Coast Care Convalescent Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Baldwin Park, California.
- Location
- 14518 E. Los Angeles St., Baldwin Park, California 91706
- CMS Provider Number
- 555199
- Inspections on file
- 25
- Latest survey
- January 2, 2026
- Citations (last 12 mo.)
- 18
Citation history
Health deficiencies cited at Coast Care Convalescent Center during CMS and state inspections, most recent first.
Three residents did not have individualized or specific care plans, with care plans lacking details such as medication names and not being updated to reflect changes in condition or treatment. Staff and leadership confirmed that care plans should be specific and resident-centered, but the plans reviewed only included general instructions like 'administer medication as ordered' and were not revised when residents' needs changed.
A licensed nurse did not check or document a resident's heart rate before administering losartan, as required by a physician's order that specified the medication should be held if the heart rate was below 60 BPM. The resident, who had hypertensive heart disease and moderate cognitive impairment, received multiple doses of losartan without the necessary heart rate monitoring, contrary to facility policy and professional standards.
A facility failed to follow its policies on advance directives and POLST for three residents, leading to potential conflicts with their healthcare wishes. One resident's POLST was incorrectly signed by a caregiver from a previous facility, and the legal representative was not informed. Another resident's advance directive was incomplete, lacking documentation and signatures. A third resident's forms were missing critical information, making them incomplete. These deficiencies highlight lapses in adhering to facility policies.
The facility did not post accurate nurse staffing data in the lobby, accessible to residents and visitors, on several occasions. The Director of Staff Development admitted to posting projected rather than actual CNA hours worked. Additionally, staffing information was not posted in the lobby as required, only at the nursing station, contrary to facility policy.
The facility failed to ensure appropriate use of psychotropic drugs for two residents by not identifying specific target symptoms and not attempting gradual dose reductions (GDR) as required. One resident was on Seroquel without specific target symptoms identified, and no GDR was attempted for Paroxetine HCL despite minimal depression symptoms. Another resident was on Zyprexa and Lexapro without documented GDR attempts or specific target symptoms. These failures could lead to inappropriate drug use, affecting residents' well-being.
The facility failed to maintain sanitary conditions in an ice machine, leading to the distribution of contaminated ice to 40 residents. Observations showed black and yellow substances in the machine, which were not cleaned according to the manufacturer's guidelines. Staff interviews revealed improper cleaning procedures, with the Dietary Aide cleaning only the exterior and the Maintenance Worker using bleach instead of the recommended products. The cleaning logs were inaccurately signed off, indicating deep cleaning that did not occur.
A resident with severe cognitive impairment was fed by a CNA standing over them, contrary to the facility's policy promoting dignity by having staff seated at eye level. The DON acknowledged that sitting promotes dignity, but usual practice involved standing, highlighting a policy-practice discrepancy.
A resident with hemiplegia and impaired cognition was at high risk for falls due to the facility's failure to ensure the call light was within reach, as required by the care plan and facility policy. The call light was observed hanging at the foot of the bed, out of the resident's reach, which was acknowledged by the DON during an interview.
A facility failed to include PASRR Level II recommended services in a resident's care plan, despite the resident's diagnoses of COPD and schizophrenia. The DSD was unaware of the need to incorporate these recommendations, contrary to the facility's policy, risking the resident's access to necessary mental health services.
A resident with major depressive disorder experienced a 10% weight loss over three months, but the facility failed to create a care plan to address this issue. Despite the resident's intact cognitive abilities and need for eating assistance, staff were unaware of the weight loss, and no monitoring was implemented. The facility's policy required care plans to be updated with changes in condition, which was not followed.
A facility failed to provide a communication board or system for a resident who only speaks Vietnamese, despite the care plan indicating its necessity. The resident, with diabetes and dementia, was at risk for miscommunication and delayed care. The Director of Staff Development confirmed the absence of such tools, contrary to facility policies requiring communication aids for non-English speakers.
A facility failed to try alternative interventions before installing side rails for a resident, risking entrapment and injury. The resident, with intact cognitive abilities and requiring assistance for movement, requested side rails due to fear of falling. Staff interviews revealed no documentation of alternative methods being attempted, despite the facility's policy requiring such assessments.
