Citrus Post-acute
Inspection history, citations, penalties and survey trends for this long-term care facility in Santa Ana, California.
- Location
- 1929 N. Fairview Street, Santa Ana, California 92706
- CMS Provider Number
- 555093
- Inspections on file
- 37
- Latest survey
- February 17, 2026
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Citrus Post-acute during CMS and state inspections, most recent first.
A resident with a documented high fall risk, confirmed by a Morse Fall score and a prior unwitnessed fall, had a care plan that included bilateral floor mats to minimize injury in case of falls. Despite this, surveyors later observed the resident with a forehead hematoma and extensive facial bruising and noted that no floor mats were present by the bed. In interviews, the resident reported the bump was from a fall at the facility, and an LVN verified that floor mats were not in place even though they were required for this high fall-risk resident. The Administrator and DON acknowledged that the care-planned fall-prevention intervention had not been implemented.
A resident with a surgical wound on the left buttock was ordered a low air-loss mattress for wound care and management, with the setting prescribed at 99 lbs. Facility policy required support surfaces to be used to prevent skin breakdown and provide pressure relief. Review of the resident’s records showed a current weight of 115 lbs, but observations revealed the mattress was set at 120 lbs, and the physician’s order and mattress setting had not been updated to match the resident’s actual weight. Leadership staff confirmed the discrepancy, and this failure was cited as having the potential to contribute to development or worsening of pressure ulcers.
The facility did not thoroughly investigate the exclusion status of a direct access employee during the background screening process, resulting in the employment of an individual who had previously used a fraudulent Social Security Number to obtain a CNA license that was later revoked. The required verification steps were not followed, leading to the hiring of an employee who appeared on the Medi-Cal exclusion list.
A resident with severe cognitive impairment experienced significant weight loss, and although a physician ordered weekly weights and an appetite stimulant, these interventions were not added to the care plan. Staff confirmed the care plan was not updated to reflect the new orders, contrary to facility policy requiring timely care plan revisions after significant changes in condition.
Surveyors found multiple failures in medication management, including improper storage temperatures, lack of labeling on opened vials, expired and soiled medications not removed from storage, and incomplete labeling of insulin pens. Additionally, loose tablets and capsules were found on top of the pharmaceutical waste bin, and medication carts contained expired, opened, or improperly labeled items. These deficiencies were confirmed by nursing staff and management.
Surveyors identified multiple failures in food safety and sanitation, including improper labeling and dating of food, storage of dented cans with intact cans, unsanitary storage of food in the walk-in refrigerator, wet-stored kitchen equipment, unclean food preparation surfaces, and corroded cutting boards. Maintenance tools were improperly stored, and there was no designated refrigerator or microwave for resident food brought from outside, with resident food found unlabeled, undated, and stored with employee food. The refrigerator lacked a thermometer and temperature monitoring, food was kept on the steam table for excessive periods, and the dishwasher operated below required temperatures.
The facility did not provide required education on safe food handling to residents and families bringing in outside food, and failed to ensure proper storage of such food. Staff interviews revealed a lack of knowledge and responsibility regarding safe food handling education, and food brought by a family was found stored at a resident's bedside at room temperature. There was no documentation that education was provided, and no designated refrigerator for resident food.
Multiple deficiencies were identified, including the failure to conduct infection surveillance, improper Legionella testing frequency, and lapses in staff infection control practices such as inadequate hand hygiene, improper PPE use, and unsafe handling of clean linen and medical equipment. These actions and inactions increased the risk of infection transmission among residents and staff.
The facility did not implement its antibiotic stewardship program as required, failing to review antibiotic orders for appropriateness and to notify physicians for re-evaluation when antibiotics were prescribed for suspected infections that did not meet criteria. As a result, several residents received full courses of antibiotics without proper review or justification.
A resident with a history of behavioral disturbances and physical aggression struck another resident in the face with a rehabilitation dowel after a dispute over television volume. The assaulted resident suffered pain, swelling, and emotional distress. The aggressor had a care plan for behavioral issues, but was able to access the dowel without staff supervision, contrary to facility policy. Staff intervened after the incident, and the facility substantiated the abuse following investigation.
A resident with no decision-making capacity had a POLST form indicating DNR status, signed by the responsible party, but the facility did not obtain a timely physician's order to match this status. The physician's signature on the POLST was delayed by 55 days, and staff interviews confirmed that a physician's order is required for code status to be effective.
A resident was observed eating breakfast in bed when a live water bug or roach was found on the bed linen next to him. The incident was witnessed by a CNA, who removed the pest, and the resident stated he preferred not to have pests on his bed while eating. The pest was later identified by a pest control technician, confirming the facility's failure to maintain a clean and homelike environment.
Three residents were not properly monitored for the use of psychotropic medications, including antipsychotics and sedative-hypnotics. One resident did not have accurate orthostatic BP monitoring while on risperidone, and nonpharmacological interventions were not attempted before starting mirtazapine, nor was there monitoring for its side effects. Another resident on Seroquel had identical BP readings recorded for different positions, indicating improper monitoring. A third resident received repeated PRN orders for zolpidem tartrate without documented physician rationale for continued use beyond 14 days, as required by facility policy.
A resident underwent an MRI that revealed a possible neck mass, and the physician ordered that the MRI results be brought to a neurology appointment. However, the MRI results were not provided to the physician in time for the appointment due to delays in obtaining and uploading the results, lack of follow-up by the case manager, and issues with translating a summary report written in Spanish. The DON and Administrator confirmed that the required procedures for handling physician orders and documentation were not followed.
A resident with impaired decision-making capacity did not receive a physician-ordered health shake with meals, as confirmed by medical record review, meal tray observations, and staff interviews. The DON acknowledged the resident had not been receiving the supplement as ordered.
Surveyors found that several residents did not receive appropriate respiratory care due to failures in changing and labeling nebulizer masks, oxygen tubing, and storage bags as required by facility policy. In some cases, oxygen therapy was administered without a physician's order or proper documentation. Staff interviews confirmed that equipment was not consistently changed or labeled, and that required documentation was missing, leading to lapses in infection control and adherence to respiratory care protocols.
A resident was given tramadol HCL for pain when their pain level was documented as six, despite the physician's order specifying administration only for severe pain rated 7-10. This was confirmed by the ADON and acknowledged by the DON during the survey.
The facility failed to ensure proper pharmaceutical services by not documenting administration of controlled medications, not removing discontinued controlled drugs from medication carts, leaving medications unattended during administration, and administering a blood pressure medication outside of ordered parameters. These actions involved several residents and were confirmed by staff interviews and record reviews.
A resident with dementia and no capacity for medical decisions was prescribed mirtazapine for depression and poor appetite, but there was no physician's order or documentation to monitor for side effects. The consultant pharmacist and DON confirmed that monitoring should have occurred, but it was not performed or documented, as verified through record review and interviews.
A resident was prescribed clonidine for hypertension without an active diagnosis of hypertension and was not administered the medication, as no qualifying blood pressure readings were recorded. The same resident received daily sodium chloride supplementation despite having a low sodium level, with no follow-up lab monitoring after the abnormal result. The DON confirmed the lack of ongoing sodium level testing.
Surveyors identified a medication error rate of 26.67% after observing eight errors during 30 medication administrations by three LVNs. Errors included failure to dilute and separately administer medications via GT as ordered, administration of an incorrect brand of artificial tears, and giving a calcium supplement without the required vitamin D. These actions were not in accordance with physician orders or facility policy, and facility leadership acknowledged the findings.
The facility did not follow posted menus or serve correct portion sizes to residents, as the new Vietnamese menu in use was not posted or communicated, and kitchen staff used incorrect scoop sizes and portions for both American and Vietnamese menu items. The Dietary Services Supervisor confirmed these discrepancies, affecting the majority of residents receiving meals from the kitchen.
The facility did not preserve the nutritive content of pureed stir fry vegetables for several residents on a Vietnamese menu, as the pureed vegetables were prepared and held on a steam table for about two hours before being served. Dietary staff and the DSS confirmed this practice, which was longer than the intended holding time, and acknowledged that it could decrease the nutritional value of the food provided to residents requiring a pureed diet.
Two residents' MDS assessments were inaccurately coded, omitting active diagnoses such as hypertension, hyponatremia, depression, and anxiety, and failing to properly document antidepressant use and the timing of antipsychotic GDR attempts. These errors were confirmed by the MDS Coordinator and acknowledged by facility leadership, with discrepancies found between medical records, physician orders, and MDS documentation.
A resident with newly diagnosed anxiety and major depressive disorder was not reassessed through the PASARR program as required. The initial PASARR Level I screening did not reflect the resident's mental health conditions, and no updated PASARR was completed after the new diagnoses. The care plan specified that new diagnoses should trigger a PASARR review, but this was not followed, as confirmed by the MDS Coordinator, Administrator, and DON.
