Country Manor La Mesa Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in La Mesa, California.
- Location
- 5696 Lake Murray Blvd, La Mesa, California 91942
- CMS Provider Number
- 055910
- Inspections on file
- 31
- Latest survey
- March 6, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Country Manor La Mesa Healthcare Center during CMS and state inspections, most recent first.
A resident with a lower leg fracture had their weight-bearing status changed to weight-bearing as tolerated, but this was not communicated to the rehabilitation team. As a result, the resident did not receive timely physical therapy, which could delay recovery. The Director of Rehabilitation and the Director of Nursing acknowledged the communication gap.
A facility failed to notify a resident's representative about critical changes in the resident's medical care, including new lab and medication orders, a new insulin order, and the unavailability of insulin. This resulted in the representative being unaware of the resident's condition and care plan.
A resident with diabetes experienced elevated blood sugar levels, but the facility failed to administer the prescribed insulin due to unavailability. The licensed nurse did not promptly notify the physician or check the emergency kit, and there was no documentation of notifying the physician or pharmacy. The facility's policy did not address procedures for unavailable medications, leading to a potential decline in the resident's condition.
A resident with multiple health conditions experienced severe weight loss due to the facility's failure to notify the RD and physician of the resident's poor meal intake for over three days. Despite policies requiring such notifications, the RD was not informed, and the physician only learned of the issue upon the resident's hospital transfer. This lack of communication prevented timely intervention and contributed to the resident's health decline.
The facility failed to assist three residents with activities of daily living, resulting in long, dirty fingernails and untrimmed facial hair. Despite care plans indicating the need for assistance, residents with conditions like hemiplegia and paraplegia were not provided with adequate grooming, impacting their comfort and hygiene.
The facility did not ensure kitchen staff followed standardized recipes, potentially affecting food taste. During pureed food preparation, a staff member used a 1/4 tsp measuring spoon instead of the required 1/8 tsp for margarine. The Dietary Manager acknowledged that not following recipes could impact food taste. The facility's policy requires adherence to standardized recipes.
The facility's QAA Committee did not identify or include deficient trends in grooming and PTSD care in their QAPI plan, as found during a recertification survey. The surveyors noted issues with basic grooming and staff's lack of knowledge in managing PTSD, which were not recognized by the QAA Committee. Interviews with the ADM and DON highlighted the expectation for these trends to be identified and included in the QAPI plan to maintain residents' dignity and care standards.
A resident with hemiplegia and hemiparesis was found with an electric fan covered in thick, gray dust, indicating a failure to maintain a clean and homelike environment. Despite a deep cleaning schedule, the fan was not cleaned, as confirmed by the infection preventionist and maintenance director. The facility's policy emphasized cleanliness, which was not followed in this case.
The facility failed to provide trauma-informed care for two residents with PTSD, as their conditions were not properly identified and addressed. Staff were unaware of the residents' PTSD diagnoses and triggers, which are crucial for preventing aggressive behaviors. The facility's policy on Trauma Informed Care was not effectively implemented, leading to a deficiency in providing appropriate care.
A facility failed to specify the indication for Apixaban use for a resident with atrial fibrillation. The physician's order listed Apixaban as a blood thinner without mentioning the specific condition it was intended to treat. A nurse acknowledged the need for a clear indication, and the DON confirmed the expectation for correct diagnosis and indication for medications. The facility's policy lacked a requirement for verifying medication indications.
The facility failed to specify appropriate target behaviors for psychotropic medications for two residents, leading to potential unnecessary medication use. One resident was prescribed risperidone for a vague 'repetitive health concern,' while another was given divalproex sodium for non-specific mood changes. Staff interviews revealed a lack of clear, measurable behaviors to justify the medications, which the DON acknowledged should be specific to assess necessity.
A facility failed to provide coordinated hospice services for a resident with chronic respiratory failure. The deficiency included a lack of documentation of hospice staff visits, no schedule for visits, and no agreement with the hospice agency. Interviews revealed inconsistencies in documentation, and the facility's policy required a written agreement that was not in place.
A Licensed Nurse failed to follow infection control procedures by not wearing a gown for a resident under enhanced barrier precautions and neglecting hand hygiene after glove removal. The resident, with a gastrostomy tube, required specific precautions to prevent infection. The Director of Nursing confirmed the expectation for staff to adhere to these procedures.