A resident was not informed about their medications during a medication pass, as the LVN failed to explain the medications and their purposes, contrary to the facility's policy. The resident, who was cognitively intact and had conditions such as Parkinson's Disease and schizophrenia, received nine medications without any explanation. The DON confirmed that medications should be explained to residents to ensure awareness and prevent errors.
A facility failed to secure medications in a medication cart, leaving them unattended and accessible to residents. A nurse left the cart unlocked and medications on top of it while attending to a resident. The DON confirmed that staff must lock carts and dispose of dropped medications properly, as per facility policies.
The facility did not meet the required square footage for 18 resident rooms, as identified through observations and interviews. Despite a waiver request claiming adequate space, the rooms did not comply with the 80 square feet per resident requirement. Residents and staff reported no issues with space for mobility or care, but the facility administrator confirmed no changes in room sizes or bed occupancy since the last survey.
Failure to Develop Specific and Resident-Centered Care Plans
Penalty
Summary
The facility failed to develop specific and resident-centered care plans for three sampled residents, resulting in care plans that did not adequately address the residents' individual needs. For one resident with hypertensive heart disease and generalized muscle weakness, the care plan only instructed staff to administer medication and diet as ordered, without specifying the medication name or providing detailed interventions. The Infection Preventionist Nurse (IPN) confirmed that the care plan lacked specificity and should have included the medication name. Another resident with a history of pneumonia, sepsis, and GERD had care plans that were not updated to reflect current conditions. The care plan for sepsis related to pneumonia remained active even though the resident was no longer receiving antibiotics or had active pneumonia. The IPN acknowledged that the care plan should have been discontinued after the last dose of antibiotics and that failure to update care plans could lead to medication errors and negatively affect resident care. The care plan for GERD also lacked specificity, as it did not list the medication by name. A third resident with dyspepsia and muscle weakness had a care plan that instructed staff to provide diet as ordered, administer medication as ordered, and frequently check for reassurance, but again did not specify the medication. The IPN and Director of Nursing (DON) both stated that care plans should be individualized, specific, and updated promptly to reflect changes in the resident's condition or treatment. The facility's policy required person-centered, comprehensive, and interdisciplinary care planning, but the reviewed care plans did not meet these standards.
Failure to Follow Physician Order for Medication Administration
Penalty
Summary
A licensed nurse failed to follow a physician's order for a resident with hypertensive heart disease and generalized muscle weakness by not checking and documenting the resident's heart rate prior to administering losartan, a medication for high blood pressure. The physician's order specifically required that losartan be held if the resident's heart rate was less than 60 beats per minute, and that the heart rate be checked daily before administration. Review of the Medication Administration Record (MAR) and Vital Summary showed that from 12/13/2025 to 12/22/2025, the resident received ten doses of losartan without any documentation of heart rate readings prior to administration on multiple days. Interviews with the Infection Preventionist Nurse (IPN) and Director of Nursing (DON) confirmed that the nurse did not carry out the physician's order as required. Facility policies reviewed indicated that care and services should be provided in accordance with physician orders, and that vital signs must be taken as ordered, especially when there are conditional parameters for medication administration. The failure to check and document the heart rate prior to administering losartan constituted a violation of professional standards of quality and facility policy.
Failure to Adhere to Advance Directive and POLST Policies
Penalty
Summary
The facility failed to adhere to its policy regarding advance directives and Physician Orders for Life-Sustaining Treatment (POLST) for three residents, leading to potential conflicts with their healthcare wishes. For Resident 43, the facility did not ensure that the Advance Healthcare Directive Acknowledgement form was filled out correctly, and the POLST was not signed by the legal representative upon admission. The resident, diagnosed with Alzheimer's disease and dementia, lacked the capacity to make decisions, and the inconsistency in documentation was noted but not corrected by the Social Services staff. The POLST was incorrectly signed by a caregiver from a previous facility, and the legal representative was not informed, leading to a discrepancy in the resident's resuscitation preferences. Resident 19's case involved a failure to complete an Advance Healthcare Directive upon admission. The resident, who had severe cognitive impairments due to conditions like dysphagia following a stroke and Parkinson's Disease, did not have a properly filled out Acknowledgement Form. The form lacked documentation on whether the resident's representative was provided with information about creating an advance directive, and it was not signed or dated by the representative. This oversight meant that the facility did not have clear documentation of the resident's or their family's healthcare wishes. For Resident 37, the facility did not ensure that the Advance Healthcare Directive Acknowledgement Form and the POLST were completed. The resident, who had moderately impaired cognition, was readmitted with conditions such as pneumonia and muscle weakness. The forms were missing critical information, including signatures and dates, which made them incomplete. The Director of Nursing acknowledged that these forms should have been completed to ensure the facility staff were aware of the resident's or legal representative's wishes, highlighting a significant lapse in following the facility's policies and procedures.
