Focused Care At Orange

Penalties

• Apr 25, 2025 — Fine ($102,448)
• Apr 16, 2025 — Fine ($17,641)
• Jan 24, 2025 — Fine ($73,345)

Inspection findings

1. Jun 3, 2026 Health · 6 findings
   • Not serious Scope/severity D

     F0584 Resident Rights Deficiencies

     Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

     Corrected Jun 4, 2026 · CMS health inspection

   • Not serious Scope/severity D

     F0695 Quality of Life and Care Deficiencies

     Provide safe and appropriate respiratory care for a resident when needed.

     Corrected Jun 4, 2026 · CMS health inspection

   • Not serious Scope/severity E

     F0755 Pharmacy Service Deficiencies

     Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

     Corrected Jun 4, 2026 · CMS health inspection

   • Not serious Scope/severity E

     F0812 Nutrition and Dietary Deficiencies

     Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

     Corrected Jun 4, 2026 · CMS health inspection

   • Not serious Scope/severity F

     K0342 Smoke Deficiencies

     Have a complete alarm system manually initiated and initiated by fire sprinkler system connection.

     Corrected Jun 4, 2026 · CMS fire safety

   • Not serious Scope/severity D

     K0353 Smoke Deficiencies

     Inspect, test, and maintain automatic sprinkler systems.

     Corrected Jun 4, 2026 · CMS fire safety

2. Nov 18, 2025 Health · 1 finding
   • Not serious Scope/severity E Complaint

     F0760 Pharmacy Service Deficiencies

     Ensure that residents are free from significant medication errors.

     Corrected Nov 25, 2025 · CMS health inspection

3. Apr 25, 2025 Health · 8 findings
   • Not serious Scope/severity E

     F0688 Quality of Life and Care Deficiencies

     Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.

     Corrected Apr 26, 2025 · CMS health inspection

   • Not serious Scope/severity D

     F0690 Quality of Life and Care Deficiencies

     Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

     Corrected Apr 26, 2025 · CMS health inspection

   • Serious Scope/severity K

     F0700 Quality of Life and Care Deficiencies

     Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.

     Corrected Apr 26, 2025 · CMS health inspection

   • Not serious Scope/severity D

     F0761 Pharmacy Service Deficiencies

     Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

     Corrected Apr 26, 2025 · CMS health inspection

   • Not serious Scope/severity E

     F0812 Nutrition and Dietary Deficiencies

     Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

     Corrected Apr 26, 2025 · CMS health inspection

   • Not serious Scope/severity F

     K0342 Smoke Deficiencies

     Have a complete alarm system manually initiated and initiated by fire sprinkler system connection.

     Corrected Apr 17, 2025 · CMS fire safety

   • Not serious Scope/severity F

     K0353 Smoke Deficiencies

     Inspect, test, and maintain automatic sprinkler systems.

     Corrected Apr 9, 2025 · CMS fire safety

   • Not serious Scope/severity D

     K0372 Smoke Deficiencies

     Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

     Corrected Apr 9, 2025 · CMS fire safety

4. Apr 16, 2025 Health · 1 finding
   • Serious Scope/severity J Complaint

     F0760 Pharmacy Service Deficiencies

     Ensure that residents are free from significant medication errors.

     Corrected Apr 15, 2025 · CMS health inspection

5. Mar 25, 2025 Health · 1 finding
   • Not serious Scope/severity D Complaint

     F0644 Resident Assessment and Care Planning Deficiencies

     Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.

     Corrected Mar 26, 2025 · CMS health inspection

6. Jan 24, 2025 Health · 5 findings
   • Not serious Scope/severity E Complaint

     F0600 Freedom from Abuse, Neglect, and Exploitation Deficiencies

     Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

     Corrected Nov 11, 2024 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0609 Freedom from Abuse, Neglect, and Exploitation Deficiencies

     Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

     Corrected Jan 25, 2025 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0610 Freedom from Abuse, Neglect, and Exploitation Deficiencies

     Respond appropriately to all alleged violations.

     Corrected Jan 25, 2025 · CMS health inspection

   • Serious Scope/severity J Complaint

     F0656 Resident Assessment and Care Planning Deficiencies

     Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

     Corrected Jan 25, 2025 · CMS health inspection

   • Serious Scope/severity J Complaint

     F0689 Quality of Life and Care Deficiencies

     Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

     Corrected Jan 25, 2025 · CMS health inspection

7. Mar 6, 2024 Health · 13 findings
   • Not serious Scope/severity E

     F0578 Resident Rights Deficiencies

     Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.

     Corrected Mar 12, 2024 · CMS health inspection

   • Not serious Scope/severity D

     F0641 Resident Assessment and Care Planning Deficiencies

     Ensure each resident receives an accurate assessment.

     Corrected Mar 29, 2024 · CMS health inspection

   • Not serious Scope/severity D

     F0645 Resident Assessment and Care Planning Deficiencies

     PASARR screening for Mental disorders or Intellectual Disabilities

     Corrected Mar 29, 2024 · CMS health inspection

   • Not serious Scope/severity D

     F0656 Resident Assessment and Care Planning Deficiencies

     Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

     Corrected Mar 29, 2024 · CMS health inspection

   • Not serious Scope/severity D

     F0688 Quality of Life and Care Deficiencies

     Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.

