Emmanuel Post Acute Care - Hayward
Inspection history, citations, penalties and survey trends for this long-term care facility in Hayward, California.
- Location
- 26660 Patrick Avenue, Hayward, California 94544
- CMS Provider Number
- 056463
- Inspections on file
- 21
- Latest survey
- March 6, 2026
- Citations (last 12 mo.)
- 32
Citation history
Health deficiencies cited at Emmanuel Post Acute Care - Hayward during CMS and state inspections, most recent first.
A nurse was observed administering several morning medications to a resident but failed to give four additional ordered 9:00 a.m. medications, including aspirin for CVA prophylaxis and vitamin supplements, resulting in a medication error rate of 17.39%. Review of the physician orders and MAR showed that the nurse had documented these omitted medications as given, and the nurse later admitted to falsely signing the MAR without administering them. The DON stated that this failure to administer ordered medications and falsification of records placed the resident at risk for poor bone health and nutritional deficiencies, contrary to facility policy requiring medications to be given as prescribed and signed only after administration.
A resident with dementia and malignant pleural effusion was discharged from a GACH with an order for an oncology referral documented in the hospital discharge and transfer instructions, but this order was not transcribed into the facility’s physician orders or acted upon by staff. The Social Services Assistant reported that staff only became aware of the needed oncology referral after the resident’s family member pointed it out, leading to a delay in arranging cancer treatment. The DON acknowledged that the reviewing nurse was responsible for following up with the physician about the referral and that the facility’s policy required licensed nurses to check physician orders for needed outside consults.
A resident with hemiplegia and hemiparesis, cognitively intact and fully dependent for mobility and toileting per MDS, experienced repeated right foot and toe injuries during transfers and showering when staff maneuvered the commode and shower chair so that the resident’s foot struck the bathroom door frame and shower room surfaces, resulting in pain and swelling. The resident reported that staff repeatedly hit the foot and toes during transport and asked staff to be more careful. A CNA and an LVN described separate incidents in which the resident’s foot was bumped during bathroom and shower care, and the DON acknowledged that no care plan or specific interventions had been developed to prevent these recurring injuries, despite facility policy requiring safety measures and immediate corrective actions to prevent accidents.
Three residents received psychotropic medications without documented evidence that non-pharmacological interventions were attempted or considered prior to medication use. Staff interviews confirmed that while non-drug interventions may have been used, they were not documented in the medical records, contrary to facility policy.
Nursing staff failed to document blood pressure checks before administering Lasix to a resident with CHF, did not follow pain medication orders for two residents by giving narcotics when pain scores were zero, and did not notify a physician of an elevated ammonia level for another resident. These actions were inconsistent with facility policies and resulted in medications not being given as ordered and inadequate monitoring of medical conditions.
Several residents requiring 1:1 feeding assistance due to physical impairments were not fed within the facility's required 15-minute timeframe after meal trays were delivered. Observations and staff interviews revealed that only one CNA was available to deliver trays and feed multiple dependent residents, resulting in delays and residents waiting with their meals at bedside without necessary assistance.
The facility failed to ensure proper pharmaceutical services, including timely availability and administration of medications, accurate documentation and accountability of controlled substances, and safe storage practices. A resident missed multiple doses of an anticoagulant due to pharmacy delays, two residents with diabetes did not receive glipizide as ordered, and controlled medications were not consistently documented or removed after discontinuation. Discontinued and expired controlled substances were found accessible in medication carts and rooms, duplicate narcotic E-kits were present, and emergency kit checks were inconsistently documented.
Surveyors identified a medication error rate of 15.15% after observing five errors among 33 opportunities, including a nurse administering insulin without priming the pen, another nurse failing to provide two scheduled medications due to unavailability, and a third nurse administering more medications than prescribed by duplicating doses. These incidents involved three residents and occurred despite facility policies requiring medications to be administered as ordered and checked against physician instructions.
Surveyors found that medications requiring refrigeration, such as unopened latanoprost eye drops and an insulin lispro pen, were stored at room temperature without documentation. Opened containers of glucose test strips and a PPD vial lacked open dates, and an opened fluticasone nasal spray was not labeled for a specific resident. Additionally, an expired Advair inhaler and PPD vial were found in use. These findings were confirmed by nursing staff and the DON, and were not in accordance with facility policy or manufacturer instructions.
The facility did not maintain the walk-in freezer temperature below zero degrees Fahrenheit, with repeated thermometer readings between 2°F and 10°F. Staff acknowledged the issue, and the freezer had not received routine maintenance for several months, contrary to facility policy. This failure had the potential to impact all residents by increasing the risk of foodborne illness.
A resident with mild cognitive impairment and right-sided weakness received an unwanted haircut despite expressing her preference to keep her hair long for cultural reasons. Staff proceeded with the haircut, disregarding her wishes and facility policy, resulting in the resident feeling terrible about the experience.
A resident with mild cognitive impairment and physical limitations received an unwanted haircut despite expressing her refusal, and her responsible party was not consulted beforehand. Staff acknowledged that the resident had refused haircuts previously and that the responsible party was not contacted for consent, contrary to facility policy requiring consent for such services.
A resident with limited ROM and one-sided impairment did not receive physician-ordered passive range of motion (PROM) exercises for two months, despite care plan and physician orders specifying active and passive ROM three times weekly. The resident reported feeling weak and not receiving rehab, and the RNA confirmed PROM was not performed, even though the resident never refused. Facility policy required such services for residents with limited ROM, but these were not provided.
Nursing staff did not follow established procedures for administering medications through a G-tube for a resident, including failing to verify tube placement, check residual volume, and using a syringe to push medications instead of gravity flow. This resulted in medication and water leaking onto the resident's abdomen, as confirmed by both the nurse and DON.
