Casa Dorinda
Inspection history, citations, penalties and survey trends for this long-term care facility in Santa Barbara, California.
- Location
- 300 Hot Springs Road, Santa Barbara, California 93108
- CMS Provider Number
- 555023
- Inspections on file
- 18
- Latest survey
- March 6, 2026
- Citations (last 12 mo.)
- 12
Citation history
Health deficiencies cited at Casa Dorinda during CMS and state inspections, most recent first.
A resident with a history of falls and cognitive impairment was not provided adequate supervision when staff failed to activate the required bed alarm after care was provided. Despite care plan and physician orders mandating the use of a bed alarm due to high fall risk, staff could not confirm the alarm was turned on, and documentation showed the alarm check was missed for the shift. The resident was later found on the floor with a displaced right hip fracture, with no alarm or call light activated, indicating a lapse in following fall prevention protocols.
The facility did not run necessary reports to verify that PBJ data was submitted to CMS, resulting in missing RN hours and licensed nursing coverage data for June 2024. The DON was unaware of the need to run these reports, despite the facility's policy requiring verification of data submission.
The facility failed to follow food safety protocols, with mislabeled food containers lacking preparation and use-by dates, and sanitizing solutions not meeting recommended concentrations. A dietary aide and sous chef acknowledged these discrepancies, which could lead to inadequate food safety and sanitation.
A facility failed to document a resident's inappropriate behavior as required by the care plan. The resident, diagnosed with Alzheimer's and major depressive disorder, had multiple episodes recorded in the MAR, but no specific documentation was found in the progress notes. A nurse confirmed the lack of detailed notes, which could hinder intervention planning.
A facility failed to update a care plan for a resident with Alzheimer's and major depressive disorder, despite multiple episodes of inappropriate behavior. The care plan, created in August 2022, was not revised to reflect these episodes, contrary to the facility's policy requiring updates as the resident's condition changes. The Minimum Data Set Nurse confirmed the care plan was not updated during the September 2024 review, and interdisciplinary team meetings did not address the behavior.
A resident with Alzheimer's and major depressive disorder requested a psychiatric consultation, which was recommended by the attending physician. However, the consultation was not ordered or documented by the RN, leaving the resident's psychosocial needs potentially unmet.
A facility failed to monitor and assess a resident's development of foot drop, leading to reduced mobility and potential contractures. The resident was observed with flexed feet, and records showed no therapy was provided despite dependency on staff for mobility. Interviews confirmed the foot drop was new and should have been reported for timely intervention.
The facility failed to ensure proper narcotic reconciliation at shift changes, as required by policy. During a medication pass observation, it was found that the narcotic count book for November lacked signatures from both incoming and outgoing nurses on several occasions. This failure to follow procedure was confirmed by a registered nurse, highlighting a lapse in ensuring accurate narcotic counts and preventing drug diversion.
The facility failed to properly store and label medications, including Polyethylene Glycol 3350 Powder and insulin pens, which were found without open dates and included medications of discharged residents. Staff acknowledged the oversight, and no policy was available for handling medications from home or hospital.
A registered nurse failed to follow proper hand hygiene protocols while taking vital signs and administering medications. The nurse did not sanitize the vital signs machine between uses, nor did they sanitize their hands after removing gloves and before preparing medications. These actions were contrary to CDC recommendations and the facility's policies, potentially leading to cross-contamination and infection spread.
A resident sustained third-degree burns on both thighs after spilling hot coffee. The facility failed to include necessary wound measurements and documentation in the care plan to monitor healing progress. Despite the DON's claim of weekly documentation, records showed only one instance of measurement. The ADON confirmed the care plan lacked instructions for weekly documentation, contrary to facility policy.
A resident with third-degree burns on both thighs was not assessed and documented according to the facility's policy and national standards. The initial assessment was conducted, but subsequent weekly documentation was not performed as required. The DON confirmed the oversight and acknowledged the lack of ongoing assessment and documentation.
The facility failed to maintain sanitary conditions in the food and nutrition services. The high temperature dish machine did not reach the required temperatures for effective sanitization, and inaccurate temperature logs were maintained. The three-compartment sink was not used effectively, with improper wash water temperature and sanitizer concentration. Additionally, a sanitizer dispensing tube was found in a hand washing sink, violating infection control policies.
