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Complaint Investigation

Mainplace Post Acute

April 27, 2026 · Orange, CA · 1835 West La Veta Avenue
Citations 1
CMS Rating 2/5
Beds 169
Provider ID 555259
Healthcare Facility
Mainplace Post Acute
Orange, CA  ·  View full profile →
Source Document
Official CMS Inspection Report (Medicare.gov)
Downloaded from CMS/Medicare.gov. Reflects what state inspectors documented and does not include the facility's plan of correction, which is submitted separately. Facilities may have taken corrective actions since this report was released.
Inspection Summary

MAINPLACE POST ACUTE in ORANGE, CA — inspection on April 27, 2026.

Found 1 citation. Severity: Standard violations.

Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.

Inspection Findings

FF0842
Resident Assessment and Care Planning Deficiencies

Review of Resident 1's H&P dated 3/11/26, showed Resident 1 had the capacity to make medical decisions. a.

Review of Resident 1's Progress Notes showed a Physician's Progress Note dated 3/16/26 at 0427 hours, listing a detailed summary of Resident 1's status and plan of care.

However, upon further review, the Physician's Progress Note also listed a detailed summary and plan of care for Residents 5 and 6. On 4/23/26 at 1457 hours, an interview and concurrent medical record review for Resident 1 was conducted with the DON.

The DON stated the Physician's Progress Notes were not reviewed after entry unless there was a new order to review.

The DON verified the medical information for Residents 5 and 6 should not be listed in the medical record for Resident 1. b.

Review of the facility's P&P titled Change in Condition revised 4/2025 showed the nurse will perform and document an assessment of the resident and identify need for additional interventions, considering implementation of existing orders or nursing interventions or through communication with the resident's provider using SBAR or similar process to obtain new orders or interventions.

Review of Resident 1's CNA Skin Observation, also referred to as the shower sheet, showed the following:- dated 3/12/26, CNA 1 indicated redness to the bilateral groin/inner thigh area. LVN 1 indicated assessment done.- dated 3/19/26, CNA 2 indicated redness to the right groin/inner thigh area. LVN 2 indicated assessment done.- dated 3/23/26, CNA 3 indicated red areas to the lower back and the groin area. LVN 3 indicated assessment done. On 4/23/26 at 1305 hours, an interview and concurrent medical record review for Resident 1 was conducted with Treatment Nurse

  • Treatment Nurse 1 stated for any new findings there should be a documented assessment, change
  • of condition documented, and the physician should be notified if necessary.

Treatment Nurse 1 verified there were no assessments, progress notes or change of condition documented to correspond with the findings on the shower sheets dated 3/12, 3/19, and 3/23/26. On 4/23/26 at 1457, an interview and concurrent medical record review for Resident 1 was conducted with the DON.

The DON verified there were no assessments, progress notes or change of condition documented to correspond with the findings on the shower sheets dated 3/12, 3/19, and 3/23/26.

The DON further verified nurses should be documenting their skin assessments.

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.

For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE

Frequently Asked Questions

What is an F-tag violation?
F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
Were these violations corrected?
Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
How often do nursing home inspections happen?
CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
What should families do about these violations?
Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in ORANGE, CA, (5) Report new concerns to state authorities.
Where can I see the full inspection report?
Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from MAINPLACE POST ACUTE or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.


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About This Inspection Report

Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.

Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.

Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.