A consultant pharmacist did not identify or report medication irregularities during monthly drug regimen reviews, resulting in a resident receiving lactulose for the wrong indication without proper monitoring, and two residents not receiving glipizide according to manufacturer guidelines. The pharmacist acknowledged not focusing on these issues, and improper medication administration times were confirmed by the DON.
A resident with alcoholic liver disease and portal hypertension was administered lactulose for constipation, despite the medication being intended for liver-related conditions. Facility staff failed to clarify the medication's indication and did not monitor its effectiveness or adverse outcomes, resulting in the resident receiving unnecessary medication.
A resident with severe cognitive impairment did not receive a lunch tray prepared according to their documented preferences, specifically missing an extra portion of protein. Staff confirmed the omission, and facility policy requires accommodation of such preferences unless otherwise documented.
A nurse failed to wear a gown and did not change gloves or perform hand hygiene while administering medications, including via a G-tube and as eye drops, to a resident under enhanced barrier precautions. The nurse entered and exited the room multiple times, handled various items, and continued care activities without following required infection control protocols, as confirmed by observation, staff interviews, and facility policy review.
Surveyors found a medication cart and a treatment cart left unlocked and unattended in a hallway, both containing medications. Staff interviews confirmed that facility policy requires these carts to be locked when not in use, but the carts were left unsecured when a nurse was called away and possibly by a wound consultant.
A resident at high risk for pressure ulcers did not receive timely wound treatment or a low air loss mattress, leading to the worsening of a sacral ulcer. The facility failed to notify the provider for nine days and did not complete a care plan for the ulcer, despite the resident's condition and family concerns.
A resident with a seizure diagnosis did not receive the prescribed medication, Levetiracetam, due to its unavailability at the facility. The medication was scheduled for administration but was not delivered on time, leading to the resident experiencing two seizure episodes the following morning. Nursing staff indicated that the issue should have been escalated to the Administrator and DON, but it was not, resulting in a system failure.
The facility did not schedule an RN for 8 hours a day, 7 days a week, as required. PBJ Reports showed no RN hours on two specific days, confirmed by the Payroll Director. The DON highlighted the need for an RN to verify LVN assessments. The ADM admitted there was no policy for RN coverage, relying on the CMS Manual's requirements.
The facility failed to maintain food safety standards, with issues including an unclean dry food bin lid, an open bag of cookies in the freezer, and a dented can of tomato soup. These deficiencies, confirmed by the DM and RD, could lead to contamination and food-borne illnesses for residents.
The facility did not submit PBJ Reports for quarters 4 of 2022 and 1 of 2023, as confirmed by the Payroll Director (PD). The PD acknowledged the importance of these submissions for facility rating and audit purposes. It was also noted that the facility lacked a specific policy for staffing submission to CMS, although the PD stated they followed the CMS Manual.
The facility failed to complete quarterly MDS assessments for two residents within the required timeframe, with one assessment 53 days overdue and another 128 days overdue. The MDSC acknowledged the delay and the lack of a specific policy for MDS completion, relying instead on the RAI Manual. This deficiency could affect the accuracy of resident assessments and care plans.
The facility failed to complete and submit the Minimum Data Sets (MDS) for two residents within the required time frames, with one resident's MDS 105 days overdue and another's 188 days overdue. This deficiency was confirmed through record reviews and interviews with the MDS Coordinator and DON, who acknowledged the importance of timely MDS completion for accurate billing and resident care. The facility lacked a policy for MDS completion timeframes, relying on the RAI Manual guidelines.
A facility was found to have a 5.71% medication error rate during a survey. One resident did not receive their prescribed Cosopt eye drops due to unavailability, and another was not instructed to rinse their mouth after using a Wixela inhaler, as required by facility policy. These errors indicate a failure to follow prescriber's orders, potentially affecting the residents' health.
A LTC facility failed to implement proper infection control practices, including a nurse not wearing gloves during nasogastric tube feeding, improper hand hygiene after using a blood glucose machine, and unclean pill cutters in medication carts. Additionally, a urinary drainage bag was found on the floor, and staff were observed not wearing masks properly in resident care areas, contrary to facility policies and local health department requirements.
A resident with dementia and muscle weakness was found to have an inaccurately coded MDS, failing to reflect a functional impairment in the left hand. Despite an OT evaluation indicating a contracture requiring orthotic treatment, the MDS showed no upper extremity impairment. The resident reported an injury to the hand, pain relieved by Tylenol, and a lack of recent physical therapy. The MDS coordinator admitted the coding error, which could negatively affect the resident's care.
A resident with diabetes and dementia did not receive necessary fingernail trimming, leading to potential harm from long, sharp nails. The resident was dependent on staff for personal hygiene, and the facility's policy required regular nail care to prevent infections and injuries. An LVN acknowledged missing the trimming, and the DSD confirmed the responsibility of licensed nurses to trim diabetic residents' nails.
A resident with an above-knee amputation did not receive necessary range of motion (ROM) exercises after being discharged from physical therapy. Despite a referral to the Restorative Nursing Program (RNP) for mobility and prosthetic training, the resident was not entered into the program due to a failure in the facility's system. The Director of Nursing acknowledged the oversight, which was crucial for the resident's physical status and preparation for a new prosthetic leg.
The facility failed to provide necessary pharmaceutical services for two residents. One resident did not receive prescribed eye drops for Glaucoma due to a delay in medication delivery, resulting in missed doses. Another resident with asthma and COPD was not instructed to rinse their mouth after using an inhaler, as required by the physician's orders. These deficiencies were contrary to the facility's policies and procedures.
