Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around February 2027
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 Mainplace Post Acute during CMS and state inspections, most recent first.
A resident’s medical record contained a physician progress note that included detailed summaries and plans of care for two other residents, and the DON acknowledged that such information should not appear in this resident’s chart and that physician notes were not routinely reviewed unless new orders were present. Additionally, CNA shower sheets documented repeated redness in the resident’s groin/inner thigh and lower back areas, with LVNs indicating assessments were completed, but the treatment nurse and DON confirmed there were no corresponding nursing assessments, progress notes, or change-in-condition documentation in the record, despite facility policy requiring such documentation.
A resident who was cognitively intact repeatedly refused showers, but staff did not document these refusals in progress notes or develop a care plan as required by facility policy. Nursing staff and medical record personnel failed to follow up on missing shower documentation, resulting in the absence of an individualized plan to address the resident's needs and preferences.
A resident with a new rash on both hands did not receive a documented change of condition assessment or required monitoring, despite a physician's order for antifungal treatment. Nursing staff confirmed that the necessary assessment, documentation, and care plan updates were not completed according to facility policy.
A resident with severe cognitive impairment and recent pituitary surgery did not receive a prescribed hydrocortisone taper because the medication order was not transcribed from hospital discharge paperwork into the facility's electronic record. The required double-check by nursing staff was not documented, resulting in the resident missing scheduled doses of the steroid.
A resident's right to manage their financial affairs was violated when the facility deposited their social security checks into the RFMS account without consent. Despite being cognitively intact, the resident was not informed or involved in the decision-making process, leading to a loss of control over their funds. The Business Office Director confirmed the lack of a formal agreement and communication, and the DON verified these findings.
A resident's medical record was incomplete and inaccurately documented, missing critical information such as lung sounds, blood pressure follow-up actions, meal intake percentages, and monitoring for urinary tract infection and diuretic side effects. These documentation gaps were confirmed by the RN Unit Manager during a review.
The facility failed to provide appropriate respiratory care for five residents, including improper maintenance of a CPAP machine, incorrect oxygen administration rates, and unsanitary storage of respiratory equipment. These deficiencies highlight a lack of adherence to physician orders and infection control protocols, potentially affecting residents' respiratory health.
The facility failed to ensure residents were free from unnecessary psychotropic medications. One resident's PRN antipsychotic order exceeded 14 days without proper evaluation, while another did not receive non-pharmacological interventions before medication administration. A third resident's records lacked documentation of required interventions, and another resident did not have informed consent or proper monitoring for medications. These deficiencies were confirmed by facility staff.
The facility failed to serve food at appropriate temperatures, affecting its palatability and nutritional value. During a tour, residents reported that hot foods were not served hot. A trayline observation showed that the plate warmer was overfilled, preventing proper heating. A test tray confirmed that several hot food items were below the required temperature. The DSS acknowledged that the current methods were insufficient to maintain hot food temperatures.
The facility failed to meet sanitary requirements in the kitchen, with issues such as improper labeling of food, utensils in disrepair, and inadequate air-drying of equipment. Observations included unlabeled turkey meat, utensils with melted handles, and wet equipment stored improperly. These deficiencies were confirmed by the DSS and acknowledged by the DON and RD.
The facility failed to inform physicians when residents were prescribed antibiotics without meeting McGeer's Criteria for a true infection, affecting several residents. This oversight was contrary to the facility's Antibiotic Stewardship Program, which aims to ensure appropriate antibiotic use. The Infection Preventionist did not document notifications to physicians, and the Director of Nursing acknowledged these findings.
Two residents were found self-administering medications without proper assessment or physician's orders. Resident 98 had topical medications at the bedside, while Resident 11 had eye drops. The facility failed to document care plans or conduct assessments for their ability to self-administer, contrary to policy. Staff interviews confirmed the lack of necessary procedures, posing a risk of inappropriate medication use.
A resident experienced a change in condition with symptoms of vomiting, abdominal discomfort, and refusal to eat. The facility failed to promptly notify the physician and conduct a thorough assessment, leading to a deficiency. Initial vital signs were taken, but no further monitoring or reassessment was documented. The resident's condition worsened, and they were found unresponsive and expired. Interviews with staff revealed awareness of the situation but a lack of timely action.
A resident with pressure injuries did not receive a physician-ordered low air loss mattress, and weekly assessments of the injuries were not conducted as per facility policy. Staff interviews confirmed lapses in communication and documentation, contributing to the deficiency in care.
A resident with a history of falls and assessed as high risk did not have floor mats placed on both sides of their bed as ordered by the physician and outlined in their care plan. This oversight was confirmed by RN 3 and acknowledged by the DON, indicating a failure to adhere to the facility's fall management policy.
The facility failed to manage pain appropriately for two residents. One resident received acetaminophen for pain levels that required tramadol, without informing the physician. Another resident did not receive non-pharmacological interventions before narcotic medication as ordered. Staff interviews confirmed these deficiencies.