A resident with diagnoses of psychosis, schizophrenia, and anxiety disorder was inaccurately documented as having no serious mental illness on the PASARR Level I Screening, resulting in the absence of a required Level II evaluation. The MDS Coordinator, Administrator, and DON confirmed the inaccuracy after reviewing the resident's medical record.
A resident was allowed to leave the facility under a physician's 'out on pass' order, but staff failed to develop a care plan addressing this ability or document the responsible party's information. The omission was confirmed during a medical record review and staff interview.
Two residents did not receive their physician-ordered therapeutic diets: one was not served soup as ordered, and another received non-pureed soup and was missing an extra entree, despite orders for a pureed, honey-thick consistency diet and double entree. Staff confirmed the discrepancies, and the DON acknowledged that licensed nurses were responsible for verifying meal trays.
Multiple residents experienced deficiencies in medical record documentation, including missing blood sugar records before insulin administration, incomplete or unsigned POLST forms, an incomplete Record of Death, and incorrect documentation of blood pressure medication administration. Facility staff confirmed these documentation lapses during interviews.
The facility did not provide documentation that its QAPI committee monitored the effectiveness of corrective actions for previously cited deficiencies related to oxygen orders, medication storage, records review, and infection control, as required by its own policies and plan of correction.
A facility failed to monitor and document the daily fluid intake for a resident with ESRD requiring dialysis, despite a physician's order for a fluid restriction of 1500 ml per day. The lack of documentation was confirmed during staff interviews, highlighting a potential risk for fluid overload and associated health issues.
A facility failed to implement an individualized care plan for a resident with a PICC line, lacking specific orders for dressing changes and measurements. This oversight posed a risk for complications, as there was no documentation of dressing changes or measurements during the resident's stay. An RN confirmed these omissions during a review.
A facility failed to properly assess and document care for a resident with a PICC line, resulting in an occlusive right axillary deep vein thrombosis and subsequent hospitalization for a pulmonary embolism. Despite protocols requiring regular assessments and maintenance, the facility did not document necessary actions, such as arm circumference measurements and flushing of unused lumens. Interviews with staff confirmed these deficiencies, highlighting a lack of adherence to established procedures.
A resident did not receive prescribed medications due to unavailability, and the facility failed to notify the physician as required by policy. The medications missed included enoxaparin sodium, levetiracetam, desmopressin acetate, and methocarbamol. An LVN confirmed the lack of notification, and the physician was unaware of the missed doses, impacting treatment decisions.
Housekeepers in an LTC facility failed to follow infection control protocols by not wearing gowns in rooms with EBP signage and using the same cloth to clean multiple surfaces for different residents. Additionally, a toilet bowl brush was improperly used for cleaning toilet seats, and grab bars were not cleaned. These actions were confirmed by the Environmental Services Supervisor and Infection Preventionist.
The facility failed to ensure kitchen staff competency, leading to deficiencies in food safety practices. Staff did not follow proper hand hygiene, lacked knowledge of TCS food cool down procedures, and failed to sanitize surfaces correctly. The CDM could not provide evidence of recent training, and new employees were deemed competent without documented assessments, posing a risk of foodborne illness to residents.
The facility failed to preserve the nutritive content of pureed vegetables for the American menu by cooking and holding them in a hot oven for over an hour before meal service. This practice potentially compromised the nutritional needs of 23 residents on a pureed diet. The RD confirmed that pureed foods should be cooked to maintain their nutritional value.
The facility failed to follow food safety and sanitation guidelines, risking foodborne illnesses. Issues included improper cooling and thawing of TCS foods, inadequate hand washing, unsanitary food preparation surfaces, and improper hair restraints. Additionally, kitchen equipment and the environment were not clean, and the ice machine and a food preparation sink lacked necessary air gaps.
The facility failed to implement its infection control program, with inaccurate surveillance data and missing records for several months. Sanitary practices were not maintained, as clean linen was improperly stored, urinary catheter bags were left on the floor, and staff did not follow hand hygiene protocols. Additionally, trash disposal was inadequate, and medication counting was unsanitary, posing a risk for disease transmission.
The facility failed to maintain essential equipment safely, with issues including improper cleaning of the ice machine, dish machine temperatures below specifications, a misaligned screen door, a damaged screen above a food prep area, and a rusted fire sprinkler in the walk-in refrigerator.
The facility failed to obtain informed consent for psychotropic medications for two residents. One resident was administered iloperidone without proper consent, as the medication was added after the consent form was signed, and the prescribing physician had not signed it. Another resident received lorazepam without a signed consent form in their medical record. These actions violated the facility's policy on Psychotropic Medication Management.
A resident was found with medications at their bedside without a physician's order, assessment, or care plan for self-administration. The facility's policy requires an assessment and IDT approval before allowing self-administration, but this was not followed. The resident had a moderate cognitive impairment, and staff confirmed the lack of necessary approvals, posing a risk of inaccurate medication administration.
The facility failed to ensure call lights were accessible for three residents, compromising their dignity and respect. Observations showed call lights were either on the floor or out of reach, contrary to the facility's policy. This oversight had the potential to delay care and negatively impact the residents' well-being.
A resident's code status was inaccurately documented and communicated, leading to a discrepancy between her expressed wishes and the facility's records. Despite the resident's capacity to make medical decisions and her desire to be a full code, the facility staff incorrectly reported her as DNR during a hospital transfer. This error was due to a POLST form signed by an unrelated individual and a failure to update the resident's electronic health record, causing potential misalignment with her treatment preferences.
The facility failed to administer Vancomycin at the correct infusion rate for a resident due to the absence of an electronic infusion pump, and another resident did not receive a prescribed health shake with meals, risking inadequate caloric intake.
A facility failed to accurately monitor a resident's hydration status, including fluid intake from meals, medication, and IV therapy, as well as urine output from an indwelling catheter. Despite physician orders to monitor intake and output, the facility's documentation was inaccurate, as confirmed by staff interviews. This posed a risk to the resident's health.
The facility failed to maintain proper care and documentation for IV accesses in two residents. For one resident, the required measurements of the PICC line's external catheter length and arm circumference were not performed or documented upon admission. For another resident, similar measurements were not documented, and the midline catheter dressing was soiled and not labeled or dated. These oversights were confirmed by RN 1 and had the potential to delay identification of catheter-related complications.
The facility failed to provide appropriate respiratory care for five residents, including administering oxygen without a physician's order, and failing to label and store oxygen and CPAP equipment properly. These deficiencies were confirmed by nursing staff and administration, highlighting lapses in following facility policies for respiratory care.
The facility failed to provide adequate pharmaceutical services, resulting in medication administration errors for multiple residents. Medications were not administered according to physician orders, and there were issues with insulin coverage and documentation. Additionally, the facility did not properly log the opening of the emergency kit and failed to ensure controlled substance counts were documented each shift.
The facility failed to monitor vital signs and document diagnoses for medications for four residents. A resident's heart rate was not checked before administering amiodarone and carvedilol, and blood glucose levels were not checked before administering insulin glargine. Another resident was prescribed losartan and ProStat without documented diagnoses. Additionally, a resident's heart rate was not monitored before administering metoprolol succinate, and another resident's blood glucose levels were not consistently checked before meals.
Failure to Implement Care-Planned Fall Prevention Interventions
Penalty
Summary
The facility failed to implement a comprehensive, person-centered care plan intervention for a resident identified as high risk for falls. The facility’s policy on comprehensive person-centered care plans required that services be furnished to attain each resident’s highest practicable well-being. Medical record review showed that after an unwitnessed fall on 1/28/26, when the resident was found lying face down on the side of the bed, the resident’s care plan for risk of falls was updated to include bilateral floor mats as an intervention to minimize injury in case of falls. A Morse Fall assessment documented a score of 65, with scores of 45 and above indicating high fall risk, confirming the resident’s elevated risk status and the need for fall-prevention interventions such as floor mats. On 2/17/26, observation of the resident revealed a round hematoma on the forehead and dark purple bruising on both cheeks, chin, and the front of the neck. During this observation, no floor mats were present in the room or on the floor next to the resident’s bed, despite the care plan intervention specifying bilateral floor mats. In a subsequent interview, the resident stated that the bump on the forehead was from a fall that occurred at the facility. During a concurrent observation and interview, an LVN confirmed that the resident did not have floor mats in place and stated that there should be floor mats due to the resident being a fall risk. The Administrator and DON later acknowledged these findings, confirming that the care-planned intervention for bilateral floor mats had not been implemented.
