All Saint's Subacute & Transitional Care
Inspection history, citations, penalties and survey trends for this long-term care facility in San Leandro, California.
- Location
- 1652 Mono Avenue, San Leandro, California 94578
- CMS Provider Number
- 555809
- Inspections on file
- 22
- Latest survey
- February 9, 2026
- Citations (last 12 mo.)
- 30 (1 serious)
Citation history
Health deficiencies cited at All Saint's Subacute & Transitional Care during CMS and state inspections, most recent first.
A resident with Type 2 DM and a G-tube, who was cognitively intact and care planned for imbalanced nutrition and risk of unstable blood glucose, did not receive ordered blood glucose monitoring and Humalog insulin per sliding scale at a scheduled time. The resident and responsible party reported missed blood sugar checks and insulin doses on multiple occasions, including one specific evening. Review of the MAR confirmed that the blood sugar was not checked and insulin was not administered at the ordered time, and no justification was documented by the nurse, contrary to facility policies requiring adherence to provider orders and timely medication administration.
Staff failed to follow PPE and hand hygiene requirements for two residents on contact precautions. One resident with diabetes and a G-tube had a housekeeper enter the room, clean the bathroom, and handle trash without PPE or hand hygiene, despite posted contact precaution signage and facility policy. An RN also entered this resident’s room without PPE, administered G-tube medication, checked blood sugar, and gave insulin, then left the room without performing hand hygiene, later acknowledging that PPE and hand hygiene were required but citing an empty PPE rack at the door. Another resident with a tracheostomy, G-tube, and ventilator-associated pneumonia had a CNA empty a urinary drainage bag while wearing a gown and gloves, then exit the room, remove the gown in the hallway, keep the soiled gloves on while walking to the nurse’s station, and touch clean gowns without performing hand hygiene, again in conflict with the posted "5 Moments for Hand Hygiene" and the facility’s hand hygiene policy.
Three residents did not receive necessary care as required by their care plans and facility policy. Two residents, both fully dependent on staff for oral hygiene due to complex medical conditions, were observed with significant oral debris and dryness, indicating oral care was not performed as required each shift. Another resident, who was comatose and dependent for toileting, was found by a family member lying on a urine-saturated draw sheet, with facility records showing a lapse in required two-hour safety checks and repositioning. Staff interviews confirmed inconsistencies in care delivery.
A facility failed to follow infection control recommendations from public health authorities, including halting new admissions and resident transfers, submitting required monitoring logs, and ensuring staff adherence to hand hygiene and PPE protocols. Direct care staff were observed entering rooms of residents on contact precautions without proper hand hygiene or PPE, and staff caring for infected and non-infected residents were not separated. These failures led to the spread of multi-drug resistant organisms and carbapenem-resistant organisms among numerous residents, many with complex medical conditions.
Four residents with complex medical conditions and confirmed NDM infection did not have individualized care plans addressing their antibiotic-resistant infection. The facility focused on isolation procedures rather than creating person-centered care plans specific to each resident's infection, contrary to facility policy and best practices.
The facility failed to accurately document controlled substances for two residents, with discrepancies between the Controlled Drug Record (CDR) and Medication Administration Record (MAR). For one resident, alprazolam was not recorded on the MAR, and for another, morphine orders were inconsistently documented. Additionally, the medication cart was found unlocked twice, contrary to facility policy requiring it to be locked when out of view.
The facility failed to properly store and label medications, including acetylcysteine without open dates, an insulin pen stored outside the refrigerator, and oral medications mixed with eye drops. Additionally, eye drops were labeled only with room numbers, risking administration errors.
The facility's kitchen staff demonstrated incompetence in essential procedures, including incorrect thermometer calibration, improper sanitizer testing, and misuse of sanitizing solutions, risking contamination for 22 residents.
The facility failed to follow food safety standards by using expired seasonings and maintaining unclean kitchen equipment. Eight seasonings were found expired or beyond use-by dates, and a tabletop can opener had residue build-up. The Registered Dietician confirmed these issues, which put 22 residents at risk for foodborne illnesses.
Two residents in an LTC facility, both with significant medical conditions and total dependence on staff for personal hygiene, were observed with long, thick facial hair, indicating a failure to provide necessary grooming assistance. A CNA was unsure of her responsibilities, and the DON acknowledged the risk of skin irritation and compromised dignity. Facility policy requires assistance for residents unable to perform ADLs.