Medication Errors and Falsified MAR During Medication Pass
Penalty
Summary
Surveyors identified a medication error rate of 17.39% when four errors were observed out of 23 opportunities during a medication pass for one of nine residents (Resident 2). During a medication pass observation, LVN 1 administered six medications to Resident 2: Docusate Sodium 250 mg, Hydrochlorothiazide 12.5 mg, Metoprolol Tartrate 25 mg, a multivitamin, Senna 8.6 mg, and Vitamin B12 2000 mcg. A review of Resident 2’s physician orders dated 3/5/26 showed that four additional medications scheduled for 9:00 a.m. were ordered but not administered at the time of observation: Aspirin 81 mg delayed release for CVA prophylaxis, Folic Acid 1 mg for supplementation, Vitamin C 250 mg for supplementation, and Vitamin D3 25 mcg for supplementation. A concurrent review of the Medication Administration Record (MAR) revealed that LVN 1 had signed these four medications as given at 9:00 a.m., despite not administering them during the observed medication pass. When questioned by the DON, LVN 1 admitted to falsely signing the MAR for these medications without actually giving them. The DON stated that LVN 1’s actions were unacceptable, involved failure to administer ordered medications, and constituted falsification of the MAR, and further stated that this omission placed Resident 2 at risk for poor bone health and nutritional deficiencies. The facility’s medication administration policy indicated that medications shall be administered in a safe and timely manner as prescribed, and that the individual administering the medication must initial the MAR on the appropriate line after giving each medication.
Failure to Implement Oncology Referral Order Resulting in Delayed Cancer Treatment
Penalty
Summary
The facility failed to implement an oncology referral ordered for a resident upon discharge from a General Acute Care Hospital (GACH). The resident, who had diagnoses including dementia and malignant pleural effusion, was readmitted to the facility with a Hospitalist Discharge Summary and Transfer Instruction (HDSTI) dated 1/6/26 that included an order to refer the resident to oncology. The resident’s cognition was documented as severely impaired on the Minimum Data Set, limiting her ability to advocate for herself. The facility’s Social Services Assistant stated that on 1/14/26, the resident’s family member brought the oncology referral order in the HDSTI to her attention, and that prior to this, the facility was not aware that the resident needed an oncology referral. Review of the facility’s Physician’s Orders dated 1/7/26 showed no order for an oncology referral, despite the HDSTI containing such an order. During an interview, the DON acknowledged that the HDSTI ordered an oncology referral while the facility’s Physician’s Orders did not, and stated it was the reviewing nurse’s responsibility to follow up with the facility physician regarding the oncology referral. The facility’s policy titled “Transportation schedule” required a licensed nurse to check the physician order sheet for any existing orders for medical appointments, consults, or procedures provided outside of the facility. The failure to act on the oncology referral resulted in a delay in the resident’s cancer treatment until the family member intervened on 1/14/26, and the DON acknowledged that this failure could cause a worsening of the resident’s malignant pleural effusion.
Failure to Prevent Recurrent Foot Injuries During Transfers and Showering
Penalty
Summary
The deficiency involves the facility’s failure to prevent recurrent right foot and toe injuries to Resident 1 during transfers and bathing activities, despite the resident’s dependence for mobility and toileting. Resident 1, who was admitted with hemiplegia and hemiparesis following a stroke and was assessed as cognitively intact with a BIMS score of 15, was documented on the MDS as unable to walk and fully dependent on staff for mobility and toileting, requiring assistance of two or more helpers. On one occasion, nurses’ notes dated 12/1/26 documented that the resident’s toe was accidentally struck by the bathroom door while he was being assisted out of the restroom, and the resident reported toe pain. CNA 1 later stated that while maneuvering the resident on the commode to exit the bathroom, the resident’s right toes struck the edge of the bathroom door frame and acknowledged she should have been more careful. On a separate occasion, an SBAR note dated 12/4/25 documented that Resident 1 complained of right foot pain following a bump during a shower, and assessment revealed swelling of the right foot. LVN 2 stated that the resident bumped his right foot while being maneuvered in a shower chair in the shower room and confirmed that the resident’s right foot was swollen on assessment. Resident 1 reported that staff repeatedly hit his right foot and toes on the door and bathroom wall while transporting him in the shower chair and commode, causing pain and swelling, and requested that staff take more care during transfers. During record review, the DON acknowledged there was no care plan in place to prevent these recurring right foot and toe injuries and confirmed that no specific interventions had been developed to address this pattern of incidents, despite the facility’s policy requiring implementation of safety procedures and immediate corrective actions to prevent accidents and incidents.
Failure to Document Non-Pharmacological Interventions Before Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that three out of five sampled residents were free from unnecessary psychotropic medications, as required. For each of these residents, psychotropic medications were administered without documented evidence that non-pharmacological interventions were attempted or considered prior to medication use. Specifically, one resident with schizoaffective and bipolar disorder received Lexapro, Depakote, and Seroquel for behavioral symptoms, but there was no documentation of non-drug interventions such as redirection, activities, or emotional support. Staff confirmed that these interventions were not documented, and previous documentation requirements had been removed by the prior DON. Another resident with dementia and depression was prescribed mirtazapine for poor meal intake, yet there was no evidence that non-drug interventions like offering appetizing food or emotional support were tried before starting the medication. A third resident with anxiety and schizophrenia received risperidone and Depakote for behavioral symptoms, but again, there was no documentation of non-drug interventions being attempted or that such interventions were contraindicated. Staff interviews confirmed that while non-drug interventions may have been used, they were not documented in the residents' records. The facility's own policy requires that non-drug approaches be attempted and documented before psychotropic medications are used.
Failure to Follow Professional Standards in Medication Administration and Monitoring
Penalty
Summary
The facility failed to ensure nursing practices met professional standards for three residents. For one resident with congestive heart failure, nursing staff administered Lasix daily as ordered to be held if systolic blood pressure (SBP) was below 100, but there was no documentation of SBP being checked prior to administration. The resident's clinical record showed only seven BP assessments over more than two months, and the facility's medication administration policy required vital signs to be recorded as indicated by medication orders. The Director of Nursing and Infection Preventionist confirmed that the system did not prompt staff to record BP before giving Lasix, and there was no documentation to support that BP was checked as required. Additionally, two residents received pain medications not in accordance with physician orders. One resident was given morphine for severe pain on five occasions when their pain score was zero, and another resident received Ultram for moderate to severe pain, but nine out of fifteen doses were given when the pain score was zero or not applicable. Both the DON and IP confirmed these medications were not administered as prescribed. Furthermore, for one resident with an elevated ammonia level, there was no documentation that the physician was notified of the abnormal result, despite facility policy requiring prompt notification of abnormal lab results. These failures resulted in medications not being given as ordered and inadequate monitoring or treatment of medical conditions.