Failure to Update Low Air-Loss Mattress Settings to Current Resident Weight
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident’s low air-loss mattress settings and corresponding physician’s order were updated to reflect the resident’s current weight, as required for appropriate pressure ulcer prevention and wound management. Facility policy titled “Support Surface Guidelines” stated that redistributing support surfaces are intended to prevent skin breakdown, promote circulation, and provide pressure relief or reduction for bed- or chairbound residents. Medical record review showed that the resident was readmitted to the facility and had a physician’s order, dated several months earlier, for a low air-loss mattress for wound care and management, with the mattress setting ordered at 99 lbs every shift. A skin assessment documented that the resident had a surgical wound on the left buttock and was on a properly functioning low air-loss mattress. Subsequent review of the resident’s Weights and Vitals Summary showed the resident’s current weight was 115 lbs. However, during observations in the resident’s room, surveyors found the low air-loss mattress was set at 120 lbs, and the ADON confirmed that both the physician’s order and the mattress setting had not been updated to reflect the resident’s current weight of 115 lbs. The Administrator and DON later acknowledged these findings. The report states that this failure had the potential for the resident to develop pressure ulcers or for existing pressure ulcers to worsen.
Failure to Investigate Exclusion Status During Background Screening
Penalty
Summary
The facility failed to thoroughly investigate the results of a background screening for a direct access employee, resulting in the employment of an individual who appeared on the Medi-Cal exclusion list. During the new hire background screening process, two CNA licenses were found under the same name: one active and employable, and another that was revoked and not employable. The facility's policy required verification of any findings of abuse, neglect, or misappropriation, and mandated that applicants with such findings not be employed. However, the process to verify whether the excluded license belonged to the same individual, such as cross-referencing Social Security Number, date of birth, or residential addresses, was not followed during the hiring of this employee. Further review and interviews revealed that the background screening process had changed under new management, and the current staff could not account for the original hiring process. The employee in question later admitted to having previously used a fraudulent Social Security Number to obtain a CNA license, which was subsequently revoked, and later applied for a new CNA license using a legal Social Security Number. The failure to thoroughly investigate and resolve the exclusion status during the hiring process led to the deficiency.
Failure to Update Care Plan for Weight Loss Interventions
Penalty
Summary
The facility failed to ensure that the comprehensive care plan for one resident was revised to reflect current care needs and interventions following a significant weight loss. The resident, who had severe cognitive impairment as indicated by a BIMS score of 5, experienced a seven-pound weight loss within one month. Medical record review showed that the physician ordered weekly weights for four weeks and the administration of an appetite stimulant (megestrol acetate) to address the weight loss. However, these new interventions were not incorporated into the resident's care plan. Interviews with facility staff, including an LVN and the ADON, confirmed that the care plan did not include the updated interventions as ordered by the physician. The facility's policy required the interdisciplinary team to review and revise care plans at least quarterly or after a significant change in condition, but this was not done in this case. The omission posed a risk of not providing individualized and person-centered care for the resident.
Medication Storage, Labeling, and Disposal Deficiencies
Penalty
Summary
Surveyors identified multiple failures in the facility's medication management practices, specifically regarding the storage, labeling, and disposal of drugs and biologicals. The temperature in the medication storage room was consistently above the facility's acceptable range, and the medication refrigerator lacked a thermometer for monitoring. Open vials of tuberculin purified protein were found without open dates, and expired IV medications remained in the refrigerator. Additionally, an opened emergency medication kit was not restocked in a timely manner, and soiled boxes of glucose gel were not removed from storage. Inspections of medication carts revealed further deficiencies. Expired, opened, and soiled supply packages were present in one cart, while another cart contained improperly labeled medications, including an opened box of artificial tears without a resident name and loose tablets and capsules. Insulin pens were not consistently labeled with expiration dates, and some liquid medication bottles were found with sticky residue. In one instance, a medication for a resident did not have a visible expiration date. The facility also failed to ensure the proper disposal of medications, as loose tablets and capsules were observed on top of the pharmaceutical waste bin in the biohazard room. These findings were verified by nursing staff and management during the survey. The facility's policies require medications to be stored securely, labeled accurately, and disposed of promptly if expired or contaminated, but these procedures were not consistently followed.
Widespread Food Safety and Sanitation Failures in Dietary Services
Penalty
Summary
The facility failed to adhere to food safety and sanitation guidelines in multiple areas of its food service operations. Surveyors observed improper labeling and dating of food items, such as an opened package of English muffins with two different open dates, and undated or unlabeled resident food items stored in the employee lounge refrigerator. Dented cans were found stored with intact cans in the dry storage area, contrary to facility policy requiring separation. In the walk-in refrigerator, opened sliced turkey breast was stored in a colander and only partially covered, not in a leak-proof, pest-proof, non-absorbent container as required. Additionally, food preparation and storage equipment, including microwaves, cups, knives, can openers, and plate warmers, were found with visible residue, stains, or food debris, and some utensils and containers were stored while still wet, not air-dried as required by policy and the USDA Food Code. Cutting boards and other food-contact surfaces were observed to be heavily marred, melted, or corroded, making them difficult to clean and sanitize. Maintenance tools such as brooms were stored on the floor in the kitchen chemical closet, rather than in an orderly manner that facilitates cleaning. The facility did not provide a designated refrigerator or microwave for resident food brought in from outside, resulting in resident and employee food being stored together. The refrigerator used for resident food lacked a thermometer and was not monitored or logged for temperature, as required by facility policy. Multiple food items belonging to residents were found unlabeled and undated, including containers of cut beets, pizza, soup, and cooked meat. Further, food was placed on the steam table more than two hours prior to tray line, exceeding the facility's policy of no more than 30 minutes before meal service. The low-temperature dishwasher was observed operating below the required 120 degrees Fahrenheit during several wash cycles, with staff unaware of the need to flush the machine to reach the correct temperature before use. These deficiencies were verified by facility leadership during the survey and had the potential to affect the majority of residents who consumed food prepared in the facility's kitchen.
Failure to Educate on and Ensure Safe Handling of Outside Food Brought by Families
Penalty
Summary
The facility failed to provide education on safe food handling to residents and visitors, as required by its own policy regarding food brought in from outside sources. Multiple staff interviews revealed that there was no consistent process for educating residents or their families about safe food storage and handling. Staff members, including the Admissions Coordinator, Activities Director, LVNs, CNAs, and others, either did not provide such education or were unaware of who was responsible for it. The facility's admission packet did not include information on safe food handling, and staff had not received in-service education on this topic. Observations showed that food brought in by family members was being stored in a refrigerator located in the employee lounge, which was not designated for resident use. The Administrator confirmed that there was no refrigerator available for residents' food and that residents were not supposed to store food in the facility. Additionally, a resident was observed keeping unlabeled, cooked sweet potatoes and peeled oranges at bedside at room temperature, which had been brought in by family the previous night. The resident stated that neither she nor her family had received education on safe food handling from the facility. Medical record reviews confirmed there was no documentation that education on safe food handling was provided to the resident or her family. Facility leadership, including the DON and ADON, acknowledged the lack of education and documentation. The Unit Manager also verified that food brought in by family should be consumed immediately or discarded, and not stored at bedside, but this practice was not followed.
Widespread Infection Control Failures and Lapses in Staff Practice
Penalty
Summary
The facility failed to maintain its infection prevention and control program as required, resulting in multiple deficiencies. The Infection Preventionist (IP) did not conduct infection control monitoring and surveillance for April 2025, including failing to review residents' antibiotic orders to determine if they met Loeb's or McGeer's Criteria for infection. This oversight led to antibiotics being administered without proper justification, as evidenced by a resident receiving antibiotics without meeting the necessary criteria. Additionally, the facility did not adhere to its Legionella Water Management Program, performing Legionella testing annually instead of the required quarterly frequency. Several lapses in infection control practices were observed among staff. One resident on contact enteric precautions for C. diff did not have proper hand hygiene protocols followed by visiting healthcare providers, who were misinformed about the type of isolation required. Staff were also observed storing personal cell phones in treatment carts, placing face shields on contaminated surfaces, and failing to don appropriate personal protective equipment (PPE) during high-contact care for residents on enhanced barrier precautions. Clean linen was transported in an uncovered cart, allowing it to come into contact with potentially contaminated surfaces. Medication administration practices were also deficient. Two LVNs did not follow proper hand hygiene procedures during medication passes, and the tip of an eye dropper touched a resident's eyelashes during administration, violating infection control policy. Additionally, a glucometer was found with red-brown smudges, indicating inadequate cleaning. These failures collectively posed a risk for the transmission of communicable diseases and infections within the facility.
Failure to Implement Antibiotic Stewardship Program and Timely Monitoring
Penalty
Summary
The facility failed to implement its antibiotic stewardship program by not conducting timely reviews of antibiotic use and not ensuring physician re-evaluation when antibiotics were prescribed for suspected infections that did not meet established criteria. Specifically, the Infection Preventionist (IP) did not review any of the 25 antibiotic orders placed in April 2025 for appropriateness, as required by facility policy. This lapse was confirmed during a review of the facility's antibiotic report and medical records, where it was found that at least one resident received a full course of antibiotics without meeting the criteria for appropriate use. Additionally, the IP did not notify physicians to re-evaluate the antibiotic therapy for two residents who were prescribed antibiotics for suspected infections that did not meet the necessary criteria. In both cases, the residents received the full course of antibiotics as ordered, and there was no documentation of physician notification or re-evaluation. These failures were identified through interviews, medical record reviews, and facility documentation, demonstrating a lack of adherence to the facility's antibiotic stewardship protocols.
