Alamitos Belmont Health And Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Long Beach, California.
- Location
- 3901 E Fourth Street, Long Beach, California 90814
- CMS Provider Number
- 056125
- Inspections on file
- 29
- Latest survey
- January 30, 2026
- Citations (last 12 mo.)
- 17 (1 serious)
Citation history
Health deficiencies cited at Alamitos Belmont Health And Rehabilitation during CMS and state inspections, most recent first.
A resident with complex medical needs and dependence on staff for daily care was scheduled for discharge to an assisted living facility without proper verification that the facility could meet their needs or confirmation of the discharge destination. The receiving facility was not expecting the resident, was not equipped to provide the required care, and confusion existed regarding the resident's identity and admission, resulting in the discharge being delayed.
A resident who required assistance with hygiene and was able to make their own decisions was discharged to a board and care facility without being informed that their insurance would not cover the cost. The resident was told by social service staff that insurance would pay, but upon arrival learned their social security check would be used, resulting in unexpected financial obligations and psychosocial distress.
The facility failed to provide consistent 3-ounce portions of meatloaf to 46 residents on regular diets, as specified in the menu. Observations revealed varying portion sizes, with some as low as 2.5 ounces. Staff initially misjudged the portion size, leading to adjustments based on resident complaints. The Dietary Supervisor and Registered Dietitian stressed the importance of following the menu for adequate nutrition.
The facility failed to prepare food that conserved flavor and appearance, as observed in bland buttered carrots and mashed potatoes. Multiple residents, including those with chronic conditions and specific dietary needs, reported dissatisfaction with the food. The Dietary Supervisor confirmed the lack of flavor, indicating a possible deviation from standardized recipes.
The facility failed to prepare puree diets correctly for residents with dysphagia, as observed with the puree meatloaf and carrots not meeting the required consistency. The puree meatloaf could not hold its shape, and the puree carrots were watery, which did not align with the diet manual's standards. This deficiency was confirmed by the dietary supervisor and registered dietitian, who noted the potential risk of aspiration for residents with difficulty swallowing.
The facility failed to ensure safe food storage and preparation, with issues such as improper labeling, dented cans, and unsanitary kitchen equipment. Staff did not perform hand hygiene, and food temperatures were not checked, leading to potential foodborne illnesses among residents.
The facility failed to properly dispose of garbage, with two dumpsters found overflowing and unable to close, as observed by the Dietary Supervisor and Environmental Services Director. This improper disposal could attract pests and rodents, posing a health risk to residents. The facility's policies and the Food Code 2022 emphasize proper disposal to prevent contamination, which was not followed.
A facility failed to ensure staff wore appropriate PPE while caring for a resident on enhanced barrier precautions due to a G-Tube. A CNA was observed without a gown, only wearing gloves, and did not perform hand hygiene after care. The resident had multiple diagnoses and required PPE for high-contact activities. Staff interviews and facility policies confirmed the need for PPE to prevent infection spread.
A resident with Parkinson's Disease and prostate cancer experienced decreased ROM in both ankles, but the facility failed to notify nursing staff and a physician in a timely manner. An RNA noticed increased stiffness in the resident's ankle in mid-October but only informed a physical therapist who no longer worked there, neglecting to report to nursing staff. This delay in communication postponed necessary evaluations and interventions.
A facility failed to follow up on a Level 2 PASRR evaluation for a resident with depression, Parkinson's Disease, and prostate cancer. Despite a positive Level 1 screening indicating the need for further evaluation, the facility did not respond to attempts to complete the Level 2 assessment. The DON was unaware of the communication attempts, leading to a closed case and potential delay in services.
A resident with type 2 diabetes and chronic kidney disease did not receive insulin as ordered by the physician. The resident's MAR showed that Insulin Glargine was administered when blood sugar levels were below the physician-ordered threshold of 150 mg/dL. The DON confirmed that this practice was against the physician's parameters, posing a risk for hypoglycemia, and emphasized the importance of following physician orders.
A resident with chronic pain conditions was inadequately assessed and monitored for pain management in an LTC facility. Despite being prescribed multiple pain medications, the resident's pain was not effectively managed, with inconsistencies in pain assessment and documentation. The MAR showed a lack of reevaluation after medication administration, and the resident reported severe pain that was not addressed timely. Staff interviews confirmed the deficiency in pain management practices.
A resident with type 2 diabetes and chronic kidney disease received Insulin Glargine despite physician orders to hold it if blood sugar was below 150 mg/dL. The insulin was administered multiple times when the resident's blood sugar was below this threshold, posing a risk for hypoglycemia. The DON confirmed the error, noting the importance of adhering to physician orders to prevent adverse effects.
A resident with a history of falling and weakness did not receive timely Restorative Nursing Aide (RNA) services after their discharge plan changed. Despite the resident's care plan aiming to improve their ADL function, RNA services were delayed until 2/19/2024, putting the resident at risk for a decline in range of motion and strength.
Failure to Ensure Safe and Appropriate Discharge Planning
Penalty
Summary
The facility failed to ensure safe and appropriate discharge planning for a resident by arranging a transfer to an assisted living facility without verifying that the receiving facility could meet the resident's needs and without confirming the accuracy of the discharge destination. The resident had complex medical conditions, including end-stage chronic kidney disease requiring dialysis, diabetes mellitus, dementia with fluctuating decision-making capacity, anxiety, and multiple healing fractures. The resident was dependent on nursing staff for activities of daily living such as toileting, showering, dressing, and transferring. Despite these needs, the facility initiated discharge orders to an assisted living facility without confirming the facility's ability to provide the necessary care or even verifying the correct facility name and location. Interviews and record reviews revealed that the receiving facility was not expecting the resident, was located in a different city, and typically only accepted independent, ambulatory residents without dementia. The Social Services Director was unable to locate the intended facility online and, upon contacting the administrator of the facility, discovered confusion regarding the resident's identity and admission. The discharge was ultimately delayed after it was determined that the transfer would not be safe or appropriate, and the discharge order was discontinued.