A facility failed to notify a physician when a resident's blood sugar exceeded 250 mg/dl, as required by the physician's orders. Additionally, nursing staff did not use standard medical abbreviations for insulin injection sites for two residents, leading to repeated injections in the same area. The facility's policy lacked guidance on medical abbreviations for injection sites, and despite training, documentation standards were not consistently followed.
A resident developed a deep tissue injury (DTI) due to the facility's failure to implement adequate preventive measures and monitor changes in the resident's condition. Initially assessed with no risk for pressure ulcers, the resident's condition deteriorated, leading to moisture-associated skin damage (MASD) and eventually a DTI. The care plan lacked interventions for turning, repositioning, hydration, and protein needs, and the facility did not update treatment orders despite the resident's declining condition.
A resident with diabetes mellitus received insulin injections at the same sites repeatedly, contrary to standard nursing practices, leading to potential complications. The facility's MAR showed repeated use of the same injection sites, and interviews with staff confirmed the importance of site rotation. The DON noted that some nurses involved were not present at training sessions, and the facility's policy lacked specific guidance on site rotation.
Failure to Communicate Change in Weight-Bearing Status
Penalty
Summary
The facility failed to coordinate the care needs of a resident with rehabilitation services following a change in the resident's weight-bearing status. The resident, who was admitted with a lower leg fracture, initially had a no weight-bearing (NWB) order and was receiving physical therapy (PT) services until the status changed. On 11/27/24, the resident's weight-bearing status was updated to weight-bearing as tolerated (WBAT) by the orthopedic doctor, but this change was not communicated to the rehabilitation services team. As a result of this communication gap, the physical therapist was not informed of the change and did not see the resident until 1/3/25, over a month later. The Director of Rehabilitation Services confirmed that they were unaware of the status change, and the Director of Nursing acknowledged the lapse in communication. This failure to promptly address the resident's updated care needs could potentially lead to a slower recovery process.
Failure to Notify Resident's Representative of Care Changes
Penalty
Summary
The facility failed to notify the representative of a resident, who was readmitted with diabetes mellitus, about several critical changes in the resident's medical care. The resident's daughter, who holds power of attorney, was not informed of new lab and medication orders, a new insulin order, or the fact that insulin was not administered as per the Nurse Practitioner's (NP) order. This lack of communication resulted in the resident's representative being unaware of the resident's condition and the plan of care. The report details specific instances where the facility did not document notifying the resident's representative about changes in the resident's condition and treatment. These include a change in the resident's blood sugar levels, the unavailability of prescribed insulin, and new orders given by the NP. The Director of Nursing acknowledged that the family should have been informed to ensure they were fully aware of the resident's care. The facility's policies require prompt notification of changes in a resident's condition to the resident, their physician, and their representative.
Failure to Administer Insulin for Elevated Blood Sugar
Penalty
Summary
The facility failed to provide a necessary medication for a resident with diabetes mellitus, leading to a potential decline in the resident's medical condition. The resident, who was readmitted to the facility with a diagnosis of diabetes, experienced an elevated blood sugar level of 297. Despite this change in condition, there was a delay in obtaining physician orders, and the necessary insulin medication, Humalog KwikPen, was not available. The licensed nurse did not follow up promptly with the physician or check the facility's emergency kit for the medication, resulting in the resident's elevated blood sugar not being addressed in a timely manner. The physician's orders for insulin administration were not executed because the medication was unavailable, and there was no documentation indicating that the physician or pharmacy were notified of this issue. The Director of Nursing confirmed that the nurse should have notified the physician if the medication was not available. The attending physician was unaware of the medication unavailability and stated that an alternative method of insulin administration could have been used. The facility's policy on administering medications did not address procedures for when a medication is unavailable, contributing to the deficiency.
Failure to Notify RD and Physician of Resident's Poor Intake
Penalty
Summary
The facility failed to promptly notify the registered dietitian (RD) and physician when a resident with a compromised medical status consumed less than 50% of his meals for more than three consecutive days. This oversight was contrary to the facility's policy and standards of practice. The resident, who had been admitted with diagnoses including diabetes mellitus, chronic kidney disease, hypertension, and Parkinson's, experienced a severe unintentional weight loss of 16 pounds (7.83%) in just 16 days. Upon admission, the resident was alert, walking, talking, and eating, as noted by a family member. However, the resident's meal intake significantly decreased, with records showing consumption of only 26% to 50% of meals over several days, and even less in subsequent days. Despite these indicators, the RD was not informed of the resident's poor intake, and the physician was only made aware of the situation when the resident was transferred to the hospital for the second time. The facility's policies required that residents with poor food intake for three or more days should have their condition reported to the RD and physician. However, this protocol was not followed, leading to a lack of timely intervention. The resident's nutrition care plan aimed to maintain adequate nutrition status, but the failure to communicate the resident's declining intake and weight loss prevented necessary adjustments to the care plan, contributing to the resident's further decline in health.