Failure to Prevent Resident-to-Resident Physical Abuse Involving Rehabilitation Equipment
Penalty
Summary
The facility failed to protect a resident's right to be free from physical abuse when one resident struck another in the face with a rehabilitation dowel. The incident occurred when one resident, who was cognitively intact, was lying in bed watching television. His roommate became agitated over the television volume, verbally confronted him, and then physically assaulted him with a dowel. The assaulted resident experienced pain, swelling, and difficulty chewing as a result, and reported feelings of anger following the event. Documentation and interviews confirmed that the aggressor had a care plan in place for potential behavioral disturbances related to a diagnosis of schizoaffective disorder, with a history of physical aggressiveness and combativeness. The care plan included interventions to monitor for aggressive behaviors. Despite this, the resident was able to obtain a rehabilitation dowel without staff supervision, which was later confirmed by the occupational therapist to be against facility policy, as residents should not have access to such equipment without staff present. Staff interviews and medical record reviews indicated that the altercation was witnessed by a CNA, who intervened and confiscated the dowel. The facility's investigation substantiated that the resident was struck, and the physical evidence matched the account given by the resident. The facility's policies required the prevention of all types of abuse, but the lack of supervision and control over rehabilitation equipment contributed to the occurrence of this physical abuse.
Failure to Ensure Physician's Order Matched Resident's POLST DNR Status
Penalty
Summary
The facility failed to ensure that a physician's order for code status matched the resident's POLST (Physician Orders for Life-Sustaining Treatment) DNR status for one resident reviewed for advance directives. Specifically, a resident who lacked capacity to make decisions had a POLST form indicating Do Not Attempt Resuscitation (DNR), which was signed by the responsible party. However, there was no corresponding physician's order for the resident's code status at the time the POLST was signed by the responsible party. The physician did not sign the POLST until 55 days after the responsible party had signed it. Facility policy required staff to document the existence of advance directives, review them for completeness, confirm their currency with the resident or legal decision maker, and notify the treating physician to obtain appropriate orders. Interviews with staff, including the SSD and DON, confirmed that every resident should have a physician's order for code status and that the POLST must be signed by a physician to be effective. The absence of a timely physician's order for the resident's DNR status was verified through medical record review and staff interviews.
Failure to Maintain a Pest-Free, Homelike Environment
Penalty
Summary
A deficiency was identified when a resident was observed sitting on his bed eating breakfast, and a live pest, later identified as a water bug or roach, was seen on top of the resident's bed linen next to him. The incident was witnessed by a CNA, who attempted to remove the pest, which then moved onto the floor and was stepped on by the CNA. The resident expressed a preference for not having pests on his bed while eating. The presence of the pest was confirmed by a pest control technician, who identified it as either a water bug or roach after reviewing a photograph of the insect. The deficiency centers on the facility's failure to maintain a safe, clean, comfortable, and homelike environment for the resident, as evidenced by the presence of a live pest on the resident's bed during a meal.
Failure to Prevent Unnecessary Psychotropic Medication Use and Inadequate Monitoring
Penalty
Summary
The facility failed to ensure that three of five sampled residents were free from unnecessary psychotropic medications and that appropriate monitoring and documentation were in place. For one resident with a history of dementia and schizophrenia, the facility did not accurately monitor orthostatic blood pressure as ordered by the physician for the use of risperidone, an antipsychotic. The blood pressure readings recorded for lying, sitting, and standing positions were identical on multiple occasions, which was verified by the DON as not possible if the procedure was performed correctly. Additionally, there was no evidence that nonpharmacological interventions were attempted prior to the initiation of mirtazapine, an antidepressant, nor was there documentation of monitoring for side effects related to this medication. Another resident prescribed Seroquel for psychosis was also not properly monitored for orthostatic hypotension. The medical record showed that blood pressure readings for different positions were the same on several dates, which was confirmed by nursing staff and the DON as incorrect. The care plan for this resident included monitoring orthostatic blood pressure as an intervention, but the documentation did not reflect accurate or appropriate monitoring as required by the physician's orders. A third resident received multiple PRN orders for zolpidem tartrate, a sedative-hypnotic, with each order extending beyond the initial 14-day period. The facility's policy requires a documented clinical rationale from the prescribing physician for continued PRN use beyond 14 days, but the medical record did not contain such documentation for the extensions. The DON confirmed the absence of the required clinical rationale in the resident's record for the continued use of zolpidem tartrate.
Failure to Provide Timely MRI Results to Physician as Ordered
Penalty
Summary
The facility failed to ensure that a physician's recommendation was carried out as ordered for a resident who required follow-up on MRI results. The resident had an MRI of the brain and cervical spine performed, which indicated a possible mass in the neck area. The physician had recommended that the MRI results be brought to the next neurology clinic appointment. However, the MRI results were not available for review at the neurology appointment, as the results had not been provided to the ordering physician in a timely manner. Documentation showed that the MRI was completed, but the results were not uploaded to the resident's medical record until several months later, and the request for the MRI results was made long after the imaging was performed. Interviews with facility staff revealed that there was a lack of follow-up to ensure the MRI results were sent to the appropriate physician. The case manager did not retain documentation of the request for imaging results and did not verify whether the results were sent to the physician's office. Additionally, there was a language barrier with the summary visit report, which was written in Spanish, and the process for translation and follow-up was not consistently followed. The Director of Nursing and Administrator acknowledged that the expected process for handling physician orders and documentation was not adhered to in this case.
Failure to Provide Ordered Nutritional Supplement with Meals
Penalty
Summary
A deficiency occurred when a resident with no capacity to understand and make decisions, who had a physician's order to receive a four-ounce health shake three times daily with meals, did not receive the ordered supplement. Medical record review confirmed the order was in place, and observations on two separate occasions showed that the health shake was not present on the resident's meal tray, despite being listed on the meal ticket. Interviews with CNAs confirmed that the health shake was missing from the tray during both lunch and breakfast. The Director of Nursing also verified that the resident had not been receiving the health shakes as ordered.
Failure to Maintain and Document Proper Respiratory Care and Equipment
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for several residents by not adhering to its own policies and procedures regarding the maintenance and administration of respiratory equipment and therapy. Multiple residents were found with respiratory equipment, such as nebulizer masks, oxygen tubing, and storage bags, that had not been changed or labeled according to the facility's policy, which required weekly changes and proper labeling for infection control. For example, storage bags for nebulizer masks for several residents were observed to be dated well beyond the required seven-day change interval, and some were not labeled with the resident's name or the date. In addition, a nasal cannula was found improperly stored, hanging from a portable oxygen tank instead of being kept in a clean bag, and some respiratory bags were not replaced or labeled as required. Further deficiencies were identified in the administration and documentation of oxygen therapy. One resident was observed receiving oxygen therapy without a physician's order or documentation in the Medication Administration Record (MAR), contrary to the facility's policy that oxygen is a drug requiring a physician's order and proper documentation. Staff interviews confirmed the absence of the required order and documentation, and staff were unable to provide a reason for the administration of oxygen to the resident. Other residents had physician orders for respiratory treatments, but the associated equipment was not maintained or changed as per policy, and staff acknowledged these lapses during interviews. The facility's own policies, as reviewed by surveyors, specified that respiratory equipment should be changed weekly and as needed, and that oxygen therapy must be ordered by a physician and documented in the resident's file. Despite these clear guidelines, observations and staff interviews revealed that these procedures were not consistently followed, leading to deficiencies in infection control and proper respiratory care for multiple residents. The Director of Nursing and other administrative staff acknowledged these findings during interviews.
Failure to Administer Pain Medication According to Physician's Order
Penalty
Summary
The facility failed to provide adequate and appropriate pain management for a resident who required such services. Specifically, a physician's order directed that tramadol HCL 50 mg be administered by mouth every six hours as needed for severe pain rated 7-10 on a 0-10 pain scale. However, medical record review showed that the medication was administered when the resident's pain level was documented as six, which did not meet the criteria specified in the physician's order. This discrepancy was verified by the Assistant Director of Nursing (ADON) during an interview and concurrent record review, and was acknowledged by the Director of Nursing (DON) upon review of the findings. The failure to follow the physician's order for pain medication administration resulted in the resident receiving tramadol HCL outside the prescribed pain level parameters.