A resident with a tracheostomy and ventilator dependence did not receive proper care as their tracheostomy tie was not changed daily as ordered by the physician. The tie, last changed nearly a month prior, posed risks of skin irritation and infection. Discrepancies were noted between the facility's practice and the physician's order, with staff acknowledging the oversight.
A facility failed to implement a consultant pharmacist's recommendations for a resident's medication regimen. The resident continued to receive quetiapine without the correct indication documented, despite recommendations to update the diagnosis to 'dementia with behaviors - biting'. The facility's policy requires action on such recommendations within 30 days, which was not followed.
The facility did not meet the required 80 square feet of space per resident for 13 residents in 6 multi-bed rooms, with space per bed ranging from 72.87 to 79.75 square feet. Despite this, care provision was not hindered, and residents had adequate personal space and privacy, with no complaints or negative consequences reported.
Failure to Administer Ordered Insulin and Perform Blood Glucose Monitoring
Penalty
Summary
The facility failed to ensure services met professional standards of quality when a resident with Type 2 Diabetes Mellitus and a G-tube did not have blood glucose monitoring and insulin administration performed as ordered. The resident’s admission record showed diagnoses including Type 2 Diabetes Mellitus with hyperglycemia and gastrostomy status, and the MDS assessment documented intact cognition with a BIMS score of 15 and a diagnosis of Diabetes Mellitus. The resident’s care plan, initiated in April 2023, identified imbalanced nutrition related to insulin resistance and risk for complications such as unstable blood glucose and cardiovascular disease, with an intervention specifying diabetes medication as ordered by the physician. During an interview with the resident and the resident’s responsible party, both reported that the resident’s blood sugar was not checked and insulin was not administered on multiple occasions, including a specific evening. Review of the MAR for that date and time confirmed that the resident’s blood sugar was not checked and Humalog insulin, ordered every six hours per sliding scale, was not given at the scheduled 6:00 p.m. dose, and the licensed nurse did not document any justification for the missed insulin administration. The facility’s policies on diabetes care and medication administration required following provider orders for blood glucose monitoring, assisting with the prescribed medication regimen, and administering medications safely, timely, and in accordance with prescriber orders within one hour of the prescribed time, which was not followed in this instance.
Failure to Follow PPE and Hand Hygiene Requirements for Residents on Contact Precautions
Penalty
Summary
The deficiency involves multiple failures by staff to follow the facility’s infection prevention and control policies, including contact precautions and hand hygiene, for two residents on contact precautions. Resident 1’s admission record showed admission with diagnoses including Type 2 diabetes mellitus with hyperglycemia and gastrostomy status, and a physician’s order placed the resident on contact precautions. Facility signage outside the room directed everyone to clean their hands before entering and when leaving, and directed staff to don gloves and gowns before room entry and discard them before room exit. Despite this, a housekeeper entered Resident 1’s room without any PPE, cleaned and emptied the bathroom and trash bins, then exited the room and did not perform hand hygiene. The housekeeper stated she knew PPE was required when cleaning Resident 1’s room but reported there was no PPE supply available that morning on the rack. Further noncompliance with infection control measures occurred when an RN provided direct care to Resident 1 without PPE and without performing hand hygiene. Resident 1’s physician orders confirmed contact precautions, and the facility’s hand hygiene policy required hand hygiene after contact with blood, body fluids, contaminated surfaces, after touching a resident, after touching the resident’s environment, and immediately after glove removal. During observation and interview, the RN was seen in Resident 1’s room without PPE, then exited without hand hygiene. The RN acknowledged that PPE was supposed to be worn because the resident was on contact precautions and explained that the PPE rack on the door was empty and PPE was stored at the nurse’s station. The RN confirmed having direct contact with Resident 1 by administering medication via G-tube, checking blood sugar, and giving insulin, and acknowledged not performing hand hygiene after this direct care and that this created an increased risk of transmission of infection. Resident 2’s records showed admission with tracheostomy status, gastrostomy status, and ventilator-associated pneumonia, and a physician’s order and care plan placed the resident on contact precautions. The care plan required staff to perform handwashing after completing care and leaving the room and to use PPE. During observation, a CNA was seen at Resident 2’s bedside emptying a urinary drainage bag while wearing a gown and gloves. The CNA then exited the room, removed and discarded the gown in a trash bin located in the hallway outside the room, but did not remove the soiled gloves. The CNA walked toward the nurse’s station while removing the gloves and touched a clean pack of gowns at the station. The CNA stated he removed the gown in the hallway because the garbage bin was outside the room and admitted he did not perform hand hygiene after emptying the urinary bag because he did not think about it. The CNA also reported that the PPE rack on Resident 2’s door was empty and that he had to obtain PPE from the nurse’s station. The facility’s hand hygiene policy and posted "Your 5 Moments for Hand Hygiene" signage required hand hygiene immediately after exposure risk to body fluids, after touching a patient or their surroundings, and immediately after glove removal, which was not followed in this instance.