Failure to Provide Timely 1:1 Feeding Assistance to Dependent Residents
Penalty
Summary
The facility failed to provide necessary one-to-one (1:1) feeding assistance to seven residents who required varying levels of help with eating, as documented in their MDS assessments. These residents had impairments affecting their upper and/or lower extremities and were identified as needing partial, substantial, or total assistance with eating. Observations showed that meal trays were delivered to these residents' bedsides, but they were not set up to eat or fed within the facility's policy timeframe of 15 minutes. In several instances, residents waited more than 15 minutes after meal delivery before receiving assistance, with some residents explicitly stating they were unable to feed themselves and were waiting for help. Staff interviews confirmed that only one CNA was delivering meal trays and was responsible for feeding multiple dependent residents sequentially, resulting in delays. The facility's policy required that residents needing full assistance be fed within 15 minutes of tray delivery and that assistance be provided according to the level of need. Despite this, observations and staff statements indicated that the required timely assistance was not provided, and residents were left waiting with their meal trays at bedside without being fed or set up to eat.
Deficiencies in Pharmaceutical Services: Medication Availability, Administration, and Controlled Substance Accountability
Penalty
Summary
The facility failed to provide adequate pharmaceutical services, resulting in multiple deficiencies related to medication availability, administration, storage, and accountability. On several occasions, a resident did not receive prescribed Lovenox injections due to pharmacy delivery delays, as documented in medication administration records and confirmed by both staff and the resident. The medication was unavailable for administration on six separate occasions, with staff noting the absence and pharmacy follow-up in progress notes. There were also failures in the administration of glipizide for two residents with diabetes. The medication was not given according to the physician's orders or manufacturer’s specifications, with doses scheduled and administered after meals instead of before, as required for optimal therapeutic effect. This was confirmed through review of medication administration records, meal schedules, and interviews with the Director of Nursing, who acknowledged the discrepancy and the error in order entry. The facility did not maintain accurate accountability for controlled substances. In multiple instances, controlled medications were signed out of the controlled drug record but not documented on the medication administration record for several residents. Discontinued or expired controlled substances were found in medication carts and the medication room, accessible to multiple staff and not counted during shift changes. Duplicate narcotic emergency drug kits were present, and opened emergency kits were not replaced in a timely manner. Additionally, staff did not consistently document emergency kit checks between shifts, and logs showed numerous missed entries. These findings were confirmed by staff and the Director of Nursing during inspections and interviews.
Medication Error Rate Exceeds Acceptable Threshold Due to Multiple Administration Failures
Penalty
Summary
The facility was found to have a medication error rate of 15.15%, exceeding the acceptable threshold of 5%, as five medication errors were observed out of 33 opportunities during medication administration for three residents. One incident involved a nurse administering insulin via a pre-filled pen to a resident without priming the pen, contrary to both manufacturer instructions and facility policy. The nurse admitted to not knowing how to prime the pen and had not done so before, resulting in the resident potentially receiving an incorrect insulin dose. Another incident involved a nurse failing to administer two scheduled medications, Flovent and Xarelto, to a resident because the medications were not available at the time of administration. The nurse documented the missed doses and notified the nurse practitioner, but the medications were not given as ordered at the scheduled time. The resident had physician orders for these medications to manage conditions including COPD and a history of stroke or blood clots. A third incident involved a nurse preparing and administering more medications than were prescribed to a resident. The nurse prepared and administered thirteen medications instead of the eleven that were ordered, including duplicating doses of cholecalciferol and docusate. The nurse acknowledged the error after reviewing the medication administration record and confirmed that the resident received two doses of these medications instead of the prescribed amounts. Facility policies required medications to be administered as prescribed and checked against physician orders, which was not followed in these cases.
Improper Medication Storage, Labeling, and Expired Drugs Identified
Penalty
Summary
Surveyors identified multiple failures in the facility's medication management practices during inspections of medication carts and rooms. Unopened bottles of latanoprost eye drops and an unopened insulin lispro pen, both requiring refrigeration per manufacturer and pharmacy labeling, were found stored at room temperature without documentation of when they were removed from refrigeration. Opened containers of glucose test strips and a vial of tuberculin purified protein derivative (PPD) were not dated with an open date, despite manufacturer instructions requiring use within a specific timeframe after opening. An opened bottle of fluticasone nasal spray was found without any patient identification, and staff were unable to determine to whom it belonged. Additionally, an Advair inhaler and a vial of PPD were found to be expired, with the inhaler remaining in use beyond the one-month period recommended after opening. These deficiencies were confirmed through observation and interviews with nursing staff and the Director of Nursing. Facility policies required proper labeling, dating, and storage of medications, including returning improperly labeled drugs to the pharmacy and discarding outdated medications. The surveyors found that these policies were not followed, as evidenced by the presence of expired medications, lack of open dates on time-sensitive products, and improper storage conditions for drugs requiring refrigeration.
