Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
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 Chapman Global Medical Center D/p Snf during CMS and state inspections, most recent first.
The facility failed to prevent LVNs from performing respiratory care tasks outside their scope of practice following regulatory changes, as evidenced by continued LVN involvement in tracheostomy care and respiratory assessments for a resident. Facility policies and procedures were not updated to reflect the new scope limitations, and staff interviews confirmed that LVNs continued these practices due to inadequate RT staffing and lack of updated guidance.
Multiple residents did not receive required monitoring for pain and injury, and physician-ordered PT, OT, and RNA services were missed or undocumented. Staff interviews confirmed that assessments and treatments were not consistently performed, and therapy was deprioritized due to staffing shortages.
Two residents dependent on ventilators experienced lapses in respiratory care, including inadequate monitoring of ventilator circuits and improper handling of oxygen therapy and disposable equipment by non-qualified personnel. One resident was found unresponsive and disconnected from the ventilator without timely intervention or documentation of required checks, while another had emergency interventions performed by a CNA outside their scope of practice. The absence of a dedicated RT and inconsistent adherence to facility policies contributed to delayed care and non-compliance.
A resident with multiple pressure injuries was found on an air mattress set to static mode, contrary to the physician's order for an alternate mode setting. An LVN incorrectly confirmed the static mode as correct, despite the order specifying a five-minute cycle for pressure redistribution.
The facility failed to provide ordered RNA services to two residents with contractures and quadriplegia, as documented in their RNA Flowsheets. The absence of daily ROM exercises and application of orthotic devices, as ordered by physicians, was confirmed by staff interviews and could lead to worsening contractures and muscle stiffness.
The facility failed to properly place low air loss mattress pumps for two residents, leaving them on the floor instead of hanging them on the footboard as recommended. Additionally, a resident with impaired cognition and mobility was observed with only one floor mat beside the bed, despite a physician's order for mats on both sides to prevent falls. Staff acknowledged these deficiencies.
The facility failed to maintain the required head of bed (HOB) elevation for two residents receiving enteral feeding via gastrostomy tubes (GT). Both residents had physician orders to keep the HOB elevated at 30 to 45 degrees during feeding, but observations showed the HOB was not elevated to the required angle. Staff interviews revealed a lack of tools and knowledge to ensure compliance with these orders, posing a risk for complications.
A facility failed to maintain proper IV access for a resident, as they did not obtain a physician's order for IV care and maintenance, nor develop a care plan for the IV access on the resident's lower extremity. The resident, with moderately impaired cognitive skills, was on IV hydration due to abnormal lab results. The absence of a physician's order for IV assessment, dressing change, and site change frequency was confirmed by RN 2 and the CNO.
A facility failed to follow its P&P for pharmaceutical waste disposal when an LVN improperly disposed of a half tablet of fludrocortisone in a sharps container instead of the designated pharmaceutical waste container. The incident involved a resident prescribed fludrocortisone for hypotension, and the LVN was observed during a medication administration session.
The facility did not act on a pharmacist's recommendations for a resident, including discontinuing chlorhexidine and performing a hemoglobin A1c test. The physician's orders remained unchanged, and there was no follow-up by nursing staff, as confirmed by the Director of Pharmacy and RN 1.
A resident did not receive medications as prescribed, resulting in a medication error rate of 8% at the facility. The resident was given an incorrect dose of lactulose and did not receive a scheduled clonidine patch. The LVN acknowledged the errors, which were contrary to the facility's medication administration policies.
The facility failed to properly store medications on two medication carts, leading to potential medication administration errors. Medications such as loperamide liquid, Carboxymethylcellulose eye drops, and Insulin Lantus were found stored together without partitions, contrary to the facility's policy. LVNs verified the findings and acknowledged the need for separate storage.
The facility failed to ensure food safety and sanitation in the kitchen, with issues including unsanitary utensils, staff's personal food in the kitchen refrigerator, and lack of hair restraints. These deficiencies were confirmed by the RD, Dietary Supervisor, and CNO.
