Courtyard Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in San Jose, California.
- Location
- 340 Northlake Drive, San Jose, California 95117
- CMS Provider Number
- 555635
- Inspections on file
- 26
- Latest survey
- September 12, 2025
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Courtyard Care Center during CMS and state inspections, most recent first.
A resident with multiple medical and cognitive conditions was involved in an altercation with another resident, but the facility did not update or revise the care plan to address the incident or implement new interventions, as required by policy. The DON confirmed that no care plan entry was made following the event.
A resident with a history of stroke and mental health disorders was involved in a physical altercation with a CNA, leading to involvement from APS and police. Despite facility policy requiring 72-hour monitoring and documentation after such incidents, only one entry was made in the resident's record during this period, as confirmed by the DON. This failure resulted in inadequate monitoring and documentation of the resident's condition following the incident.
A resident with multiple chronic conditions and a high fall risk score was admitted without a baseline fall care plan in place. Despite experiencing several falls, the resident's care plan did not address fall risk, and this omission was confirmed by the ADON during record review.
The facility failed to notify the Long Term Care Ombudsman of 82 transfers/discharges, affecting 71 residents. The Social Services Director confirmed that no notifications were sent since May 2024 due to the absence of an Ombudsman, despite facility policy requiring such notifications.
The facility failed to provide appropriate pharmaceutical services by not having glipizide and duloxetine available for two residents, leading to missed doses. Additionally, discrepancies were found between the controlled drug records and medication administration records for four residents, involving oxycodone. These issues were confirmed by the interim DON, highlighting a failure to adhere to the facility's policies on medication availability and record accuracy.
A facility was found to have a medication error rate of 7.7%, exceeding the acceptable threshold. Errors included improper insulin administration, unavailability of glipizide and duloxetine, and incorrect application of Ketotifen eye drops. These incidents involved multiple residents and highlighted failures to follow physician orders and facility protocols.
The facility failed to maintain safe food storage and handling practices, with expired food items found in storage, improperly dried cookware, and incomplete temperature logs for a refrigerator. These deficiencies potentially exposed 65 residents to food-borne illnesses.
The facility failed to implement proper infection control practices, including unlabeled wash basins, improper PPE use, unlabeled oxygen tubing, and inadequate GT dressing care. A urinary catheter bag was also found touching the floor. These deficiencies had the potential to compromise residents' health and safety.
The facility failed to ensure informed consent for psychotropic medications for several residents. A resident with schizoaffective disorder had incomplete consent for Risperidone, lacking details on risks and benefits. Another resident's responsible party was not informed of chest X-ray results. A third resident on multiple psychotropic medications had incomplete consent forms, missing details on side effects and lacking signatures. The Interim Director of Nursing acknowledged these deficiencies.
The facility did not follow its policy for documenting an advance directive and completing the POLST form for a resident. The POLST form was marked for an advance directive, but the healthcare agent field was empty, and no signed advance directive was found in the resident's record. The social services director confirmed the absence of this documentation, which should have been placed on the chart and communicated to staff upon admission.
A facility failed to develop a comprehensive care plan for a resident with dementia. The resident's electronic health record lacked a dementia care plan, which was confirmed by the facility's nurse consultant. The facility's policy requires individualized care plan interventions for dementia, but this was not implemented for the resident.
A facility failed to follow a physician's order for a resident to be placed in a wheelchair for interaction on specific days, as observed during multiple interviews and record reviews. The resident, diagnosed with major depressive disorder, mood disorder, and muscle weakness, was consistently found lying in bed instead of being in a wheelchair, contrary to the care plan. This non-compliance with the physician's orders had the potential to impact the resident's physical, mental, and psychosocial well-being.
A resident with end-stage renal disease did not receive consistent dialysis care due to missing dialysis communication sheets (DCS) for several treatment days. The facility's policy requires communication of critical dialysis information, but the DCS forms were absent from the resident's records, as confirmed by the Interim Director of Nursing.
The consultant pharmacist failed to conduct the Abnormal Involuntary Movement Scale (AIMS) for two residents on psychotropic medications, Seroquel and Risperidone, as required by facility policy. The pharmacist acknowledged the absence of AIMS assessments, which are necessary for monitoring the effects of these medications. Despite the facility's claim of using a different system, the pharmacist was unaware of any alternative monitoring method.