A Pharmacy Consultant failed to identify an irregularity in a diabetic resident's medication regimen review, as the resident did not have an HbA1C test for 10 months despite being on insulin. The facility's policy required monthly reviews to identify irregularities, but no recommendations were made regarding the HbA1C test. The DON acknowledged the oversight and the potential complications from not monitoring HbA1C levels.
A facility failed to ensure proper medication storage and labeling, as medications were found at a resident's bedside without a physician's order or care plan. Additionally, an expired culture swab was discovered in a treatment cart, which had not been removed during a previous check. Staff interviews confirmed these deficiencies.
A facility failed to maintain safe infection control practices when an LVN used inappropriate wipes to clean a wrist blood pressure monitoring device with a Velcro cuff. The wipes were intended for hard, non-porous surfaces, not suitable for the cuff. The LVN confirmed the misuse and acknowledged the potential for spreading germs and bacteria.
A resident did not receive the pneumococcal vaccine despite consent being obtained, as the facility's IP failed to administer it within the expected timeframe due to being busy during influenza season. The DON acknowledged the oversight.
A resident's room was found to be in disrepair, with scratches and chipped paint on the wall adjacent to the bed. The resident expressed a desire for a neat and clean environment, as she spent a lot of time in her room. The DON was informed and verified the findings.
A resident's care plan for continuous oxygen therapy was not followed, as the resident received oxygen at four liters per minute instead of the prescribed two liters per minute. This discrepancy was confirmed during an observation and interview with an LVN, highlighting a failure to adhere to the care plan and physician's order.
The facility failed to properly store garbage in one of its dumpsters, as the right-side lid was missing, exposing the contents. The Maintenance Director confirmed the lid had been broken since August 2024 and was awaiting repair or replacement by the garbage company. Despite this, the dumpster was still in use, and the issue was acknowledged by the RD, DSS, and DON.
The facility did not provide adequate communal dining space for residents who do not require staff assistance with meals. During a resident council meeting, several residents expressed that only those needing assistance could access the communal dining area, limiting their socialization opportunities. The administrator acknowledged the issue and mentioned plans to address it.
A facility failed to develop comprehensive care plans for two residents, omitting a problem statement for breast cancer treatment with Femara and lacking measurable timeframes for mobility goals. This posed a risk of inconsistent care, as confirmed by the DON.
A resident was not informed or given the right to choose when the facility changed his weekly outpatient psychiatric services to monthly in-house services. The resident, who was cognitively intact and capable of making decisions, expressed that he did not agree with the change and would have preferred to continue with his outpatient services. The facility's failure to communicate and obtain consent was confirmed by staff interviews and acknowledged by the DON.
A resident's physician-ordered lab tests were delayed by seven days, and critical abnormal results were not promptly reported to the physician. The resident was later diagnosed with acute renal failure, and the delay in reporting and treatment had the potential to adversely affect the resident's health.
A resident with multiple medical conditions left the facility AMA without receiving appropriate discharge instructions or notifying the physician in advance. The facility staff failed to follow the P&P, leading to potential risks for the resident post-discharge.
Inaccurate Physician Note and Missing Skin Assessment Documentation
Penalty
Summary
The deficiency involves failures in maintaining accurate and complete medical records for a resident in accordance with facility policy and accepted professional standards. The facility’s policy on nursing clinical documentation requires that the clinical record be a concise and accurate account of treatment, care, response to care, signs, symptoms, and progress of the resident’s condition. For one resident, admitted on a specified date and documented as having capacity to make medical decisions, review of the physician’s progress note dated 3/16/26 at 0427 hours showed that, in addition to a detailed summary and plan of care for this resident, the same note also contained detailed summaries and plans of care for two other residents. During an interview and concurrent record review, the DON stated that physician progress notes were not reviewed after entry unless there was a new order to review and verified that the medical information for the other residents should not have been listed in this resident’s medical record. The facility’s policy on change in condition requires nurses to perform and document an assessment of the resident, identify the need for additional interventions, and communicate with the provider as needed. Review of the resident’s CNA Skin Observation (shower sheets) showed multiple entries documenting redness in the groin/inner thigh and lower back areas on three separate dates, with LVNs indicating that assessments were done. However, the treatment nurse confirmed there were no corresponding assessments, progress notes, or change-in-condition documentation in the medical record related to these findings. In a subsequent interview, the DON also verified that there were no such assessments or progress notes corresponding to the shower sheet findings and further verified that nurses should be documenting their skin assessments.