The facility's infection control committee failed to meet for one quarter in 2024 due to the absence of the Infection Control Chair, leading to a lapse in discussing infection control statistics and posing a risk for disease transmission.
The facility's assessment was outdated and did not involve direct care staff, residents, or their representatives. It lacked a plan for staffing resources, recruitment, retention, and contingency for staffing needs, as confirmed by the CNO.
The facility lacked a full-time, dedicated Infection Preventionist (IP) to oversee its Infection Prevention and Control Program. The position was vacant since January 2024, and the Director of Infection Prevention/Acting IP was primarily stationed at the acute care unit, spending only limited time at the facility. The CNO confirmed the facility shared IP personnel with the acute care unit and was actively seeking to fill the position.
A resident's protected health information was left visible on an unattended staff computer in a hallway accessible to visitors. The computer, used by a Respiratory Therapist, displayed the resident's name and medications, violating confidentiality policies. An LVN confirmed the breach during an observation.
The facility failed to properly dispose of garbage and refuse, with two waste dumpsters observed overflowing and not closed, potentially causing unsanitary conditions. This was confirmed by the RD, Dietary Supervisor, and CNO, and violated the facility's sanitation policy requiring tightly closed containers to prevent pests.
The facility failed to maintain a homelike environment for four residents, as observed in two rooms with walls in disrepair, including holes, scratches, and unfinished patchwork. The residents were cognitively impaired and not interviewable. The CNO acknowledged the need for repairs.
A facility failed to provide restorative nursing assistant (RNA) services as ordered for a resident with contractures, leading to a potential decline in range of motion (ROM) functions. The resident received inconsistent RNA services due to staffing challenges, with RNA staff often reassigned to CNA duties. The Director of Nursing acknowledged the issue and was working on recruiting additional RNA staff.
LVNs Performed Respiratory Care Outside Scope After Regulatory Change
Penalty
Summary
The facility failed to ensure that Licensed Vocational Nurses (LVNs) performed their duties within their legal scope of practice when providing care to patients, specifically those with tracheostomies. Despite regulatory changes from the Board of Vocational Nursing and Psychiatric Technicians (BVNPT) effective 10/1/25, which restricted LVNs from performing certain respiratory care tasks, LVNs continued to conduct activities such as pre- and post-nebulizer treatment assessments, tracheostomy care, suctioning, and manipulation of ventilators. These actions were documented in patient records and confirmed through staff interviews, indicating that LVNs were performing tasks outside their authorized scope. The facility's policies and procedures (P&Ps) related to respiratory care and tracheostomy management had not been updated to reflect the new BVNPT regulations. Multiple P&Ps, including those for tracheostomy tube suctioning, speaking valve cleaning, and tracheostomy care, did not specify the limitations imposed on LVNs. Staff interviews revealed that LVNs were aware of the regulatory changes but continued to perform restricted tasks due to insufficient respiratory therapist (RT) staffing. Some LVNs stated they performed these tasks out of necessity when RTs were unavailable, and documentation showed that these practices persisted after the effective date of the new regulations. Interviews with the Director of Nursing (DON), RT Manager, and other staff confirmed that the facility was aware of the changes in LVN scope of practice but had not yet fully implemented the necessary staffing adjustments or policy updates. The DON acknowledged that LVNs were performing respiratory care outside their scope and that the facility's job descriptions and policies were outdated. The RT Manager also noted that the number of RTs was insufficient to meet patient needs, leading to continued reliance on LVNs for restricted respiratory care tasks.