Failure to Inform Resident of Financial Obligations Prior to Discharge
Penalty
Summary
The facility failed to inform a resident that their insurance would not cover the cost of a board and care facility prior to discharge. The resident, who was admitted with diagnoses including hypertension and repeated falls and required supervision or assistance with hygiene, was able to make their own decisions. Prior to discharge, the resident specifically asked the social service staff if their insurance would pay for the board and care facility, and was incorrectly told that it would. Upon arrival at the new facility, the resident learned that their social security check would be used to pay for their stay, resulting in a share of cost that the resident was not prepared for. The Social Service Director acknowledged that she did not explain the financial obligations to the resident before discharge and recognized that the resident had the right to be informed. The Director of Nursing confirmed that residents should be informed in writing about payment expectations before discharge or transfer. The resident reported experiencing stress and anxiety due to the unexpected financial burden and stated that they would have preferred to be informed beforehand to make an informed decision. The facility's policy requires that appropriate information be communicated to the receiving provider, but this was not followed in this case.
Inconsistent Portion Sizes Lead to Nutritional Deficiency
Penalty
Summary
The facility failed to adhere to the prescribed menu and portion sizes, which resulted in 46 out of 81 residents on regular texture diets receiving incorrect portions of meatloaf. The menu specified a 3-ounce portion of meatloaf, but during an observation, it was found that the portions varied, with some pieces weighing as little as 2.5 ounces. This discrepancy was confirmed by a staff member who initially believed the portion size to be 2 ounces and adjusted the portions due to resident complaints about small sizes. However, upon checking the menu spreadsheet, the staff member acknowledged the correct portion size was indeed 3 ounces. Interviews with the Dietary Supervisor and Registered Dietitian highlighted the importance of following the menu spreadsheet to ensure residents receive adequate nutrition. The facility's standardized recipe and policies also emphasized the need for accurate portion control using appropriate equipment. The failure to provide consistent portion sizes had the potential to result in decreased nutrient intake and unintended weight loss among residents.
Deficiency in Food Preparation and Flavor
Penalty
Summary
The facility failed to prepare food by methods that conserved flavor and appearance, as observed during a survey. Specifically, the buttered carrots lacked butter flavor, and the mashed potatoes were bland and tasteless. This deficiency was identified through observations, interviews, and record reviews, indicating that the facility did not adhere to its policy of ensuring food is palatable and attractive. The Dietary Supervisor and Registered Dietitian confirmed during a test tray evaluation that the food did not meet flavor expectations, suggesting that the cook may not have followed the standardized recipes. The deficiency affected multiple residents, including those with specific dietary needs and medical conditions. Resident 42, who has chronic kidney disease, COPD, and protein-calorie malnutrition, reported that the food was bland. Resident 82, diagnosed with dysphagia and protein-calorie malnutrition, described the food as horrible. Resident 78, with chronic systolic heart failure and acute respiratory failure, stated the food was like poison, and Resident 27, with dysphagia and hypertension, also found the food unsatisfactory. These residents required various levels of assistance with eating and had specific dietary orders, such as no added salt and different texture modifications. The facility's policies and procedures for food preparation, dated July 19, 2024, required that food be prepared to conserve nutritive value, flavor, and appearance, using approved and standardized recipes. However, the facility's failure to adhere to these procedures resulted in poorly prepared food being served to residents. The standardized recipes for buttered carrots and mashed potatoes included specific ingredients and preparation methods, but the lack of flavor in the served food indicated a deviation from these guidelines. The Dietary Supervisor acknowledged that residents might not eat the food if it was not flavorful, which could lead to dissatisfaction and potential nutritional issues.
Failure to Prepare Puree Diets Correctly
Penalty
Summary
The facility failed to prepare foods in a form designed to meet individual needs for residents on a puree level 4 diet. During an observation, it was noted that the puree meatloaf could not hold its shape, and the puree carrots were watery, which did not meet the required consistency for a puree diet. The dietary supervisor and registered dietitian confirmed that the puree meatloaf was spread out on the plate and the puree carrots had liquid seeping from them, which is inconsistent with the diet manual's definition of a puree diet. The puree diet is intended for residents with dysphagia and those without teeth, and it requires the food to be lump-free, not firm or sticky, and to hold its shape on the plate without liquids separating from the food. The facility's diet manual and recipes for puree foods, such as meatloaf and buttered carrots, were reviewed. The manual specifies that the puree diet should be prepared to a pudding-like consistency, with no lumps or liquid separation, to prevent aspiration and ensure the food is easily swallowed. However, the puree meatloaf and carrots did not meet these standards, as observed during the test tray evaluation. The registered dietitian highlighted the potential risk of aspiration for residents with difficulty swallowing if the food is not prepared correctly. The facility's recipes for puree foods were also reviewed, indicating specific instructions for achieving the correct texture, but these were not followed, leading to the deficiency.
Deficiencies in Food Safety and Sanitation Practices
Penalty
Summary
The facility failed to ensure safe and sanitary food storage and preparation practices, as observed during a survey. Staff did not properly label food products, including Jello and dry potatoes, and failed to label residents' food from outside with the resident's name. This lack of labeling could lead to cross-contamination and incorrect diets being served to residents. Additionally, three dented cans were stored with non-dented cans, posing a risk of botulism, and various kitchen utensils and equipment were found to be chipped, cracked, or rusted, which could result in physical contamination of food. The kitchen equipment and food preparation surfaces were not adequately cleaned and sanitized. Observations revealed that the clean area for storing pots and pans had crumbs and food particles, pans had food residue, and the toaster and microwave had food splatter and residue. The tray-line top was rusted and dirty, and the resident's freezer temperature was not monitored, which could lead to food spoilage. Furthermore, staff did not perform hand hygiene appropriately, as they were observed touching garbage covers and picking up items from the floor without washing their hands before handling food. Food temperatures were not checked prior to tray-line service, and the mashed potatoes in the steamtable were found to be at 125 degrees Fahrenheit, below the required holding temperature of 140 degrees Fahrenheit. This failure to monitor and maintain proper food temperatures could result in serving undercooked or cold food to residents. The facility's policies and procedures were not followed, as evidenced by the lack of temperature logs and the improper handling and storage of food items, which could lead to foodborne illnesses among the residents.
