Channel Islands Post Acute
Inspection history, citations, penalties and survey trends for this long-term care facility in Santa Barbara, California.
- Location
- 3880 Via Lucero, Santa Barbara, California 93110
- CMS Provider Number
- 555875
- Inspections on file
- 31
- Latest survey
- August 22, 2025
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Channel Islands Post Acute during CMS and state inspections, most recent first.
The facility did not consistently provide the required nursing staff hours, with several days falling below mandated DHPPD and CNA minimums. During this period, multiple residents experienced falls and two were transferred to the hospital. The DON and DSD confirmed staffing shortages, which were sometimes addressed by using staff from a sister facility or administrative staff with CNA licenses.
Staff failed to promptly communicate a resident's significant change in condition, including increased fatigue, confusion, and decreased food intake, to the appropriate licensed nurse and physician. Despite CNAs observing and attempting to report these changes, inconsistencies and incomplete communication led to a delay in treatment, and the resident was ultimately sent to the hospital after further decline.
A resident with anxiety disorders and altered mental status did not have their dentures, delivered by a dental provider, documented in the inventory records, nor was their loss recorded in the theft and loss log. Staff interviews and record reviews confirmed that the inventory list was not updated and required procedures for tracking personal items were not followed, despite facility policies mandating such documentation.
Surveyors found expired medications and products available for use, improper medication administration by nursing staff, and inconsistent medication re-ordering processes. Multiple residents did not receive their prescribed medications due to pharmacy delivery delays and missing cycle medications. Additionally, the contents of an IV emergency kit did not match its label, with staff acknowledging these discrepancies and failures to follow facility policy.
A resident with a history of suicidal ideations, alcohol abuse, and opioid use was found self-administering multiple supplements without a documented assessment, care plan, or interdisciplinary team notes, contrary to facility policy requiring evaluation and documentation for self-administration of medications.
Two residents were found to be living in rooms with environmental deficiencies, including a loose floor tile creating a raised gap, cobwebs on the ceiling, wall scratches with exposed underlayer, and missing bathroom tiles. Maintenance and housekeeping logs showed no entries for these issues, and staff confirmed the problems had not been addressed as required by facility policy.
Three residents were inaccurately assessed in the MDS, with one receiving insulin injections, another taking an anticoagulant, and a third using tobacco, but these were not properly documented in their assessments. Clinical records, medication administration, and direct observations confirmed the use of these treatments and behaviors, while MDS entries failed to reflect the actual care and status of the residents.
The facility did not complete required PASRR Level I and Level II screenings for two residents with mental health diagnoses. One resident was admitted with schizophrenia and bipolar disorder but had no PASRR Level I screening on file, while another resident with psychosis had a positive Level I screening for serious mental illness but no Level II evaluation was completed. The DON confirmed these omissions during interviews.
Medications requiring refrigeration, such as PPD, insulin, and hepatitis vials, were found stored in a medication refrigerator at 32°F, which is below the facility's policy range of 36°F to 46°F. An RN confirmed the out-of-range temperature and that the medications were not stored as required.
Dietary staff did not label or date several food items in storage, including stuffing packets, bread buns, and hamburger patties, as required by facility policy. The Assistant Administrator confirmed these deficiencies during an inspection.
A resident with multiple medical conditions was discharged home with the expectation of receiving home health services, but the facility did not confirm that these services were in place before discharge. The resident did not receive the needed care, contacted the facility for assistance, and reported a fall after discharge. Facility staff did not follow up with the home health agency or the resident to ensure continuity of care, and authorization from the VA was still pending.
A resident's personal belongings, including a cell phone and reading glasses, were mistakenly relocated to another room due to staff miscommunication about the resident's COVID-19 isolation status. The resident, who has COPD, CHF, and pneumonia, experienced agitation and accused staff of taking his phone. The items were later found and returned.
A facility failed to implement a comprehensive care plan for a resident with an ADL self-care deficit, despite the resident's diagnoses of COPD, CHF, and pneumonia. The care plan did not adequately address the resident's need for assistance with tasks like toileting, as required by the facility's policy, placing the resident at risk of unmet care needs.
A resident in a LTC facility, requiring assistance with ADLs due to conditions like COPD and CHF, was left waiting for over an hour for a urinal, resulting in urination on himself. The resident's care plan highlighted the need for staff assistance due to muscle weakness and a deep tissue injury. Other residents reported similar delays in staff response, indicating a broader issue with call light wait times.