Deficiencies in Pharmaceutical Services and Medication Management
Penalty
Summary
The facility failed to provide necessary pharmaceutical services to meet the needs of several residents, as evidenced by multiple deficiencies in medication management and administration. For one resident, hydromorphone, a controlled medication, was signed out on the Controlled Medication Count Sheet on several occasions, but there was no documentation in the Medication Administration Record (MAR) to confirm that the medication was actually administered. The Unit Manager confirmed that staff are required to document administration of controlled medications on both the MAR and the Controlled Medication Count Sheet, but this was not done for the specified dates and times. Additionally, the facility did not ensure timely removal of unused or discontinued controlled medications from medication carts for three residents. In these cases, controlled medications such as hydrocodone/APAP and lorazepam were found in the medication carts with no active physician orders, and the medications had not been administered. The Unit Manager verified that these medications remained in the carts despite the orders being discontinued, and the corresponding Controlled Medication Count Sheets reflected that the medications were not used. There were also failures in medication administration practices. During a medication pass, a nurse was observed leaving a resident's medications unattended on the bedside table on two separate occasions while leaving the room to retrieve supplies. The nurse acknowledged that medications should never be left unattended. Furthermore, another resident received a blood pressure medication despite the resident's systolic blood pressure being above the physician-ordered hold parameter. The nurse who administered the medication confirmed that the medication should not have been given under those circumstances.
Failure to Monitor for Antidepressant Side Effects
Penalty
Summary
The facility failed to ensure that medication side effects were monitored for a resident who was prescribed mirtazapine, an antidepressant. According to the facility's policy, the consultant pharmacist is required to perform a comprehensive monthly medication regimen review (MRR) for each resident, including evaluating responses to medication therapy and documenting any irregularities or clinically significant risks. For one resident with a history of dementia and no capacity to make medical decisions, there was a physician's order for mirtazapine to address depression and poor appetite. However, there was no corresponding physician's order to monitor for side effects of mirtazapine, and the medication administration records (MARs) did not show any documentation that side effects were being monitored. Interviews with the DON and the consultant pharmacist confirmed that monitoring for medication side effects should have occurred, but the consultant pharmacist was unaware that this monitoring was not being performed for the resident. The deficiency was acknowledged by both the Administrator and the DON during interviews, and the lack of monitoring was verified through medical record review.
Failure to Ensure Resident Drug Regimen Was Free from Unnecessary Medications
Penalty
Summary
A deficiency was identified in the facility's medication management for one resident who was found to have a physician's order for clonidine, a medication used to treat hypertension, without an active diagnosis of hypertension documented in the medical record. The order specified administration of clonidine as needed for systolic blood pressure (SBP) greater than 160 mmHg, but the resident's medical records from February to May did not show any SBP readings above this threshold, nor was the medication administered during this period. Additionally, the resident was determined to lack capacity to make medical decisions. The same resident was also prescribed sodium chloride 250 mg daily as a supplement, and was administered this medication consistently from February to May. However, laboratory results showed the resident's sodium levels were below the normal range, with the last recorded sodium level at 132 mEq/L on 3/31, and no further sodium monitoring was documented after this date. The Director of Nursing confirmed that no additional sodium level testing had been performed following the abnormal result.
Medication Error Rate Exceeds Regulatory Threshold Due to Multiple Administration Failures
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, as required by regulation and its own policies. During medication administration observations, eight errors were identified out of 30 opportunities, resulting in a 26.67% error rate. Three licensed nurses were involved in these errors, which affected one sampled resident and two non-sampled residents. The errors included improper administration of medications via gastrostomy tube (GT), failure to administer prescribed medications, and administration of medications not ordered by the physician. One nurse did not follow physician orders for a resident receiving medications via GT. The nurse failed to dilute potassium chloride as ordered, did not administer medications separately, and did not flush the GT between medications, contrary to both physician orders and facility policy. Medication residue was observed in cups, and the nurse confirmed the medications were not supposed to be combined. The nurse also acknowledged not diluting the potassium chloride as required, despite the physician's explicit instructions. Another nurse administered a different brand of artificial tears than what was ordered for a resident, without verifying if the ingredients matched the prescribed medication. A third nurse administered calcium without vitamin D to a resident, despite the physician's order specifying a combination of calcium with vitamin D. The nurse confirmed the correct medication was not available in the cart at the time and acknowledged administering a medication not ordered by the physician. Facility leadership was informed of these findings and acknowledged the deficiencies.
Failure to Follow Menus and Serve Correct Diet Portions
Penalty
Summary
The facility failed to ensure that menus were followed and that residents received the correct diets and portion sizes as specified. Specifically, 133 out of 137 residents who received food from the kitchen were affected when the posted Vietnamese menu was not the one being used, and the new Vietnamese menu in use was not posted or communicated to residents. During observation, the meals served did not match the posted menu, and the Dietary Services Supervisor (DSS) confirmed that the new menu had not been made available to residents. Additionally, kitchen staff did not use the correct scoop sizes or serve the correct portions as outlined in the facility's menu and menu spreadsheet. For example, staff used smaller or larger scoops than required for various menu items, and did not provide the correct number of items (such as pork balls) per the menu instructions. The DSS verified that incorrect scoop sizes were used for both American and Vietnamese menu items, resulting in residents not receiving the prescribed portions.
Pureed Food Nutrient Loss Due to Prolonged Holding on Steam Table
Penalty
Summary
The facility failed to ensure the nutritive content of pureed foods, specifically the pureed stir fry vegetables on the Vietnamese menu, was preserved for residents requiring a pureed diet. Observations and interviews revealed that the pureed vegetables were prepared at 9:45 AM and placed on the steam table, where they remained for approximately two hours before being served at lunchtime. The steam table was maintained at temperatures exceeding 170 degrees F, and food temperature logs confirmed that the pureed vegetables were held at high temperatures for an extended period. This process was acknowledged by dietary staff and the Dietary Services Supervisor (DSS), who confirmed that the pureed foods were held on the steam table significantly longer than the intended 30 minutes prior to trayline. Facility documentation showed that five residents receiving the Vietnamese menu required a pureed diet, and these residents were directly affected by the preparation and holding practices. Reference materials reviewed by surveyors indicated that prolonged cooking and holding at high temperatures can reduce the nutrient content of foods, particularly water-soluble and fat-soluble vitamins and certain minerals. The DSS acknowledged that the practice of preparing and holding pureed vegetables for two hours prior to service could decrease their nutritive value, potentially impacting the nutritional needs of the affected residents.
Inaccurate MDS Assessments for Diagnoses and Medication Use
Penalty
Summary
The facility failed to ensure the accuracy of Minimum Data Set (MDS) assessments for two residents, resulting in incorrect coding of active diagnoses and medication use. For one resident, the MDS assessment did not reflect active diagnoses of hypertension, hyponatremia, and depression, despite medical records and physician orders indicating these conditions. The assessment also failed to accurately document the use of antidepressant medication and incorrectly recorded the date of the last attempted gradual dose reduction (GDR) for antipsychotic medication. The MDS Coordinator confirmed these discrepancies, noting that some orders may have been carried over from a hospital stay without proper medical indication and that laboratory results were misinterpreted when coding the diagnosis of hyponatremia. Another resident's MDS assessments were also found to be inaccurate, as they did not include documented diagnoses of anxiety disorder and major depressive disorder, despite these being present in the resident's medical history and physician notes. The assessments showed the resident was cognitively intact but failed to code the relevant psychiatric diagnoses in Section I of the MDS. The MDS Coordinator acknowledged that these diagnoses should have been included as soon as they were documented by the physician or on the next assessment. Interviews with the MDS Coordinator, Administrator, and Director of Nursing confirmed the findings and acknowledged the inaccuracies in the MDS assessments. These failures had the potential to impact the provision of necessary care and services to meet the residents' needs, as the assessments did not accurately reflect their current medical conditions and medication use.
Failure to Coordinate PASARR Assessment After New Mental Health Diagnoses
Penalty
Summary
The facility failed to coordinate an assessment with the Pre-Admission Screening and Resident Review (PASARR) program for a resident who had newly documented diagnoses of anxiety disorder and major depressive disorder. Medical record review showed that the resident's history and physical examinations reflected these mental health conditions, but the PASARR Level I screening completed did not indicate the presence of a serious diagnosed mental disorder. Additionally, there was no evidence that a new PASARR was completed after the new diagnoses were made. The resident's care plan included interventions requiring a Level I or Level II PASARR review for any new diagnosis warranting such assessment, as well as annual reviews if required. During interviews, the MDS Coordinator confirmed that a new PASARR should have been submitted following the new diagnoses, and both the Administrator and DON acknowledged the findings. This lapse resulted in the resident not being properly assessed for specialized services related to mental illness.
Inaccurate PASARR Level I Screening for Mental Illness
Penalty
Summary
The facility failed to ensure that the Level I PASARR screening for a resident accurately reflected the presence of serious mental illness. The resident in question was admitted and readmitted with diagnoses including unspecified psychosis, schizophrenia, and anxiety disorder. However, the PASARR Level I Screening completed for this resident indicated that there was no diagnosis of a serious mental disorder, such as depressive disorder, anxiety disorder, panic disorder, schizophrenia, or symptoms of psychosis, delusions, or mood disturbance. As a result, the screening was marked negative and a Level II evaluation was not conducted. During interviews and medical record reviews, the MDS Coordinator confirmed that the PASARR Level I Screening was inaccurate for this resident. The Administrator and DON were also informed and acknowledged these findings. The deficiency centers on the failure to accurately complete the PASARR Level I Screening, which is required to identify individuals with serious mental illness or intellectual disabilities for appropriate placement and further evaluation.