Failure to Develop Care Plan for Resident's Refusal of Showers
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan addressing a resident's repeated refusals to shower or bathe. Despite the facility's policy requiring the interdisciplinary team to create a person-centered care plan that includes measurable objectives and timeframes for all identified needs, there was no care plan in place for the resident's ongoing refusals. The resident, who was cognitively intact and able to make decisions, had a documented history of refusing showers on multiple occasions, as evidenced by shower sheets and staff interviews. However, these refusals were not documented in the resident's progress notes, and no care plan was initiated to address the refusals or to outline alternative interventions or education efforts. Interviews with nursing staff and review of facility records confirmed that required documentation and follow-up actions were not completed. The assigned CNAs and licensed nurses did not consistently report or document the refusals as required by facility policy, and missing shower sheets were not followed up by medical record staff or the Director of Staff Development. The lack of a care plan for the resident's refusals meant that individualized, consistent care was not ensured, and the facility's own procedures for addressing such refusals were not followed.
Failure to Assess and Monitor Change in Skin Condition
Penalty
Summary
The facility failed to provide necessary care and services for a resident who developed a rash on both hands. According to the facility's policy, any change in a resident's condition, such as a new skin issue, requires a licensed nurse to perform and document an assessment, notify the physician and responsible party, and monitor and document the resident's condition for at least three days. In this case, a physician ordered miconazole nitrate cream to be applied to the resident's hands for the rash, but there was no documented evidence that a change of condition assessment or required monitoring was completed. Interviews with nursing staff confirmed that the assessment and documentation were not performed as required by policy. The resident involved was cognitively intact and able to make decisions, as indicated by a BIMS score of 13 and a recent history and physical examination. Despite the new order for antifungal treatment, the medical record lacked documentation of assessment, monitoring, or care plan updates related to the rash. Nursing staff acknowledged the omission, and the DON confirmed awareness of the findings during the survey.
Failure to Administer Steroid Taper as Ordered
Penalty
Summary
A deficiency occurred when the facility failed to administer hydrocortisone (Cortef) as ordered for a resident who had recently undergone pituitary tumor removal and was readmitted from an acute care hospital. The resident, who had severe cognitive impairment and lacked capacity to make medical decisions, was discharged from the hospital with specific orders for a hydrocortisone taper. These orders included a series of scheduled doses to be administered over several days, starting with a 25 mg dose, followed by 20 mg and 10 mg doses, and then a maintenance dose of 5 mg every afternoon. Upon review, it was found that the hydrocortisone taper was not transcribed from the hospital discharge paperwork into the facility's electronic medical record. The process for admitting residents required the admission nurse to review and transcribe discharge orders, which were then to be double-checked by the night shift RN supervisor. However, the hydrocortisone order was missed during this process, and there was no documentation indicating that the required double-check or recapitulation of orders had been completed by the RN supervisor. Interviews with facility staff, including the RN, unit manager, pharmacy consultant, and DON, confirmed that the hydrocortisone order was present in the hospital discharge paperwork but was not entered into the facility's system or administered as prescribed. The pharmacy consultant explained the importance of a steroid taper and the potential effects of abrupt discontinuation, but the report did not document any specific adverse outcomes for the resident. The deficiency was substantiated by the lack of documentation and failure to follow the facility's policy and procedure for medication administration.
Plan Of Correction
How corrective action will be accomplished for those residents affected by the deficient practice: The Facility was made aware of the incident. MD was notified and transcribed the missing Hydrocortisone order. MD was notified of the incident, conducted an investigation, and completed an incident report. Initiated monitoring for resident 1. Resident remains in stable condition and no negative effects were noted on resident 1. How the facility will identify other residents having the potential to have been affected by the deficient practice and corrective action taken: The Medical Records Director/Designee conducted audits on all admissions on April 4, 7, 8, 9, 2025, and ensured that orders from the Hospital are carried out promptly. The DON conducted in-service to the Licensed Nurses on 4-4-25 regarding the admission process to ensure that discharge orders from the Hospital are being carried out correctly. The Admission nurse who failed to transcribe the Hydrocortisone was given 1:1 in-service and training on the admission process on 03-20-25 and guided on verification/comparing of hospital discharge orders and ensuring that each order is double-checked for accuracy and completeness. What measures will be put into place to ensure that the deficient practice does not recur: The Admission nurse will verify admission orders from the Hospital, review with the Attending Physician for accuracy, and transcribe to the resident's admission records. The RN Supervisor of the next shift will compare admission orders from the Hospital versus the ones on the resident's record. If noted with discrepancy, the MD will be notified for order clarification and will carry out the orders promptly. In addition, the RN Unit Manager/Designee will check again the next day if orders were carried out correctly by comparing orders and will sign the sheet to verify it was checked for accuracy. The DON/Designee will be notified of the findings for follow-up. How the facility plans to monitor its performance to make sure solutions are sustained: The facility will utilize QA tools every month for 3 months and quarterly thereafter. The results of the findings will be forwarded to the QA Committee monthly for follow-up and recommendations. The Designee will check again the next day if orders were carried out correctly by comparing orders and will sign the sheet to verify it was checked for accuracy. The DON/Designee will be notified of the findings for follow-up.