The facility failed to ensure that residents with a positive Level I PASRR received a Level II evaluation. Two residents with significant mental health histories did not have their cases reopened for Level II evaluations as directed by the Department of Health Care Services. The DON was unaware of the need to resubmit Level I PASRRs after the initial cases were closed.
The facility failed to ensure a safe environment by leaving unsecured medications in resident rooms without proper assessment or authorization for self-administration. This affected two residents, one with diabetes and another with spinal stenosis, who had medications left at their bedside without staff supervision.
Failure to Maintain Sufficient Nursing Staff Levels
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of all residents, as evidenced by multiple days where the Direct Care Service Hours Per Patient Day (DHPPD) and Certified Nursing Assistant (CNA) hours fell below the required minimums. Record review showed that on several dates, the actual DHPPD and CNA hours did not meet the 3.5 and 2.4 minimums, respectively, as mandated by state guidelines. The Director of Nursing (DON) validated these findings during a concurrent interview and record review. The Director of Staff Development (DSD) confirmed that the facility has implemented CNA classes and occasionally receives staffing support from a sister facility or administrative staff who are licensed CNAs, but last-minute call-ins due to family emergencies have contributed to staffing shortages. A review of facility fall logs during the period of insufficient staffing revealed multiple resident falls and two hospital transfers. Specifically, one resident fell on one date, two residents fell on another, and two residents fell on a subsequent date, with two hospital transfers occurring during the same timeframe. There were no reported missed or medication errors within the period reviewed. The facility's policy on adequate staffing states that sufficient staff must be maintained on each shift to meet resident needs, but the documented staffing levels did not consistently meet this standard.
Failure to Communicate Change in Condition Resulting in Delay of Treatment
Penalty
Summary
Facility staff failed to ensure prompt communication of a significant change in condition for one resident, resulting in a delay in treatment. The resident, who had a history of alcohol cirrhosis with ascites, hepatic encephalopathy, pleural effusion, heart failure, and generalized swelling, experienced increasing fatigue, confusion, and difficulty eating. Certified Nursing Assistants (CNAs) observed these changes, including the resident becoming more tired, needing assistance with meals, eating less, and displaying confusion and altered speech. Although CNAs reported some changes to licensed nurses, there were inconsistencies in communication, with one CNA later admitting to the Assistant Administrator that she had not reported the change in condition to the nurse as initially claimed. Licensed nurses did not receive complete or timely information about the resident's altered mental status and physical decline. As a result, the resident's significant change in condition, including weakness, dysphagia, and altered level of consciousness with abnormal vital signs, was not promptly communicated to the physician. The delay in recognizing and reporting these changes led to a delay in treatment, and the resident was eventually sent to the hospital after further decline was noted. Review of facility policy confirmed that staff were required to report such changes to licensed nurses, but this procedure was not followed.
Failure to Document and Track Resident's Dentures
Penalty
Summary
The facility failed to ensure that a resident's right to retain and use personal possessions was honored when a set of dentures delivered to the resident was neither documented in the inventory records nor subsequently located. The resident, who had diagnoses including anxiety disorders and altered mental status, was admitted with a process in place for documenting personal belongings. However, review of the resident's records showed that the dentures, delivered by a dental provider, were not entered into the inventory of personal effects, and there was no record of their loss in the theft and loss log. Multiple staff interviews confirmed that the inventory list had not been updated since admission, and the required procedures for documenting and tracking personal items were not followed. Observations of the resident revealed a sunken facial appearance, and staff interviews indicated that packages and personal items are typically logged, labeled, and added to the inventory list. Despite these procedures, the dentures were not accounted for, and staff responsible for maintaining these records were unaware of the missing item. Review of facility policies confirmed that all personal items, especially those affecting health and safety, should be documented and tracked, but these policies were not adhered to in this case.
