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Complaint Investigation

New Orange Hills

November 26, 2025 · Orange, CA · 5017 E. Chapman Avenue
Citations 2
CMS Rating 1/5
Beds 145
Provider ID 555286
Healthcare Facility
New Orange Hills
Orange, CA  ·  View full profile →
Inspection Summary

NEW ORANGE HILLS in ORANGE, CA — inspection on November 26, 2025.

Found 2 citations. 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.

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Inspection Findings

FF0684
Quality of Life and Care Deficiencies
Potential for More Than Minimal Harm

Review of Resident 6's Order Summary Report showed a physician's order dated 3/4/24, for Accucheck one time daily in the morning AC.

Review of Resident 6's MDS assessment dated [DATE], showed Resident 6 was cognitively intact.

Review of Resident 6's MARs from October to November 2025 failed to show glucose monitoring was completed on 10/28, 11/14, 11/19, and 11/22/25. On 11/25/25 at 1427 hours, an interview and concurrent medical record review was conducted with RN 2. RN 2 verified Resident 6's glucose monitoring was not completed on 10/28, 11/14, 11/19, and 11/22/25. RN 2 stated the licensed nurse should have charted the reason why Resident 6's glucose monitoring was not done so whatever happens to the resident, it was documented. On 11/25/25 at 1540 hours, an interview and concurrent medical record review was conducted with the DON.

The DON acknowledged the above findings.

The DON stated if Resident 6 refused, the licensed nurse should have put refused or document in the progress notes.

The DON stated it was important to check the blood sugar to ensure the blood sugar was within normal limits and the resident was not having symptoms of hypoglycemia or hyperglycemia.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

11/26/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

New Orange Hills

5017 E.

Chapman Avenue Orange, CA 92869

SUMMARY STATEMENT OF DEFICIENCIES

Review of the facility's P&P titled Documentation (undated) showed the resident's record is a concise and accurate account of treatment, care, response to care, signs, symptoms and progress of the resident's condition.

Closed medical record review for Resident 4 was initiated on 11/19/25. Resident 4 was admitted to the facility on [DATE], and discharged on 11/14/25.

Review of Resident 4's LTC admission H&P examination dated 11/7/25, showed the resident had no decision making capacity.

Review of Resident 4's SBAR Communication Form dated 11/12/25, showed the resident had a fall and no changes were observed.

However, review of Resident 4's Fall Risk Evaluation dated 11/12/25, showed the resident had no falls in the past three months. On 11/25/25 at 1410 hours, an interview and concurrent closed medical record review was conducted with RN 2. RN 2 verified Resident 4 fell on [DATE], and the Fall Risk Evaluation dated 11/12/25 showed Resident 4 had no falls in the past three months. RN 2 stated the licensed nurse who did Resident 4's Fall Risk Evaluation did not include the current fall. RN 2 stated the licensed nurse should have chosen one to two falls in the past three months because Resident 4 fell. On 11/25/25 at 1525 hours, an interview and concurrent closed medical record review was conducted with the DON.

The DON verified Resident 4's Fall Risk Evaluation was inaccurate.

The DON acknowledged Resident 4 had a fall on 11/12/25, and the Fall Risk Evaluation showed no falls in the past three months.

The DON stated the licensed nurse did not count the present fall and should have included the fall as part of the history of fall.

Facility ID:

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.


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