Failure to Uphold Resident's Financial Rights
Penalty
Summary
The facility failed to uphold a resident's right to manage their financial affairs, specifically concerning the handling of social security funds. Resident 2, who was cognitively intact and capable of making decisions, was not involved in the decision-making process regarding their financial affairs. The facility deposited Resident 2's social security checks into the Resident Fund Management Service (RFMS) account without the resident's knowledge or consent. This action was contrary to the facility's policy, which requires signed authorization from the resident or their authorized agent before making deposits into the RFMS account. The Business Office Director admitted that the facility did not inform Resident 2 about the deposits until after they were made and acknowledged the absence of a formal agreement allowing the facility to manage the resident's finances. The lack of documentation and communication resulted in Resident 2 losing control over their social security benefits, which were deposited without their consent. The Director of Nursing confirmed these findings, highlighting a significant lapse in the facility's adherence to its policies and procedures regarding resident financial rights.
Incomplete and Inaccurate Medical Record Documentation
Penalty
Summary
The facility failed to ensure the medical record was complete and accurately documented for a resident, leading to several deficiencies. The resident's Medication Administration Record (MAR) did not include documentation of lung sounds from October 4 to October 10, despite physician orders requiring this information to be recorded every shift. Additionally, there was no documentation of nursing actions taken after a low blood pressure reading of 91/49 mmHg was recorded on October 20. The resident's meal intake percentages were also missing for several days in October, and there was no documentation of monitoring for signs and symptoms of a urinary tract infection, as required by the care plan. Furthermore, the resident was on Bumex, a diuretic, which required monitoring for side effects such as dehydration. However, there was no documentation indicating that the resident was monitored for these side effects. The RN Unit Manager confirmed these documentation gaps during a concurrent closed medical record review and interview. These failures in documentation had the potential to impact the resident's care needs, as their medical information was incomplete and inaccurate.
Deficiencies in Respiratory Care and Equipment Maintenance
Penalty
Summary
The facility failed to provide appropriate respiratory care for five residents, leading to deficiencies in the management and maintenance of respiratory equipment. Resident 440's CPAP machine was not maintained according to the manufacturer's guidelines, and the physician's order for the CPAP settings was not clarified, leaving the resident without specific inspiratory and expiratory settings. Additionally, there was no documented evidence of regular cleaning of the CPAP tubing assembly and water tub, which is crucial for preventing germ growth. Resident 55 received continuous oxygen at an incorrect rate, as the staff administered four liters per minute instead of the prescribed two liters per minute. The physician's order lacked specificity regarding the amount of oxygen to be administered, leading to inconsistencies in care. Furthermore, the resident's nasal cannula was not stored in a sanitary manner, posing an infection control risk. Similar issues were observed with Resident 98, whose nebulizer mask was not stored in a clean bag, and Resident 101, whose nasal cannula was left hanging on the bedside drawer without proper storage. Resident 27's nasal cannula tubing was found on the floor, and the resident reported being off oxygen for two days despite having a physician's order for oxygen administration. The tubing was not stored in a sanitary manner, and there was a lack of adherence to infection control protocols. These deficiencies highlight the facility's failure to ensure proper respiratory care and equipment maintenance, potentially affecting the respiratory health and well-being of the residents.
Failure to Implement Non-Pharmacological Interventions and Limit PRN Orders
Penalty
Summary
The facility failed to ensure residents were free from unnecessary psychotropic medications, as evidenced by the cases of four residents. For one resident, the facility did not limit the PRN order for an antipsychotic medication to 14 days, and there was no documented physician evaluation or justification for extending the use beyond this period. Interviews with the RN and DON confirmed these findings, indicating a lack of compliance with the facility's policy on psychotropic medications. Another resident did not receive non-pharmacological interventions prior to the administration of psychotropic medications, despite having orders for such interventions. The resident's MAR showed regular administration of medications like mirtazapine, fluoxetine, and eszopiclone, but non-pharmacological interventions were documented only once. Interviews with nursing staff confirmed the absence of documentation for these interventions, highlighting a failure to adhere to the care plan. A third resident's records showed a lack of non-pharmacological interventions before administering medications for anxiety and depression. The MAR and progress notes lacked documentation of these interventions, which were supposed to be implemented as per the care plan. Additionally, another resident did not have informed consent or a gradual dose reduction attempt for melatonin, and there was no specific monitoring for side effects of mirtazapine and melatonin. The DON confirmed these deficiencies, indicating a failure to follow the facility's procedures for psychotropic medication management.