The facility failed to conduct Abnormal Involuntary Movement Scale (AIMS) assessments for residents on psychotropic medications, leading to potential unnecessary medication use. A resident with schizoaffective disorder was on Seroquel without AIMS monitoring, and another with paranoid schizophrenia had not been assessed since 2021. Two other residents on antipsychotics also lacked AIMS documentation. The facility did not have a replacement system for AIMS, as confirmed by the Consultant Pharmacist and Interim Director of Nursing.
A facility failed to protect residents' private medical information when a resident was discharged with medications labeled with the names and prescriptions of two other residents. The incident was confirmed by the DON and RN, indicating a breach of the facility's policy on safeguarding resident information.
Failure to Update Care Plan After Resident Altercation
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan following a resident-to-resident altercation involving a resident with significant medical and cognitive conditions. The resident, who had diagnoses including anoxic brain damage, alcohol dependence, anxiety disorder, and type II diabetes mellitus, was observed in the hallway yelling and grabbing another resident's arm. Despite this incident, there was no care plan entry created to address the altercation or to outline interventions to prevent recurrence or address the resident's needs. Record review and interview with the DON confirmed that the interdisciplinary team typically updates care plans after incidents, but in this case, no such update was made. Facility policies require that care plans be reviewed and revised upon a resident's status change, and that the interdisciplinary team collaborates on intervention options. However, these procedures were not followed, resulting in the absence of documented interventions or updates to the resident's care plan after the altercation.
Failure to Document and Monitor Resident After Staff Altercation
Penalty
Summary
A deficiency occurred when the facility failed to provide care and services in accordance with professional standards of practice for a resident with a history of cerebral infarction, mood disorder, and major depressive disorder with psychotic symptoms. After an altercation between the resident and a CNA, in which both parties admitted to physical contact, the resident's daughter contacted adult protective services and the police were involved. The resident was observed in bed with no visible injuries following the incident. Despite facility policy requiring increased supervision and documentation for at least 72 hours following such incidents, there was only one documented entry in the resident's clinical record during the required monitoring period. The DON confirmed that nursing staff should have documented the resident's status for 72 hours post-incident, but this was not done, with only a single entry recorded. This lack of documentation failed to ensure the resident's health, safety, and well-being were adequately monitored after the incident.
Failure to Develop Fall Risk Care Plan for High-Risk Resident
Penalty
Summary
The facility failed to develop a baseline fall care plan for a resident who was admitted with multiple diagnoses, including type 2 diabetes mellitus, end stage renal disease, muscle weakness, and osteoarthritis. Upon admission, the resident was assessed as high risk for falls, as indicated by a fall risk assessment score of 15. Despite this high risk status and the resident experiencing several falls while in the facility, there was no care plan in place to address fall risk in the resident's clinical record. During an interview, the Assistant Director of Nursing (ADON) confirmed that there was no care plan to address the resident's fall risk and acknowledged that a separate care plan for falls should have been present. The facility's own policy requires the development and implementation of a comprehensive, person-centered care plan with measurable objectives and timeframes to meet each resident's identified needs, including those related to fall risk.
Failure to Notify Ombudsman of Transfers/Discharges
Penalty
Summary
The facility failed to notify the Long Term Care Ombudsman in writing of transfers or discharges for 82 instances, affecting 71 residents and their responsible parties. This deficiency was identified through interviews and record reviews, which revealed that transfer notification forms were missing from the electronic health records of residents transferred to acute care hospitals. The Social Services Director (SSD) confirmed that the facility had not notified the Ombudsman of any transfers or discharges since May 2024, due to the absence of an Ombudsman. A review of the facility's records indicated that from May 2024 to January 2025, there were 98 transfers or discharges, but only seven notifications were sent to the Ombudsman in January 2025. The facility's policy requires that transfer/discharge notices be provided to the resident, their representative, and the Ombudsman, with evidence maintained of such notifications. However, the SSD admitted that neither the Ombudsman nor the residents or their representatives received the required notices, except for those in January 2025.
