New Orange Hills
Inspection Findings
F-Tag F0684
F 0684
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Level of Harm - Minimal harm or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interview and medical record review, the facility failed to ensure the necessary care and services were provided when monitoring the blood pressure for one of six sampled residents (Resident 2). * The facility failed to ensure Resident 2's blood pressure was monitored as per the physician's order. In addition, the facility failed to ensure the staff had used an approved device to monitor Resident 2's blood pressure. This failure posed the risk for the resident to have inaccurate blood pressure readings.Findings: On 9/18/25 at 1430 hours, an interview was conducted with Resident 2. Resident 2 verbalized his concern about the facility nurses using a wrist blood pressure machine to obtain his blood pressure readings. Resident 2 stated he did not want his blood pressure obtained with a wrist blood pressure machine because it was inaccurate and often gave a systolic blood pressure (SBP) reading of 99 mmHg. Resident 2 stated the nurses would have to retake his blood pressure five times before getting an accurate blood pressure reading. Resident 2 further stated the nurses were obtaining his blood pressure from his dialysis access site on the left arm, which was not supposed to happen. Medical record review for Resident 2 was initiated
on 9/18/25. Resident 2 was readmitted to the facility on [DATE REDACTED]. Review of Resident 2's H&P examination dated 11/14/24, showed Resident 2 had the capacity to understand and make decisions. Resident 2's diagnoses included End Stage Renal Disease (ESRD) on hemodialysis, high blood pressure, and history of diabetes. Review of Resident 2's Order Summary Report showed the following physician's orders:- dated 11/9/24, for amlodipine (blood pressure medication) 10 mg daily for hypertension, with instructions to hold if Resident 2's systolic blood pressure was less than 110 mmHg; and- dated 2/1/25, no blood pressure readings to be obtained from Resident 2's hemodialysis access site on the left arm. Review of Resident 2's Physician Progress Note dated 9/9/25, showed Resident 2's plan of treatment included the monitoring of Resident's 2 blood pressure for his high blood pressure diagnosis. On 9/18/25 at 1530 hours, concurrent
interview and medical record review was conducted with LVN 1 and the DON. When asked what machine was used to obtain Resident 2's blood pressure readings, LVN 1 stated she used a wrist blood pressure machine. When asked which arm LVN 1 used to obtain the blood pressure readings, LVN 1 stated Resident 2 would offer the arm where he wanted to have his blood pressure readings done. The DON stated the nurses were to use the facility's blood pressure machines, not a wrist blood pressure machine. The DON also stated the nurses should check the orders to ensure the blood pressures were obtained as ordered by
the physician. The DON and LVN 1 verified Resident 2 had an order to not have his blood pressure obtained from Resident 2's left arm hemodialysis access site.
Residents Affected - Few
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 REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99) Previous Versions Obsolete
Facility ID:
If continuation sheet
Event ID:
NEW ORANGE HILLS in ORANGE, CA inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
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 NEW ORANGE HILLS or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.