The facility failed to ensure effective oversight in kitchen sanitation, as the RD did not review monitoring logs for the high-temperature dish machine and three-compartment sink. Observations revealed that the dish machine and sink were operating below required temperatures and sanitizer levels, with inaccurate log entries. The RD and DDS/CDM acknowledged the lack of structured oversight, leading to potential foodborne illness risks for residents.
The facility failed to serve the correct portion size for regular diet orders, as a server used a 4-ounce spoon instead of the required 8-ounce portion for Shrimp and Sausage Jambalaya. This affected the nutritional intake of 20 residents on a regular diet with regular portions.
Failure to Ensure Bed Alarm Activation Results in Resident Fall and Hip Fracture
Penalty
Summary
The facility failed to follow its policy and procedure regarding fall prevention interventions for a resident with a significant history of falls and cognitive impairment. The resident, who had diagnoses including Alzheimer's disease, unspecified dementia, major depressive disorder, recurrent mild muscle weakness, gait abnormalities, and a history of falls, was assessed as high risk for falls and had a care plan and physician order requiring a bed alarm to be activated whenever in bed. Despite these interventions, the bed alarm was not activated after the resident was changed in bed during a shift change. Interviews with the DON, ADON, licensed nurses, and a CNA revealed that staff could not recall if the bed alarm was turned back on after providing care, and documentation confirmed that the required alarm check was not completed for the evening shift. The facility's policy required alarms to be tested at the start of each shift and after resident care, but this was not consistently followed. The resident was found on the floor after calling for help, with no bed alarm or call light activated, and subsequently sustained a displaced right hip fracture. Record reviews, including care plans, physician orders, and progress notes, confirmed that the bed alarm was a required intervention for this resident due to poor safety awareness and a high fall risk. The failure to ensure the bed alarm was activated directly resulted in the resident being able to exit the bed unassisted, leading to a fall and serious injury. Staff interviews and documentation indicated lapses in following established protocols for alarm use and shift checks.
Failure to Verify PBJ Data Submission to CMS
Penalty
Summary
The facility failed to run necessary reports to ensure that payroll-based journal (PBJ) data was accurately submitted to the Centers for Medicare and Medicaid Services (CMS). Specifically, the facility did not generate reports 1700D (employee report), 1702D (individual daily staffing report), and 1702S (staffing summary report) to verify that the data was received by CMS. As a result, CMS did not receive registered nurse (RN) hours and licensed nursing coverage data for June 2024. During an interview, the Director of Nursing (DON) acknowledged responsibility for sending staffing information to CMS but was unaware of the need to run these reports to confirm data submission. The facility's policy and procedure, dated January 15, 2024, indicated that after data submission, the DON should generate a report from CASPER to verify submission, which was not done.
Food Safety and Sanitization Deficiencies
Penalty
Summary
The facility failed to adhere to food safety requirements, as evidenced by the improper labeling of prepared food containers and inadequate sanitizing solutions. During an inspection, three stainless steel containers in the kitchen freezer were found mislabeled with a future date, lacking both a preparation date and a use-by date. This discrepancy was acknowledged by a dietary aide, who attributed the error to a possible oversight by weekend staff. The facility's policy mandates that all prepared foods not in their original containers must be covered, labeled, and dated, with leftovers used within 72 hours or discarded. Additionally, the facility did not maintain the recommended concentration of sanitizing solutions used for cleaning kitchen surfaces. Testing of three red buckets revealed varying concentrations, with one bucket below the recommended range. The sous chef suggested that the solution might have been diluted or not changed as required, leading to inadequate disinfection. The facility's policy requires regular testing of sanitizing solutions to ensure they maintain the proper strength for food contact surfaces, with a recommended concentration between 200 ppm and 400 ppm.