Pharmaceutical Services and Record Discrepancies
Penalty
Summary
The facility failed to provide appropriate pharmaceutical services by not having two medications, glipizide and duloxetine, available for two residents. During a medication pass observation, it was noted that glipizide was not available for a resident with Type 2 Diabetes Mellitus, and duloxetine was not available for another resident with schizoaffective disorder. The facility's policy requires medications to be available on the day they are ordered, but this was not adhered to, leading to missed doses for these residents. Additionally, there were discrepancies between the controlled drug records (CDR) and the medication administration records (MAR) for four residents. Instances were found where oxycodone, a controlled medication, was recorded in the CDR but not documented as given in the MAR. This discrepancy was confirmed by the interim Director of Nursing, who noted that the times recorded in the CDR and MAR should match, as per the facility's policy on controlled substance administration and accountability. The failure to maintain accurate records of controlled medications and ensure their availability as per physician orders had the potential to affect the health of the residents. The facility's policies on pharmaceutical services and controlled substance accountability were not followed, leading to these deficiencies.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility was found to have a medication error rate of 7.7%, exceeding the acceptable threshold of 5%. This was identified during medication administration observations involving four residents. One incident involved a Licensed Vocational Nurse (LVN) administering insulin aspart to a resident without priming the pen injector needle with the required two units, contrary to the recommended procedure. Another incident involved an LVN not having glipizide on hand for a resident, necessitating a call to the physician and pharmacy for a refill, which delayed the administration of the medication. Further observations revealed that duloxetine was not available for another resident, requiring the LVN to contact the pharmacy to restock the medication. Additionally, an LVN administered Ketotifen eye drops to both eyes of a resident, despite the physician's order specifying administration to only the right eye. These errors indicate a failure to adhere to physician orders and facility protocols, potentially impacting the therapeutic effectiveness of the medications for the residents involved.
Deficiencies in Food Storage and Handling Practices
Penalty
Summary
The facility failed to maintain safe and sanitary conditions for food storage, preparation, and distribution, as observed during a survey. Expired food items were found in various storage areas, including gelatin, ground beef, buns, and a pie crust, all past their expiration dates. These items were stored in different refrigerators and a freezer, indicating a lack of proper inventory management and oversight in the kitchen. Additionally, cookware was not properly dried before storage, as seven large metal sheet pans were found stacked wet on a storage rack, contrary to the facility's procedure that requires air drying of dishes and utensils. Furthermore, the temperature log book for a refrigerator used to store food brought in by visitors was incomplete, with missing temperature records for several days. This lapse was acknowledged by the director of staff development, who confirmed that the temperatures should have been recorded. These deficiencies in food storage and handling practices potentially exposed 65 residents to food-borne illnesses, as they received food from the facility's kitchen.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to implement proper infection control practices in several instances. Staff did not label resident wash basins with identifiers in shared bathrooms, as observed in resident rooms AA and BB. This was confirmed by a Certified Nursing Assistant and the Interim Director of Nursing, who acknowledged that resident items should be labeled with the resident's name and room number. Additionally, staff did not wear the appropriate personal protective equipment (PPE) when entering a room under enhanced droplet precautions. The Interim Director of Nursing and a Licensed Vocational Nurse entered a room without wearing a faceshield, despite the requirement being clearly indicated on the door sign. The Maintenance Supervisor also failed to wear the correct PPE, wearing a regular face mask instead of an N-95 mask and faceshield. Another deficiency was noted when staff did not label oxygen tubing for a resident, as observed with Resident 21, whose nasal cannula device lacked a label with a date or initials. A Licensed Vocational Nurse confirmed that oxygen tubing should be labeled with the date of change. Furthermore, the facility did not ensure the dressing around a gastrostomy tube (GT) was intact for Resident 7. The GT dressing was loose, and the tape was not adhering properly. A Certified Nursing Assistant was observed not wearing a gown while providing close contact care, contrary to the facility's policy for enhanced barrier precautions. Lastly, a urinary catheter bag was found touching the floor for Resident 38, which was verified by a Certified Nursing Assistant. The Infection Preventionist stated that urine bags must not touch the floor, aligning with the facility's policy to prevent complications such as urinary tract infections. These failures in infection control practices had the potential to compromise residents' health and safety and lead to the spread of communicable illnesses.