Plan Of Correction
Chapman Global Medical Center Plan of Correction Scope changes of LVN staff, including what respiratory care they can provide and instructing them to notify the charge nurse of any respiratory care needed that falls within the limitations defined by the BVNPT so that an RN can complete these duties. Resident #1 was assessed by the RN to ensure no adverse effects were present from the LVN providing the care to the patient. No issues were identified. By 11/15/25, all LVNs will be educated on the changes to the LVN scope of practice for providing respiratory care from the BVNPT effective 10/1/25 by their supervisor. The education will be done during unit huddles, staff meetings, or online. The DON reviewed the LVN JD and found it outdated. By 11/15/25, the Facility will revise the Job Description, Scope of Practice Policies, and Procedures in accordance with the California Vocational Nursing Practice Act and The Respiratory Care Board Regulations. All LVNs will be educated on the revised JD and will sign the new JD to ensure understanding of the changes.
Failure to Provide Necessary Care, Therapy, and Restorative Services
Penalty
Summary
The facility failed to provide necessary care and services to ensure residents maintained their highest physical well-being, as evidenced by multiple deficiencies in monitoring, documentation, and adherence to physician orders for five sampled residents. For one resident with a right upper arm fracture, there was no consistent monitoring for pain, redness, swelling, or warmth of the extremities, despite care plan interventions requiring such assessments. Documentation was lacking for musculoskeletal assessments and CNA care during specific shifts, and there was no evidence that pain observed by PT staff was reported to nursing. Interviews with staff confirmed that assessments were not completed and that signs of injury were not always checked or documented. The facility also failed to follow physician orders for physical therapy (PT) and occupational therapy (OT) treatments for two residents. Records showed missed PT and OT sessions over several weeks, with the rehabilitation department prioritizing other hospital patients over those in the skilled nursing facility. The Director of Nursing acknowledged the lack of therapy documentation and confirmed that required treatments were not consistently provided as ordered. Additionally, the facility did not provide daily Restorative Nursing Assistant (RNA) services as ordered for four residents. Medical records revealed multiple dates where RNA services, including range of motion exercises and application of orthotic devices, were not performed or documented. Staff interviews indicated that on days with staffing shortages, the RNA was reassigned to CNA duties, resulting in missed restorative care. The Director of Nursing verified that these services were not provided on the specified dates due to staffing issues.
Failure to Provide Safe and Appropriate Respiratory Care for Ventilator-Dependent Residents
Penalty
Summary
The facility failed to provide necessary respiratory care and services for two residents who were dependent on ventilators with tracheostomy tubes. For one resident, the ventilator circuit was not effectively monitored, resulting in the resident being found disconnected from the ventilator and unresponsive. Documentation showed that after being readmitted, the resident was alert and oriented, but there was no evidence of required ventilator checks or suctioning as per physician orders and facility policy. The resident was later found unresponsive, disconnected from the ventilator, and required manual ventilation and a Code Blue response. The ventilator alarm log was found to have inaccurate time settings, and it was unclear if the alarm sounded during the incident. Interviews revealed that there was no dedicated respiratory therapist (RT) in the facility, and the RT assigned was also responsible for the acute care unit, leading to lapses in monitoring and care. For the second resident, the facility failed to ensure that policies and procedures for respiratory care were followed when oxygen therapy and parts of the disposable ventilator circuit were replaced and rinsed by a non-qualified staff member. The resident, who had severely impaired decision-making capacity, experienced a sudden change in condition, turning blue and requiring an increase in FiO2. During the event, a CNA replaced the HME filter and rinsed the T-adapter, and also increased the FiO2, actions that were outside the CNA's scope of practice. The RT was not present at the time, and the nurse on duty did not immediately intervene, instead asking the CNA to assist. The RT manager confirmed that CNAs were not permitted to perform these tasks and that the T-adapter should not have been rinsed. Both incidents were compounded by the lack of a dedicated RT in the facility, with RTs being shared with the acute care hospital. This led to delays in care and interventions, as well as non-compliance with facility policies and procedures regarding ventilator management, suctioning, and equipment handling. Documentation and interviews confirmed that required assessments, monitoring, and interventions were not consistently performed or documented, directly contributing to the deficiencies identified.