Improper Garbage Disposal Leads to Potential Health Risks
Penalty
Summary
The facility failed to properly dispose of garbage and refuse, as observed on 11/12/2024, when two dumpsters were found overflowing with trash, preventing the lids from closing. This was confirmed during an observation and interview with the Dietary Supervisor, who acknowledged that staff disposed of all food trash in these dumpsters. The overflowing trash and open lids were identified as a potential attractant for pests and rodents, which could carry diseases and pose a risk to the residents. Further observation and interview with the Environmental Services Director revealed that the trash vendor typically collected the trash once a day, but was delayed due to a holiday. The Environmental Services Director confirmed that the overflowing dumpsters and inability to close the lids were not acceptable, as they could attract flies and create an unpleasant environment. The facility's Policies and Procedures, as well as the Food Code 2022, emphasize the importance of proper garbage disposal to prevent nuisances and potential contamination, which were not adhered to in this instance.
Failure to Use PPE for Resident on Enhanced Barrier Precautions
Penalty
Summary
The facility failed to ensure that staff wore appropriate personal protective equipment (PPE) while providing direct care to a resident on enhanced barrier precautions (EBP). During an observation, a Certified Nursing Assistant (CNA) was seen tending to a resident's care without wearing the required PPE, specifically a gown, while only wearing gloves. The CNA adjusted the resident's blanket and then left the room without performing hand hygiene, despite signage indicating the need for PPE due to the resident's EBP status. The resident in question was admitted with multiple diagnoses, including metabolic encephalopathy, a gastrostomy tube (G-Tube), type 2 diabetes mellitus, and hypertension. The resident was assessed as moderately impaired in cognitive skills and dependent on assistance for mobility and self-care. The facility's order summary report indicated that enhanced barrier precautions were necessary for the resident due to the presence of a G-Tube, requiring PPE for high-contact care activities. Interviews with facility staff, including a Licensed Vocational Nurse (LVN) and the Director of Nursing (DON), confirmed the requirement for PPE to prevent the spread of infections. The facility's policy on infection prevention and control outlined the need for gown and gloves during high-contact activities, especially for residents with medical devices like G-Tubes. The failure to adhere to these guidelines posed a risk of infection transmission within the facility.
Failure to Notify Staff of Resident's Decreased Ankle Mobility
Penalty
Summary
The facility failed to ensure timely notification of nursing staff and a physician when a resident exhibited decreased range of motion (ROM) in both ankles. This deficiency was identified through observation, interviews, and record reviews. The resident, who was admitted with diagnoses including depression, Parkinson's Disease, and prostate cancer, initially had no ROM limitations according to assessments conducted in August. However, by November, a Joint Mobility Assessment revealed minimum ROM limitations in the resident's bilateral ankles. The resident's care plan, which was updated in November, included interventions for the newly identified bilateral ankle limitations, but there was a delay in notifying the appropriate medical personnel. A Restorative Nursing Assistant (RNA) noticed increased stiffness in the resident's right ankle in mid-October but only informed a physical therapist who no longer worked at the facility. The RNA did not report the change to nursing staff, which was against the facility's policy requiring immediate notification of any change in a resident's condition. Interviews with the Director of Rehab and the Director of Staff Development confirmed that the RNA should have reported the decline in ROM to both rehab and nursing staff immediately. The facility's policy and job descriptions clearly state the responsibility of RNAs to report changes in residents' conditions to ensure timely evaluation and intervention. The delay in communication resulted in a postponement of necessary evaluations and interventions for the resident's condition.
Failure to Follow Up on Level 2 PASRR Evaluation
Penalty
Summary
The facility failed to follow up on a Level 2 Preadmission Screening and Resident Review (PASRR) evaluation for a resident diagnosed with depression, Parkinson's Disease, and prostate cancer. The resident was admitted with a positive PASRR Level 1 screening indicating the need for a Level 2 evaluation due to a serious mental illness. However, the facility did not respond to multiple attempts to complete the Level 2 evaluation, resulting in the case being closed without the necessary assessment. The Director of Nursing (DON) was unaware of the attempts to contact the facility for the evaluation until the review. The Notice of Attempted Evaluation letter was uploaded into the electronic medical record, but the DON was not informed, leading to a failure to complete a new Level 1 screening to reopen the case. This oversight had the potential to delay services for the resident, as the Level 2 PASRR is crucial for ensuring all resident needs are met.
Failure to Administer Insulin According to Physician's Orders
Penalty
Summary
The facility failed to ensure that a resident with type 2 diabetes and chronic kidney disease received her insulin as ordered by the physician. The resident's care plan included interventions for diabetes management, specifically receiving diabetes medications as prescribed. However, a review of the Medication Administration Record (MAR) for October and November 2024 revealed that Insulin Glargine was administered on multiple occasions when the resident's blood sugar levels were below the physician-ordered threshold of 150 mg/dL. This administration occurred despite the physician's explicit instructions to hold the insulin if the blood sugar was below this level. During an interview, the Director of Nursing (DON) acknowledged that the insulin was given contrary to the physician's parameters, which posed a risk for hypoglycemia. The DON emphasized the importance of adhering to physician orders to prevent adverse effects, particularly since insulin is a high-risk medication. The facility's policy required nurses to administer medication according to the written orders of the attending physician, which was not followed in this case, leading to the deficiency.
Inadequate Pain Management Assessment and Monitoring
Penalty
Summary
The facility failed to accurately assess and monitor the effectiveness of pain management for a resident, leading to a deficiency in care. The resident, who was admitted with diagnoses including depression, Parkinson's Disease, and prostate cancer, was prescribed various pain medications such as Percocet, Tylenol, Cyclobenzaprine, and Gabapentin. Despite these prescriptions, the resident's care plan indicated that the pain was not relieved by the current medications, and the resident frequently reported experiencing severe pain. The Medication Administration Record (MAR) for the resident showed inconsistencies in pain assessment and documentation. The MAR indicated that the effectiveness of Tylenol was often marked as unknown, and the resident's pain level was consistently documented as 0, despite the resident reporting significant pain. Additionally, there was no record of reevaluation for pain after administering Percocet, and the pain characteristics were not monitored as required by the care plan. Interviews with the resident and staff revealed that the resident frequently experienced severe pain and felt that the facility was not adequately addressing his pain management needs. The Director of Staff Development acknowledged that the nurses were not documenting a full pain assessment, and there was a lack of reevaluation of pain after medication administration. The facility's policy required documentation of the response to pain medication and contacting the physician if the pain management program was ineffective, which was not consistently followed in this case.
