Citrus Heights Health Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Covina, California.
- Location
- 161 S. Reeder Ave, Covina, California 91724
- CMS Provider Number
- 555932
- Inspections on file
- 6
- Latest survey
- August 6, 2025
- Citations (last 12 mo.)
- 21
Citation history
Health deficiencies cited at Citrus Heights Health Center during CMS and state inspections, most recent first.
A deficiency was cited when a resident's right to request, refuse, or discontinue treatment, participate in or refuse experimental research, and formulate an advance directive was not upheld by the facility.
Three residents did not receive appropriate care due to failures in monitoring for bleeding while on anticoagulant therapy, lack of adherence to hospice physician orders and coordination, and insufficient evaluation and education regarding diabetes management prior to discharge. These deficiencies included missing documentation, unclear responsibilities between facility and hospice staff, and inadequate discharge planning and teaching.
Surveyors found five cups of orange-colored frozen food in the kitchen freezer that were not labeled or dated, and the Dietary Supervisor could not identify the contents or preparation date. Facility policy requires all stored food items to be labeled and dated.
The facility did not submit required direct care staffing data for a quarter through the PBJ system due to a transition in the controller position and lack of a submitter ID for the new controller, resulting in noncompliance with CMS reporting requirements.
A resident admitted with multiple medical conditions had their initial comprehensive MDS assessment completed, but the facility failed to submit the assessment to CMS within the required 14-day timeframe. Staff interviews and record reviews confirmed the late submission, which did not comply with federal requirements for timely MDS data transmission.
A resident with schizophrenia, bipolar disorder, and major depression was admitted and receiving psychotropic medication, but the facility failed to complete the required PASARR screening before or after admission. Review of records and staff interviews confirmed that only an outdated PASARR was on file, and no current screening was conducted as mandated by facility policy.
A resident with a PICC line in the left upper arm had blood drawn by venipuncture from the same arm, despite facility policy and national guidelines advising against this practice. The laboratory staff did not communicate with nursing staff or receive reminders to avoid the arm with the PICC line, leading to a deficiency in following professional standards of nursing practice.
A resident who was fully dependent on staff for self-care, nonverbal, and receiving enteral feeding was observed with dry, chapped, and cracked lips, indicating inadequate oral hygiene. Staff interviews revealed that oral care was not consistently provided because the resident did not eat orally, despite facility policy requiring assistance with ADLs and maintenance of personal and oral hygiene for all dependent residents.
A resident with diabetes and end stage renal disease was discharged home without prior confirmation that Home Health nursing services for diabetes management were arranged, as the Social Services Director did not confirm with the agency before discharge, resulting in a lapse in continuity of care.
A facility failed to identify a potential chemical restraint for a resident by having a physician order for Ativan if the resident attempted to get out of bed unassisted. The resident had multiple diagnoses, including muscle weakness and cerebral infarction, and was dependent on staff for care. The order did not specify a medical symptom that the medication could relieve, potentially restricting the resident's movement for staff convenience. The facility's policy defined chemical restraint as any drug used for discipline or staff convenience, not required to treat medical symptoms.
A facility failed to create a comprehensive care plan for a resident with limited range of motion (ROM) in both lower extremities, despite the resident's dependence on all activities of daily living and diagnoses of dementia and Alzheimer's disease. The lack of a care plan led to a delay in implementing necessary ROM exercises and interventions, which were only started months after admission. This oversight was contrary to the facility's policies requiring a person-centered care plan with measurable objectives.
A facility failed to prevent a decline in ROM for a resident with dementia and Alzheimer's, as no joint mobility assessment was conducted upon admission. The resident experienced a 26-50% loss of ROM in the knees, causing discomfort. Delays in PT evaluation due to communication issues with hospice and lack of ROM exercises until months after admission contributed to the deficiency.
A resident with dementia and Alzheimer's was prescribed Buspirone and Clonazepam for anxiety-related blowing behavior without proper assessment. The facility failed to document the necessity for increased medication dosage or conduct a psychiatric evaluation to determine the behavior's cause. Inconsistent monitoring and lack of comprehensive assessment led to this deficiency.