Failure to Document Resident's Inappropriate Behavior
Penalty
Summary
The facility failed to ensure that specific inappropriate behaviors of a resident were documented as required by the care plan. The care plan for the resident, who had diagnoses including Alzheimer's disease with late onset and major depressive disorder, required monitoring and documentation of inappropriate behavior episodes towards staff members three times a day. However, a review of the resident's progress notes from January 1, 2024, to December 4, 2024, revealed that there was no specific documentation of these behaviors, despite multiple episodes being recorded in the Medication Administration Record (MAR) during the same period. During an interview, a registered nurse acknowledged the resident had incidents of inappropriate behavior on multiple occasions throughout the year but confirmed that there were no progress notes detailing the specifics of these episodes. This lack of documentation as instructed in the care plan had the potential to inadequately identify what behavior needed to be monitored and hindered the planning of interventions to address the resident's inappropriate behavior.
Failure to Update Care Plan for Resident's Inappropriate Behavior
Penalty
Summary
The facility failed to update the care plan for a resident with inappropriate behavior, as required by their policy and procedure. The resident, who has Alzheimer's disease with late onset and major depressive disorder, experienced multiple episodes of inappropriate behavior over several months. Despite these occurrences, the care plan, which was initially created in August 2022, was not revised to reflect these episodes or to implement effective interventions. The facility's policy mandates that care plans be revised as changes in the resident's condition dictate and reviewed at least quarterly, but this was not adhered to in this case. The Minimum Data Set Nurse confirmed that the care plan for monitoring the resident's inappropriate behavior was not updated during the quarterly review in September 2024. Additionally, the interdisciplinary team meetings did not address the monitoring of the resident's behavior, as noted in the meeting reports from October 2023 to October 2024. This oversight in updating the care plan and addressing the resident's behavior in team meetings highlights a lapse in the facility's adherence to its own policies and procedures.
Failure to Implement Psychiatric Consultation for Resident
Penalty
Summary
The facility failed to ensure that a doctor's recommendation for a psychiatric consultation was followed for a resident diagnosed with Alzheimer's disease and major depressive disorder. The resident had expressed feelings of depression and requested to see a psychiatrist, which was noted in the social services notes. The attending physician also documented the need for a psychiatric consultation in the physician notes. However, there was no evidence in the medical records that the resident was seen by a psychiatrist. During an interview, a registered nurse and the Director of Nursing acknowledged the resident's request for a psychiatric consultation. The registered nurse admitted to forgetting to order the psychiatric consultation and failing to document the resident's request. This oversight resulted in the resident's psychosocial health care needs potentially being unattended, as there were no progress notes or consultation notes indicating that the psychiatric consultation was carried out.
Failure to Monitor and Assess Resident's Foot Drop
Penalty
Summary
The facility failed to monitor and assess the development of foot drop in one of the residents, leading to a deficiency in maintaining or improving the resident's range of motion. During an observation, the resident was found in a supine position with their feet on a pillow, and the toes of both feet were flexed outward instead of upward. A review of the resident's physical therapy evaluation from February 2022 indicated that the resident's ankle dorsiflexion and plantar flexion were within normal limits at that time, with no extension or flexed feet noted. However, the resident's annual MDS from April 2024 and a subsequent quarterly MDS indicated that the resident did not receive any therapies from the rehabilitation department, despite being dependent on staff for mobility. Interviews with the assistant director of nursing and the director of rehabilitation confirmed the presence of the foot drop and acknowledged that it was a new development. The assistant director of nursing suggested that the foot drop might be due to the resident's positioning and mentioned the need to contact the doctor for a rehabilitation evaluation. The director of rehabilitation agreed with the findings and noted that the foot drop should have been reported for assessment and timely intervention. This lack of monitoring and intervention resulted in reduced mobility of the resident's foot, with the potential for contractures.
Failure in Narcotic Reconciliation Count
Penalty
Summary
The facility failed to ensure that the change of shift narcotics reconciliation count was properly conducted and documented by two licensed nurses, as required by their policy. During a medication pass observation, it was noted that the narcotic count book for November was missing several signatures from both incoming and outgoing licensed nurses. Specifically, on multiple occasions, nurses failed to sign at the start and end of their shifts, which is a critical step in ensuring the accuracy of the narcotic count and preventing drug diversion. The facility's policy, revised in October 2023, mandates that narcotics be counted daily at shift change by two licensed nurses, with both the incoming and outgoing nurses required to sign the narcotic count log. However, the record review revealed that on several dates in November, this procedure was not followed, as evidenced by the missing signatures. During an interview, a registered nurse confirmed the absence of signatures in the narcotic count book, acknowledging the oversight.