Failure to Follow Insulin Administration Parameters
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors by not adhering to the physician's ordered parameters for insulin administration. The resident, who was admitted with diagnoses of type 2 diabetes and chronic kidney disease, had specific orders for Insulin Glargine to be held if blood sugar levels were below 150 mg/dL. However, the medication was administered on multiple occasions when the resident's blood sugar levels were below this threshold, as documented in the Medication Administration Record (MAR) for October and November 2024. The Director of Nursing (DON) acknowledged that the insulin was given contrary to the physician's orders, which posed a risk for hypoglycemia and other adverse effects. The facility's policy required nurses to administer medication according to the physician's written orders, emphasizing the importance of following these parameters to prevent potential harm. Despite this policy, the insulin was administered incorrectly, highlighting a significant medication error in the care of the resident.
Failure to Provide Timely Restorative Nursing Aide Program
Penalty
Summary
The facility failed to provide a Restorative Nursing Aide (RNA) program to a resident who was not discharged home as initially planned and continued to stay in the facility. The resident, who had a history of falling and weakness, was admitted with intact cognition and required partial to moderate assistance for activities of daily living (ADLs). Despite the resident's care plan indicating a goal to increase their level of function in ADLs, RNA services were not initiated until 2/19/2024, even though the resident remained in the facility from 2/6/2024 to 3/6/2024. The delay in providing RNA services was due to the initial discharge plan, which recommended home health services and did not indicate the need for restorative programs. However, the resident's physician requested RNA services on 2/17/2024, and the services were started on 2/19/2024. Interviews with the Director of Rehabilitation and the Director of Nursing confirmed that the lack of RNA services could affect the resident's range of motion and strength. The facility's policy indicated that residents should be assessed for physical/occupational therapy or maintenance ROM programs to achieve or maintain their level of self-care or mobility.
Latest citations in California
Two residents with dementia, schizoaffective disorder, and major depressive disorder, both with moderately impaired cognition and needing moderate ADL assistance, were found unclothed together in one resident's bed. One resident later stated she did not want sexual activity and did not consent, while the other resident could not recall the encounter. An LVN reported that both residents verbally consented at the time but acknowledged no assessment had been done to determine their capacity to consent to sexual activity. The DON identified the incident as sexual abuse and confirmed that allowing sexual activity without prior capacity assessment was inconsistent with facility policy and that the resident was not protected from sexual abuse.
Two residents with dementia, schizoaffective disorder, major depressive disorder, and moderately impaired cognition, both needing moderate assistance with ADLs, were found unclothed together in one resident’s bed. The resident later stated she did not consent to sexual contact, while the other resident did not recall any sexual activity. An LVN documented the incident and acknowledged it constituted sexual abuse that should have been reported immediately to the abuse coordinator and appropriate agencies, but did not report it. The administrator, who serves as the abuse coordinator, stated she relies on staff to notify her immediately of such allegations so they can be reported to CDPH, law enforcement, and the Ombudsman, but this did not occur, resulting in the allegation not being reported as required.
A resident with Parkinson’s disease, osteoporosis, and osteoarthritis reported being punched in the face by another resident, resulting in facial bruising. The resident’s MDS showed intact cognition, and a change in condition evaluation documented the assault; however, the MD was not notified until more than a day later. The care plan directed licensed nurses to assess the resident’s body, and staff observed a purplish bruise on the right lower eyelid/orbital area, but this was not documented in the progress notes. Required every-shift monitoring for 72 hours after the change in condition was not documented on multiple day shifts. The DON confirmed lack of awareness of the bruise and acknowledged missing documentation and monitoring, despite facility policies requiring immediate provider notification and complete, accurate charting of changes in condition.
A nurse left a medication cart unlocked and unattended in the hallway while administering insulin to a resident with diabetes, cardiac, and post-surgical conditions. The cart was out of the nurse's direct line of sight, contrary to facility policy requiring medication carts to be locked when not in use. The DON confirmed that medications should be secured to prevent unauthorized access.
A resident’s legal representative requested copies of the resident’s medical records through a faxed request from a law office’s third-party service, but the records were not provided within the required timeframe. The MRD confirmed receiving the request and stated he had forwarded the documents to the DON for review over a month earlier and had not received them back to release. Upon review of federal requirements for record access, the ADON acknowledged that the facility did not comply with the regulation requiring provision of copies within two working days of request.
Two CNAs violated privacy and confidentiality requirements when one CNA used a personal cell phone to record and photograph two residents during a perceived altercation and then sent the video to another CNA. The residents, who had significant medical conditions including paraplegia, seizures, dysphagia, and severe cognitive impairment, were dependent on staff for ADLs. The second CNA reported that a family member later took her phone without permission, accessed the contents, and transmitted the videos and photos to facility leadership. Facility staff, including an LVN, the DSD, and the administrator, stated that HIPAA rules and facility policies prohibit staff from recording residents on personal devices and allow resident photographs only with consent and for medical purposes as part of the chart, and that the facility’s "Stop and Watch" process requires observation and reporting, not filming.
A resident with a stage 4 sacrococcygeal PI, Parkinson’s disease, hypertension, moderate cognitive impairment, and high assistance needs was not provided care consistent with the facility’s pressure injury prevention policy. Although the care plan included daily wound treatment and use of a LAL mattress, it lacked an individualized repositioning schedule and did not document education or reminders about repositioning. Facility documentation showed only that the resident was assisted to roll each shift, with no evidence of q2h turning in bed or of how often incontinence briefs were checked and changed. After the resident refused Foley catheter reinsertion, the IDT did not identify incontinence as a risk factor or add new wound-protective or moisture-preventive interventions, and the subsequent care plan for non-compliance omitted such measures. The TXN and DON confirmed that repositioning and protection of the wound from incontinence were not clearly implemented or reflected in the care plan, despite policy requirements.
A resident with Parkinson’s disease, cognitive impairment, and significant assistance needs for mobility and toileting experienced two early-morning falls resulting in head injuries. After the first fall, the IDT documented potential interventions such as a bed alarm and floor mat but did not identify the cause of the fall, did not obtain a physician order for the floor mat, and did not ensure the care plan addressed supervision or bed alarm function. Before and after the falls, the care plan lacked interventions for supervision despite poor safety awareness and failure to use the call light, and the second fall occurred when the resident slid from bed while reaching for a snack bag placed on the bedside table. IDT follow-up documentation for the second fall was incomplete, and staff acknowledged that fall causes were not identified and resident-centered interventions were not fully implemented.