Failure to Assist Residents with ADLs
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living (ADL) for three residents who were unable to perform self-care activities such as grooming, bathing, and toileting. Resident 21, who was admitted with hemiplegia and hemiparesis following a stroke, was observed with long, dirty fingernails and expressed a desire for them to be trimmed. A licensed nurse acknowledged that the resident's fingernails had not been trimmed weekly as expected, which could lead to infection since the resident used his hands to eat. The care plan for Resident 21 indicated a need for extensive assistance with personal hygiene, but this was not adequately provided. Similarly, Resident 57, also with hemiplegia and hemiparesis following a stroke, was found with long fingernails on a hand that he could not open. The Infection Preventionist noted that the resident's grooming was missed, despite the care plan indicating a need for extensive assistance with personal hygiene. Resident 67, who was receiving palliative care and had paraplegia, was observed with a thick beard and moustache causing discomfort. The resident expressed a need for grooming assistance, which was confirmed by a CNA who stated that grooming should occur twice a week. The Director of Nursing emphasized the importance of regular grooming to maintain residents' self-esteem and presentability, but the facility's policy was not followed, resulting in the observed deficiencies.
Failure to Follow Standardized Recipes in Food Preparation
Penalty
Summary
The facility failed to ensure that kitchen staff adhered to standardized recipes during food preparation, which could potentially affect the taste of the food served to residents. During an observation of pureed food preparation, a kitchen staff member was seen using a 1/4 teaspoon measuring spoon instead of the required 1/8 teaspoon to add margarine, stating that she used less than the 1/4 teaspoon to measure the margarine. The Dietary Manager confirmed that not following the recipe could impact the taste of the food. The facility's policy on standardized recipes, revised in April 2007, mandates the use of standardized recipes in food preparation.
QAA Committee Fails to Identify Deficient Trends in Grooming and PTSD Care
Penalty
Summary
The facility's Quality Assessment and Assurance Committee (QAA) failed to identify and include deficient trends in their Quality Assurance Performance Improvement (QAPI) plan, as discovered during a recertification survey. The surveyors found issues related to basic grooming, such as nail care and beard care, and a lack of staff knowledge in managing residents with Post Traumatic Stress Disorder (PTSD). These trends were not recognized by the QAA Committee and were absent from the QAPI plan, which primarily focused on monitoring falls, pressure ulcers, and infection control. Interviews with the Administrator (ADM) and the Director of Nursing (DON) revealed that the expectation was for the QAA Committee to identify such trends and incorporate them into the QAPI plan. The ADM and DON both acknowledged the importance of identifying these trends to maintain residents' dignity and ensure a high standard of care, particularly for those with PTSD. The facility's policy on Quality Assurance and Performance Improvement, dated February 2020, outlines the objectives of the QAPI program, which include identifying and prioritizing quality deficiencies, but these were not adhered to in this instance.
Failure to Maintain Clean Environment for Resident
Penalty
Summary
The facility failed to maintain a clean and homelike environment for a resident, identified as Resident 57, who was observed with an electric fan filled with thick, gray dust. This deficiency was noted during an observation and interview on January 13, 2025, where the resident, who was admitted with hemiplegia and hemiparesis following a stroke, stated that the fan had not been cleaned but did not wish to complain. The resident was cognitively intact, as indicated by a BIMS score of 15 on the Minimum Data Set dated November 11, 2024. Further observations and interviews with the infection preventionist and the maintenance director confirmed the presence of dust on the fan, which was acknowledged as a failure in maintaining a sanitary environment. The maintenance director admitted that the cleaning of the fan was missed, despite a deep cleaning schedule that included such tasks. The director of nursing also confirmed that electric fans should be cleaned weekly to ensure a homelike environment. The facility's policy on maintaining a homelike environment emphasized the importance of cleanliness and orderliness, which was not adhered to in this instance.