Failure to Ensure Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to ensure that residents were fully informed about the risks and benefits of their treatments, specifically regarding psychotropic medications. Resident 23, who was diagnosed with cerebral vascular accident and schizoaffective disorder, had an informed consent form for Risperidone that was incomplete, lacking details about the risks, benefits, and side effects. Similarly, Resident 70, with diagnoses of deconditioning and schizoaffective disorder, had an informed consent form for Olanzapine that also did not include necessary information about the medication's risks, benefits, and side effects. Resident 34, who suffered from a hypoxic brain injury, had a chest X-ray performed, but there was no documentation indicating that the responsible party was informed of the results, which showed clear lungs. This lack of communication was contrary to the facility's policy requiring notification of significant changes or new treatments to the resident's responsible party. The Interim Director of Nursing (IDON) acknowledged the absence of documentation regarding the communication of the X-ray results. Resident 174, diagnosed with anxiety disorder, major depressive disorder, and paranoid schizophrenia, was on multiple psychotropic medications, including Risperidone, Buspirone, and Sertraline. The informed consent forms for these medications were incomplete, lacking specific details about frequency, indications, possible side effects, and adverse reactions. Additionally, there was no signature from the resident or a representative, and the forms did not indicate whether consent was verbal. The IDON confirmed these deficiencies and noted that the facility had changed its consent forms since a new company took over.
Failure to Document Advance Directive and POLST Form
Penalty
Summary
The facility failed to adhere to its policy and procedure regarding advance directives and the completion of the Physician Order for Life-Sustaining Treatment (POLST) form for a resident. Specifically, the POLST form for a resident, admitted on an unspecified date, was marked for an advance directive, but the field for a healthcare agent was left empty. Additionally, there was no documented copy of an advance directive signed by the resident or their responsible party in the clinical record. During an interview and record review, the social services director confirmed the absence of the advance directive documentation, which was contrary to the facility's policy that requires copies of advance directives to be placed on the resident's chart and communicated to the staff upon admission.
Failure to Implement Dementia Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for a resident diagnosed with dementia. During a review of the resident's electronic health record, it was found that there was no care plan addressing the resident's dementia. This oversight was confirmed during an interview with the facility's nurse consultant, who acknowledged that the resident should have had a specific cognitive care plan. The facility's policy on dementia care, revised in December 2022, requires care plan interventions to be related to each resident's individual symptoms and rate of dementia progression, aiming for improvement or maintenance of the expected stable rate of decline associated with dementia. However, this policy was not followed for the resident in question.
Failure to Follow Physician's Orders for Resident Interaction
Penalty
Summary
The facility failed to provide necessary care and services in accordance with the resident's goals for care, specifically for one resident, referred to as Resident 38. The deficiency was identified when the physician's order for Resident 38 to be up in a wheelchair for interaction every Monday, Wednesday, and Friday was not followed. During multiple observations and interviews, it was noted that Resident 38 was consistently found lying in bed and not placed in a wheelchair as per the physician's orders. Licensed Vocational Nurse (LVN) A confirmed that Resident 38 was not in a wheelchair during the observed times and had not seen the resident in a wheelchair even when stationed elsewhere. Resident 38's medical records indicated diagnoses of major depressive disorder, mood disorder, and muscle weakness, which necessitated the need for interaction as part of their care plan. The facility's policy and procedure on the provision of physician-ordered services required nursing and support staff to ensure compliance with activity restrictions prescribed by the physician. The failure to adhere to these orders had the potential to put Resident 38 at risk for decline in physical, mental, and psychosocial well-being.