Failure to Develop Care Plan for Resident's Leave of Absence
Penalty
Summary
The facility failed to develop a comprehensive care plan addressing a resident's ability to leave the facility under a physician's 'out on pass' order. The resident had physician orders allowing them to leave the facility for up to four hours and, later, to go out on pass with a responsible party. However, the resident's medical record did not include the name or contact information for the responsible party, nor did it contain a care plan specific to the resident's out on pass status. On review of facility documentation, it was found that the resident had left the facility on pass, as recorded in the Release of Responsibility for leave of absence log. During an interview and concurrent medical record review, an RN confirmed that the resident's medical record lacked information about the responsible party and that no care plan had been developed to address the resident's ability to leave the facility. This omission was verified by the RN during the review.
Failure to Provide Physician-Ordered Therapeutic Diets
Penalty
Summary
The facility failed to ensure that two residents received diets as ordered by their physicians. For one resident, a review of the medical record and direct observation revealed that the lunch tray did not include soup, despite a physician's order specifying a fortified, pureed diet with soup at lunch and dinner. Both a CNA and an LVN confirmed that the soup was missing from the tray, and the resident's orders were not followed as written. For another resident, who was at risk for aspiration and excessive weight loss due to dysphagia, the lunch tray included soup that was not pureed, contrary to the physician's order for a pureed, honey-thick consistency diet. Additionally, the tray did not include the required extra entree. Staff interviews and medical record reviews confirmed that the resident should have received all items in pureed form and a double portion of the entree, as ordered. The DON stated that licensed nurses were responsible for checking trays to ensure compliance with diet orders, but this process failed to prevent the deficiencies.
Deficient Medical Record Documentation and Incomplete Advance Directive Forms
Penalty
Summary
The facility failed to maintain accurate and complete medical records for several residents, resulting in multiple documentation deficiencies. For one resident with Type 2 Diabetes Mellitus, blood sugar levels were not documented in the medical record prior to the administration of insulin glargine, despite a physician's order requiring this information and instructions to notify the physician if levels were outside specified parameters. The licensed nurse administering the insulin confirmed that blood sugar checks were performed but not documented in either the Medication Administration Record (MAR) or progress notes, and the Director of Nursing (DON) stated that such documentation was expected. In another instance, a resident's Physician Orders for Life-Sustaining Treatment (POLST) form was incomplete, with Section D regarding advance directives left blank, and there was no evidence in the medical record indicating whether the resident or their responsible party wanted more information on advance directives. Additionally, another resident's POLST form lacked the required physician signature and date, which was verified by the Social Services Director (SSD) as missing. For a deceased resident, the Record of Death form was incompletely filled out, missing documentation of personal articles taken and lacking the DON's signature, and the discharge section of the resident's Clothing and Possession form was left blank, leaving uncertainty about the disposition of the resident's dentures. Furthermore, a resident's medication administration record showed that midodrine, a blood pressure medication, was documented as administered even when the resident's systolic blood pressure exceeded the physician-ordered threshold for holding the medication. The nurse responsible confirmed that the medication was actually held, and the MAR was incorrect. These documentation failures were acknowledged by facility staff during interviews and had the potential to result in inaccurate medical information for residents.
Failure to Monitor Effectiveness of QAPI Plan of Correction
Penalty
Summary
The facility failed to ensure that its Quality Assurance Performance Improvement (QAPI) committee implemented and monitored the effectiveness of its plan of correction for previously cited deficiencies at F695, F761, F842, and F880. According to the facility's QAPI Program, the committee is responsible for developing monitoring tools, creating plans of correction, and evaluating the effectiveness of corrective actions. The plan of correction submitted after the last recertification survey outlined specific responsibilities for the DON, SSD, and IP or their designees to review compliance data and bring results to monthly QAPI meetings for a set period. During an interview and document review with the Administrator and DON, it was found that there was no documentation to show that the QAPI committee had monitored the effectiveness of the corrective actions for the cited deficiencies. This lack of documentation indicated that the committee did not follow through with the required monitoring and evaluation processes as outlined in their own policies and the submitted plan of correction.
Failure to Monitor Fluid Restriction for Dialysis Resident
Penalty
Summary
The facility failed to monitor and document the daily fluid intake for a resident with end-stage renal disease (ESRD) who required dialysis treatments at an outpatient center. The resident had a physician's order for a fluid restriction of 1500 ml per 24 hours, which was to be divided between the dietary and nursing departments. However, the medical record review revealed a lack of documented evidence that the resident's daily fluid intake totals were monitored and recorded as ordered. During interviews, LVN 2 was unable to provide documentation of the fluid intake monitoring, and RN 1 acknowledged the findings. The failure to adhere to the physician's fluid restriction order had the potential to result in fluid overload, which could lead to adverse health outcomes for the resident, such as shortness of breath, high blood pressure, and cardiac issues.
Failure to Implement Individualized Care Plan for PICC Line Management
Penalty
Summary
The facility failed to develop and implement an individualized care plan for a resident who was admitted with a PICC line in the right upper arm. The care plan, titled 'Potential for Infection related to the right upper arm PICC line,' was initiated by an RN but lacked specific orders to change the catheter site dressing and to measure the PICC line's external catheter length and upper arm circumference. This omission posed a risk for the resident to develop complications associated with the PICC line. During a review of the resident's medical records, it was found that there was no documentation indicating that the catheter site dressing was changed or that measurements of the PICC line's external catheter length and upper arm circumference were obtained while the resident was in the facility. The RN verified these omissions during an interview and concurrent medical record review, confirming the facility's failure to adhere to its policy of developing a comprehensive care plan in conjunction with the resident and their representative.
Failure to Document and Maintain PICC Line Leads to Resident Complications
Penalty
Summary
The facility failed to ensure proper care and documentation for a resident with a Peripherally Inserted Central Catheter (PICC) line, leading to significant health complications. The facility's policies and procedures required regular assessments and documentation of the PICC line, including measuring the arm circumference and flushing unused lumens. However, these protocols were not followed for a resident who was admitted with a PICC line in the right upper arm. The medical record lacked documentation of the necessary assessments and maintenance, such as arm circumference measurements, PICC external catheter length, and flushing of unused lumens. The resident, who was admitted with a PICC line, showed signs of complications, including slight swelling in the right upper arm. Despite the care plan indicating a potential for infection and the need for regular assessments, the facility did not document any shift assessments or maintenance activities. This oversight resulted in the resident developing an occlusive right axillary deep vein thrombosis, as confirmed by a radiology report. The resident's condition worsened, with symptoms including redness, edema, and pain in the right arm, leading to a transfer to an acute care hospital where a pulmonary embolism was diagnosed. Interviews with the facility's RN and DON confirmed the lack of documentation and adherence to the established protocols. Additionally, a licensed nurse failed to conduct and document a change of condition assessment when the resident's family reported pain and swelling in the right arm. This failure to act and document appropriately contributed to the resident's deteriorating condition and subsequent hospitalization.
Failure to Administer Medications as Ordered and Notify Physician
Penalty
Summary
The facility failed to ensure that a resident's medications were administered as ordered by the physician, resulting in significant medication errors. The resident did not receive enoxaparin sodium, levetiracetam, desmopressin acetate, and methocarbamol due to a lack of availability. The facility's policy requires that medications be administered as prescribed and that any unavailability be communicated to the attending physician. However, the facility did not notify the resident's physician about the unavailability of these medications, which is a violation of their policy. The medical record review and interviews revealed that the resident's medications were not administered on specific dates and times, and there was no documentation indicating that the physician was informed of this issue. An LVN confirmed that she did not notify the physician about the missed medications, acknowledging that she should have done so to prevent potential complications. The physician also confirmed that he was not informed about the missed medications, which hindered his ability to make necessary treatment decisions.
Infection Control Lapses in Housekeeping Practices
Penalty
Summary
The facility failed to adhere to infection control practices during the cleaning of resident rooms, as observed in the actions of Housekeepers 1 and 2. Housekeeper 1 was seen cleaning multiple resident rooms without wearing a gown, despite the presence of Enhanced Barrier Precautions (EBP) signage, which mandates gown usage during high-contact activities. Additionally, Housekeeper 1 used the same washcloth to clean multiple surfaces within the same room, such as tray tables, nightstands, and call lights, without changing the cloth between different residents' equipment. This practice was observed in rooms housing Residents 1 through 9. Furthermore, Housekeeper 1 used a toilet bowl brush to clean both the toilet seats and bowls, which is against the facility's infection control protocol. The housekeeper also neglected to clean the restroom grab bars in shared restrooms, which are high-contact surfaces. These actions were confirmed during an interview with Housekeeper 1, who admitted to using the same cloth for different surfaces and forgetting to clean the grab bars. Housekeeper 2 also failed to follow infection control protocols by not wearing a gown while cleaning a room with EBP signage and using a single washcloth to clean multiple surfaces for Residents 10, 11, and 12. The Environmental Services Supervisor and the Infection Preventionist both confirmed that the housekeeping staff should not use the same cloth for different residents' equipment and should always wear a gown in rooms with EBP signage. These lapses in protocol had the potential to spread infections among the residents.