Failure to Provide Trauma-Informed Care for Residents with PTSD
Penalty
Summary
The facility failed to provide trauma-informed care for two residents diagnosed with PTSD, as their conditions were not properly identified and addressed. Resident 26, who had hemiplegia and PTSD following a stroke, expressed distress when war movies were shown, yet staff were unaware of his PTSD diagnosis. Interviews with staff, including CNAs and a licensed nurse, revealed a lack of awareness about the resident's PTSD and its triggers, which are crucial for preventing aggressive behaviors. Similarly, Resident 46, diagnosed with PTSD and major depressive disorder, had a history of trauma from military service. Despite this, staff were not informed of his PTSD diagnosis, as evidenced by interviews with CNAs and a licensed nurse who were unaware of the resident's condition. The Social Service Director confirmed that PTSD information should be documented in the care plan and accessible to staff, but the Kardex used by CNAs did not list PTSD for either resident. The Director of Nursing emphasized the importance of staff being aware of PTSD triggers to avoid re-traumatization. The facility's policy on Trauma Informed Care, which outlines the need for culturally sensitive and person-centered care, was not effectively implemented, as staff were not trained to recognize or address the residents' PTSD. This oversight in identifying and managing PTSD diagnoses led to a deficiency in providing appropriate care for the affected residents.
Lack of Clear Indication for Anticoagulant Use
Penalty
Summary
The facility failed to provide a clear indication for the use of anticoagulant medication, Apixaban, for one resident, identified as Resident 51. Resident 51 was admitted with a diagnosis of atrial fibrillation, which typically requires anticoagulation therapy. However, the physician's order dated 9/30/23 only indicated the use of Apixaban as a blood thinner without specifying the underlying condition, such as atrial fibrillation, as the reason for its use. During an interview, Licensed Nurse 11 acknowledged that there should have been a clear indication for the medication and that the attending physician should have been consulted to verify the intended use of Apixaban. The Director of Nursing confirmed that the expectation was for every medication to have the correct diagnosis and indication. A review of the facility's medication administration policy revealed it did not include a requirement for verifying the indication of medications.
Failure to Specify Target Behaviors for Psychotropic Medications
Penalty
Summary
The facility failed to specify appropriate and measurable target behaviors for the use of antipsychotic and psychotropic medications for two residents, leading to potential unnecessary medication use. Resident 6 was readmitted with a diagnosis of psychosis and was prescribed risperidone for a vague target behavior described as 'repetitive health concern.' Interviews with staff revealed that Resident 6 was unable to communicate needs and exhibited no specific behaviors that warranted the medication. The Director of Nursing (DON) acknowledged that the target behavior should be specific and measurable to determine the necessity of the medication. Similarly, Resident 52, diagnosed with major depressive disorder, was prescribed divalproex sodium for non-specific behaviors described as 'feeling happy and upbeat to feeling sad and impulsiveness.' Observations and interviews indicated that Resident 52 was non-communicative and exhibited behaviors such as pinching and scratching staff, but the specific target behavior for the medication was unclear. The DON confirmed that the target behavior should match the resident's manifested behavior to assess the continued need for the medication. The facility's policy requires that psychotropic medications be clinically indicated for specific conditions, which was not adhered to in these cases.
Failure to Ensure Provision of Hospice Services
Penalty
Summary
The facility failed to ensure the provision of hospice services for a resident, identified as Resident 67, who was admitted with chronic respiratory failure with hypercapnia. The deficiency was identified through observation, interview, and record review, revealing that the facility did not have documentation of hospice staff visits, lacked a schedule for hospice staff visits, and did not have an agreement with the hospice agency. This lack of coordination had the potential to result in uncoordinated medical care for Resident 67. During the review of Resident 67's records, it was found that the physician's orders indicated admission to hospice, but there was no documentation of hospice staff visits in the hospice binder or nursing progress notes. Interviews with licensed nurses revealed inconsistencies in the documentation of hospice visits, with one nurse stating that a hospice nurse visited but did not document the visit. The hospice licensed nurse confirmed that visits were documented in the hospice electronic medical record but acknowledged that documentation was missed in the hospice binder. Additionally, the facility did not have a formal agreement with the hospice agency, as confirmed by the Director of Nursing. The facility's policy required a written agreement outlining the responsibilities of the facility and the hospice agency, but this was not in place. The lack of a hospice agreement and proper documentation of visits and care plans contributed to the deficiency in providing coordinated hospice care for Resident 67.