A facility reported a 16% medication error rate due to a nurse's failure to follow physician orders for a resident with hypertension and rheumatoid arthritis. The nurse did not check the resident's blood pressure and heart rate immediately before administering amlodipine and metoprolol, nor did they provide food with metoprolol and hydroxychloroquine as required. This non-compliance with medication administration protocols was confirmed by the Director of Nursing.
The facility failed to keep two of four garbage dumpster lids closed, as required by their waste disposal policy. This was observed during a survey, with the dumpsters being more than halfway full and located near the skilled nursing facility. The Director of Dietary Services acknowledged the need to keep lids closed to prevent pest attraction. Additionally, a fly was observed in the kitchen, potentially entering through a nearby delivery door.
CNA 3 and the DON failed to wear the required PPE for a resident with an indwelling foley catheter, as per physician orders and facility policy. The resident, with spinal stenosis and neuromuscular dysfunction of the bladder, required enhanced barrier precautions. Observations showed staff not wearing gowns during high-contact care, contrary to infection prevention protocols.
Failure to Honor Resident Rights Regarding Treatment and Advance Directives
Penalty
Summary
A deficiency was identified regarding the failure to honor a resident's right to request, refuse, or discontinue treatment, to participate in or refuse experimental research, and to formulate an advance directive. The report notes that the facility did not ensure these resident rights were upheld, as required by regulation. Specific actions or omissions by facility staff that led to this deficiency are not detailed in the report, nor are there descriptions of the residents' medical histories or conditions at the time of the incident.
Failure to Monitor Anticoagulant Therapy, Follow Hospice Orders, and Ensure Diabetes Education at Discharge
Penalty
Summary
The facility failed to provide appropriate care and services for three residents by not ensuring proper monitoring and adherence to physician orders. For one resident on anticoagulant therapy, there was no documented monitoring for signs and symptoms of bleeding in the medication administration records for several months, despite care plans and physician orders requiring such monitoring. Staff interviews confirmed that the monitoring was not scheduled or documented, and the coding on the medication record was incorrect, which could have led to the order being missed. Another resident receiving hospice care had conflicting physician orders between the hospice provider and the facility, with no interdisciplinary team meetings conducted as ordered by the hospice physician. The facility staff did not clarify or follow the hospice physician's orders, leading to confusion about which orders to follow and potentially affecting the resident's plan of care. The facility's policy required coordination with hospice representatives to ensure appropriate care, but this was not done. A third resident, who had diabetes and was being discharged home, did not receive a documented evaluation of their or their family member's knowledge regarding diabetes management, including blood sugar checks and insulin administration. The discharge instructions did not confirm whether the resident or family member understood how to manage diabetes care at home, and there was a lack of timely confirmation with the home health agency regarding post-discharge nursing support. The facility's policy required teaching and discharge instructions to be provided and understood prior to discharge, but this was not ensured.
Unlabeled and Undated Frozen Food Items Found in Kitchen Freezer
Penalty
Summary
During a tour of the facility's kitchen, surveyors observed five cups of an orange-colored frozen substance stored in the walk-in freezer without any labels or dates to identify the contents or indicate when they were prepared or should be used by. The Dietary Supervisor was unable to confirm whether the cups contained ice cream or sorbet and did not know when they had been prepared. Both the cups and the tray they were placed on lacked any labeling or use-by dates. Review of the facility's policies confirmed that all food items, including leftovers, are required to be labeled and dated when stored in the storeroom, refrigerator, or freezer.
Failure to Submit Required PBJ Staffing Data
Penalty
Summary
The facility failed to submit the required direct care staffing information for one of two quarters (Quarter 2) through the Payroll-Based Journal (PBJ) system, as mandated by CMS. This deficiency was identified during a review of the PBJ Staffing Data Report, which showed that no data was submitted for the specified quarter. The facility's policy and procedure required quarterly submission of PBJ data within the specified timeframe, but this was not followed for the quarter in question. During an interview, the Administrator explained that the corporate controller office was responsible for submitting the PBJ data. The previous controller resigned in March, and the new controller had not yet received the submitter ID from the State, resulting in the failure to submit the required data. The Administrator acknowledged the importance of submitting PBJ data for accurate staffing and compliance with regulations.