Deficiency in Serving Food at Appropriate Temperatures
Penalty
Summary
The facility failed to ensure that food was served at appropriate temperatures, impacting the palatability and nutritional status of residents. During an initial tour, three residents reported that hot foods were not served hot, with one resident specifically mentioning items like fried eggs, bacon, pancakes, waffles, and egg sandwiches. A trayline observation revealed that the plate warmer was overfilled, with plates stacked above the heated compartment, which did not maintain the necessary temperature for hot foods. A test tray observation confirmed that several hot food items, including Pacific Rim Pork Roast, Red Beans and Rice, and Carrots with Parsley, were served at temperatures below the facility's policy requirements. The Dietary Services Supervisor (DSS) acknowledged that the metal hot plates, which were supposed to keep food hot, were not in use due to parts being ordered. The DSS admitted that the current use of plate warmers was insufficient to maintain the required temperatures for hot foods by the time they reached the residents. The Director of Nursing (DON), Registered Dietitian (RD), and DSS were informed of these findings.
Sanitary Deficiencies in Kitchen Operations
Penalty
Summary
The facility failed to meet sanitary requirements in the kitchen, as observed during an inspection. The inspection revealed that food items in the refrigerator were not properly labeled or dated, specifically a container of turkey meat that lacked an opened or use-by date. This was confirmed by the Dietary Services Supervisor (DSS), who acknowledged that the individual responsible for storing the food should have labeled it appropriately. Additionally, the facility did not maintain kitchen utensils in good repair or sanitary conditions. Several portion servers were found with partially melted handles and chipped surfaces, which were verified by the DSS. Furthermore, utensils set to air-dry were found with food particles and residue, and the drawer holding clean utensils contained white dry particles and water droplets. These findings were confirmed by the DSS, who took the items to be washed. The facility also failed to ensure that equipment and utensils were air-dried before storage. A blender and multiple metal pans were observed still wet and stored improperly, which could lead to cross-contamination. The DSS confirmed these observations and acknowledged that the items should have been completely dry before storage. The Director of Nursing (DON), Registered Dietitian (RD), and DSS were informed of these findings.
Failure to Notify Physicians of Inappropriate Antibiotic Use
Penalty
Summary
The facility failed to inform the physician of residents prescribed antibiotics when their signs and symptoms did not meet McGeer's Criteria for a true infection. This deficiency was identified for five of 30 final sampled residents and 24 nonsampled residents. The failure to notify the physician had the potential risk for continued use of unnecessary antibiotics, which could result in adverse reactions and the development of antibiotic-resistant bacteria. The facility's Antibiotic Stewardship Program (ASP) was designed to promote appropriate antibiotic use and optimize infection treatment while reducing adverse events. The program included monitoring antibiotic use, summarizing resistance patterns, and assessing residents for infections using standardized tools. However, the facility did not adhere to its policy of notifying physicians when residents were prescribed antibiotics without meeting the infection criteria. The Infection Preventionist (IP) was responsible for conducting surveillance and completing a Surveillance Data Collection Form for each resident with signs of infection. The IP was supposed to notify the prescribing physician if the criteria were not met, but documentation of such notifications was not found for the residents in question. The Director of Nursing (DON) acknowledged these findings during an interview.
Failure to Assess Residents for Safe Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that two residents, Resident 11 and Resident 98, were assessed for their ability to safely self-administer medications. Resident 98 was found with a tube of Preparation H and mometasone furoate at the bedside without a physician's order for self-administration. Despite having the capacity to make medical decisions, there was no care plan or assessment documented to address Resident 98's ability to self-administer these medications. Interviews with LVN 5 and the DON confirmed the absence of necessary documentation and procedures for self-administration. Similarly, Resident 11 had bottles of Lumify and Systane eye drops at the bedside, which she self-administered without a physician's order or assessment for self-administration. The medical record review showed no documentation of a care plan or assessment for Resident 11's ability to self-administer these medications. Interviews with LVN 10 and RN 3 revealed that they were unaware of the medications at the bedside and confirmed the lack of necessary orders and assessments. The facility's policy requires an interdisciplinary team assessment to determine if self-administration is clinically appropriate and safe. However, this process was not followed for Residents 11 and 98, leading to a potential risk of inappropriate medication use. The DON acknowledged the findings and the risk associated with medications being accessible at the bedside without proper authorization and assessment.
Failure to Timely Address Change in Condition
Penalty
Summary
The facility failed to conduct timely assessments and follow-up actions for a resident who experienced a change in condition. The resident, identified as Resident 138, had an episode of vomiting, abdominal discomfort, and refused to eat. Despite these symptoms, the facility did not promptly notify the physician or conduct a thorough assessment of the resident's abdominal pain. The initial vital signs were taken, but there was no documented evidence of subsequent monitoring or reassessment of the resident's condition. The facility's policy on significant change in condition requires that a nurse perform and document an assessment, notify the physician, and monitor the resident for at least three days. However, in this case, the physician was not notified until approximately three and a half hours after the change in condition was noted. Additionally, there was no evidence of further vital signs being taken or an assessment of the resident's abdominal discomfort, which was a critical oversight given the resident's symptoms. Interviews with facility staff, including an LVN, RN, and the DON, revealed that the staff were aware of the change in condition but failed to take appropriate and timely actions. The DON acknowledged the delay in notifying the physician and the lack of documented follow-up assessments. The resident's condition deteriorated, and they were found pale, cold, and clammy, with labored breathing, before being declared expired. This series of inactions and delayed responses contributed to the deficiency identified in the report.