Failure to Follow Physician's Order for Air Mattress Setting
Penalty
Summary
The facility failed to provide the necessary care and services to promote the healing of pressure injuries for a resident. The resident, who was admitted with several wounds including a Stage 3 pressure injury to the sacrum and Stage 4 pressure injuries to the left and right hips and right ankle, was observed lying on an air mattress set to the static mode. This setting was contrary to the physician's order, which specified that the air mattress should be set to the alternate mode with a cycle of five minutes to aid in pressure redistribution. During an observation and interview, an LVN incorrectly confirmed that the static mode was the correct setting, despite the physician's order indicating otherwise. This discrepancy was later verified during a follow-up interview and medical record review with the same LVN.
Failure to Provide Ordered RNA Services
Penalty
Summary
The facility failed to ensure that two residents, identified as Residents 9 and 11, received Restorative Nursing Assistant (RNA) services as ordered by their physicians. Resident 9, who had a history of contractures and quadriplegia, was supposed to receive daily passive range of motion (ROM) exercises and have specific splints and orthotic devices applied for certain durations. However, the RNA Flowsheet for February 2025 showed no documented evidence that these services were provided on specific days. Similarly, Resident 11, also with a history of contractures and quadriplegia, had orders for daily ROM exercises and the application of orthotic devices, but the RNA Flowsheet indicated missing documentation for several days in February 2025. Interviews with RNA 1 and RN 1 confirmed the absence of documentation and acknowledged that the lack of RNA services could lead to worsening contractures and muscle stiffness. The Chief Nursing Officer (CNO) also verified the missing RNA signatures in the RNA Flow Sheets and expressed expectations for the RNA services to be performed as ordered to prevent further contractures. The failure to provide these services as ordered had the potential to negatively impact the residents' ROM function and overall physical condition.
Improper Equipment Placement and Fall Prevention Measures
Penalty
Summary
The facility failed to ensure the proper placement of low air loss mattress pumps for two residents, as per the manufacturer's recommendations. For one resident, the pump was observed on the floor under the bed, contrary to the user manual's instructions to hang it on the footboard. A Licensed Vocational Nurse (LVN) confirmed the incorrect placement and acknowledged it was not supposed to be under the bed. Similarly, another resident's low air loss mattress control unit was also found on the floor, with a Registered Nurse (RN) stating that the hook did not fit the footboard, preventing proper placement. The Chief Nursing Officer (CNO) was informed and acknowledged these findings. Additionally, the facility did not implement the physician's order for floor mats on both sides of a resident's bed, which was necessary for fall prevention. The resident, who had severely impaired cognition and was dependent on staff for mobility, was observed with a floor mat on only one side of the bed. An LVN verified the absence of the second mat and recognized the resident's risk for falls, confirming the need for mats on both sides as per the physician's order.
Failure to Maintain Proper HOB Elevation During Enteral Feeding
Penalty
Summary
The facility failed to ensure appropriate care and services for the use of gastrostomy tubes (GT) for two residents. Resident 3, who had severe cognitive impairment and difficulty swallowing, was observed on multiple occasions with the head of the bed (HOB) not elevated at the required 30-degree angle or higher while receiving enteral feeding. Despite physician orders to maintain the HOB at 30 to 45 degrees during and after feeding, the bed lacked a device to measure the elevation, and staff were unable to confirm the correct angle. Interviews with staff, including a Licensed Vocational Nurse (LVN) and a Certified Nursing Assistant (CNA), revealed a lack of knowledge and tools to ensure compliance with the physician's orders. Similarly, Resident 13, who also had difficulty swallowing and was on tube feeding, was observed with the HOB not elevated to the required angle during feeding. The resident's care plan and physician orders specified the need for the HOB to be elevated at 30 to 45 degrees, yet observations showed it was only at a 15-degree angle. Staff interviews confirmed the absence of a device to measure the HOB elevation and acknowledged the failure to comply with the physician's orders. These deficiencies posed a risk for complications related to the use of GT for both residents.