A resident with severe cognitive impairment and multiple neurological diagnoses was dependent on staff for hygiene and mobility. During an IDT meeting, the resident’s family member communicated specific care preferences, but facility staff did not develop or update a comprehensive person-centered care plan to include these preferences. Review of care plans over several months showed no documentation of the communicated preferences, despite facility policy requiring the IDT to create a measurable, time-framed care plan based on assessed needs and expressed preferences.
A resident with COPD and severely impaired cognition, dependent on staff for all ADLs and mobility, had a physician order for continuous supplemental O2 at a fixed rate of 2 L/min. During observations, the resident was found receiving O2 at 3 L/min. An LVN recognized the discrepancy and reported it to an RN supervisor, but there was no documentation of any clinical rationale for the increased flow, no physician notification, and no order change. The care plan directed staff to administer O2 as ordered, and facility policy required verification of the order, documentation of flow rate and rationale, and appropriate reporting, which were not followed.
Failure to Protect Cognitively Impaired Resident From Sexual Abuse
Penalty
Summary
The facility failed to ensure a resident was free from sexual abuse when two cognitively impaired residents were found unclothed together in one resident's bed without prior assessment of their capacity to consent to sexual activity. One resident had dementia, schizoaffective disorder, and major depressive disorder, with documentation of fluctuating capacity to understand and make decisions and a Minimum Data Set (MDS) indicating moderately impaired cognition and a need for moderate assistance with ADLs. During an interview at her bedside, this resident stated she did not want to engage in sexual activity and did not consent to sexual contact with the other resident. The second resident involved also had dementia, schizoaffective disorder, and major depressive disorder, with an MDS showing moderately impaired cognition and a need for moderate assistance with ADLs. In an interview, he stated he liked women and liked to socialize with women but could not recall whether he engaged in sexual activity with the first resident. An LVN reported observing both residents unclothed in the first resident's bed and stated that, at the time of the incident, both residents verbally consented to sexual activity, but she was not aware of any assessment having been performed to determine either resident's capacity to consent. The DON stated the incident was considered sexual abuse, that it was not the facility's practice to allow sexual activity without appropriate assessment, and that the facility failed to ensure the resident was protected from sexual abuse, contrary to the facility's abuse prevention policy.
Failure to Report Alleged Sexual Abuse Between Cognitively Impaired Residents
Penalty
Summary
The deficiency involves the facility’s failure to report an allegation of sexual abuse between two residents to the State Survey Agency, Ombudsman, and local law enforcement as required by federal regulations and the facility’s own abuse reporting policy. A nurse documented that one resident (Resident 2) and another resident (Resident 4) were found unclothed together in Resident 2’s bed, and the nurse acknowledged that this situation constituted sexual abuse and should have been reported immediately to the abuse coordinator and appropriate agencies, but she did not report the incident. The facility’s policy stated that all staff are mandated reporters and must notify appropriate authorities within two hours of becoming aware of abuse and immediately notify the Abuse Prevention Coordinator and their supervisor. Resident 2 had dementia, schizoaffective disorder, major depressive disorder, fluctuating capacity to understand and make decisions, and moderately impaired cognition, and required moderate assistance with ADLs. During an interview at her bedside, Resident 2 stated she did not consent to sexual contact with Resident 4. Resident 4 also had dementia, schizoaffective disorder, major depressive disorder, moderately impaired cognition, and required moderate assistance with ADLs, and stated he did not recall engaging in sexual activity with any residents. The Administrator, who served as the abuse coordinator, stated she was responsible for reporting all abuse allegations to CDPH, law enforcement, and the Ombudsman, and that staff were responsible for notifying her immediately of sexual abuse allegations so they could be reported and investigated. The failure of staff to notify the Administrator and report the incident resulted in the sexual abuse allegation not being reported as required, causing a delay in an onsite investigation by CDPH.
Failure to Assess, Notify, and Monitor Resident After Facial Trauma
Penalty
Summary
The deficiency involves the facility’s failure to follow professional standards of nursing practice in assessing and monitoring a resident after a reported change of condition related to facial trauma. The resident was admitted with Parkinson’s disease, age-related osteoporosis, and osteoarthritis, and had intact cognitive skills for daily decision-making per a recent MDS. On the evening of 3/26/2026, a Change in Condition Evaluation documented that another resident hit this resident on the nose and both cheeks. The evaluation showed that the attending physician was not notified until 10 p.m. on 3/27/2026, approximately 26.5 hours after the reported incident, and the physician’s recommendation was to monitor the resident’s nose and cheeks for any changes and pain. The resident’s care plan, initiated on 3/26/2026, documented the report that another resident hit him on the nose and both cheeks and included an intervention for licensed nurses to check and assess the resident’s body. In an interview, the resident described that the other resident came into the room, stood on the left side of the bed, and punched him in the face. A photograph taken two days after the alleged incident showed a purplish-blue bruise on the right lower orbital area, although the resident declined to provide a copy of the picture. A CNA later reported observing a purple bruise on the resident’s right lower eyelid on 3/27/2026, described as extending from the inner to the middle lower eyelid and about the size of the tip of her fifth digit. During record review and interviews, an LVN stated that on 3/27/2026 the resident’s right lower eyelid had a dime-sized purplish bruise, but there was no documentation of this bruise in the progress notes. The LVN also stated that the resident should have been monitored every shift for 72 hours after the change of condition, yet there was no documented evidence of monitoring on the 7 a.m. to 3 p.m. shifts on 3/27/2026, 3/28/2026, and 3/29/2026. The DON reported not being made aware of the right eyelid bruise, confirmed that the resident should have been monitored every shift for at least 72 hours following the change of condition, and acknowledged there was no confirmed documentation of monitoring on the identified shifts. Facility policies required immediate physician consultation for significant changes in condition and complete, accurate documentation of changes and services provided, but the facility failed to identify, document, and monitor the resident’s change of condition in accordance with these policies.