Failure to Provide Pressure Ulcer Care and Equipment
Penalty
Summary
The facility failed to provide necessary care and services to prevent the development and worsening of pressure injuries for Resident 840. The resident, who was unable to make medical decisions, was ordered by a physician to have a low air loss (LAL) mattress for wound management. However, observations on multiple occasions revealed that the resident did not have the LAL mattress in place as required. This lack of appropriate equipment was contrary to the facility's policy and the resident's care plan, which emphasized the use of pressure-relieving devices to prevent skin breakdown and promote healing. Additionally, the facility did not adhere to its policy of conducting weekly assessments of pressure injuries. The medical records showed inconsistencies in the documentation of the resident's pressure injuries, particularly the Stage 4 pressure injury on the thoracic spine, which was not assessed or documented as required on certain dates. This oversight in monitoring and documenting the resident's condition further contributed to the deficiency in care. Interviews with facility staff, including the LVN, SSD, and DON, confirmed the lapses in providing the LAL mattress and conducting proper assessments. The staff acknowledged the failure to follow up on the resident's need for the LAL mattress and the lack of documentation to support any follow-up actions. The DON verified that the facility should have provided the LAL mattress while waiting for insurance approval or delivery from the hospice company, highlighting a breakdown in communication and responsibility among the staff.
Failure to Implement Fall Prevention Measures
Penalty
Summary
The facility failed to ensure that a resident, identified as Resident 91, was free from accident hazards by not placing floor mats on both sides of the resident's bed as ordered by the physician and outlined in the resident's care plan. This oversight was observed on two separate occasions, where Resident 91 was seen lying in bed without the required floor mats in place. The resident had a documented history of falls within the facility, with incidents occurring on multiple dates, and was assessed as being at high risk for falls. The care plan, which included the use of bilateral floor mats, was not adhered to, despite the resident's agreement with the plan. The facility's policy on fall management, revised in June 2018, mandates appropriate assessment and interventions to prevent falls and minimize complications. However, the failure to implement the physician's order for floor mats was confirmed during an interview with RN 3, who acknowledged the resident's fall history and the responsibility of supervisors to ensure fall interventions were followed. The Director of Nursing was also informed and acknowledged the findings, indicating a lapse in the facility's adherence to its fall management policy.
Inadequate Pain Management for Two Residents
Penalty
Summary
The facility failed to provide appropriate pain management for two residents, Residents 85 and 98, as per the physician's orders and facility policies. For Resident 98, the facility did not administer pain medication according to the prescribed parameters. The resident was given acetaminophen for pain levels that exceeded the mild pain threshold specified in the physician's order. This occurred on multiple occasions, with pain levels recorded between 4 and 6, which should have warranted the administration of tramadol instead. There was no documentation indicating that the physician was informed of these deviations from the prescribed pain management plan. For Resident 85, the facility did not consistently implement non-pharmacological interventions before administering narcotic pain medication as ordered. The resident's care plan included various non-drug interventions such as repositioning, dim lighting, relaxation, distraction, music, and massage, which were to be attempted prior to administering Dilaudid. However, the medical administration records for August, September, and October showed that these interventions were not documented as being attempted before the administration of the narcotic medication on several occasions. Interviews with facility staff, including an LVN and the DON, confirmed these findings. The LVN acknowledged the administration of pain medication outside the ordered parameters for Resident 98, and the DON confirmed that such practices could lead to ineffective pain management. Similarly, an RN confirmed the lack of documentation for non-pharmacological interventions for Resident 85, which was acknowledged by the DON.
Pharmacy Consultant Fails to Identify Irregularity in Diabetic Resident's Medication Review
Penalty
Summary
The Pharmacy Consultant at the facility failed to identify an irregularity in the medication regimen review for a resident with diabetes who was on insulin. The resident did not have any HbA1C level checked for 10 months, despite the physician's plan to routinely check the HbA1C every three to six months. The facility's policy and procedure for Medication Regimen Review, revised in August 2017, required the pharmacist to review each resident's medication regimen monthly to identify irregularities and unnecessary drugs. However, the Pharmacy Consultant did not make any recommendations regarding the HbA1C test for the resident from December 2023 to October 2024. During an interview, the Director of Nursing (DON) acknowledged the findings and stated that the frequency of the HbA1C test depended on the physician's order, which was not present in the resident's records. The DON also noted the potential serious complications that could arise from not monitoring the HbA1C levels, such as diabetic ketoacidosis, sepsis, and potential death. The Pharmacy Consultant, during a telephone interview, mentioned that recommendations about HbA1C were not usually made for residents on insulin in the long-term care setting, as it was considered more meaningful in outpatient care settings.