Failure to Maintain Walk-In Freezer Temperature Below Required Standard
Penalty
Summary
The facility failed to maintain the walk-in freezer temperature below zero degrees Fahrenheit as required by professional standards and facility policy. Multiple observations over several days showed the freezer temperature consistently ranged from 2°F to 10°F, as recorded on different thermometers. Despite the food items being frozen solid to the touch, the thermometer readings remained above the required threshold. Staff, including the Dietary Manager and Maintenance Director, acknowledged the temperature readings and confirmed that the freezer should be kept below zero degrees Fahrenheit to ensure food safety. The facility's policy required immediate action and documentation when temperatures were out of range, as well as monthly inspections and maintenance per manufacturer guidelines. However, the walk-in freezer had not been serviced since February due to a change in Maintenance Director, and there was no evidence that necessary repairs or corrective actions were promptly initiated when the temperature deviations were identified. This lapse had the potential to affect all residents by increasing the risk of foodborne illness.
Resident's Right to Personal Grooming Preferences Not Honored
Penalty
Summary
Facility staff failed to honor a resident's and her responsible party's wishes regarding hair care, resulting in the resident receiving an unwanted haircut. The resident, who had a mild cognitive impairment (BIMS score of 12/15) and right-sided weakness requiring substantial assistance with personal hygiene, expressed to staff that she did not want her hair cut due to cultural preferences for long hair. Despite her clear communication, staff proceeded with the haircut, reportedly telling her it was necessary because she could not care for her long hair herself. The resident reported feeling terrible as a result of this action and stated that staff cursed at her during the interaction. Record review confirmed the resident was signed up for and received a haircut, and facility policy states that residents have the right to be groomed as they wish and to exercise their rights without interference or coercion. Interviews with the Social Services Director indicated that residents can refuse haircuts and have the right to choose their hair style, including calling outside stylists. However, in this instance, the resident's preferences and rights were not respected, leading to the deficiency.
Failure to Obtain Consent for Resident's Haircut
Penalty
Summary
The facility failed to ensure that a resident's responsible party was given the opportunity to exercise the resident's rights regarding personal care decisions, specifically related to haircuts. The resident, who was mildly cognitively impaired and had right-sided weakness requiring substantial assistance with personal hygiene, received a haircut against her wishes. The resident reported that she had expressed her desire not to have her hair cut to staff, but staff insisted and proceeded with the haircut, citing the length and her inability to care for it herself. The resident stated that the haircut made her feel terrible due to her cultural preference for long hair. Interviews with facility staff revealed that the process for determining which residents needed haircuts involved asking residents directly or, for those unable to make decisions, contacting the responsible party or nurse. In this case, the activity staff and co-director acknowledged that the resident had refused haircuts when offered and that the responsible party was not contacted for consent prior to the haircut. The responsible party confirmed she was not informed about the haircut beforehand and would have refused the service if consulted, as she typically maintained the resident's hair during visits. Record review showed documentation of the haircut appointment and payment, but there was no evidence that consent was obtained from either the resident or her responsible party, as required by the facility's own policy. The policy stated that consent should be obtained for treatments and procedures, and refusals should be addressed by the interdisciplinary team. Despite this, the facility proceeded with the haircut without proper consent or consideration of the resident's and responsible party's preferences.
Failure to Provide Ordered Passive Range of Motion (PROM) Exercises
Penalty
Summary
A resident with limited range of motion (ROM) and impairment on one side of the upper and lower extremities did not receive physician-ordered passive range of motion (PROM) exercises for two months. The resident was admitted with a mild cognitive impairment and required substantial to maximal assistance with personal hygiene. Physician orders and the care plan specified that the resident should receive active and passive ROM exercises to both upper and lower extremities three times per week for three months to maintain their current level of function and prevent contractures. However, progress notes indicated that the resident did not receive or refuse PROM exercises to the right extremity during this period. During interviews, the resident reported feeling weak and stated they had not received rehabilitation services. The restorative nursing aide (RNA) confirmed that PROM exercises were not performed on the right hand, citing the resident's inability to raise the hand, despite being aware of the physician's orders. The RNA also stated that the resident never refused the exercises. Facility policy required that residents with limited ROM receive treatment and services to increase or prevent further decrease in ROM, but this was not followed for this resident.
Failure to Follow G-Tube Medication Administration Protocol
Penalty
Summary
Nursing staff failed to follow facility policy and procedures for administering medications via a gastrostomy tube for one resident. During a medication pass, the registered nurse did not verify tube placement or check residual volume prior to administering medications, despite a physician's order requiring verification of tube placement before feeding and medication administration. The nurse also administered medications by pushing them through the tube with a syringe, rather than allowing them to flow by gravity as required by facility policy. Water and medication liquid were observed seeping from the tube onto the resident's abdomen during the process, and the nurse wiped the excess fluid off several times. Interviews with the nurse and the Director of Nursing confirmed that the correct procedure was not followed, including the need to check tube placement, residual volume, and to administer medications by gravity. The facility's policy and procedure outlined specific steps for confirming tube placement, checking gastric residual volume, and administering medications by gravity flow, none of which were properly followed during the observed medication administration for the resident with a G-tube.
Consultant Pharmacist Failed to Identify and Report Medication Irregularities
Penalty
Summary
The facility's consultant pharmacist (CP) failed to identify and report medication irregularities during the monthly drug regimen review (MRR) for three residents. For one resident with alcoholic liver disease and portal hypertension, lactulose was prescribed for constipation, but the actual indication was for liver disease, as confirmed by the resident and hospital discharge summary. The facility's records and staff interviews revealed that the medication was being monitored for the wrong indication, and appropriate monitoring for liver disease was not conducted. The CP acknowledged not identifying or reporting this irregularity, stating her focus was on psychotropic medications. For two other residents prescribed glipizide for diabetes, the medication was not administered according to the manufacturer's specifications. One resident's glipizide was scheduled after breakfast instead of 30 minutes before a meal, as required for optimal effectiveness. The medication administration records confirmed that the drug was consistently given after breakfast. The second resident's glipizide was ordered to be given with meals but was administered at times inconsistent with the recommended timing, with doses given well after the scheduled meal times. Interviews with the Director of Nursing (DON) confirmed the improper administration times for glipizide and the lack of adherence to physician orders and manufacturer guidelines. The CP admitted that these issues had not been the focus of her recommendations and had not been identified as irregularities in her reviews. The facility's policies require the CP to assist in identifying medication-related issues and ensuring medications are administered to maximize effectiveness, but these requirements were not met in these cases.