Deficiencies in Kitchen Staff Competency and Food Safety Practices
Penalty
Summary
The facility failed to ensure that kitchen staff were competent in their duties, leading to several deficiencies in food safety and sanitation practices. Three of the eleven kitchen staff members did not follow proper hand hygiene protocols, as they were observed changing gloves without washing their hands in between. This was despite the facility's policy requiring hand washing after glove removal and handling soiled items. The facility's Certified Dietary Manager (CDM) was unable to provide evidence of recent in-service training on hand hygiene, which contributed to these lapses. Additionally, two kitchen staff members demonstrated a lack of knowledge and monitoring of the cool down procedures for time/temperature control for safety (TCS) foods. The staff failed to record the cooling process of TCS foods, such as tuna salad and partially cooked chicken, on the cooling log. Interviews revealed that the staff were unaware of the correct temperature requirements for cooling TCS foods, and the CDM could not provide documentation of training on this process within the past year. Furthermore, one kitchen staff member did not sanitize food preparation surfaces properly, using a paper towel instead of a cloth stored in a sanitizing solution. Another staff member was unable to demonstrate knowledge of dish machine procedures, including checking rinse cycle temperatures and testing sanitizing solutions. The CDM admitted that new employees were deemed competent after three weeks without documented training or competency assessments. These failures in training and competency had the potential to lead to unsafe food handling practices, posing a risk of foodborne illness to the facility's residents.
Failure to Preserve Nutritive Content of Pureed Foods
Penalty
Summary
The facility failed to ensure the nutritive content of pureed foods for the American menu, specifically the pureed vegetables, was preserved. This deficiency was identified through observation, interview, and document review. The pureed vegetables, particularly green peas, were cooked and held in a hot oven for more than one hour prior to meal service, which potentially compromised their nutritional value. The process involved cooking the peas in hot water, pureeing them, and then placing them in an oven at 450 degrees Fahrenheit until the lunch meal tray line began. This practice had the potential to not meet the nutritional needs of the 23 residents who received an American menu pureed diet. The Registered Dietitian (RD) confirmed that pureed foods should be cooked in a manner that preserves their nutritive value.
Food Safety and Sanitation Deficiencies in Kitchen Operations
Penalty
Summary
The facility failed to adhere to food safety and sanitation guidelines, posing a risk of foodborne illnesses to its residents. The cool down process for time and temperature control for safety (TCS) food was not monitored, as evidenced by partially cooked chicken and tuna salad not being properly logged or cooled according to USDA Food Code standards. The Registered Dietitian (RD) and Certified Dietary Manager (CDM) confirmed that the time and temperature of partially cooked or heated food were not monitored, and the cooling log was not checked during monthly audits. Food preparation surfaces were not sanitized properly, with staff using paper towels instead of cloths stored in sanitizing solutions, contrary to the facility's policy. Additionally, the thawing process for meats was not followed, with discrepancies in the dates and methods used for thawing various meats. The RD and CDM acknowledged that the thawing process was not consistent with the facility's policy, and there was confusion among staff regarding the correct procedures. Hand washing protocols were not followed by several kitchen staff members, who failed to wash their hands between glove changes. Food preparation equipment and the kitchen environment were not maintained in a clean condition, with residues found on various surfaces and equipment. Hair restraints were not worn properly by several kitchen employees, and the kitchen floor was not in a cleanable condition. Furthermore, the ice machine and a food preparation sink lacked the required air gap, increasing the risk of contamination.
Infection Control and Sanitation Deficiencies in LTC Facility
Penalty
Summary
The facility failed to implement its infection prevention and control program according to its policies and procedures. The infection control surveillance program was not accurately maintained for May 2024, as it only included residents who exhibited signs and symptoms of infection and were prescribed antimicrobial medications. The Infection Preventionist (IP) acknowledged that the surveillance data collection forms for certain residents were inaccurate and did not meet McGeer's criteria for a true infection. Additionally, there was a lack of infection control data for the months of January, February, and March 2024, which the IP could not account for. The facility also failed to maintain sanitary conditions in several areas. Clean linen was improperly stored in the laundry room, with freshly washed linen touching used gowns, dusty fans, and personal items such as jackets and water bottles. Furthermore, the facility did not ensure that indwelling urinary catheter drainage bags for two residents were kept off the floor, and staff failed to don gowns when providing catheter care, despite enhanced barrier precautions being in place. Additional deficiencies included improper disposal of trash, with overflowing bins in the shower room, and failure to perform hand hygiene before and after medication administration. During a narcotic count, a nurse was observed counting medication tablets on a piece of paper with a spoon, indicating a lack of sanitary practices. These failures posed a risk for the transmission of communicable diseases to other residents in the facility.
Deficiencies in Equipment Maintenance and Safety
Penalty
Summary
The facility failed to maintain essential equipment in safe operating condition, as evidenced by several deficiencies observed during a survey. The ice machine was not cleaned and sanitized according to the manufacturer's specifications. The Maintenance Director admitted to cleaning the ice machine once a month using an incorrect method, which involved using undiluted scale remover and sanitizer, contrary to the manufacturer's guidelines. This improper cleaning process was confirmed by the Registered Dietitian (RD), who acknowledged that the manufacturer's instructions should be followed. Additionally, the dish machine was found to be operating below the required temperatures for both the wash and rinse cycles. Observations showed that the wash temperature was 100 degrees Fahrenheit and the rinse temperature was 108 degrees Fahrenheit, both below the manufacturer's specified minimum of 120 degrees Fahrenheit. The Maintenance Director suggested that the water needed to run for a few minutes to reach the required temperatures, indicating a failure to ensure the dish machine was functioning correctly. Other deficiencies included a metal screen door in the kitchen that was not flush with the door jamb, creating a gap, and a screen above a food preparation counter that was bent and torn. Furthermore, a fire sprinkler in the walk-in refrigerator had a brown residue resembling rust and was not intact with the ceiling. The Maintenance Director confirmed these issues, acknowledging that the screen door had been problematic since he started working at the facility two years ago and that the fire sprinkler needed replacement.
Failure to Obtain Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to obtain informed consent prior to administering psychotropic medications to two residents, which is a violation of their own policy on Psychotropic Medication Management. Resident 32, who had the capacity to make medical decisions, was administered iloperidone without proper informed consent. Although the resident signed a consent form for other medications, the iloperidone was added after the form was signed, and the prescribing physician had not signed the consent form. This oversight was confirmed during interviews with the Assistant Director of Nursing (ADON), the Medical Records Director, and Resident 32, who expressed concerns about the antipsychotic medication. Similarly, Resident 540, who also had the capacity to understand and make decisions, was administered lorazepam without an informed consent form being present in their medical record. The medication was given on two occasions, and the Medical Records Director confirmed that while a consent form existed in the office, it had not been signed by the prescribing physician or uploaded to the resident's electronic health records. The ADON verified the absence of the informed consent in the medical record during the review. These deficiencies indicate that the facility did not adhere to its policy requiring informed consent for psychotropic medications, potentially leaving residents uninformed about the medications and their side effects. The lack of signed consent forms and the failure to update electronic health records contributed to these deficiencies, as confirmed by staff interviews and medical record reviews.
Failure to Assess Resident for Safe Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that it was safe for a resident, identified as Resident 95, to self-administer medications. During an observation, medications were found at the bedside of Resident 95 without a physician's order, assessment, or care plan for self-administration. The facility's policy requires a licensed nurse to complete a Self-Administration Assessment Review, which must be approved by the IDT, before allowing a resident to self-administer medications. However, this procedure was not followed for Resident 95, who was observed with medications at the bedside and reported that nurses usually left medications for her to take later. Further investigation revealed that Resident 95 had a moderate cognitive impairment and no documentation in the medical record indicated a physician's order or assessment for self-administration of medications. Interviews with facility staff confirmed that Resident 95 did not have the necessary approvals or assessments in place. The failure to adhere to the facility's policy for self-administration of medications posed a risk of inaccurate medication administration for Resident 95.