Plan Of Correction
Facility Response Submission of the Plan of Correction does not constitute admission or agreement by the Provider of the truth of the facts alleged or conclusion set forth in this statement of deficiencies. The Plan of Correction is prepared and/or executed solely because it is required by the provision of Federal and State laws. This Plan of Correction constitutes the facility's credible allegation of compliance Corrective Action On 4/7/2026 Resident 1 was reassessed by LVN 3 and no skin issue was identified. On 4/7/2026 LVN 3 received one-on-one in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. Identification of other residents and corrective action On 4/8/2026 DON and/or designee reviewed audits provided by medical records for all change of condition in month of April to ensure proper documentation and monitoring are in place. No other deficient practice noted. Measures to prevent recurrence On 4/7/2026 LVN 3 received one-on-one in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. On 4/8/2026 Licensed nurses received in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. Monitoring and incorporation into the QA system HID will audit change of conditions using Change of Condition Audit form daily Monday-Friday and will report any finding during daily stand-up meeting Monday-Friday on-going. DON or designee will review change of conditions from prior day during daily clinical meetings (Monday -Friday) on going to ensure the nurse notified the attending physician regarding resident's significant change of condition and documented. Any deficient finding will be reported to DON and/or administrator for further corrective action/recommendation. Any trend of deficient finding(s) will be documented on Change of Condition Audit Form and will be reviewed during the monthly QA meeting for further review and/or recommendation(s). Administrator who will then report to the Quality Assurance (QA) team during monthly Quality Assurance (QA)/Quality Assurance and Performance Improvement (QAPI) for further evaluation/recommendation and to provide feedback and program modification if needed x3 months or until compliant. Date Corrective action to be completed: 4/8/2026
Medication Cart Left Unlocked During Medication Pass
Penalty
Summary
During a medication pass for a resident with a history of surgical aftercare, cardiac arrest, heart failure, and type 2 diabetes mellitus, a licensed nurse prepared and administered Novolog insulin using a pen-injector. The nurse left the medication cart unlocked and unattended in the hallway, approximately two feet outside the resident's bedroom doorway, while administering the injection inside the room. The cart was out of the nurse's direct line of sight during this time. The nurse acknowledged that the cart was left unlocked and should have been secured when not in direct view. Facility policy and procedure documents reviewed indicated that medication carts must be kept closed and locked when out of sight of the medication nurse or aide, and that compartments containing drugs and biologicals are to be locked when not in use. The Director of Nursing confirmed that medications should be locked and secured to prevent unauthorized access by unlicensed staff and residents. The failure to lock the medication cart during the medication pass was observed and confirmed through interviews and record review.
Plan Of Correction
From 4/4/2025 through 4/7/2025, the DON, DSD, and ADSD completed 1:1 inservices with licensed staff regarding the facility policy and procedure titled Storage of Medications. Medication carts must be kept locked when unattended. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 3 times a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 2 times a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 1 time a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will random monitor medication carts being locked when unattended for 1 month. System effectiveness will be evaluated during the facility's monthly Quality Assurance Performance Improvement Committee meetings for three (3) months.
Failure to Timely Provide Resident Medical Records Upon Request
Penalty
Summary
The facility failed to provide timely access to medical records as required under 42 CFR 483.10(g)(2) for one resident. The resident’s face sheet showed an admission date of November 18, 2025, with multiple diagnoses, but no additional clinical details were provided. A legal representative’s office faxed an initial request for the resident’s medical records on February 26, 2026. As of March 26, 2026, the legal representative’s staff reported that the office had not yet received the requested records from the facility. On April 2, 2026, the Medical Record Director (MRD) confirmed documentation that a third-party service for the law office had requested the resident’s medical records on February 26, 2026. The MRD stated he had submitted the requested documents to the Director of Nursing (DON) for review over a month prior but had not received them back to proceed with releasing the records. During a concurrent interview and record review, the Assistant Director of Nursing (ADON) reviewed the State Operations Manual Appendix PP guidance on residents’ rights to access personal and medical records, which requires that copies be provided within two working days of request. The ADON acknowledged that this regulatory requirement was not followed by the facility.
Plan Of Correction
F0573 Right to Access/Purchase Copies of Records What corrective action(s) will be accomplished for those Residents found to have been affected by the deficient practice? Medical Records Director (MRD) released medical records for Resident 1 as requested by the legal representative (Legal Staff) on April 21, 2026. How will other individuals with the potential to be affected by this deficient practice be identified and protected? No other Resident was identified to have been effected by the deficient practice. What systemic changes will be implemented to ensure that the deficient practice does not recur? The Quality Assurance Committee met on April 14, 2026 to review the Policy and Procedure which was then forwarded to the Knolls West Post Acute legal team for further evaluation. Revision of the policy will be discussed and approved by the Quality Assurance Committee to ensure the facility meets all Federal and State Regulations. F0573 Right to Access/Purchase Copies of Records (CONT.)The Administrator and the Medical Records Director (MRD) are responsible for informing the requesting party for the demand for payment for the requested medical documentation being provided and until payment is received the facility will hold the chart copies.How corrective action(s) will be monitored to ensure solutions are being achieved and sustainedThe Resident's Responsible Party will be notified upon receipt of the Medical Records Request and review in the presence of the facility representative. Records will be provided if it does not pertain to any legal matters after payment is received. The Administrator and/or Designee is responsible for reporting to the Quality Assurance Committee on a monthly basis and monitoring to ensure that corrective action is implemented and evaluated for its effectiveness. The same will be reviewed on a quarterly basis to the Quality Assurance Committee meeting x 3 quarters or until 100% compliance is achieved and sustained.Date of CompletionApril 23, 2026
Unauthorized Resident Recording and Disclosure Violating Privacy and Confidentiality
Penalty
Summary
The deficiency involves a failure to protect residents’ privacy and confidentiality when a CNA used a personal cell phone to record and photograph two residents without their knowledge or consent, and then shared that content with another CNA. One resident had paraplegia, depression, muscle weakness, dorsalgia, and polyneuropathy, was cognitively intact, and dependent on staff for ADLs. The other resident had diagnoses including seizures, dysphagia, acute kidney dysfunction, and muscle weakness, was able to make needs known but could not make medical decisions, had severely impaired decision-making, and was also dependent on staff for ADLs. Both residents were therefore in a position of dependence on staff for care at the time of the incident. According to CNA 2, on a specific date she recorded a video of the two residents because one resident started an altercation with the other. She stated she recorded the incident for “evidence” and to show CNA 1, acknowledging that recording residents was not part of facility policy and that she should not have recorded or taken photographs of them. CNA 1 confirmed that she received the video on her personal cell phone from CNA 2 and stated that the recording was made for “safety purposes” due to a situation that was perceived as potentially escalating to physical aggression. CNA 1 reported that she did not share or post the video on social media or distribute it to others, but that a family member took her phone without permission and accessed its contents. CNA 1 further stated that this family member sent the video and pictures of the two residents to the facility, and that she notified the facility that her phone had been taken but did not disclose that it contained videos or photographs of the residents because she was unaware that the family member had accessed or distributed them. The DSD reported receiving a text message from an unknown number containing approximately two videos and an undetermined number of photographs of the two residents, along with the names of CNA 1 and CNA 2. The DSD, LVN 2, and the Administrator each stated that staff were required to follow HIPAA regulations, that staff were not permitted to record or possess videos or photographs of residents on personal devices, and that any photographs of residents required consent and had to be for medical purposes as part of the medical record. Facility policies on confidentiality, residents’ rights, and dignity stated that unauthorized release, access, or disclosure of resident information, including video or audio, was prohibited and that staff must protect resident privacy and treat residents with dignity and respect. The videos received by the DSD did not show an altercation between the residents, and staff interviews confirmed that filming residents was not part of the facility’s “Stop and Watch” process, which instead required observation, intervention, and reporting of changes in condition or behaviors to nursing staff.