Expired Medications, Missed Doses, and Medication Management Failures
Penalty
Summary
The facility failed to adhere to its pharmaceutical services policies in several key areas. Surveyors observed that expired medications and products, including a nutritional shake, sodium chloride, acetic acid, estradiol cream, and an inhaler, were available for resident use. Nursing staff acknowledged the presence of these expired or improperly stored items and confirmed that they should have been discarded according to facility policy. Additionally, a nurse administered more eye drops than ordered by the physician to a resident, contrary to the documented medical order and facility procedures for medication administration. The facility did not maintain a consistent medication re-ordering process, as evidenced by multiple entries in the re-ordered medication binder showing that numerous residents were either out of medications or had only a few doses left. Nursing staff stated that medications were supposed to be ordered five days in advance, but this was not consistently done. Furthermore, the facility did not ensure timely and consistent availability of resident medications. Several residents did not receive their prescribed medications due to delays in pharmacy delivery or missing cycle medications, and staff interviews confirmed that this was a recurring issue. The facility's agreement with the pharmacy for monthly cycle medication refills was not being fulfilled as planned. Surveyors also found discrepancies in the contents of the intravenous emergency kit, where two bags of sodium chloride were present but not listed on the kit's label. Nursing staff acknowledged that the kit contents did not match the label and stated that the pharmacy was responsible for ensuring accuracy. These failures collectively had the potential to negatively impact resident care and safety, as the facility did not follow its own policies for medication storage, administration, re-ordering, and emergency kit management.
Failure to Assess and Document Self-Administration of Medications
Penalty
Summary
A resident was found with multiple self-administered medications, including Primal Harvest Hair Growth Complex, Immuneti Advanced Immune Defense, and Primal Multivitamins, at their bedside. The resident reported self-administering these supplements since admission. The resident's medical record indicated a history of suicidal ideations, alcohol abuse, and opioid use. No self-administration assessment was completed for the resident, and there was no documentation of the resident's desire to self-administer medications. Additionally, there were no interdisciplinary team notes or care plan entries regarding self-administration, despite facility policy requiring assessment, documentation, and care planning for residents who wish to self-administer medications. Nursing staff and facility leadership confirmed the absence of required documentation and assessments.
Failure to Maintain Safe, Clean, and Homelike Resident Rooms
Penalty
Summary
The facility failed to provide a safe, clean, and homelike environment for two residents. In one instance, a resident's room was observed to have a loose floor tile that was partially lifted, creating a raised gap. Review of the maintenance logbook for the relevant section of the facility showed no requests or entries for floor tile repairs in this resident's room or bathroom. During an interview and observation with the Maintenance Supervisor, the issue was confirmed, and it was acknowledged that the problem existed. In another case, a different resident's room was found to have cobwebs hanging from the ceiling above the bed, visible scratches with paint coming off the wall behind the headboard, and missing tiles around the bathtub in the bathroom, exposing residue on the wall. The maintenance logbook for this section also showed no entries for maintenance work in this room. The Maintenance Supervisor confirmed the presence of these issues and stated that repairs had not yet been completed. The Laundry and Housekeeping Supervisor and District Manager of Laundry and Housekeeping Services acknowledged that the room had been overlooked. Facility policy requires housekeeping and maintenance services to maintain a sanitary, orderly, and comfortable environment, and staff are expected to report findings directly or add them to the maintenance logbook.
Inaccurate MDS Assessments for Injections, Anticoagulant, and Tobacco Use
Penalty
Summary
The facility failed to accurately assess and document the clinical status of three residents in the Minimum Data Set (MDS) assessments. One resident with a diagnosis of Type 2 Diabetes was prescribed and administered insulin injections as documented in the Medication Administration Record and physician's notes, but the MDS assessment incorrectly indicated that the resident did not receive any injections during the observation period. Another resident was prescribed and received Apixaban, an anticoagulant, as confirmed by physician orders and the Medication Administration Record, yet the MDS assessment inaccurately recorded that the resident did not receive any anticoagulant medication during the look-back period. In both cases, the MDS coordinator acknowledged the discrepancies between the clinical records and the MDS entries during interviews and record reviews. A third resident, who was documented as a smoker in the physician's notes and a smoking evaluation, and was observed both with a vaping device and smoking cigarettes on facility grounds, was incorrectly assessed in the MDS as not using any form of tobacco. The MDS coordinator confirmed the inaccuracy after reviewing the resident's records and observations. These failures to accurately assess and document the residents' clinical statuses in the MDS have the potential to result in care needs not being properly identified or addressed.