Inaccessible Call Lights Compromise Resident Dignity
Penalty
Summary
The facility failed to ensure the dignity and respect of residents by not providing accessible call lights for three residents. The facility's policy and procedure (P&P) titled 'Call light: Accessibility and Timely response' required staff to ensure call lights were within reach of residents. However, observations revealed that the call lights for Residents 81, 96, and 540 were not accessible. Resident 81's call light was found on the floor during multiple observations, and a Certified Nursing Assistant (CNA) confirmed it should not be there. Resident 96's call light was hanging on the wall and later found on the floor, which the Licensed Vocational Nurse (LVN) acknowledged should be within reach. Resident 540's call light was under her pillow, out of reach, and this was verified by another LVN. The medical records and care plans for these residents indicated that they required assistance with activities of daily living (ADL) and had the capacity to understand and make decisions. Despite these needs, the facility did not adhere to its own P&P, resulting in the call lights being inaccessible. This oversight had the potential to delay care and negatively impact the residents' psychosocial well-being, as they were unable to summon assistance when needed.
Failure to Accurately Document and Honor Resident's Code Status
Penalty
Summary
The facility failed to accurately identify and honor the code status of a resident, referred to as Resident 32, which led to a significant discrepancy in her medical records and care instructions. Resident 32, who had the capacity to make medical decisions, expressed her desire to be a full code, meaning she wished to receive full cardiopulmonary resuscitation (CPR) in the event of cardiac or respiratory arrest. However, during a transfer to an acute care hospital, the facility staff incorrectly informed the ambulance personnel that she was a Do Not Resuscitate (DNR), based on a POLST form that was not signed by Resident 32 but by another individual unrelated to her. The medical records review revealed inconsistencies in Resident 32's POLST forms and care plans. One POLST form indicated a full code status, while another, incorrectly signed by someone else, indicated a DNR status. The facility's social services department and medical records department failed to ensure the accuracy and proper documentation of Resident 32's code status. The SSD admitted to initiating a care plan that incorrectly reflected Resident 32's wishes, and the Medical Records Director acknowledged keeping an outdated POLST form in the medical records office, which contributed to the confusion. Interviews with facility staff, including RN 3 and the SSD, confirmed the errors in communication and documentation regarding Resident 32's code status. The staff failed to verify and update the resident's POLST form in the electronic health record, leading to the incorrect assumption of her DNR status during her hospital transfer. This oversight had the potential to result in care that was not aligned with Resident 32's treatment preferences, causing her distress and fear.
Deficiencies in Medication Administration and Nutritional Support
Penalty
Summary
The facility failed to provide necessary care and services for two residents, leading to deficiencies in their treatment. For one resident, the facility did not follow the physician's order to administer Vancomycin intravenously at the correct infusion rate. The medication was supposed to be infused at 177 ml per hour, but the nurse set the flow regulator at 150 ml per hour due to the absence of an electronic infusion pump. This discrepancy in the infusion rate was confirmed by the nurse during an interview and medical record review. Another resident did not receive a prescribed health shake with their meals, as ordered by the physician. During a lunch meal observation, it was noted that the resident's meal tray did not include the health shake, which was confirmed by a staff member. This omission posed a risk of inadequate caloric intake for the resident, potentially leading to weight loss.
Inaccurate Monitoring of Resident's Hydration Status
Penalty
Summary
The facility failed to accurately monitor the hydration status of Resident 539, which included inadequate documentation of fluid intake and output. The facility's policy and procedure for monitoring intake and output, dated August 2014, required nursing personnel to record intake and output when necessary to evaluate hydration status. However, the facility did not ensure that Resident 539's fluid intake from meals, medication administration, free water, liquid supplements, IV hydration, and IV flushes was accurately documented. Additionally, the facility failed to monitor the actual urine output from Resident 539's indwelling catheter, recording only the frequency of voiding instead. Resident 539 had several physician's orders related to fluid management, including monitoring intake and output every shift and notifying the physician for signs of dehydration or fluid volume overload. Despite these orders, the medical record review revealed discrepancies in the documentation of daily fluid intake and output. For instance, the daily totals for fluid intake and output recorded in the MAR did not reflect the actual amounts consumed or voided by the resident. Interviews with facility staff, including a CNA, LVN, and RN, confirmed that the documentation did not accurately capture Resident 539's fluid intake and output. The interviews further revealed that CNAs reported fluid intake and output to LVNs, who were responsible for documenting this information in the MAR. However, the MAR did not show accurate monitoring of Resident 539's daily fluid intake and actual urine output. The RN verified that the fluid intake should have included all sources, such as meals, medication administration, and IV therapy, but the records did not reflect this. These failures in documentation and monitoring had the potential to compromise Resident 539's hydration status and posed a risk for negative health outcomes.
Deficiencies in IV Access Care and Documentation
Penalty
Summary
The facility failed to provide necessary care and services for maintaining intravenous accesses for two residents, Resident 12 and Resident 539. For Resident 12, the facility did not perform or document the required measurements of the PICC line's external catheter length and arm circumference upon admission. This oversight was confirmed during an interview with RN 1, who acknowledged the absence of documentation and stated that such assessments should have been conducted upon admission and weekly thereafter. The facility's policy required these measurements to be documented, but this was not adhered to in Resident 12's case. For Resident 539, the facility similarly failed to measure and document the external catheter length and arm circumference as per the resident's plan of care. Additionally, the midline catheter dressing was observed to be soiled with dried blood and was not labeled or dated, which was against the facility's guidelines. RN 1 confirmed these findings and acknowledged that the necessary measurements and documentation were not completed. The dressing was supposed to be changed weekly, but there was no evidence of this being done or documented. These deficiencies in care had the potential to delay the identification of catheter-related complications for both residents. The facility's policies and procedures required regular assessments and documentation to ensure the safe administration of IV fluids and to monitor for potential complications, but these were not followed, leading to the identified deficiencies.
Deficiencies in Respiratory Care for Residents
Penalty
Summary
The facility failed to provide appropriate respiratory care for five residents, leading to several deficiencies. Resident 8 was administered oxygen without a physician's order or a care plan to monitor oxygen use and saturation levels. This oversight was confirmed by a CNA and an LVN, who acknowledged the absence of documentation and the need to inform the physician about the resident's oxygen use. Residents 12 and 86 had issues with their oxygen equipment. Resident 12's nasal cannula tubing was found undated, unlabeled, and on the floor, with no physician's order for oxygen therapy. Similarly, Resident 86's oxygen tubing was undated and unlabeled, and the tubing was improperly placed on the wheelchair handle. These findings were verified by nursing staff, who confirmed the equipment should have been labeled and stored properly. Residents 16 and 79 also experienced deficiencies in respiratory care. Resident 16's CPAP mask was not stored in a bag when not in use, contrary to facility policy. Resident 79's oxygen tubing and humidifier were not labeled or dated, and the CPAP mask was improperly stored. These issues were acknowledged by the facility's nursing staff and administration, who confirmed the equipment should have been labeled and stored according to policy.
Medication Administration and Documentation Deficiencies
Penalty
Summary
The facility failed to provide adequate pharmaceutical services to meet the needs of its residents, as evidenced by multiple medication administration errors and lack of proper documentation. For Resident 7, the facility did not administer medications such as carvedilol, losartan, and furosemide according to the physician's orders, resulting in the administration of carvedilol when the resident's systolic blood pressure (SBP) was below the specified threshold. Additionally, the facility did not provide insulin coverage for blood sugar levels between 351-401 mg/dl and lacked a physician's order for intervention when blood sugar levels fell below 70 mg/dl. Resident 23 also experienced deficiencies in medication management. The facility failed to clarify the parameters for administering Glucose Oral Gel 40% and did not include coverage for blood sugar levels between 71-149 mg/dl in the insulin sliding scale order. Furthermore, the facility did not clarify the parameters for holding lisinopril and failed to administer metoprolol as ordered by the physician, despite the resident's blood pressure and pulse being within the parameters for administration. The facility also demonstrated a lack of proper documentation and adherence to procedures regarding the emergency kit (E-kit) and controlled substance counts. The E-kit was opened without proper logging, and the controlled count verification forms were missing signatures for several shifts. These failures in documentation and procedure adherence had the potential to negatively impact the health and well-being of the residents.
Failure to Monitor Vital Signs and Document Diagnoses for Medications
Penalty
Summary
The facility failed to ensure that four residents were free from unnecessary drugs, as evidenced by the lack of adherence to physician's orders regarding medication administration. Resident 540's heart rate was not checked before administering amiodarone and carvedilol, and blood glucose levels were not checked before administering insulin glargine. These checks were required by the physician's orders to prevent potential adverse effects from these medications. Resident 7 was prescribed losartan and ProStat without documented diagnoses for these medications, which is necessary to justify their use. The absence of diagnoses for these medications indicates a failure to ensure that the drug regimen was appropriate and necessary for the resident's condition. Resident 17's heart rate was not monitored before administering metoprolol succinate, as required by the physician's orders. Additionally, Resident 78's blood glucose levels were not consistently checked before meals, despite having a diagnosis of diabetes mellitus. These oversights in monitoring vital signs and blood glucose levels could lead to the administration of unnecessary medications and potential side effects.
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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