Failure to Maintain IV Access for a Resident
Penalty
Summary
The facility failed to provide the necessary care and services for the maintenance of intravenous (IV) access for a resident, identified as Resident 21. The deficiency was observed when the facility did not obtain a physician's order for the care and maintenance of the IV access, nor did they develop a plan of care for the resident's IV access to the lower extremity. This oversight was noted during an observation on February 10, 2025, when Resident 21 was seen with an IV fluid infusing at 70 ml per hour, but the IV access was not visible due to bed covers. Further investigation revealed that the resident had moderately impaired cognitive skills and was on IV hydration due to abnormal laboratory results. Upon reviewing the medical records, it was found that there was no documented evidence of a physician's order for the IV access assessment, dressing change, or the frequency of changing the peripheral IV access site. Additionally, the resident's plan of care did not address the use and maintenance of the IV access site. Interviews with RN 2 and the Chief Nursing Officer (CNO) confirmed these findings, with RN 2 acknowledging the absence of a physician's order for the necessary IV care and the lack of a developed care plan for the resident's IV use.
Improper Disposal of Medication
Penalty
Summary
The facility failed to properly dispose of unused medication in accordance with its policy and procedures (P&P). During a medication administration observation, a Licensed Vocational Nurse (LVN) was seen disposing of a half tablet of fludrocortisone, a corticosteroid medication, in a sharps container instead of the designated pharmaceutical waste container. The facility's P&P, dated October 2022, specifies that all unusable medications, including partially used tablets, should be disposed of in pharmaceutical waste containers. The incident involved a resident who was prescribed fludrocortisone 0.05 mg daily for hypotension. The LVN obtained a 0.1 mg tablet, cut it in half, administered the required dose, and improperly disposed of the remaining half tablet.
Failure to Act on Pharmacy Consultant's Recommendations
Penalty
Summary
The facility failed to ensure that the Pharmacy Consultant's recommendations from the monthly drug regimen review (MRR) were acted upon for Resident 13, who was reviewed for unnecessary medications. The pharmacist recommended discontinuing chlorhexidine, an antiseptic medication, as it was not recommended for residents on a ventilator, and also suggested performing a hemoglobin A1c level test due to the resident's diagnosis of diabetes. These recommendations were documented in the MRR dated 12/31/24 and 1/28/25, respectively, and were signed by the physician. However, there was no documented response from the physician regarding the approval or disapproval of these recommendations. The medical record review revealed that the physician's order to administer chlorhexidine 0.12% oral rinse twice a day remained active and had not been discontinued. Additionally, there was no evidence that the laboratory order for the hemoglobin A1c level was obtained from the physician. Interviews with the Director of Pharmacy and RN 1 confirmed that the charge nurses failed to follow up with the physician about the MRR recommendations. The Chief Nursing Officer (CNO) was also informed and verified these findings, indicating a lapse in the facility's process for addressing pharmacist recommendations in a timely manner.
Medication Administration Errors Lead to Deficiency
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, with an observed rate of 8%. This deficiency was identified through the case of a resident who did not receive their medications as prescribed. Specifically, the resident was supposed to receive lactulose 30 grams via GT daily for elevated ammonia levels and clonidine 0.3 mg/24 hours transdermal patch weekly for muscle spasticity. However, during a medication administration observation, it was noted that the resident was only given 20 grams of lactulose instead of the prescribed 30 grams, and the clonidine patch was not applied at all. The facility's policies and procedures for medication administration, which require verification of the correct medication and adherence to the administration schedule, were not followed. The LVN responsible for administering the medications acknowledged the errors during an interview and review of the resident's medical records. These failures in medication administration had the potential to negatively impact the resident's health, as the prescribed treatments were not delivered as ordered by the physician.