Failure to Post Accurate Nurse Staffing Information
Penalty
Summary
The facility failed to adhere to its policy for posting accurate nurse staffing data in the lobby, a location accessible to residents and visitors. Specifically, the facility did not post accurate hours for Certified Nurse Assistants (CNAs) on multiple dates, including 10/15/2024, 10/16/2024, 10/17/2024, 10/18/2024, 10/19/2024, and 10/23/2024. The Director of Staff Development (DSD) acknowledged that the posted staffing numbers were incorrect, as the projected hours were posted instead of the actual hours worked. This discrepancy was noted during a review of the Staffing and Nursing Hours (SNH) and Nursing Staffing Assignment and Sign-in Sheet (NSASS) records. The Director of Nursing (DON) confirmed that the purpose of the SNH form is to provide accurate information about the hours staff provided direct care to residents. Additionally, on 10/23/2024, it was observed that there was no staffing information posted in the facility's lobby, which is a prominent location accessible to visitors. The DSD confirmed that the staffing information was only posted at the nursing station, not in the lobby as required by the facility's policy. The facility's policy mandates that nurse staffing data should be posted daily at the beginning of each shift in a prominent place accessible to residents and visitors, such as the lobby area. The failure to post accurate and accessible staffing information could potentially affect the quality of care provided to residents.
Failure to Ensure Appropriate Use of Psychotropic Drugs
Penalty
Summary
The facility failed to ensure that two residents on psychotherapeutic drugs were free from unnecessary medication. For one resident, the facility did not identify specific target symptoms for the use of Seroquel, which was prescribed for schizophrenia manifested by hearing voices and responding to internal stimuli. The Licensed Vocational Nurse (LVN) and the Director of Nursing (DON) acknowledged that the target behavior was vague, making it difficult to monitor the effectiveness of the medication. Additionally, the facility did not attempt a gradual dose reduction (GDR) for Paroxetine HCL, despite the resident's minimal to no worsening of depression symptoms, as noted in the resident's records. Another resident had been on Zyprexa and Lexapro for schizophrenia and depression, respectively, without any documented evidence of a past failed attempt at GDR. The DON admitted that there was no specific target symptom identified for the use of Zyprexa, as the assumption was made that the resident was hearing voices due to talking to herself. The facility's policy requires that GDR be attempted at least twice a year, and the lack of specific target symptoms and GDR attempts could lead to inappropriate use of psychotropic drugs. The facility's policy and procedure for psychotropic and psychotherapeutic drugs require a written physician order specifying the duration and circumstances for medication use, including specific behavior manifestations. The failure to adhere to these policies and procedures resulted in the potential for inappropriate use of psychotropic drugs, affecting the residents' physical, emotional, and psychosocial well-being.
Sanitation Failure in Ice Machine Maintenance
Penalty
Summary
The facility failed to maintain sanitary conditions in the storage and distribution of ice, as evidenced by the presence of black and yellow substances in the internal components of a Manitowoc ice machine. Observations revealed these substances around the ice dicer and water outlet, which were not cleaned according to the manufacturer's recommendations. The Dietary Supervisor acknowledged the presence of these substances and admitted that the machine had not been cleaned as required, potentially leading to health hazards for residents. The ice from this contaminated machine was distributed to 40 residents before breakfast. Interviews with staff, including a Dietary Aide and Maintenance Worker, revealed a lack of proper cleaning procedures. The Dietary Aide was instructed to clean only the exterior of the ice machine, while the Maintenance Worker admitted to not following the manufacturer's cleaning guidelines, using bleach instead of the recommended cleaner and sanitizer. The cleaning logs were inaccurately signed off, indicating deep cleaning that did not occur. The Director of Nursing confirmed the risk of illness from the contaminated ice, highlighting the failure to maintain sanitary conditions as per the facility's policy and procedure on sanitation.
