New Orange Hills

In the surveyor’s words

From the most serious findings on record at New Orange Hills, in the surveyor’s own words.

• Actual harm, isolatedF689Nov 10, 2025

  Based on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to provide the necessary care and services to prevent accidents for one of three sampled residents (Resident 1). * The facility failed to ensure Residents 1's bed was in a low position as per the resident's care plan. Resident 1 fell from the bed and sustained a fracture on left lower leg. This failure contributed in Resident 1 sustaining serious injuries from fall and suffering from pain.Findings: According to the National Institute of Health publication titled Biomechanical Evaluation of Injury Severity Associated with Patients Falls from Bed published on 11/15/2008, showed falling from a high bed is dangerous, with potential effects ranging from sprains to… […]

• No harm, potential for more than minimal, widespreadF761Feb 1, 2022

  Based on observation, interview, facility P&P review, and facility document review, the facility failed to verify and maintain the emergency supplies and biologicals in the crash carts (a self-contained cart stocked with emergency medical equipment, supplies, and drugs for use during the medical emergencies) for two of two crash carts in the facility. This failure posed the risk for the residents to receive delayed care and outdated medications in the event of an emergency. Findings: Review of the facility's P&P titled Emergency Cart Policy (undated) showed to secure the necessary equipment and supplies readily available for the provision of emergency care, the following are the procedures: 1. Emergency cart is to be checked by a Licensed Nurse daily on day shift. 2. […]

• No harm, potential for more than minimal, patternF656Feb 18, 2026

  Based on observation, interview, and medical record review, the facility failed to develop and/or implement the comprehensive care plans for two of 27 sampled residents (Residents 4 and 99) and three nonsampled residents (Residents 35, 118, and 124). * The facility failed to develop a care plan for Resident 118's use of buspirone HCl (an anxiety medication) and include the specific targeted behaviors in the care plan interventions for Resident 118's use of psychotropic medications. * The facility failed to implement the care plan intervention for Resident 99's bladder incontinence. * The facility failed to develop a care plan interventions to address when Resident 4 and 124 have tremors or was moving while being shaved during showers. […]

• No harm, potential for more than minimal, patternF695Feb 18, 2026

  Based on observations, interviews, medical record reviews, and facility P&P review, the facility failed to provide the necessary respiratory care services for three sampled residents (Residents 23, 49, and 55) and two nonsampled resident (Residents 25 and 64) reviewed for respiratory care. * The facility failed to ensure Resident 23 was administered with oxygen as ordered by the physician. * The facility failed to notify the physician and hospice care when Resident 49 was not provided the BiPAP machine nightly as ordered due to a missing piece of the BiPAP mask. * The facility failed to ensure Resident 25's nasal cannula was stored in a sanitary condition when not in use. *The facility failed to ensure Resident 64's nasal cannula was stored in a sanitary condition. […]

• No harm, potential for more than minimal, patternF812Feb 18, 2026

  Based on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the sanitary requirements were met in the kitchen. * The facility failed to ensure the kitchen utensils had a smooth cleanable surface and in good condition. * The facility failed to ensure the yellow cutting board used for cutting cooked meat, poultry, and fish was kept in a sanitary condition and with cleanable surface. * The facility failed to ensure the lid for the heavy-duty blenders used for pureed preparation was free from dust. * The facility failed to ensure the storage racks in the dry storage room were free from dust. * The facility failed to ensure the scoops used for food portioning and measuring cups were air dried prior to storing. […]