Plan Of Correction
This Plan of Correction is the facility's credible allegation of compliance. Preparation and/or execution of this plan of correction does not constitute admission or agreement by the provider of the truth or facts alleged, or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of federal and state law. F0583 Personal Privacy/Confidentiality of Records How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: Corrective actions were immediately implemented for Resident 1 and Resident 2 upon identification of the deficient practice. The facility initiated an investigation on 03/23/2026 and conducted immediate interviews with staff and residents utilizing structured interview tools to assess scope, impact, and additional potential concerns. Interviews confirmed the incident was isolated and no additional residents reported privacy violations or concerns. The staff members involved were removed from duty immediately. Following completion of the investigation, both employees were terminated in accordance with facility policy due to violation of resident rights, HIPAA, and facility confidentiality policies. Both employees completed formal Declarations and Attestations of Deletion of Unauthorized Recordings, confirming removal of all recordings and non-distribution of content. Documentation includes: Ashley Zelaya, CNA – Declaration executed 03/30/2026 at 9:21 AM, attesting deletion of all recordings and acknowledgment of policy violation Leslie Bram Reyes, CNA – Declaration executed 03/26/2026 at 10:42 AM, attesting deletion of all recordings and acknowledgment of policy violation Residents and/or responsible parties were notified. Social Services completed assessments with no identified psychosocial harm. All corrective actions were completed by 03/26/2026. How the facility identifies other residents having the potential to be affected by the same deficient practice and what corrective action will be taken. A facility-wide audit was initiated on 03/25/2026 using the Briarcrest Comprehensive Privacy, Recording, and Resident Rights Audit Tool. The audit included direct observation, staff interviews, and resident interviews to evaluate compliance with privacy practices, personal device use, and HIPAA requirements. Interviews were conducted using standardized staff and resident interview tools to ensure consistency and thoroughness in data collection. Findings from the audit confirmed that no additional residents were affected by the deficient practice and no additional incidents of unauthorized recording or disclosure were identified. Staff were immediately re-educated by Director and staff development on HIPAA Privacy Rule requirements, the facility's prohibition on personal device recordings, and the appropriate use of the Stop and Watch process for reporting changes in resident conditions. This corrective action was completed by 03/27/2026. What measures will be put into place or what systemic changes will the facility make to ensure that the deficient practice does not recur. The facility implemented systemic changes to prevent recurrence of the deficient practice by reinforcing a zero-tolerance policy for unauthorized recordings and strengthening staff accountability related to resident privacy and confidentiality. Staff completed mandatory re-training by the Director of Staff Development on Resident Rights, HIPAA, and Privacy/Confidentiality requirements. Staff were required to re-acknowledge facility policies related to confidentiality and personal device use. The facility implemented routine supervisory rounding to monitor compliance with personal device restrictions. In addition, the facility installed visible signage at the receptionist area clearly articulates that video recording is strictly prohibited inside resident rooms and in any facility areas where residents are present. The facility also posted signage throughout the entire facility, in both English and Spanish, indicating that video recording is not allowed to ensure clear communication to staff, visitors, and all individuals entering the facility. Privacy and HIPAA compliance were further integrated into new employee orientation, annual competencies, and ongoing in-service education. The Director of Staff Development completed initial re-education by 03/27/2026, and staff completed required training by 04/05/2026. How the facility plans to monitor its performance to make sure that solutions are sustained. To ensure sustained compliance, the facility incorporated privacy and confidentiality monitoring into its Quality Assurance and Performance Improvement (QAPI) program. The facility implemented an ongoing monitoring system beginning on 03/25/2026 utilizing the established audit tool, which confirmed that no additional residents were affected, and no further incidents occurred during the initial audit period. The facility will continue monitoring through weekly audits for four consecutive weeks, followed by monthly audits for three months. These audits will include direct observation of staff practices, verification of compliance with personal device policies, and evaluation of adherence to HIPAA and privacy requirements. Audit findings will be documented using standardized tools and reviewed by the Director of Nursing, with results reported to the Quality Assurance and Performance Improvement (QAPI) Committee for analysis and trending. If any issues are identified, immediate corrective action will be implemented, including re-education and progressive discipline as appropriate. If no trends or repeat deficiencies are identified after the monitoring period, the facility will discontinue routine auditing and remove the issue from active QAPI monitoring. Dates when corrective action will be completed. 4/17/2026
Failure to Implement Repositioning and Moisture Management for Stage 4 Pressure Injury
Penalty
Summary
The deficiency involves the facility’s failure to provide care and services to prevent deterioration of a stage 4 sacrococcygeal pressure injury in accordance with its own pressure injury prevention policy. The resident had a documented stage 4 PI of the sacral region, Parkinson’s disease, hypertension, moderate cognitive impairment, and required substantial/maximal assistance with toileting hygiene, rolling, and transfers. A Braden Scale score of 16 identified the resident as at risk for pressure injury. The Skilled Evaluation Nurse note indicated a pressure-reducing device for the bed but did not indicate that the resident was to be turned and repositioned every two hours. The resident’s care plan for the stage 4 sacrococcyx PI included cleansing with normal saline, applying Santyl ointment, and covering with dry and foam dressings daily, as well as providing pressure relief and a low air loss mattress to support body alignment and position. However, the care plan did not include an individualized repositioning schedule or education and reminders about the importance of repositioning. Documentation from the facility’s records showed that the resident was assisted to roll left and right every shift, but there was no documentation that the resident was turned and repositioned every two hours while in bed, nor was there documentation of the frequency of incontinence brief checks and changes after each episode. After the resident refused reinsertion of a Foley catheter, nursing progress notes documented the refusal but the IDT wound management conference record did not identify incontinence as a risk factor affecting healing of the stage 4 PI and did not document any new recommendations following the catheter refusal. A subsequent care plan addressing the resident’s potential for worsening condition related to non-compliance with Foley catheter reinsertion did not include wound protective measures or moisture-preventive interventions. During interviews, the treatment nurse acknowledged uncertainty about how often the resident was turned/repositioned or how frequently incontinence briefs were checked and changed, and confirmed that the care plan did not include measures to ensure turning at least every two hours or effective measures to protect the sacrococcyx PI. The DON stated that staff were supposed to ensure turning at least every two hours and protection of the wound dressing from incontinence, and that the IDT did not address this risk, so the care plan was not revised, despite facility policy requiring prompt cleaning after incontinence, use of barrier products, individualized repositioning schedules, and ongoing review of interventions for effectiveness.