Failure to Timely Submit MDS Assessment
Penalty
Summary
The facility failed to complete and transmit the initial Minimum Data Set (MDS) assessment in a timely manner for one resident. The resident was admitted with diagnoses including venous thromboembolism, anemia, and insomnia. The resident's initial comprehensive MDS assessment was completed on 3/28/2025, but the submission to the Centers for Medicare & Medicaid Services (CMS) Quality Improvement and Evaluation System (QIES) Assessment Submission and Processing (ASAP) system did not occur until 5/9/2025, which was more than 14 days after the assessment completion date. Interviews with the MDS coordinator and the Director of Nursing confirmed that the MDS entry was submitted late and acknowledged the importance of timely submission to ensure proper communication with CMS regarding the care provided. Review of the MDS RAI Version 3.0 Manual confirmed that MDS assessments must be submitted within 14 days of completion, a requirement that was not met in this instance.
Failure to Complete Required PASARR Screening for Resident with Mental Illness
Penalty
Summary
The facility failed to conduct the required Preadmission Screening and Resident Review (PASARR) for a resident with multiple mental health diagnoses, including schizophrenia, bipolar disorder, and major depression. The resident was admitted with these diagnoses and was receiving psychotropic medication. A review of the resident's admission record and Minimum Data Set (MDS) indicated cognitive impairment and a need for maximal assistance with daily activities. Despite these factors, the only PASARR screening on file was dated prior to admission, and no additional screenings were completed before or after the resident's admission. Interviews with the MDS Coordinator and the Director of Nursing confirmed that the facility did not submit a PASARR screening for the resident as required. The facility's policy mandates that all new admissions and readmissions be screened for mental disorders, intellectual disabilities, or related disorders through the PASARR process, regardless of payer source. The absence of a current PASARR screening was acknowledged by facility staff during the review of both paper and electronic records.
Failure to Follow Professional Standards During Blood Draw for Resident with PICC Line
Penalty
Summary
A deficiency occurred when a resident with a PICC line in the left upper arm had blood drawn by venipuncture from the same arm, contrary to professional standards and facility policy. The resident was receiving antibiotics through the PICC line at the time, and a folded gauze dressing was observed below the left elbow, which the resident stated was from a blood draw performed earlier that morning. The facility's Director of Nursing confirmed that blood should not be drawn by needle stick from the same arm as a PICC line, as this could lead to complications. The Infection Prevention Nurse was unable to find any nursing resources supporting the practice of venipuncture on the same arm as a PICC line and noted that laboratory staff did not communicate with facility staff before performing the blood draw. The facility did not provide laboratory staff with reminders or warnings to avoid venipuncture on the arm with the PICC line, and there was no documentation of communication regarding the blood draw. Review of facility policy and national guidelines indicated that venipuncture, peripheral IV insertion, and blood pressure measurements should be avoided on the same arm as a PICC line, and that reminder signs should be placed for healthcare team members. The failure to follow these standards resulted in a deficiency related to professional standards of nursing practice.
Failure to Provide Necessary Oral and Personal Hygiene for Dependent Resident
Penalty
Summary
Facility staff failed to provide necessary assistance with activities of daily living (ADLs), specifically personal and oral hygiene, to a resident who was completely dependent on staff for self-care. The resident, who had diagnoses including hemiplegia following a stroke, cognitive communication deficit, and vascular dementia, was nonverbal, unable to make decisions, and received nutrition via a G-tube. Observations revealed the resident had dry, chapped, and cracked lips with flaking, indicating a lack of adequate oral care. Staff interviews confirmed that mouth care was typically provided after meals, but since the resident did not eat orally, this care was not consistently given. Further interviews with facility staff, including a CNA, the Infection Prevention Nurse, and the DON, confirmed that both facility and hospice staff were responsible for providing personal and oral care, regardless of the resident's hospice status. Facility policies required staff to assist residents unable to perform ADLs independently and to maintain personal and oral hygiene. However, the observed condition of the resident's lips and staff statements indicated that these policies were not followed, resulting in the resident not receiving the necessary care to maintain oral hygiene and comfort.