Failure to Maintain Resident Dignity During Feeding
Penalty
Summary
The facility failed to provide care that maintained or enhanced a resident's dignity and respect, specifically for one resident who was observed being fed by a CNA while the CNA was standing over them. This action was contrary to the facility's policy, which emphasized the importance of promoting resident dignity by having staff seated at eye level with residents during feeding. The resident in question had been readmitted to the facility with diagnoses including encephalopathy and muscle weakness, and was assessed as needing assistance with feeding due to severely impaired cognition. During the observation, the CNA was standing at the resident's right side while feeding them, which was confirmed by the CNA's own admission that she preferred to stand due to the bed's height. Interviews with the RN and DON revealed that the usual practice was for staff to stand while feeding residents, although the DON acknowledged that sitting at eye level was the preferred method to promote dignity. The facility's policy on resident dignity explicitly stated that staff should avoid standing over residents while assisting them to eat, highlighting a discrepancy between policy and practice.
Failure to Ensure Call Light Accessibility for Resident
Penalty
Summary
The facility failed to provide reasonable accommodation for a resident, identified as Resident 30, by not ensuring the call light was within reach and appropriate for the resident's physical ability. Resident 30 was admitted with diagnoses including hemiplegia and hemiparesis following cerebrovascular disease, affecting the right dominant side. The resident's care plan, revised in April 2024, indicated a risk for falls due to a history of cerebrovascular accident with right hemiplegia, and instructed nursing staff to provide the call light within reach and instruct the resident to use it. However, during an observation in October 2024, the call light was found hanging at the foot of the bed, out of the resident's reach. The resident's Minimum Data Set (MDS) from July 2024 indicated moderately impaired cognition and a need for maximum assistance with daily activities, including toileting hygiene and dressing. A Fall Risk Assessment from October 2024 assessed the resident as high risk for falls due to being chair-bound and needing assistance with elimination. During an interview, the Director of Nursing acknowledged that the call light was not within reach and emphasized the necessity for it to be accessible to ensure the resident could call for help if needed. The facility's policy, revised in 2018, also required call lights to be within easy reach of residents.
Failure to Implement PASRR Level II Recommendations
Penalty
Summary
The facility failed to incorporate Pre-Admission Screening and Resident Review (PASRR) Level II recommended specialized add-on services into the assessment, care planning, and transitions of care for Resident 38. This deficiency was identified during a review of Resident 38's records, which showed that the resident was readmitted with diagnoses of chronic obstructive pulmonary disease (COPD) and schizophrenia. The PASRR Level II report recommended mental health rehabilitation activities and psychotherapy/counseling as necessary specialized services to address the resident's mental health needs. During an interview and record review with the Director of Staff Development (DSD), it was revealed that the DSD was unaware that the PASRR Level II recommendations needed to be included in the resident's care plan. The facility's policy and procedures indicated that PASRR Level II evaluations should be incorporated into residents' assessments and care plans, but this was not done for Resident 38, placing the resident at risk of not receiving appropriate specialized care.
Failure to Create Care Plan for Resident's Weight Loss
Penalty
Summary
The facility failed to create a care plan for a resident who experienced a 10% weight loss over three months. The resident, who was admitted with a diagnosis of major depressive disorder, had intact cognitive abilities and required assistance with eating. Despite the significant weight loss documented in the resident's records, no care plan was developed to address this issue. Interviews with facility staff, including a registered nurse and the director of nursing, revealed that they were unaware of the resident's weight loss and acknowledged that a care plan should have been created. The absence of a care plan meant that staff were not monitoring the resident's weight loss, which could potentially lead to further weight loss. The facility's policy indicated that care plans should be revised as changes in a resident's condition occur, but this was not done in this case.
Failure to Provide Communication Tools for Non-English Speaking Resident
Penalty
Summary
The facility failed to provide a communication board or other functional communication system for a non-English speaking resident, identified as Resident 24, who only speaks and understands Vietnamese. Resident 24 was readmitted to the facility with diagnoses including diabetes mellitus and dementia. The resident's care plan, dated the same day as the readmission, indicated that a communication device should be available to help the resident communicate daily needs. However, during an observation, it was noted that there was no communication board or system available in Vietnamese for Resident 24, and the facility had no Vietnamese-speaking staff. The Director of Staff Development (DSD) confirmed the absence of a communication device in Vietnamese after searching the resident's bedside table and drawer. The DSD acknowledged that such a device should always be available to prevent delays in care, especially in emergencies. The facility's policy and procedure documents indicated that communication boards should be provided for residents who do not speak or understand English, and a designated cellular phone with a translation application should be available. Despite these policies, the necessary communication tools were not provided, placing Resident 24 at risk for miscommunication and delayed care.