Failure to Provide Timely Oral and Incontinent Care
Penalty
Summary
The facility failed to provide necessary treatment and care services in accordance with professional standards of practice, comprehensive assessment, and care plan for three residents. Two residents, both dependent on staff for oral hygiene due to conditions such as traumatic brain injury, ventilator dependence, and gastrostomy status, did not receive proper oral care. Observations revealed one resident with dried, tan-colored matter on the lips and brown, dry matter at the corners of the mouth, as well as sticky, creamy matter inside the mouth. The other resident was observed with a dry, coated upper lip and a thick, peeling layer of skin. Staff interviews confirmed that oral care was not performed as required every shift, and facility policy stated that oral care should be provided every shift and as needed for residents with special needs. Another resident, who was comatose, dependent for toileting hygiene, and used an external urinary condom catheter, did not receive timely incontinent care. A family member reported finding the resident lying on a draw sheet saturated with dry urine up to the shoulders and upper body, and that nursing staff had not repositioned or changed the soiled linen. Facility records indicated a gap in required two-hour safety checks, with the resident not being checked for over six hours during the night. Staff interviews provided conflicting accounts regarding the resident's condition and care provided during the relevant period. Facility policies required residents who are unable to carry out activities of daily living independently to receive necessary services to maintain good nutrition, grooming, and personal and oral hygiene, as well as to be repositioned at least every two hours. The failure to adhere to these policies resulted in residents not receiving the necessary oral and incontinent care as outlined in their care plans and facility procedures.
Failure to Follow Infection Control Practices Resulting in Widespread MDRO and CRO Transmission
Penalty
Summary
Facility 2 failed to implement and follow infection prevention and control practices as recommended by the local public health department (LPHD), resulting in the spread of multi-drug resistant organisms (MDROs) and carbapenem-resistant organisms (CROs) among residents. Despite explicit recommendations from the LPHD to halt new admissions and prevent movement of residents between buildings, the facility continued to admit and transfer residents from another facility under a different license. The facility also did not submit required adherence monitoring logs for hand hygiene, PPE use, and environmental cleaning, nor did it provide complete line lists with laboratory test dates for residents who tested positive for CROs. Additionally, the facility failed to notify the California Department of Public Health about the outbreak in a timely manner and did not provide adequate documentation of outbreak notification and education to residents and families. Direct care staff were observed not following basic infection control protocols, such as performing hand hygiene and donning appropriate PPE before entering rooms of residents on contact precautions. For example, a CNA entered a resident's room without hand hygiene or PPE, embraced the resident, and then exited the building, despite a contact precaution sign being posted. These lapses in infection control were observed during surveyor visits and interviews, and staff confirmed that recommended practices were not consistently followed. The facility also failed to separate staff caring for residents infected with MDROs from those caring for non-infected residents, contributing to cross-contamination. As a result, numerous residents became infected with various MDROs, including carbapenem-resistant Pseudomonas aeruginosa (CRPA), carbapenem-resistant Acinetobacter baumannii (CRAB), and New Delhi metallo-beta-lactamase (NDM) producing organisms. The report details the medical histories and conditions of affected residents, many of whom had complex medical needs such as ventilator dependence, quadriplegia, and chronic respiratory failure. The cumulative failures led to an Immediate Jeopardy situation, as the facility's actions placed residents at significant risk of harm.