Failure to Complete Required PASRR Screenings for Residents with Mental Health Diagnoses
Penalty
Summary
The facility failed to ensure that required PASRR (Preadmission Screening and Resident Review) Level I and Level II screenings were completed for two residents with mental health diagnoses. For one resident admitted with diagnoses including unspecified schizophrenia and bipolar disorder, there was no evidence of a PASRR Level I screening in the medical record from the time of admission through the date of review. The Director of Nursing confirmed that the PASRR Level I screening was missed for this resident. For another resident admitted with a diagnosis of unspecified psychosis, the pre-admission PASRR Level I screening indicated a positive result for serious mental illness, which required a Level II mental health evaluation. However, there was no documentation of a Level II PASRR evaluation in the medical record from the time of the positive Level I screening through the date of review. The Director of Nursing confirmed that the PASRR Level II evaluation was not completed for this resident. The facility's policy requires Level I screenings for all admissions and Level II evaluations when indicated, but these procedures were not followed in these cases.
Improper Refrigeration of Medications
Penalty
Summary
Surveyors observed that medications requiring refrigeration, including Tuberculin (PPD), insulin, and hepatitis vials, were stored in a medication refrigerator with a temperature reading of 32°F, which is below the facility's policy requirement of 36°F to 46°F (2°C to 8°C). During the observation, a registered nurse confirmed the temperature was outside the acceptable range and acknowledged that the medications were not stored according to policy. The facility's policy specifies that medications needing refrigeration must be kept within the specified temperature range and monitored with a thermometer, with maintenance notified if temperatures are out of range. The improper storage temperature was directly observed and confirmed by staff during the survey.
Failure to Label and Date Stored Food Items
Penalty
Summary
The facility failed to ensure that dietary staff properly labelled and dated food items in storage, as observed during a kitchen inspection. Specifically, three packets of traditional stuffing were found with only a date received and no indication of the date opened or expiry date. Additionally, an open bag of bread buns and a bag containing four hamburger patties were found in the freezer section without any date markings or expiry dates. The Assistant Administrator acknowledged these findings during the observation. A review of the facility's policy on labeling and dating foods indicated that staff are responsible for marking the date at the time of processing and/or storage, and that a use-by date must be provided for all food items.
Failure to Ensure Home Health Services in Place Prior to Discharge
Penalty
Summary
The facility failed to ensure adequate discharge planning for a resident who was discharged home with the expectation of receiving home health services. The resident, who had a history of a right acetabulum and pubis fracture, Type 2 Diabetes Mellitus, and long-term insulin use, was discharged with arrangements for physical therapy, occupational therapy, and nursing services through a home health agency (HHA). Although the facility's social services staff faxed referral documents to the HHA, there was no evidence that the facility confirmed receipt of the referral or that services were in place prior to discharge. After discharge, the resident contacted the facility to report that he had not received the expected caregiver services and had already experienced a fall at home. Interviews with facility staff revealed that the social services department did not typically follow up with HHAs or discharged residents unless notified by the HHA of an issue. The HHA reported they had not seen the resident because they were awaiting VA authorization and had been unable to contact the resident. Documentation showed that the VA had not processed the authorization request in a timely manner, and the HHA had not received the necessary information to proceed. The facility's policy required social services to ensure continuity of care during discharge, but in this case, the lack of confirmation and follow-up resulted in the resident not receiving needed home health services.
Resident's Personal Belongings Misplaced Due to Staff Miscommunication
Penalty
Summary
The facility failed to honor a resident's right to retain and use personal possessions, resulting in a deficiency. This incident involved a resident who was admitted with chronic obstructive pulmonary disease, congestive heart failure, and pneumonia. The resident's personal belongings, including a cell phone, charger, and reading glasses, were mistakenly relocated to another room. This occurred due to a miscommunication among staff regarding the resident's COVID-19 isolation status. The resident experienced agitation and made verbal accusations towards the staff, claiming that his phone was taken away. A licensed nurse confirmed the resident's complaint and explained that the certified nursing assistant had transferred the resident's belongings to another room due to the misunderstanding about the resident's isolation status. The items were eventually found and returned to the resident. The facility's policy on resident rights emphasizes the importance of allowing residents to keep and use personal possessions unless it infringes on the rights or safety of others.