Failure to Ensure Resident's Drug Regimen Was Free from Unnecessary Drugs
Penalty
Summary
A resident with a history of alcoholic liver disease and portal hypertension was admitted to the facility and prescribed lactulose. The physician's order indicated lactulose was to be administered for constipation, with instructions to hold the medication if the resident had more than three bowel movements daily. However, the resident stated that the medication was for his liver, and the hospital discharge summary confirmed that lactulose was intended for alcoholic cirrhosis with portal hypertension, not constipation. The facility staff, including the MDS Coordinator, acknowledged that the medication was being given for the wrong indication. Further review and interviews revealed that the facility did not monitor the effectiveness or adverse outcomes of lactulose as it was prescribed for the incorrect indication. The Consultant Pharmacist also noted that the dosage was higher than typically used for constipation and was more appropriate for hepatic encephalopathy. The facility's policy required clarification of medication orders that seemed excessive or unrelated to the resident's diagnosis, but this was not followed, resulting in the resident receiving unnecessary medication without proper monitoring.
Failure to Provide Meal According to Resident Preferences
Penalty
Summary
A resident with severe cognitive impairment, as indicated by a BIMS score of 0 out of 15 on the Minimum Data Set assessment, did not receive a lunch tray prepared according to their documented meal preferences. Specifically, the resident's meal tray card listed a preference for an extra portion of protein, along with pickles, crackers, and soup. However, during an observation, the meal tray was prepared and placed on the cart for delivery without the extra protein portion as specified. During an interview and observation, both the Registered Dietitian and Dietary Manager confirmed that the resident was not provided with the double protein portion, as evidenced by a photo and the meal tray card. The Dietary Manager acknowledged the importance of honoring resident meal preferences, stating it is a resident's right. Facility policy requires staff to accommodate resident food preferences whenever possible, with documentation required if preferences cannot be met, but there was no indication that such documentation or justification was provided in this case.
Failure to Follow Enhanced Barrier Precautions and Hand Hygiene During Medication Administration
Penalty
Summary
Facility staff failed to follow appropriate infection prevention and control practices during medication administration for a resident with a gastrostomy tube (G-tube). During observation, a registered nurse (RN) did not wear a protective gown while administering medications via the G-tube, despite a clearly posted sign indicating the need for enhanced barrier precautions (EBP) for high-contact activities such as device care or use, including feeding tubes. The RN was observed entering the resident's room wearing only a surgical mask and gloves, and she stated she was unsure if a gown was required, mistakenly believing the EBP applied to the resident's roommate. Throughout the medication administration process, the RN did not change gloves or perform hand hygiene between different care activities and after touching various surfaces both inside and outside the resident's room. The RN was seen preparing and administering multiple medications, including eye drops and inhalation medication, without changing gloves or washing hands between procedures. Excess liquid from the G-tube was wiped from the resident's abdomen with a tissue, and the RN continued to access the tube and administer medications without changing gloves. The RN also left and re-entered the room multiple times, handling items such as spoons and cups of water, without removing gloves or performing hand hygiene. The facility's policies and procedures require the use of gowns and gloves for high-contact activities involving indwelling medical devices, such as feeding tubes, and mandate hand hygiene before and after medication administration and between procedures. The RN acknowledged during interviews that she did not change gloves or perform hand hygiene as required, and the Director of Nursing confirmed that staff are expected to follow these protocols. The failure to adhere to established infection control practices was directly observed and confirmed through staff interviews and policy review.
Unattended and Unlocked Medication and Treatment Carts
Penalty
Summary
Surveyors observed that both a medication cart and a treatment cart were left unlocked and unattended in the hallways of station 2. The medication cart contained residents' medications and was left unsecured when a Licensed Vocational Nurse (LVN) was called away to attend to another issue. The treatment cart, which contained medications used for wound care, was also found unlocked and unattended, with staff indicating that it may have been left that way by a wound consultant. Interviews with the LVNs, the Director of Staff Development, and the Director of Nursing confirmed that the facility's expectation is for all medication and treatment carts to be locked when not in use or when unattended.
Failure to Provide Adequate Pressure Ulcer Care
Penalty
Summary
The facility failed to provide adequate pressure ulcer care for a resident, leading to the worsening of a sacral pressure ulcer. The resident, who was admitted with conditions including stroke, hemiplegia, type 2 diabetes, and dysphagia, was at high risk for pressure ulcers. Despite this, the facility did not notify the provider to obtain wound treatments for nine days after the ulcer was first identified. The resident's sacral pressure ulcer grew significantly in size during this period. Additionally, the facility did not provide the resident with a low air loss mattress, a crucial pressure-relieving device, for four days after it was ordered. The resident's family expressed concern about the lack of a low air loss mattress, but the facility was unable to provide one until it was delivered by an outside company. This delay contributed to the deterioration of the resident's skin condition. Furthermore, the facility failed to complete a care plan for the resident's sacral pressure ulcer. Despite documentation of the wound's presence and size by nursing staff, there was no evidence of a care plan being developed to address the ulcer. The facility's policy required that care plans be developed to address risk factors for pressure ulcers, but this was not done in this case, resulting in inadequate care for the resident.
Failure to Administer Seizure Medication
Penalty
Summary
The facility failed to provide the ordered medication Levetiracetam, also known as Keppra, to a resident with a diagnosis of seizures. The resident was admitted to the facility with a physician's order for Levetiracetam to be administered twice daily for seizure precautions. However, the medication was not available for the scheduled dose on the evening of 8/14/24. This resulted in the resident not receiving the necessary medication, which had the potential to delay treatment and lead to seizure episodes. The resident subsequently experienced two seizure episodes the following morning. Interviews with nursing staff revealed that the absence of the medication should have been escalated to the Administrator and the Director of Nursing (DON) for immediate action. The facility's policy and procedure required that medications be requested, received, and administered in a timely manner, but this was not adhered to, leading to a system failure. The DON acknowledged that the situation was not properly elevated, and the physician was not informed about the unavailability of the medication.