Failure to Attempt Alternatives Before Bed Rail Installation
Penalty
Summary
The facility failed to attempt appropriate alternative interventions before installing side rails for a resident, which could lead to the risk of entrapment and physical injuries. The resident, who was admitted with diagnoses including morbid obesity, schizophrenia, and major depressive disorder, requested bilateral one-half side rails due to a fear of falling and to aid in self-repositioning. The resident's cognitive abilities were intact, and they required substantial assistance with rolling. During an observation, the resident confirmed using the side rails to help turn in bed. Interviews with facility staff revealed that there was no documentation of alternative interventions being attempted before the installation of the side rails. A registered nurse mentioned that alternatives such as floor mats, roll guards, and concave mattresses could have been considered. A licensed vocational nurse noted that foam bolsters were attempted but removed due to the resident's anxiety, and no further alternatives were tried. The Director of Nursing acknowledged the need for staff to attempt more than one alternative and document these efforts before resorting to side rails. The facility's policy required an assessment and trial of alternative methods before implementing side rails.
Failure to Explain Medications to Resident
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of a resident, identified as Resident 23, during a medication pass. Licensed Vocational Nurse 1 (LVN 1) did not explain the medications and their purposes to Resident 23, which was against the facility's Policy and Procedure on Medication and Treatment Administration. This oversight resulted in Resident 23 being uninformed about the medications being administered, which included treatments for conditions such as schizophrenia, hyperlipidemia, Parkinson's Disease, and seizure disorders. Resident 23 was readmitted to the facility with diagnoses including Parkinson's Disease and muscle weakness and was cognitively intact according to the Minimum Data Set. During the medication pass, LVN 1 administered nine medications without naming or explaining them to Resident 23. The Director of Nursing confirmed that medications should be explained to residents to ensure they are aware of what they are taking and to prevent potential medication errors. The facility's policy also indicated that licensed nurses should explain medication use and side effects to residents.
Medication Storage Deficiency
Penalty
Summary
The facility failed to ensure the secure storage of medications in the medication cart at Station One, specifically for Resident 34. During a medication pass observation, a registered nurse (RN 1) was seen preparing medications for Resident 34 and walked away from the medication cart without locking it. This left the cart and the medications on top of it unattended. RN 1 admitted to leaving medications such as Actos, ASA, and Bupropion on top of the cart and acknowledged that the cart should have been locked to prevent unauthorized access by residents. Resident 34, who was admitted with diagnoses including major depressive disorder, attention and concentration deficit, and anxiety, had an order for several medications, including Actos, ASA, Bupropion, Docusate Sodium, and Prednisolone Acetate Ophthalmic Suspension. The Director of Nursing (DON) confirmed that licensed staff are required to lock the medication cart when unattended and dispose of dropped medications properly. The facility's policies also indicated that medication storage should prevent access by other residents, and medications removed from the cart should be transferred to a designated holding area.
Non-Compliance with Room Size Requirements
Penalty
Summary
The facility failed to ensure that 18 out of 21 resident rooms met the required square footage of 80 square feet per resident in multiple resident rooms. This deficiency was identified through observation, interviews, and record reviews. The rooms in question were Rooms 1, 2, 3, 4, 5, 6, 7, 8, 10, 11, 12, 14, 15, 17, 18, 19, 20, and 22. Despite the facility's request for a room waiver, which claimed that there was ample space for wheelchairs, medical equipment, and resident mobility, the rooms did not meet the regulatory requirements for space per resident. During the survey, it was observed that the rooms provided adequate space for nursing care, comfort, and privacy, and residents were able to move freely. Interviews with residents and staff indicated that there were no issues with space for mobility or care provision. However, the facility administrator acknowledged that the room sizes had not changed since the last recertification survey, and the number of beds remained the same, indicating a continued non-compliance with the square footage requirement.
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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