Failure to Develop Comprehensive Care Plans for Residents with NDM Infection
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for four residents who tested positive for an antibiotic-resistant infection known as Carbapenemase-Producing Organisms (CPO), specifically the New Delhi metallo-β-lactamase (NDM) enzyme. Despite laboratory reports confirming NDM infection for these residents, their care plans did not address this specific infection. The residents involved had complex medical histories, including conditions such as anoxic brain damage, acute respiratory failure, cardiac arrest, critical illness myopathy, COPD, tracheostomy status, cervical spine fusion, and ventilator dependence. The absence of individualized care plans for their NDM infection was identified through observation, interview, and record review. During interviews, the DON acknowledged that care plans should have been developed for all residents with infections, especially during an outbreak, but stated that the facility focused only on isolation types rather than the specific infections. Review of the facility's policy indicated that comprehensive, individualized care plans with measurable objectives and timetables are required for each resident, and should be updated as residents' conditions change. However, this process was not followed for the residents with NDM infection, resulting in a lack of person-centered care planning for their identified needs.
Controlled Substance Documentation and Security Deficiencies
Penalty
Summary
The facility failed to ensure accurate accountability of controlled substances for two residents, leading to potential misuse or diversion of medications. For Resident 49, alprazolam 0.25 mg was recorded on the Controlled Drug Record (CDR) but not on the Medication Administration Record (MAR) on two separate occasions. This discrepancy was confirmed during interviews with the Director of Nursing (DON) and a Licensed Vocational Nurse (LVN), who acknowledged the failure to document the medication on both records. The facility's policy requires that controlled medications be documented on the MAR, which was not adhered to in this case. Additionally, for Resident 15, there was a lack of proper documentation for morphine sulfate prescriptions. The CDR and MAR did not match, with only one CDR sheet available for two different morphine orders. This inconsistency was noted by a Registered Nurse (RN) and the DON, who recognized the risk of medication errors due to the mismatch. Furthermore, the medication cart was observed to be unlocked on two occasions, posing a risk of unauthorized access to medications. The facility's policy mandates that medication carts be locked when out of the nurse's view, which was not followed, as observed by an LVN and confirmed by the DON.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to store and label medications according to manufacturer specifications and accepted professional principles. Two containers of acetylcysteine, used for breaking up mucus in lung disease patients, were found without an open date in the medication refrigerator for two residents. This oversight was confirmed by an LVN, who acknowledged the risk of administering ineffective medication if not labeled with an open date. Additionally, an unopened insulin pen was improperly stored in a medication cart instead of the refrigerator, contrary to the facility's policy and manufacturer guidelines, which could lead to reduced effectiveness. Further observations revealed that oral medications were stored in the same compartment as eye drops in a medication cart, increasing the risk of administering medications via the wrong route. Four bottles of artificial tears were labeled only with room numbers, posing a risk of being administered to the wrong resident if room assignments changed. These labeling and storage deficiencies had the potential to result in residents receiving incorrect or expired medications.
Incompetence in Kitchen Staff Procedures
Penalty
Summary
The facility failed to ensure that kitchen staff were competent in their job duties, leading to potential contamination risks. A cook demonstrated an incorrect method for calibrating a food thermometer by adding hot water to a mixture of cold water and ice, which was not in line with the facility's policy. The Registered Dietician (RD) confirmed that this method was incorrect and could result in inaccurate temperature readings, which are crucial for food safety. Additionally, a dietary aide (DA) incorrectly tested the sanitizer strength in the dish machine by using a chlorine test strip on the bottom of the machine instead of on a wet plate, as required by the facility's policy. The RD confirmed that the method used by the DA was improper and did not comply with the established procedures for ensuring the correct sanitizer concentration. Furthermore, there was confusion among the kitchen staff regarding the preparation and use of sanitizing solutions. A dietary aide used a spray bottle with a sanitizer solution that was not properly labeled and did not know the correct concentration. Another aide prepared the solution but was unsure of its strength, and a Territory Representative confirmed that the solution was too concentrated and not suitable for food contact surfaces. This lack of knowledge and adherence to proper procedures posed a risk of contamination for the 22 residents receiving food from the kitchen.