Improper Storage and Labeling of Medications
Penalty
Summary
The facility failed to ensure that biologicals and medications were properly stored and labeled, as observed during a medication pass on the East Wing, first floor. Five plastic containers of Polyethylene Glycol 3350 Powder for Solution, a laxative, were found with room numbers labeled on the caps but missing open dates. Additionally, one of these containers belonged to a discharged resident and had not been removed from the medication cart. The registered nurse acknowledged the oversight, noting the absence of open dates and the presence of the discharged resident's medication. Further observations at the first-floor nursing station medication room revealed three used insulin pens belonging to a discharged resident stored in the medication refrigerator. These insulin pens, including NovoLOG Flex Pen, Insulin Glargine (LANTUS), and insulin aspart (NovoLOG), were used but lacked open dates. The licensed vocational nurse could not explain why these medications remained in the refrigerator. The facility's policy required staff to label medications with open dates, but no policy was available for handling medications brought from home or hospital or for discontinued medications.
Failure to Follow Hand Hygiene Protocols
Penalty
Summary
The facility failed to ensure proper hand hygiene practices were followed by a registered nurse (RN 2) during the process of taking vital signs and administering medications. On December 3, 2024, RN 2 was observed using a hand sanitizer and donning surgical gloves before entering a resident's room with a vital sign machine. However, RN 2 did not sanitize the vital signs machine, which had been used on another resident, before or after taking the resident's vital signs. After completing the task, RN 2 removed the gloves but did not sanitize his hands before preparing medications for the resident. RN 2 continued to neglect hand hygiene by failing to sanitize hands before re-entering the resident's room to administer medications and after exiting the room. This was observed again later the same day when RN 2 did not perform hand hygiene before entering and after exiting the resident's room to administer medications. These actions were in violation of both the CDC's hand hygiene recommendations and the facility's own policies, which require hand hygiene before and after direct resident contact and after glove removal.
Failure to Document and Measure Burn Wounds Weekly
Penalty
Summary
The facility failed to ensure that a comprehensive care plan for a resident's burn wound included necessary wound measurements and documentation to monitor healing progress. The incident occurred when a Licensed Vocational Nurse (LVN) accidentally caused a resident to spill hot coffee on their lap, resulting in third-degree burns on both thighs. Although the Director of Nursing (DON) reported that weekly measurements and documentation were performed, the medical record showed that the burn wounds were only measured and documented once, the day after the incident. The Assistant Director of Nursing (ADON) confirmed that the care plan did not specify the need for weekly measurements and documentation, which was contrary to the facility's policy requiring weekly documentation of skin conditions until resolved.
Failure to Document and Assess Burn Wounds
Penalty
Summary
The facility failed to adhere to professional standards of quality in the assessment and documentation of a resident's burn wounds. The resident sustained third-degree burns on both thighs, which were initially assessed and documented the day after the injury. However, the facility did not continue to assess and document the wounds as required by their policy and national standards. The facility's policy mandates weekly documentation of wounds expected to take 14 days or longer to resolve, but this was not followed for the resident's burn wounds. During an interview, the Director of Nursing (DON) confirmed that the resident's burn wounds were only documented once and acknowledged the lack of ongoing assessment and documentation. The DON explained that their electronic health record system includes a template for documenting skin integrity observations, which was not utilized for this resident. The failure to initiate and maintain the required weekly observation and documentation for the resident's burn wounds led to the deficiency identified in the report.