Failure to Confirm Home Health Services Prior to Resident Discharge
Penalty
Summary
The facility failed to ensure that a follow-up for needed Home Health (HH) services was completed and confirmed prior to the discharge of a resident who required ongoing care for diabetes management. The resident, who had moderately impaired cognition and required moderate assistance with personal hygiene and toileting, was diagnosed with diabetes mellitus and end stage renal disease. The Social Services Director (SSD) sent a fax request for a Home Health Registered Nurse (HH RN) to visit the resident at home but did not call to confirm the service with the HH agency before the resident was discharged. The resident was discharged home with a family member before confirmation of the HH RN visit was obtained. The facility's own policy and the Director of Social Services' job description required coordination and confirmation of follow-up care and services prior to discharge. The lack of timely confirmation of HH services prior to discharge resulted in a failure to ensure continuity of care for the resident's diabetes management needs.
Failure to Identify Potential Chemical Restraint
Penalty
Summary
The facility failed to identify a potential chemical restraint for a resident by having a physician order that indicated the administration of Ativan if the resident attempted to get out of bed unassisted. The resident, who was admitted with multiple diagnoses including generalized muscle weakness and cerebral infarction, had moderately impaired cognition and was dependent on staff for bathing and toileting. The resident was also always incontinent of bowel and bladder. The physician's order, dated as of 9/12/2024, allowed for the administration of Ativan, a sedative, without specifying a diagnosis or symptom that the medication could relieve, thus potentially restricting the resident's movement for staff convenience. During an interview and record review, the Director of Nursing acknowledged that the order served to restrict the resident's movement and did not indicate a medical symptom that the medication could relieve. The facility's policy and procedure on identifying involuntary seclusion and unauthorized restraint defined chemical restraint as any drug used for discipline or staff convenience and not required to treat medical symptoms. The policy further stated that the risk of falling is not considered a medical symptom or self-injurious behavior that warrants the use of restraints. This deficiency had the potential to restrict the resident's movement for staff convenience or discipline.
Failure to Develop Comprehensive Care Plan for Resident with Limited ROM
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident with limited range of motion (ROM) in both lower extremities. The resident, who was admitted with diagnoses of dementia and Alzheimer's disease, was dependent on all activities of daily living and had functional limitations in ROM. Despite these conditions, there was no care plan in place to address the resident's impaired ROM until several months after admission. The Director of Nursing (DON) confirmed that a care plan should have included interventions such as ROM exercises, monitoring for pain, exercise tolerance, skin integrity, and decline in ROM, but these were not implemented until a physical therapy evaluation was completed months later. Observations and interviews revealed that the resident's knees could only extend up to 90 degrees, indicating a lack of proper intervention since admission. A physical therapist began assessing and implementing ROM exercises only after a significant delay, and training for certified nursing assistants on these exercises started even later. The facility's policies required a comprehensive, person-centered care plan with measurable objectives and timetables, which was not developed for this resident, leading to a potential decline in the resident's ROM.
Failure to Prevent Decline in Range of Motion for Resident
Penalty
Summary
The facility failed to provide necessary services to prevent a further decrease in range of motion (ROM) for a resident, identified as Resident 153. The resident was admitted with diagnoses including dementia and Alzheimer's disease and was dependent on all activities of daily living. The Minimum Data Set (MDS) indicated functional limitations in the resident's lower extremities. Despite these indications, the facility did not perform an assessment of joint mobility upon admission to establish a baseline for monitoring any decline or improvement in ROM, as required by the facility's policy and procedure. The deficiency was further highlighted during observations and interviews with the physical therapist (PT) and the Director of Nursing (DON). The PT noted a significant delay in conducting a PT evaluation due to communication issues with the hospice agency, which was responsible for the resident's care. The PT evaluation eventually revealed a 26-50% loss of ROM in the resident's knees, causing discomfort. The DON confirmed the absence of a joint mobility assessment upon admission and acknowledged the lack of communication with the hospice agency to request an evaluation for physical or occupational therapy. Additionally, a Certified Nursing Assistant (CNA) reported that ROM exercises were not provided to the resident until several months after admission, further contributing to the deficiency.
