning and communication processes.
Failure to Administer Oxygen as Ordered
Penalty
Summary
The facility failed to ensure that a resident who needed respiratory care was provided care consistent with professional standards of practice and the comprehensive person-centered care plan. Specifically, the facility did not administer the resident's oxygen via nasal cannula as ordered by the physician. The resident, who had diagnoses of atrial fibrillation and shortness of breath, was ordered to receive oxygen at 2 liters via nasal cannula. However, observations on multiple occasions revealed that the resident's oxygen was set at 3 liters instead of the prescribed 2 liters. This discrepancy was confirmed by a Licensed Vocational Nurse (LVN) who acknowledged that the oxygen was set incorrectly and noted the potential negative outcomes of such an error. The Director of Nursing (DON) stated that her expectations were for oxygen to be administered at the correct dose and for LVNs to check the settings each time they entered the room. The facility's respiratory policy also emphasized the importance of verifying the oxygen administration order, including the method, flow rate, and oxygen saturation parameters. Despite these guidelines, the facility's failure to adhere to the physician's order for oxygen administration placed the resident at risk of not receiving appropriate care to maintain their highest level of well-being.
Failure to Provide Dental Services
Penalty
Summary
The facility failed to provide or obtain dental services for a resident with significant dental issues. Resident #7, who had diagnoses of head injuries, stroke, and speech and language deficits, was admitted with missing teeth and dental decay. Despite being on a pureed diet due to difficulty in chewing and swallowing, the resident did not receive a dental consult. The resident's MDS annual assessment indicated severe cognitive impairment and obvious dental issues, yet no follow-up was conducted after an initial discussion with the family in September 2023. Interviews with staff revealed that a request for dental services was sent, but the insurance would not cover it, and no further action was taken. The social worker admitted that the previous social worker failed to follow up on the dental consult. The Director of Nursing stated that it was the responsibility of the social services to arrange dental services, but there was no policy in place for dental services. This lack of follow-up and coordination led to the resident not receiving necessary dental care, potentially causing pain and self-esteem issues.
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What surveyors actually found near you
We read the 140 citations issued within 25 miles in the last 12 months — including the 4 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
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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) |
|---|---|---|---|---|
| Oak Grove Nursing Home | 13.3 mi | ★★★★★ | 0 | 0 |
| Magnolia Manor | 13.7 mi | ★★★★★ | 2 | 0 |
| Oakwood Manor Nursing Home | 15.5 mi | ★★★★★ | 5 | 0 |
| Vidor Health & Rehabilitation Center | 15.6 mi | ★★★★★ | 22 | 1 |
| Sabine Heights Nursing And Rehabilitation Center | 15.8 mi | ★★★★★ | 15 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release October 2026) and official state health department websites.