Failure to Schedule RN for Required Hours
Penalty
Summary
The facility failed to schedule a registered nurse (RN) for 8 hours a day, 7 days a week, as required by regulations. This deficiency was identified during a review of Payroll Based Staffing (PBJ) Reports for the second quarter of 2023, which revealed that there were no RN hours recorded on February 20, 2023, and March 4, 2023. The Payroll Director confirmed the absence of an RN on these dates. The Director of Nursing emphasized the importance of having an RN on duty to verify assessments made by licensed vocational nurses (LVNs). The Administrator acknowledged the lack of a policy for RN coverage and stated that the facility followed the CMS Manual, which mandates 24-hour licensed nursing services and an RN for 8 consecutive hours daily, 7 days a week.
Food Safety Deficiencies in Storage and Preparation
Penalty
Summary
The facility failed to adhere to professional standards for food safety, as observed during a survey. In the dry food storage area, a bin containing flour was found with a fine dusting of white powder on the lid, which was confirmed by the Dietary Manager (DM) and Registered Dietician (RD) to attract pests. The facility's policy and the USDA Food Code emphasize the importance of keeping storage areas clean to prevent pest attraction. Additionally, in the walk-in freezer, a bag of pre-baked cookies was found open to air, which the DM and RD acknowledged could lead to freezer burn and contamination. The facility's policy and the USDA Food Code require that frozen foods be stored in airtight packaging to prevent contamination. Furthermore, a can of tomato soup with a large dent was found in the dry food storage area, ready for use. The DM and RD both stated that dented cans could pose a contamination risk, and the facility's policy requires such cans to be separated and returned to the vendor. The USDA Food Code also highlights the potential hazards of using dented cans, as they may allow bacteria or other contaminants to enter the food. These deficiencies in food storage and preparation practices had the potential to lead to food-borne illnesses for the 88 residents receiving food from the kitchen.
Failure to Submit PBJ Reports for Staffing Audit
Penalty
Summary
The facility failed to electronically submit complete and accurate direct care staffing information based on payroll data to the Centers for Medicare and Medicaid Services (CMS). During interviews and record reviews with the Payroll Director (PD), it was revealed that the Payroll Based Staffing (PBJ) Reports for quarter 4 of 2022 and quarter 1 of 2023 were not submitted. The PD acknowledged the importance of submitting these reports for facility rating and audit purposes. Additionally, it was noted that the facility did not have a specific policy for staffing submission to CMS, although the PD stated they followed the CMS Manual, which requires submissions by the end of the 45th calendar day after each fiscal quarter.
Failure to Complete Timely MDS Assessments
Penalty
Summary
The facility failed to ensure that the quarterly Minimum Data Sets (MDS) for two residents were completed within the required timeframe of 14 days from the Assessment Reference Date (ARD). Resident 61's quarterly MDS was 53 days overdue, and Resident 143's quarterly MDS was 128 days overdue. This deficiency was identified during a review of the residents' admission records and confirmed through interviews with the Minimum Data Set Coordinator (MDSC) and the Director of Nursing (DON). The MDSC acknowledged that the assessments were not completed on time and emphasized the importance of timely MDS completion for accurate resident assessment and care planning. The MDSC also revealed that there was no specific policy in place for MDS completion and submission timeframes, and they relied on the Resident Assessment Instrument (RAI) Manual for guidance. The manual specifies that MDS completion should occur no later than 14 days after the ARD, and transmission should follow within another 14 days. The failure to complete these assessments on time had the potential to impact the quality of care provided to the residents, as it could lead to outdated care plans that do not reflect the residents' current health status.
Failure to Timely Complete and Submit MDS Assessments
Penalty
Summary
The facility failed to ensure that the Minimum Data Sets (MDS) for two residents were completed and submitted to the Centers for Medicare and Medicaid Services (CMS) within the required time frames. Specifically, the Discharge MDS for two residents, identified as Resident 31 and Resident 83, were not completed and transmitted within 14 days of the Assessment Reference Date (ARD). Resident 31's Discharge MDS was 105 days overdue, and Resident 83's was 188 days overdue. This deficiency was identified during a review of the residents' admission records and confirmed through interviews with the Minimum Data Set Coordinator (MDSC) and the Director of Nursing (DON). Resident 31 was admitted with multiple diagnoses, including Acute Pancreatitis with infected Necrosis, while Resident 83 was admitted with Unspecified Dementia. The MDSC acknowledged that the discharge MDS assessments were not completed on time and highlighted the importance of timely MDS completion for accurate insurance billing and addressing resident needs. The MDSC also noted the absence of a facility policy for MDS completion and submission timeframes, relying instead on the Resident Assessment Instrument (RAI) Manual guidelines. The CMS MDS Manual specifies that Discharge Assessments should be completed no later than 14 days after the discharge date and transmitted no later than 14 days after the MDS completion date.