Improper Medication Storage and Expired Supplies Found in Facility
Penalty
Summary
The facility failed to ensure proper storage and labeling of medications and treatment supplies, as evidenced by the observation of medications stored at the bedside of a resident without a physician's order or care plan. During an initial tour, a Licensed Vocational Nurse (LVN) observed a tube of CalaZinc cream, a spray bottle of Sea-Clens Wound Cleanser, and a tube of Critic-Aid skin paste in the bedside drawer of a resident. The resident's medical records did not show any physician's orders for these medications, nor was there a care plan addressing their use or storage at the bedside. Interviews with nursing staff confirmed that the medications were brought from home and that there was no authorization for their bedside storage. Additionally, the facility failed to remove expired treatment supplies from a medication cart. During an inspection of Treatment Cart 1, an expired culture swab was found, which had the potential to be ineffective or contaminated if used. The LVN responsible for the cart acknowledged missing the expired item during a previous check. The Director of Nursing (DON) confirmed that expired supplies should be immediately removed from the treatment cart to prevent potential risks.
Inappropriate Disinfection of Blood Pressure Cuff
Penalty
Summary
The facility failed to maintain safe infection control practices, as observed during a medication administration for a resident. A licensed nurse (LVN 1) was seen using Micro Kill One Germicidal Alcohol wipes to clean a wrist blood pressure monitoring device with a Velcro cuff. These wipes are intended for hard, non-porous surfaces, and not suitable for the blood pressure cuff, which is not a hard surface. LVN 1 confirmed the inappropriate use of the wipes and acknowledged that improper cleaning could lead to the spread of germs and bacteria, potentially causing serious health complications.
Failure to Administer Pneumococcal Vaccine
Penalty
Summary
The facility failed to ensure the administration of the pneumococcal vaccine to a resident, identified as Resident 31, who was reviewed for immunizations. The facility's policy, revised in July 2023, mandates offering and administering vaccines, including pneumococcal, to eligible residents after obtaining consent. Resident 31, who lacked the capacity to make medical decisions, had a representative who consented to the pneumococcal vaccination on September 21, 2024. However, a review of the resident's immunization report on October 23, 2024, showed no evidence of the vaccine being administered. During an interview on October 23, 2024, the Infection Preventionist (IP) confirmed that the consent for the pneumococcal vaccine was obtained but the vaccine had not been administered. The IP explained that vaccines should be administered within five days of obtaining consent, but due to being busy during the influenza season, the pneumococcal vaccine was not given to Resident 31. The Director of Nursing (DON) was informed of these findings and acknowledged the deficiency.
Failure to Maintain Homelike Environment
Penalty
Summary
The facility failed to maintain a homelike environment for a resident, identified as Resident 102, who resided in Room A. During an observation and interview, it was noted that the wall adjacent to Resident 102's bed was in disrepair, with visible scratches and areas where the paint was chipped. Resident 102 expressed a desire for her room to be neat and clean, as she spent a significant amount of time there, and indicated that the wall needed repair and repainting. The Director of Nursing (DON) was informed of these findings and verified the condition of the room.
Failure to Implement Oxygen Therapy Care Plan
Penalty
Summary
The facility failed to implement the comprehensive care plan for a resident, identified as Resident 55, who was receiving continuous oxygen therapy. The care plan specified that oxygen should be administered at a rate of two liters per minute via nasal cannula if the resident's oxygen saturation levels were less than 90%. However, during an observation and interview with LVN 9, it was verified that the resident was receiving oxygen at a rate of four liters per minute, contrary to the physician's order and the care plan. The facility's policy and procedure, revised in May 2017, emphasized ensuring each resident receives quality care to maintain their highest practicable well-being according to the interdisciplinary comprehensive assessment and plan of care. Despite this policy, the discrepancy in the oxygen administration rate for Resident 55 was identified, posing a risk of not providing appropriate individualized care. The medical record review confirmed the physician's order and care plan, highlighting the failure to adhere to the specified oxygen administration rate.
Improper Garbage Storage Due to Broken Dumpster Lid
Penalty
Summary
The facility failed to ensure proper storage and coverage of garbage in one of its four dumpsters, which had the potential to attract pests and rodents that carry diseases. During an observation, it was noted that the right-side lid of one dumpster was missing, leaving the garbage exposed. The Maintenance Director confirmed that the lid had been broken since August 2024 and had not been repaired or replaced by the garbage company. Despite this, the dumpster continued to be used for garbage storage. The issue was acknowledged by the RD, DSS, and DON during a subsequent meeting.
Inadequate Communal Dining Space for Independent Residents
Penalty
Summary
The facility failed to provide sufficient space for communal dining for residents who did not require staff assistance with meals. During a resident council meeting, three residents expressed that only those needing assistance had access to the communal dining area, limiting their ability to socialize and affecting their quality of life. Residents expressed a desire for the option to eat in a communal setting rather than being confined to their rooms. The facility's administrator acknowledged the issue and indicated that efforts were underway to address the lack of communal dining space for these residents.