     Corrected Mar 29, 2024 · CMS health inspection

   • Not serious Scope/severity D

     F0695 Quality of Life and Care Deficiencies

     Provide safe and appropriate respiratory care for a resident when needed.

     Corrected Mar 29, 2024 · CMS health inspection

   • Not serious Scope/severity D

     F0791 Quality of Life and Care Deficiencies

     Provide or obtain dental services for each resident.

     Corrected Mar 7, 2024 · CMS health inspection

   • Not serious Scope/severity F

     F0802 Nutrition and Dietary Deficiencies

     Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.

     Corrected Mar 7, 2024 · CMS health inspection

   • Not serious Scope/severity F

     F0812 Nutrition and Dietary Deficiencies

     Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

     Corrected Mar 29, 2024 · CMS health inspection

   • Not serious Scope/severity F

     F0908 Environmental Deficiencies

     Keep all essential equipment working safely.

     Corrected Mar 29, 2024 · CMS health inspection

   • Not serious Scope/severity F

     K0342 Smoke Deficiencies

     Have a complete alarm system manually initiated and initiated by fire sprinkler system connection.

     Corrected May 15, 2024 · CMS fire safety

   • Not serious Scope/severity E

     K0372 Smoke Deficiencies

     Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

     Corrected May 15, 2024 · CMS fire safety

   • Not serious Scope/severity C

     K0922 Gas, Vacuum, and Electrical Systems Deficiencies

     Meet requirements for the use and maintenance of medical gas equipment.

     Corrected May 15, 2024 · CMS fire safety

8. Feb 15, 2024 Health · 1 finding
   • Not serious Scope/severity D Complaint

     F0880 Infection Control Deficiencies

     Provide and implement an infection prevention and control program.

     Corrected Feb 20, 2024 · CMS health inspection

Owners and managers (as published by CMS)

• ABERNATHY, MARY — managing control - governing body, NOT APPLICABLE, since 05/01/2024
• CONLEY, SHAWN — adp of the snf, NOT APPLICABLE, since 05/01/2021
• CONLEY, SHAWN — operational/managerial control, NOT APPLICABLE, since 05/01/2021
• COOPER, KIMBERLY — managing control - governing body, NOT APPLICABLE, since 01/29/2024
• COOPER, KIMBERLY — operational/managerial control, NOT APPLICABLE, since 01/29/2024
• DAVIDSON, JAMES — operational/managerial control, NOT APPLICABLE, since 07/01/2021
• DAVIDSON, JAMES — adp of the snf, NOT APPLICABLE, since 07/01/2021
• FONTENOT, CINDY — adp of the snf, NOT APPLICABLE, since 09/21/2020
• FONTENOT, CINDY — operational/managerial control, NOT APPLICABLE, since 09/21/2020
• HUMPHREY, ERIC — managing control - governing body, NOT APPLICABLE, since 05/01/2024
• LEGG, STEPHEN — managing control - governing body, NOT APPLICABLE, since 01/01/2024
• MCKENZIE, MARK — adp of the snf, NOT APPLICABLE, since 05/01/2021
• MCKENZIE, MARK — operational/managerial control, NOT APPLICABLE, since 05/01/2021
• MCKENZIE, MARK — managing control - governing body, NOT APPLICABLE, since 05/01/2024
• NEWTON, ELIZABETH — operational/managerial control, NOT APPLICABLE, since 02/22/2024
• NEWTON, ELIZABETH — managing control - governing body, NOT APPLICABLE, since 02/22/2024
• PALANG, RONALD — operational/managerial control, NOT APPLICABLE, since 07/01/2021
• PALANG, RONALD — adp of the snf, NOT APPLICABLE, since 07/01/2021
• POLK, KARTEEDRIA — adp of the snf, NOT APPLICABLE, since 08/15/2024
• POLK, KARTEEDRIA — operational/managerial control, NOT APPLICABLE, since 08/15/2024
• STRUBBE, LORETTA — operational/managerial control, NOT APPLICABLE, since 05/01/2021
• STRUBBE, LORETTA — adp of the snf, NOT APPLICABLE, since 05/01/2021
• TINNERMAN, LINDA — managing control - governing body, NOT APPLICABLE, since 01/01/2024
• TURNER, LESLIE — managing control - governing body, NOT APPLICABLE, since 01/01/2024
• CHAMBERS COUNTY PUBLIC HOSPITAL DISTRICT NO. 1 — operational/managerial control, NOT APPLICABLE, since 05/01/2021
• FOCUSED POST ACUTE CARE PARTNERS LLC — adp of the snf, NOT APPLICABLE, since 06/16/2025
• FOCUSED POST ACUTE CARE PARTNERS LLC — operational/managerial control, NOT APPLICABLE, since 02/01/2017
• FOCUSED POST ACUTE CARE PARTNERS MANAGEMENT, LLC — operational/managerial control, NOT APPLICABLE, since 05/01/2021
• FOCUSED POST ACUTE CARE PARTNERS MANAGEMENT, LLC — adp of the snf, NOT APPLICABLE, since 07/15/2025
• FPACP ORANGE LLC — adp of the snf, NOT APPLICABLE, since 07/15/2025
• FPACP ORANGE LLC — operational/managerial control, NOT APPLICABLE, since 05/01/2021