Improper Medication Storage on Facility's Medication Carts
Penalty
Summary
The facility failed to ensure proper storage, labeling, and disposal of medications on two of its medication carts, posing a risk for medication administration errors. During an observation of Medication Cart A, it was found that a bottle of loperamide liquid, Carboxymethylcellulose 0.5% eye drops, and an Albuterol Sulfate inhaler were stored together in one tray without partitions. Additionally, a vial of Insulin Lantus and a bottle of Calcitonin Sodium Nasal spray were also stored together in another tray without partitions. These findings were verified by LVN 5, who acknowledged that the medications should have been stored separately. Similarly, an observation of Medication Cart B revealed that a vial of Insulin Lantus and a bottle of Carboxymethylcellulose 0.5% eye drops were stored together in one tray without partitions. LVN 6 confirmed these findings and stated that the medications should have been stored separately with partitions. The facility's policy on medication storage and security, as outlined in their Pharmacy Manual, requires that medications be stored in segregated and secure conditions to minimize the potential for errors, theft, or diversion. The failure to adhere to these policies resulted in the identified deficiencies.
Food Safety and Sanitation Deficiencies in Kitchen
Penalty
Summary
The facility failed to meet food safety and sanitary requirements in the kitchen, as observed during a survey. The deficiencies included the use of food preparation utensils and equipment that were not in good, sanitary, and cleanable working conditions. Specifically, a spatula was found with brown discoloration and heavily worn, two scoops had melted handles and were heavily worn, and three white cutting boards were heavily marred with black discoloration. These findings were verified by the Registered Dietitian (RD) during an observation and interview. Additionally, the facility did not ensure that staff's personal food items were kept out of the kitchen refrigerator, as a dietary aide's personal salad was found stored in the kitchen's reach-in refrigerator. Furthermore, the kitchen staff failed to wear appropriate hair restraints, as observed with a staff member who had sideburns and a mustache without a beard restraint. These issues were acknowledged by the RD, Dietary Supervisor, and Chief Nursing Officer (CNO) during interviews, confirming the facility's non-compliance with food safety standards.
Infection Control Committee Meeting Lapse
Penalty
Summary
The facility failed to implement appropriate infection control practices as required by their policies and procedures. Specifically, the infection control committee did not meet for one quarter in 2024 to discuss infection control within the subacute unit. This lapse occurred because the Medical Doctor, who also served as the Infection Control Chair, was out of the country until January 30, 2025, resulting in the committee missing the November 2024 quarterly meeting. The absence of this meeting prevented the discussion of quarterly infection control statistics, posing a risk for the transmission of disease-causing microorganisms.
Facility Assessment Lacks Comprehensive Staffing Plan
Penalty
Summary
The facility failed to ensure that the Facility Assessment was comprehensive and up-to-date, as required by the revised CMS guidance. The assessment did not actively involve direct care staff, residents, or their representatives in its development. Additionally, it lacked a detailed plan for staffing resources necessary to care for residents, particularly during weekends, and did not include strategies for recruitment and retention of direct care staff or a contingency plan for staffing needs. During an interview and document review, the Chief Nursing Officer (CNO) confirmed that the Facility Assessment was outdated and did not reflect the latest CMS updates. The CNO acknowledged the absence of involvement from key stakeholders in the assessment process and the lack of necessary resources and plans to address staffing needs. This oversight had the potential to impact the facility's ability to meet residents' care needs effectively.
Lack of Dedicated Infection Preventionist
Penalty
Summary
The facility failed to have a full-time, dedicated Infection Preventionist (IP) responsible for the Infection Prevention and Control Program. The organizational chart updated in February 2025 showed the position for Infection Control Supervisor/Infection Control was vacant. According to the QSO-22-19 dated June 29, 2022, Skilled Nursing Facilities (SNFs) are required to have an IP with specialized training onsite at least part-time. However, the Director of Infection Prevention/Acting IP was primarily stationed at the acute care unit and only spent one to two hours at the facility, confirming that there had been no dedicated IP personnel since January 2024. The Chief Nursing Officer (CNO) also verified that the facility shared IP personnel with the acute care unit and was actively interviewing to fill the position.