Expired Seasonings and Unclean Equipment in Kitchen
Penalty
Summary
The facility failed to adhere to professional standards for food safety by storing and using expired seasonings and maintaining unclean kitchen equipment. During an observation in the kitchen, eight different dry seasonings were found to be either expired or beyond their use-by dates. These seasonings, including sweet basil, tarragon, ground cloves, crushed Italian seasoning, Cajun seasoning, ground ginger, ground black pepper, and ground cinnamon, were stored on a wall shelf behind the cooking area. The Registered Dietician (RD) confirmed the expiration and use-by dates and acknowledged that kitchen staff should dispose of seasonings past their expiration dates, as per the facility's food storage chart. Additionally, a tabletop can opener was observed to be unclean, with a white and deep brown residue build-up on its gear and cavity. The RD confirmed that the can opener was dirty and should be cleaned after each use. The facility's policy and procedure on sanitization, dated 2008, requires that all equipment be washed to remove or completely loosen soils. These deficiencies placed 22 residents who received food from the kitchen at risk for foodborne illnesses.
Failure to Assist Residents with Personal Hygiene
Penalty
Summary
The facility failed to provide necessary assistance with Activities of Daily Living (ADL) for two residents, Resident 40 and Resident 59, who were unable to maintain personal hygiene and grooming due to their medical conditions. Resident 59, who was admitted in March 2024, had diagnoses including encephalopathy and traumatic hemorrhage of the cerebrum, and was totally dependent on staff for personal hygiene. Observations revealed that Resident 59 had long, thick facial hair, and a Certified Nurse Assistant (CNA) from an agency was unsure if shaving was her responsibility. The Licensed Vocational Nurse (LVN) confirmed that CNAs were responsible for maintaining Resident 59's grooming, and the family representative expressed that Resident 59 would have preferred to be shaved occasionally. Similarly, Resident 40, admitted in January 2024 with encephalopathy and acute and chronic respiratory failure with hypoxia, was also totally dependent on staff for personal hygiene. Observations showed that Resident 40 had long, thick facial hair, and the LVN noted that this could lead to skin irritation or breakdown. The Director of Nursing (DON) stated that CNAs were expected to maintain residents' personal hygiene and grooming, and acknowledged the risk of compromised skin integrity and dignity due to long facial hair. The facility's policy indicated that residents unable to perform ADLs should receive necessary services to maintain grooming and hygiene.
Failure to Change Tracheostomy Tie as Ordered
Penalty
Summary
The facility failed to provide proper tracheostomy care for a resident, identified as Resident 59, by not changing the tracheostomy tie daily as ordered by the physician. The resident, who was dependent on a ventilator, had a tracheostomy tie that was last changed on 6/14/24, despite the physician's order requiring it to be changed every shift, as needed if soiled or dislodged, and after a shower. This oversight was observed during a survey on 7/9/24, when the tracheostomy tie was found to be dated nearly a month prior. Interviews with the Registered Nurse Supervisor and the Respiratory Therapist Director revealed discrepancies in the facility's practice and the physician's order. The RN Supervisor acknowledged that the tracheostomy ties should be changed daily, while the RT Director stated they should be changed every 2-3 days. Both acknowledged the risk of skin irritation and infection due to the failure to change the tracheostomy tie as required. The facility's policy, dated 2001, also indicated that tracheostomy care should be provided at least once daily for established tracheostomies.
Failure to Implement Pharmacist's Recommendations for Medication Indication
Penalty
Summary
The facility failed to act upon the consultant pharmacist's recommendations regarding the medication regimen of Resident 19, who was receiving quetiapine. The consultant pharmacist's Medication Regimen Review (MRR) for April 2024 recommended updating the diagnosis to 'dementia with behaviors - biting' to justify the use of quetiapine. However, as of July 10, 2024, these recommendations had not been reviewed by the physician, and the resident continued to receive quetiapine without the correct indication documented. During interviews and record reviews, the Director of Nursing (DON) confirmed that the pharmacist's recommendations were not implemented for Resident 19. The facility's policy and procedure for Medication Regimen Review and Reporting requires that recommendations be acted upon within 30 days, but this was not adhered to. The DON acknowledged the importance of having correct indications for medication use to ensure resident safety and prevent unnecessary side effects.
Deficiency in Resident Room Space Requirements
Penalty
Summary
The facility failed to provide the required 80 square feet of space per resident for 13 residents occupying 6 multi-bed rooms. During an observation, it was noted that the rooms had less than the mandated space per bed, with measurements ranging from 72.87 to 79.75 square feet per bed. Despite this deficiency, there was sufficient space for the provision of care, and no heavy equipment was present that could interfere with residents' care. Residents had adequate personal space and privacy, and there were no complaints or negative consequences reported due to the decreased space.
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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