Medication Administration Errors Observed
Penalty
Summary
The facility was found to have a medication error rate of 5.71% during a medication pass observation, which exceeded the acceptable threshold of 5%. This error rate was determined after two medication errors were observed out of 35 opportunities. The first error involved Resident 143, who did not receive their prescribed dose of Cosopt eye drops, a medication used to treat glaucoma, at the scheduled time. The Licensed Vocational Nurse (LVN) responsible for administering the medication was unable to locate the eye drops in the medication cart or the medication room, resulting in the resident missing their 12 noon dose. The second error involved Resident 144, who was not instructed to rinse their mouth after using a Wixela Inhub Inhalation, which is prescribed for asthma and chronic obstructive pulmonary disease (COPD). The facility's policy requires that residents rinse their mouth after using inhalers to remove any residual medication. However, the LVN administering the medication failed to provide these instructions, contrary to the facility's policy and the physician's orders. These deficiencies indicate a failure to administer medications in accordance with prescriber's orders, potentially impacting the health conditions of the residents involved.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to implement proper infection prevention and control practices in several instances. A Licensed Vocational Nurse (LVN) did not wear gloves while administering nasogastric tube feeding to a resident diagnosed with dementia and sepsis. This action was contrary to the facility's policy, which mandates the use of disposable gloves to prevent contamination during enteral nutrition administration. Additionally, the same LVN did not perform hand hygiene after sanitizing a used blood glucose machine, which is a critical step to prevent the spread of infections as per the facility's hand hygiene policy. Further deficiencies were observed in the handling and storage of medical equipment. Unclean pill cutters with white powdery substances were found in medication carts at two different nurses' stations. The facility's policy requires that reusable medical equipment be cleaned and disinfected between uses to prevent cross-contamination. Additionally, a resident's urinary drainage bag was found lying on the floor, which is against the facility's policy that requires such bags to be hung to prevent infection. Moreover, three direct care staff members were observed not wearing their face masks properly in resident care areas, which is a requirement by the local health department and the facility's policy to prevent the spread of infections like COVID-19, Influenza, and RSV. The improper use of masks by staff in patient care areas poses a risk of spreading infections to vulnerable residents, as highlighted by the facility's infection preventionist.
Inaccurate MDS Coding for Resident's Upper Extremity Impairment
Penalty
Summary
The facility failed to ensure the accuracy of the Minimum Data Set (MDS) for a resident, leading to a potential deficiency in care. The resident, who was admitted with diagnoses including unspecified dementia, muscle weakness, and the absence of both legs below the knee, was observed to have a functional impairment in the left hand. This impairment was not accurately reflected in the resident's annual MDS, which incorrectly indicated no upper extremity impairment. The resident reported an injury to the left hand several months prior, resulting in an inability to extend the fingers and occasional pain relieved by Tylenol. Despite having a contracture of the left hand requiring treatment with an orthotic, as noted in an Occupational Therapy evaluation, the MDS did not reflect this condition. During an interview, the MDS coordinator acknowledged that the MDS should have been coded to reflect the upper extremity impairment. The failure to accurately code the MDS could negatively impact the care the resident receives. The facility's policy on comprehensive assessments and care delivery requires that care areas triggered during the MDS completion be used to make decisions about care and treatment, which was not adhered to in this case. The resident also indicated that they had not received physical therapy for the left hand in many months and required assistance with applying a splint, which had not been provided by the staff.
Failure to Trim Resident's Fingernails
Penalty
Summary
The facility failed to ensure that a resident received necessary fingernail trimming, which had the potential to result in skin scratches, wounds, and infections. The resident, who was admitted in January 2024, had diagnoses of diabetes mellitus and dementia, with severely impaired cognition and was dependent on staff for personal hygiene. The resident's care plan indicated a need for substantial assistance with personal hygiene due to dementia and limited mobility. During an observation, the resident was seen scratching herself with long, unevenly trimmed fingernails, which had brown/yellow matter underneath. The Licensed Vocational Nurse (LVN) acknowledged the oversight in trimming the resident's fingernails, which could harm the resident's skin. The Director of Staff Development confirmed that diabetic residents' fingernails should be trimmed by licensed nurses to prevent self-harm. The facility's policy emphasized the importance of regular nail care to prevent infections and skin injuries.
Failure to Provide ROM Exercises for Resident with Amputation
Penalty
Summary
The facility failed to provide range of motion (ROM) exercises for a resident with limited ROM, identified as Resident 34. Resident 34 was admitted to the facility in 2023 and had a Brief Interview for Mental Status (BIMS) score of 15/15, indicating intact cognition. The resident had multiple diagnoses, including muscle weakness, acquired absence of the right leg above the knee, paralytic gait, and was undergoing orthopedic aftercare following surgical amputation. Despite being discharged from physical therapy on January 31, 2024, with a recommendation to join the Restorative Nursing Program (RNP) for mobility, strengthening, and prosthetic training, the resident did not receive the necessary RNA services due to a failure in the facility's system. Interviews with the Restorative Nurse Assistant (RNA) and the Regional Manager Physical Therapist (RMPT) revealed that Resident 34 was not entered into the RNA program, which was crucial for maintaining his physical status and preparing for a new prosthetic leg. The Director of Nursing (DON) acknowledged that the RNA referral was not executed by the nursing team, as she did not follow up after delegating the task. The facility's policy and procedures on restorative nursing care emphasized the importance of active ROM exercises and training to assist residents in adjusting to their disabilities and using prosthetic devices. However, these procedures were not followed, leading to the deficiency in care for Resident 34.
Pharmaceutical Service Deficiencies in Medication Administration
Penalty
Summary
The facility failed to provide necessary pharmaceutical services for two residents, resulting in medication not being administered as prescribed. For Resident 143, who has Alzheimer's Disease and Glaucoma, the prescribed Cosopt eye drops were unavailable for administration on three consecutive occasions. The medication was not delivered by the pharmacy due to being out of stock, and the facility did not reorder the medication in a timely manner, as per their policy, which requires reordering three to four days in advance. This led to missed doses on two consecutive days. For Resident 144, who has asthma and COPD, the facility failed to provide proper instructions for medication administration. The resident was prescribed Wixela Inhub Inhalation Aerosol Powder, which requires rinsing the mouth after use to prevent side effects such as oral thrush. During medication administration, the LVN did not instruct the resident to rinse their mouth after using the inhaler, contrary to the physician's orders and the facility's policy. The Director of Nursing confirmed that licensed nurses should follow doctor's orders, including reminding residents to rinse their mouths after inhaler use.
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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