Deficient Care Planning for Residents' Medical and Mobility Needs
Penalty
Summary
The facility failed to develop comprehensive care plans for two residents, addressing their specific medical and mobility needs. For Resident 2, the care plan did not include a problem statement for breast cancer treatment with Femara, a hormone-based chemotherapy medication. Additionally, the care plan for Resident 2's limited physical mobility lacked a measurable timeframe for achieving the goal of requiring minimal assistance with mobility tasks. This oversight was identified during a medical record review and an interview with Resident 2, who confirmed the ongoing use of Femara for breast cancer treatment. Similarly, the care plan for Resident 3, who required partial to moderate assistance with various mobility tasks, also lacked a documented target date for achieving the goal of minimal assistance. This deficiency was confirmed during a review of Resident 3's medical records and an interview with the Director of Nursing (DON), who acknowledged that the residents' medications should have been included in their care plans. These failures posed a risk of not providing appropriate, consistent, and individualized care to the residents.
Failure to Inform Resident of Change in Psychiatric Services
Penalty
Summary
The facility failed to ensure that Resident 1 was informed in advance and given the right to choose his treatment services when the facility changed his outpatient psychiatry services to in-house psychiatry services. Resident 1, who was cognitively intact and had the capacity to make decisions, was not notified or consulted about this change. The resident had been receiving weekly outpatient psychiatric services, but the facility unilaterally switched him to monthly in-house psychiatric services without his knowledge or consent. This change was confirmed through interviews with the resident, the Case Manager, and the Social Services Director (SSD), who all verified that there was no documentation showing Resident 1 was informed or agreed to the change in services. Resident 1 expressed that he did not agree with the change and would have preferred to continue with his weekly outpatient psychiatric services. The Case Manager justified the change by stating that since the facility provided in-house psychiatry and psychology services, there was no reason to send the resident out weekly for his appointments. However, the lack of communication and failure to obtain Resident 1's consent for this change in his treatment plan was acknowledged by the Director of Nursing (DON) during a follow-up interview. This oversight had the potential to prevent the resident from participating in his treatment decisions, as required by the facility's policy on Resident Rights.
Failure to Provide Timely Laboratory Services and Report Abnormal Results
Penalty
Summary
The facility failed to provide the laboratory services for a resident as per the physician's order. The physician had ordered CBC, CMP, and HbA1C tests to be completed in the morning on 1/31/24, but these tests were not conducted until 2/8/24, seven days later. Additionally, the facility did not ensure that the abnormal laboratory test results were reported to the physician in a timely manner. The resident's lab results from 2/8/24 showed critical levels of BUN, Creatinine, and eGFR, which were not promptly communicated to the physician. The licensed nurse documented only one attempt to notify the physician on 2/9/24 and did not follow up further when the physician did not respond. The Medical Director was also not notified of the abnormal results when the primary physician could not be reached. The resident's medical record showed that the physician was finally notified on 2/12/24, at which point the resident was diagnosed with acute renal failure and ordered to start intravenous fluids for hydration. The delay in reporting the abnormal lab results and the subsequent delay in treatment had the potential to adversely affect the resident's physical health and well-being. Interviews with the RN and DON confirmed these findings and verified that the facility's policies and procedures were not followed in this instance.
Failure to Implement AMA Discharge Policy
Penalty
Summary
The facility failed to implement their policy and procedure (P&P) regarding discharge against medical advice (AMA) for one resident. The resident, who had a diagnosis of diabetes mellitus with ketoacidosis, dementia, Alzheimer's disease, and psychosis, left the facility AMA without being provided appropriate instructions, including the need to contact the physician immediately. Additionally, the physician was not informed of the resident's intention to leave AMA until after the resident had already left the facility. This lack of communication and failure to follow P&P had the potential to place the resident at risk for medical complications post-discharge. Interviews with facility staff, including the Nursing Supervisor, Social Services Director (SSD), and Director of Nursing (DON), confirmed that the resident and their caregiver were not given the necessary discharge instructions. The caregiver had previously indicated an inability to care for the resident at home, and the facility's failure to notify the physician and provide proper discharge instructions contributed to the resident's unsafe departure. The DON and Case Manager arranged transportation for the resident without ensuring the caregiver was prepared to receive them, further complicating the situation.
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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) |
|---|---|---|---|---|
| Orange Healthcare & Wellness Centre, Llc | 0.6 mi | — | 24 | 0 |
| Town & Country | 0.7 mi | — | 27 | 0 |
| Healthbridge Children's Hospital - Orange D/p Snf | 1.7 mi | — | 0 | 0 |
| French Park Care Center | 1.8 mi | — | 10 | 0 |
| Citrus Post-acute | 2.1 mi | — | 3 | 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 August 2026) and official state health department websites.