Missing Dialysis Communication Sheets for a Resident
Penalty
Summary
The facility failed to provide consistent dialysis care for a resident, identified as Resident 32, who required dialysis treatment. Resident 32 was admitted with a diagnosis of cerebrovascular accident and end-stage renal disease, necessitating dialysis on Tuesday, Thursday, and Saturday. However, the dialysis communication sheets (DCS) for several treatment days, specifically from January 16 to January 28, were missing from the resident's clinical record. This absence of documentation meant that critical information regarding the resident's dialysis care was not properly communicated, potentially putting the resident at risk for complications. During an interview and record review with the Interim Director of Nursing (IDON), it was confirmed that the DCS forms were not present in the resident's chart or the white binder that accompanies the resident to and from the dialysis center. The facility's policy on hemodialysis, last revised in June 2023, mandates that licensed nurses communicate with the dialysis facility using a DCS or other written format to include medication administration, physician orders, laboratory values, vital signs, dialysis treatment provided, and any adverse reactions. The failure to adhere to this policy resulted in a deficiency in the standard of care provided to Resident 32.
Consultant Pharmacist Fails to Conduct AIMS for Residents on Psychotropic Medications
Penalty
Summary
The consultant pharmacist (CP) failed to identify and report irregularities during the medication regimen review (MRR) for two residents. For Resident 25, who has a diagnosis of Schizoaffective Disorder and is prescribed Seroquel, the CP verified that the Abnormal Involuntary Movement Scale (AIMS) was not conducted. The CP acknowledged that the facility should have performed the AIMS initially and every six months, but since 2022, the facility reportedly does not use AIMS, and the CP did not recommend it. The facility's policy requires ongoing evaluation of the effects of psychotropic medications during the pharmacist's monthly review, but this was not adhered to. Similarly, for Resident 174, diagnosed with paranoid schizophrenia and prescribed Risperidone, the AIMS was last conducted in September 2021. The CP confirmed that the AIMS was last recommended in December 2022, but the facility claimed to use a different system, which the CP was unaware of. The facility's policy mandates that a resident's drug regimen must be free of unnecessary drugs, which includes adequate monitoring, but this was not followed. The lack of AIMS assessments for both residents indicates a failure to monitor the effects of psychotropic medications adequately.
Lack of AIMS Assessments for Residents on Psychotropic Medications
Penalty
Summary
The facility failed to ensure that four residents were free from unnecessary psychotropic medications due to the lack of Abnormal Involuntary Movement Scale (AIMS) assessments. These assessments are crucial for monitoring involuntary movements that can develop as side effects of long-term antipsychotic medication use. Resident 25, diagnosed with schizoaffective disorder, was prescribed Seroquel, an antipsychotic medication known to cause extrapyramidal symptoms, including tardive dyskinesia. However, the facility did not conduct AIMS assessments for this resident, as confirmed by the Consultant Pharmacist (CP), who noted that the facility had not used AIMS since 2022 and did not have a replacement system in place. Similarly, Resident 174, diagnosed with paranoid schizophrenia and prescribed Risperidone, had not undergone an AIMS assessment since 2021. The CP verified this lapse and mentioned that the facility claimed to use a different system, though no specifics were provided. Additionally, Residents 23 and 70, both on antipsychotic medications for schizoaffective disorder, also lacked documented AIMS assessments in their medical records. The Interim Director of Nursing (IDON) confirmed the absence of a specific form or assessment to monitor abnormal involuntary movements, indicating a systemic issue in the facility's monitoring practices for residents on psychotropic medications.
Unauthorized Disclosure of Residents' Medical Information
Penalty
Summary
The facility failed to ensure the protection of residents' private medical information when Resident 1 was discharged with medications labeled with medical information relevant to Resident 2 and Resident 3. This incident occurred when Resident 1, who was cognitively intact with a BIMS score of 15, was discharged to another skilled nursing facility. Upon discharge, Resident 1 was given medications that did not belong to her but were labeled with the names, prescriptions, and drug indications of Resident 2 and Resident 3. Resident 1's friend returned these medications to the facility, highlighting the breach of confidentiality. Interviews with the Director of Nursing (DON) and Registered Nurse A (RN A) confirmed that the medications belonging to Resident 2 and Resident 3 were mistakenly given to Resident 1. The facility's policy on safeguarding resident identifiable information was not followed, resulting in the unauthorized disclosure of Resident 2 and Resident 3's private medical information. The DON acknowledged that the facility did not have authorization to disclose this information, and the incident violated the residents' rights to have their medical information protected against unauthorized release.
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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