Failure to Implement Comprehensive Care Plan for Resident with ADL Deficit
Penalty
Summary
The facility failed to develop and implement a comprehensive person-focused care plan for a resident with an activities of daily living (ADL) self-care deficit. This deficiency was identified during a review of the resident's clinical record, which revealed that the resident was admitted with diagnoses including Chronic Obstructive Pulmonary Disease (COPD), Congestive Heart Failure (CHF), and pneumonia. The comprehensive care plan dated 6/10/24 indicated that the resident had an ADL self-care deficit related to muscle weakness and unsteady gait, requiring staff assistance for various tasks such as washing hands, adjusting clothing, and using the toilet. However, the facility's policy and procedure for care planning, revised in 11/2023, mandates that the interdisciplinary team (IDT) implement a comprehensive person-centered care plan with measurable objectives and timeframes to meet the resident's needs. The review of the resident's admission Minimum Data Sheet (MDS) dated 6/16/24 showed that the resident had moderate cognitive impairment and required assistance for ADLs, but the care plan did not adequately address these needs. This oversight placed the resident at risk of not having their care needs met due to the lack of a proper plan.
Delayed Assistance with Toileting Leads to Resident Incident
Penalty
Summary
The facility failed to provide necessary assistance to a resident, identified as Resident 1, who required help with activities of daily living, specifically toileting. Despite the resident's request for a urinal, staff did not respond for over an hour, resulting in the resident urinating on himself. This incident was documented in a complaint report, where the resident expressed concerns about staff not listening to his needs, including issues with his mattress, toothbrush, and television, in addition to the delayed response for toileting assistance. Resident 1 had been admitted for post-acute care therapy with multiple diagnoses, including COPD, CHF, pneumonia, muscle weakness, and unsteadiness on feet, necessitating assistance with personal care. The resident's care plan indicated a need for staff assistance with various ADLs due to an ADL self-care deficit and a deep tissue injury requiring protection from excessive moisture. Interviews with other residents revealed that call light response times were often delayed, with one resident stating an average wait time of 15 minutes or more, and another reporting waits of 20 minutes or longer for assistance, including pain medication.
Failure to Ensure Level II PASRR Evaluations
Penalty
Summary
The facility failed to ensure that residents with a positive Level I Preadmission Screening and Resident Review (PASRR) received a Level II evaluation. Specifically, after the cases for two residents were closed, the facility did not resubmit Level I PASRRs to reopen the cases as directed by the Department of Health Care Services. This failure was identified during interviews, record reviews, and policy reviews conducted by surveyors. Resident #80, who had a medical history including bipolar disorder, major depressive disorder, anxiety disorder, PTSD, and paranoid schizophrenia, was readmitted to the facility. Despite having a positive Level I screening, the Level II evaluation was not scheduled due to the resident being isolated as a health or safety precaution. The Director of Nursing (DON) was unaware that a new Level I should have been completed to reopen the case after the Level II evaluation was closed. Similarly, Resident #5, who had a medical history including bipolar disorder, major depressive disorder, anxiety disorder, hydrocephalus, traumatic brain injury, and schizoaffective disorder, also had a positive Level I screening. The Level II evaluation was not scheduled because the resident was unable to participate. The DON did not review the reason for the evaluation's non-completion and was unaware that a new Level I should have been completed to reopen the case.
Unsecured Medications in Resident Rooms
Penalty
Summary
The facility failed to ensure the residents' environment remained as free of accident hazards as possible when unsecured medications were observed in residents' rooms without staff present. This deficiency affected Resident #33, who had a medical history including type two diabetes mellitus and gastro-esophageal reflux disease, and Resident #65, who had a medical history including spinal stenosis and depression. Both residents had medications left unsecured in their rooms without proper assessment or authorization to self-administer their medications. Resident #33 was observed with two medications on their bedside table, which they stated were for their stomach and diabetes. The nurse had left the medications in the room, and the resident indicated they would take them when ready. The nurse confirmed that medications should not be left at the bedside and admitted not knowing if the resident had been assessed to self-administer. Further interviews revealed that the nurse did not stay with the resident to ensure the medications were taken, contrary to facility policy. Resident #65 was found with a bottle of Osteo-Biflex on their bedside table, which was not included in their medical orders. The resident stated they had been taking the supplement since admission and had informed their physician, who approved its use. However, there was no documentation or assessment for self-administration. The DON and Administrator confirmed that medications should be securely stored and inaccessible to residents unless they had been assessed and authorized to self-administer, which was not the case for Resident #65.
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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