Sanitary Conditions Not Maintained in Food and Nutrition Services
Penalty
Summary
The facility failed to maintain sanitary conditions in the food and nutrition services, as evidenced by multiple deficiencies observed during a survey. Firstly, the high temperature dish machine was not reaching the proper wash, rinse, and final rinse temperatures required to effectively sanitize dishes according to the manufacturer's guidelines. Despite the dish machine's final rinse temperature needing to reach 180 degrees Fahrenheit, it was observed to be significantly lower. The issue was compounded by inaccurate temperature logs and a lack of reporting by the dishwashing staff to supervisory personnel. The Director of Dining Services confirmed that the dish machine was not meeting the required temperatures and required a heating element replacement after an external service assessment. The facility's policy and procedure for high-temperature machine ware washing were not adhered to, leading to potential cross-contamination and foodborne illness risks for residents on oral diets. The FDA Food Code Annex also emphasizes the importance of adhering to the manufacturer's guidelines to ensure effective sanitization, which was not followed in this case. Secondly, the three-compartment sink used for washing pots and pans was not implemented effectively to properly wash and sanitize foodservice equipment. Observations revealed that large food storage bins and lids were only partially immersed in the sanitizing solution, leaving parts of the equipment unsanitized. The wash water temperature in the first compartment was also found to be below the required 110 degrees Fahrenheit, and the sanitizer concentration in the third compartment was below the necessary 200 parts per million. The facility's policy and procedure for using the three-compartment sink were not followed, leading to improper sanitization of foodservice equipment. Lastly, a tube used to dispense sanitizer was found in the hand washing sink, which is designated solely for hand washing. This was confirmed by both the lead diet aide and the Executive Chef, who acknowledged that the tube should not have been in the hand washing sink due to infection control concerns. The facility's hand washing policy clearly states that hand sinks should only be used for hand washing and not for any other purposes. These deficiencies collectively indicate a failure to maintain sanitary conditions in the food and nutrition services, posing a risk of cross-contamination and foodborne illness to the residents.
Lack of Effective Oversight in Kitchen Sanitation
Penalty
Summary
The facility failed to ensure that the director of dining services received sufficient consultations from the facility's Registered Dietitian (RD) to oversee the sanitation of the main kitchen. Specifically, the RD did not review the monitoring logs for the high-temperature dish machine, which resulted in unaddressed sanitation concerns. During an observation, the dish machine was found to be operating below the required temperatures for sanitization, and the monitoring logs contained inaccurate entries. The Sous Chef confirmed that the dish machine was not meeting the manufacturer's guidelines for wash and rinse cycles, and the RD admitted there was no structured schedule for oversight of kitchen sanitation. Additionally, the RD did not review the monitoring log for the main kitchen's three-compartment sink to ensure accurate guidance was available and followed. During an observation, the wash water temperature and sanitizer concentration were found to be below the required levels. The facility's policy and procedures for the three-compartment sink were not being adhered to, and the monitoring log did not provide proper direction to the dishwashing staff. The RD confirmed that there was no formal schedule for kitchen audits and that he was not responsible for providing the monitoring log for the three-compartment sink. The facility's policies and job descriptions for the Director of Dining Services and the Dietitian/Nutritional Services Manager indicated responsibilities for ensuring sanitation and safety standards. However, the lack of effective oversight and routine inspections led to deficiencies in the sanitation of the main kitchen, potentially causing foodborne illness to the residents. The RD and DDS/CDM acknowledged the absence of effective oversight and monitoring related to kitchen sanitation.
Failure to Serve Correct Portion Sizes for Regular Diet Orders
Penalty
Summary
The facility failed to ensure the correct portion size for regular diet orders was served according to the planned menu. During an observation, a server was seen using a 4-ounce serving spoon to plate the main entree of Shrimp and Sausage Jambalaya for residents on a regular diet with regular portion sizes. The Registered Dietitian (RD) pointed out that the planned menu specified an 8-ounce portion for this dish. Despite this, the server continued to use the 4-ounce spoon, serving only one scoop instead of the required two scoops to meet the 8-ounce portion size. This discrepancy was noted after three meal delivery carts had already been distributed to residents, potentially affecting the nutritional intake of 20 residents on a regular diet with regular portions. The facility's policy and procedure on portion control and menu planning were reviewed and indicated that specific portion sizes should be listed on the menu and that food should be served with standard-sized utensils to ensure accurate portion sizes. The policy also emphasized that portions that are too small could result in residents not receiving the necessary nutrients. The RD verified that the facility's Resident Diet Information list indicated 20 residents on a regular diet with regular portions, and the planned lunch menu specified an 8-ounce portion for the Shrimp and Sausage Jambalaya. The facility's job description for the Dietitian/Nutritional Services Manager also included monitoring portion control to ensure food is prepared and presented acceptably.
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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