Infection Control Breach During Medication Administration
Penalty
Summary
The facility failed to adhere to infection control procedures when a Licensed Nurse (LN) did not wear a gown while attending to a resident under enhanced barrier precautions (EBP). The resident, who had a gastrostomy tube, required specific precautions to prevent cross-contamination and infection. During medication administration and vital sign checks, the LN neglected to don a gown, which is a requirement for residents with EBP, as indicated by the sign on the resident's door. Additionally, the LN did not perform hand hygiene consistently after removing gloves, particularly after touching a trash bin, which is considered contaminated. This oversight occurred while the LN was preparing and administering medications to the resident. The Director of Nursing confirmed that the expectation was for staff to follow EBP procedures and perform hand hygiene to prevent infections, as residents are prone to infections. The facility's policies on EBP and hand hygiene emphasize the importance of these practices in preventing the spread of infections.
Failure to Notify Physician and Document Injection Sites
Penalty
Summary
The facility failed to adhere to professional nursing standards by not notifying the physician when a resident's blood sugar levels exceeded 250 mg/dl, as per the physician's orders. This oversight occurred for one resident, who had six out of eighteen blood sugar checks recorded over 250 mg/dl without any documented evidence of physician notification. The facility's policy required immediate notification of the physician for blood glucose levels over 250 mg/dl, but this protocol was not followed, as confirmed by interviews with the Licensed Nurse and the Director of Nursing. Additionally, the nursing staff did not use standard medical abbreviations to document specific body sites for insulin injections for two residents. This lack of specificity in documentation led to repeated injections in the same area, potentially causing decreased absorption, bruising, and pain. The MAR entries for insulin administration were often vague, with only one entry using a medically accepted abbreviation. Interviews with nursing staff and the DON revealed that the use of standardized medical abbreviations was a nursing standard of practice that was not consistently followed. The facility's policy on the care of older adults with diabetes did not provide guidance on the use of medical abbreviations for injection sites. The DON acknowledged the importance of documenting specific injection sites to ensure proper rotation and prevent complications. Despite training provided to nurses on medication administration, there was a lack of adherence to these standards, as evidenced by the incomplete documentation and the absence of one nurse from the training session.
Failure to Prevent Deep Tissue Injury in Resident
Penalty
Summary
The facility failed to prevent the development of a deep tissue injury (DTI) in a resident who was initially admitted with intact skin, except for some bruising. Upon admission, the resident was assessed with a Braden Scale score indicating no risk for pressure ulcers. However, the resident's condition changed over time, with the development of moisture-associated skin damage (MASD) in the groin and buttocks areas, which was documented by a certified nursing assistant and a licensed nurse. Despite the documentation of these skin issues, there was no evidence of a low air loss mattress being ordered or a dermatology consult being recommended. The resident's care plan did not include interventions for turning and repositioning every two hours, hydration, or protein needs, which are critical for preventing pressure ulcers. The resident's condition deteriorated, with increased incontinence and decreased mobility, leading to a decline in food intake and weight loss. Despite these changes, the facility's treatment administration record showed no updates or changes in the physician's orders for skin treatments, and the resident continued to receive the same treatment for MASD without any adjustments. Interviews with staff revealed that the resident became more dependent on care and exhibited signs of confusion and weakness. The facility's wound consultant nurse confirmed that the MASD and DTI are distinct conditions, with the latter developing from prolonged pressure. The resident was eventually sent to the hospital, where a DTI was identified, measuring 15 cm by 17 cm, indicating that the injury had developed over time due to inadequate preventive measures and monitoring by the facility.
Failure to Rotate Insulin Injection Sites
Penalty
Summary
The facility failed to ensure proper rotation of insulin injection sites for a resident with diabetes mellitus, leading to potential issues such as increased bruising, pain, and decreased absorption of medication. The resident was admitted with a diagnosis of diabetes mellitus and was prescribed insulin injections using a Humalog Kwik Pen. The Medication Administration Record (MAR) revealed that the same injection sites were repeatedly used over several days, contrary to standard nursing practices. Interviews with nursing staff and the Director of Nursing (DON) confirmed that the rotation of injection sites is a standard practice to prevent complications, yet it was not consistently followed. The DON acknowledged that the facility's nurses were trained on medication administration, including insulin injections, but noted that some nurses involved in the deficiency were not present at the training sessions. The Pharmacy Consultant also confirmed that rotating injection sites is a standard practice and noted that the resident's medication record was not reviewed in time to catch the issue. The facility's policy on diabetes care did not provide specific guidance on rotating insulin injection sites, contributing to the oversight.
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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