Resident Health Information Confidentiality Breach
Penalty
Summary
The facility failed to maintain the confidentiality of a resident's protected health information, specifically for one resident. On two separate occasions, a staff computer located in the residents' hallway was left unattended with the resident's personal health information displayed on the screen. This information included the resident's name and scheduled medications, and the computer was accessible to residents' family members and visitors who used the hallway. During an observation and interview, a Licensed Vocational Nurse (LVN) confirmed that the computer was unattended and displaying the resident's personal health information. The LVN noted that the computer was used by a Respiratory Therapist, who should have either logged out or used a paper cover to protect the screen when not present. Despite this expectation, the computer was again found unattended with the resident's information visible, confirming a breach of confidentiality as outlined in the facility's policy and procedures.
Improper Disposal of Garbage and Refuse
Penalty
Summary
The facility failed to ensure proper disposal of garbage and refuse, as evidenced by two of eight waste dumpsters being observed overflowing with trash and not properly closed. This was identified during an observation and interview with the Registered Dietitian (RD) on February 11, 2025, at 0942 hours. The RD confirmed that the waste dumpster lids should be closed to prevent attracting pests and rodents. Further interviews with the RD, Dietary Supervisor, and Chief Nursing Officer (CNO) on February 13, 2025, confirmed the findings. The facility's policy and procedure on sanitation, dated August 2024, requires food waste to be kept in leakproof, nonabsorbent, tightly closed containers and disposed of as frequently as necessary to prevent nuisance or unsightliness. The failure to adhere to these guidelines had the potential to cause unsafe sanitary conditions and harbor pests and rodents.
Facility Fails to Maintain Homelike Environment
Penalty
Summary
The facility failed to maintain a homelike environment for four residents, as observed in Rooms A and B. Resident 23, residing in Room A, was found in a room with a wall behind the bed that had a hole, scratches, and unfinished patchwork. Similarly, Residents 10, 14, and 18, residing in Room B, were observed in a room where the wall behind their beds was in disrepair, with holes, scratches, unfinished patchwork, and peeled paint. These observations were made during a survey, and the residents were not interviewable due to cognitive impairment. The Chief Nursing Officer (CNO) was shown photos of the disrepair and acknowledged the need for repairs in these rooms.
Failure to Provide Ordered RNA Services
Penalty
Summary
The facility failed to provide restorative nursing assistant (RNA) services as ordered for a resident, leading to a potential decline in the resident's range of motion (ROM) functions. The resident, who had a history of contractures, muscle wasting, and atrophy, was supposed to receive daily ROM exercises and the application of bilateral hand splints and PRAFOs as per the physician's orders. However, the RNA services were inconsistently provided, with the resident receiving these services on only a few days throughout the month. Interviews with facility staff revealed that the RNA was often reassigned to work as a certified nursing assistant (CNA) due to staffing challenges, which contributed to the inconsistency in providing the ordered RNA services. The Director of Nursing (DON) acknowledged the issue and stated that the facility prioritized residents' hygiene and activities of daily living (ADL) assistance over RNA services, while also working on recruiting additional RNA staff. This failure to adhere to the physician's orders had the potential to negatively impact the resident's ROM status and increase stiffness in the resident's extremities.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Orange
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Healthbridge Children's Hospital - Orange D/p Snf | 0.7 mi | — | 0 | 0 |
| New Orange Hills | 1.7 mi | — | 25 | 0 |
| The Hills Post Acute | 1.8 mi | — | 0 | 0 |
| Orange Healthcare & Wellness Centre, Llc | 1.8 mi | — | 24 | 0 |
| Town & Country | 2 mi | — | 27 | 0 |
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