Failure to Identify Fall Causes and Implement Supervision and Safety Interventions
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to keep the environment free from accident hazards and to provide adequate supervision and assistance devices to prevent accidents for a resident with significant fall risk. The resident had diagnoses including stage 4 sacral pressure ulcer, Parkinson’s disease, and hypertension, and was assessed as moderately cognitively impaired, with poor decision-making and a need for assistance with toileting, transfers, and ambulation. On one occasion, the resident was found on the floor at approximately 4:05 AM with a right forehead laceration requiring transfer to an acute care hospital for suturing. Following this first fall, the IDT Fall Management Follow-Up record listed interventions such as a medication regimen review, bed in lowest position, landing floor mat, and bed alarm, but there was no documented evidence identifying the cause of the fall. The resident’s care plan addressing strength and safety awareness deficits did not include supervision for safety despite poor safety awareness and not remembering to use the call light. The care plan for the actual fall with minor injury did not include ensuring that the bed alarm was functioning. Additionally, physician orders from 9/10/2025 to 1/29/2026 did not contain an order for a floor mat, despite this intervention being recommended in the IDT record. A second fall occurred at around 4:10 AM when the resident was again found on the floor next to the bed, holding a snack bag. The resident, described as alert but forgetful, stated that she had been trying to reach a snack bag on the bedside table and slid down from the bed, and redness was observed on the left side of the forehead after reportedly hitting the bedside table. The IDT Fall Management Follow-Up record for this second fall was incomplete, with no checked interventions. Interviews with the MDS nurse and DON confirmed that the IDT records should have identified the causes of the falls, that frequent monitoring and supervision were not care planned despite the resident’s cognitive impairment and poor safety awareness, and that the recommended floor mat was never ordered or applied, contrary to the facility’s own policies on assessing falls and developing comprehensive person-centered care plans.
Failure to Incorporate Resident Care Preferences Into Person-Centered Care Plan
Penalty
Summary
Surveyors identified a failure to develop a comprehensive person-centered care plan that incorporated a resident’s specific care preferences. The resident was readmitted on 8/31/2025 with multiple diagnoses, including metabolic encephalopathy, Alzheimer’s disease, blindness in the right eye, a history of TIA, and cerebral infarction without residual deficits. An MDS dated 10/30/2025 documented that the resident’s cognition was severely impaired and that the resident was dependent on staff for oral hygiene, toileting hygiene, personal hygiene, and movement. On 3/17/2026, the IDT met with a family member, who communicated specific care preferences for the resident. During interviews, the SSD and DSD confirmed that the family member had provided detailed care preferences at the 3/17/2026 IDT meeting, but a review of the resident’s care plans from 8/31/2025 to 3/31/2026 showed no documented care plan addressing those preferences. The DSD stated that a care plan should have been developed to reflect the resident’s care preferences, that it is the MDS nurse’s responsibility to develop the care plan, and that the absence of such a care plan could result in the preferences not being honored. The Administrator stated that the care plan is essential as it is used by staff as a guide to understand and implement the resident’s plan of care. The facility’s policy on Comprehensive Person-Centered Care Plans required the IDT to develop a comprehensive person-centered care plan with measurable objectives and time frames to meet identified needs, which was not done in this case.
Failure to Administer Oxygen Therapy as Ordered
Penalty
Summary
The deficiency involves the facility’s failure to administer oxygen therapy as ordered by the physician for a resident with COPD. The resident was admitted with chronic obstructive pulmonary disease and had severely impaired cognition, requiring total staff assistance for all ADLs and mobility. A physician’s order dated 3/27/2026 directed that the resident receive continuous supplemental oxygen at a fixed rate of 2 L/min, with no indication that staff could adjust the flow rate. The resident’s care plan for altered respiratory status related to COPD instructed staff to administer oxygen as ordered. On 3/31/2026, during observations at the bedside at 8:45 a.m. and 9:40 a.m., the resident was noted to be receiving oxygen at 3 L/min, which did not match the physician’s order. An LVN reported that the resident was on 3 L/min when he checked vital signs that morning and stated this was not the ordered rate; he said he reported this to the previous shift’s RN supervisor but was unsure what action was taken. Another RN supervisor confirmed there was no documentation in the record to support an increased flow rate or any notification to the physician about the change from 2 L/min to 3 L/min, and reiterated that the order was for a fixed rate of 2 L/min. During a concurrent observation and interview, the prior RN supervisor acknowledged the resident was on 3 L/min and that the flow rate needed to be corrected to match the order. The facility’s oxygen administration policy required staff to verify a physician order, document the flow rate and rationale, and report information per professional standards, which was not followed in this instance.
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