Failure to Assess and Manage Psychotropic Medication Use
Penalty
Summary
The facility failed to properly assess and manage the use of psychotropic medications for a resident, identified as Resident 153, who was admitted with diagnoses including dementia and Alzheimer's disease. The resident was prescribed Buspirone and Clonazepam for anxiety manifested by persistent blowing behavior. However, the facility did not ensure that the resident was assessed for the use of these medications, nor did they ensure that the increase in Buspirone dosage was justified by clinically significant behavior. The Director of Nursing (DON) acknowledged that the resident was not on these medications upon admission and that the increase in Buspirone dosage was made without proper documentation of the behavior causing discomfort or harm. The Social Services Director (SSD) mentioned that the in-house psychiatrist did not assess the resident, as the resident was not under their care, and the behavior was assumed to be anxiety-related without proper evaluation. Observations showed that the resident exhibited the blowing behavior inconsistently, and there was no documentation to determine if it was a habit or anxiety-related. The facility's policy and procedure on psychotropic medications require documentation of the reason for treatment, expected outcomes, and alternative treatments. However, there was no evidence of a psychiatric consultation or assessment to determine the cause of the resident's behavior. The Medication Administration Record (MAR) showed inconsistent monitoring of the behavior, with a significant increase in episodes over several months, yet no comprehensive assessment was conducted to address the underlying cause of the behavior.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to maintain a medication error rate below 5 percent, with a reported rate of 16 percent during a medication administration observation. This deficiency involved Licensed Vocational Nurse 1 (LVN 1) who did not adhere to physician orders for Resident 152. Specifically, LVN 1 did not check the resident's blood pressure and heart rate immediately before administering amlodipine and metoprolol, medications used to treat high blood pressure. Additionally, LVN 1 failed to administer metoprolol and hydroxychloroquine with food as ordered, which could lead to potential side effects such as stomach issues. Resident 152, who was admitted with diagnoses of hypertension and rheumatoid arthritis, required specific monitoring and administration instructions for their medications. The physician's orders clearly indicated that amlodipine and metoprolol should be withheld if the resident's systolic blood pressure was below 110 or heart rate was below 60, and that metoprolol and hydroxychloroquine should be given with food. LVN 1's actions did not comply with these orders, as the nurse checked the resident's vital signs an hour before medication administration and did not provide food with the medications. The Director of Nursing confirmed the necessity of following these protocols to prevent medication errors and potential harm to residents.
Improper Garbage Disposal Practices
Penalty
Summary
The facility failed to ensure that two of four garbage dumpsters had their lids closed, as required by the facility's Policy and Procedure titled 'Non-medical Waste Disposal.' This oversight was observed during a survey, where it was noted that the dumpsters, located in a shed a few meters from the skilled nursing facility, were more than halfway full of garbage with their lids left open. The Director of Dietary Services (DDS) acknowledged that the dumpsters should remain closed to prevent attracting pests such as rats and flies, which could lead to the spread of infectious diseases. Additionally, during observations in the kitchen, a fly was seen flying around, which the DDS suggested could have entered through the delivery door. This door was in close proximity to the kitchen, potentially allowing pests to enter the facility. The facility's Pest Management Service Report was reviewed, and it was noted that staff had been in-serviced regarding the importance of keeping dumpster lids closed. The facility's policy emphasized the need to cover trash receptacles to prevent odor, reduce disease transmission, and avoid attracting insects or rodents.
Failure to Follow Enhanced Barrier Precautions for Resident with Foley Catheter
Penalty
Summary
Certified Nursing Assistant 3 (CNA 3) and the Director of Nursing (DON) failed to adhere to the required personal protective equipment (PPE) protocols for Resident 203, as indicated by the resident's physician orders, signage outside the resident's room, and the facility's policy for Enhanced Barrier Precaution. Resident 203, who was admitted with multiple diagnoses including spinal stenosis and neuromuscular dysfunction of the bladder, had an indwelling foley catheter, which necessitated enhanced barrier precautions. The physician's order specified the use of hand hygiene, gown, and gloves during high-contact care activities due to the presence of the urinary catheter. During observations, CNA 3 was seen brushing Resident 203's teeth and transferring the resident from a wheelchair to the bed without wearing a gown, only using a surgical mask and gloves. Similarly, the DON also handled the resident's indwelling foley catheter without wearing a gown. The Infection Preventionist Nurse confirmed that under enhanced barrier precautions, staff should perform hand hygiene and wear a full gown and gloves during direct touch care to prevent potential infections. The facility's policy and signage also indicated the necessity of wearing a gown and gloves for high-contact activities, which was not followed by the staff.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
