Extended Care Hospital Of Westminster
Inspection history, citations, penalties and survey trends for this long-term care facility in Westminster, California.
- Location
- 206 Hospital Circle, Westminster, California 92683
- CMS Provider Number
- 555211
- Inspections on file
- 25
- Latest survey
- November 5, 2025
- Citations (last 12 mo.)
- 22
Citation history
Health deficiencies cited at Extended Care Hospital Of Westminster during CMS and state inspections, most recent first.
Three residents were placed on bed exit alarms without documented informed consent, despite facility policy requiring consent from the resident or responsible party. Nursing staff and the DON confirmed that informed consent was never obtained for the use of these alarms, even for residents lacking decision-making capacity due to dementia.
CNAs were observed feeding two fully dependent residents at the same time by alternating spoonfuls and beverages, contrary to facility policy requiring individualized attention during meals. Multiple residents with severe cognitive impairment and total dependence on staff for eating were affected, and staff interviews confirmed this was a routine practice. Facility leadership acknowledged that this practice did not align with training or policy.
Several residents were administered antipsychotic medications without documentation of attempted nonpharmacological interventions, and staff failed to accurately monitor or document orthostatic blood pressure as required by physician orders and facility policy. In multiple cases, blood pressure readings were either identical across different positions or taken hours apart, and abnormal readings were not reassessed or reported. Staff interviews confirmed gaps in understanding and documentation, and the facility's policies for monitoring side effects and obtaining informed consent were not consistently followed.
A resident with severe cognitive impairment and limited English proficiency did not receive individualized cultural music or TV programming in their primary language, as required by their care plan and activity assessments. Despite staff awareness of the resident's preferences and needs, observations and interviews confirmed that only English-language TV was provided in the room and no radio was available, resulting in a lack of culturally appropriate activities.
The facility did not provide staff supervision or safety equipment for four residents who smoked in the designated area, and did not assess their ability to smoke safely unsupervised. Additionally, a resident who experienced two falls did not have all care plan interventions implemented, including missing blood pressure monitoring in different positions and incomplete placement of floor pads. The resident's change in neurological status, specifically speech, was not communicated to the physician as required.
Two residents receiving GT feedings had formulas at their bedsides with labels that did not match physician orders, including incorrect feeding rates and missing times. Unopened feeding formula bags were also stored at the bedside instead of in a temperature-controlled utility room, contrary to facility policy. Nursing staff and the DON confirmed these practices did not follow established procedures for enteral feeding safety and labeling.
Two residents did not receive pain management in accordance with physician orders and facility policy. One resident was given Tylenol for moderate pain when the order specified use only for mild pain, and staff did not contact the physician for an appropriate order. Another resident received PRN Tylenol for moderate to severe pain without documentation or implementation of non-pharmacological interventions prior to medication administration, as required by policy.
The facility did not ensure that nurses and nurse aides were competent in obtaining and evaluating orthostatic hypotension, as evidenced by the lack of specific training, competency assessments, and proper documentation. Several residents experienced significant drops in blood pressure that were not properly identified or reported, and staff interviews revealed inconsistent knowledge and practices regarding orthostatic hypotension monitoring.
A nurse failed to administer a complete dose of a medication to a resident, leaving significant residue in the medication cup, and did not follow proper procedure to ensure the full dose was given. Additionally, the facility did not accurately reconcile and document the removal and administration of controlled substances for a resident, resulting in discrepancies between medication removal records and the MAR. The DON confirmed these findings.
Surveyors found that medications for oral and external use were stored together without separation, daily temperature monitoring of the medication refrigerator was not consistently documented, and enteral formulas and supplements were kept in a utility room without temperature monitoring. Staff confirmed these deficiencies during interviews.
Surveyors found that food in the kitchen was not properly labeled or dated, the heated plate lowerator was unclean with utensils and debris present, the walk-in freezer had significant ice build-up, and the dishwasher drainpipe lacked the required air gap for backflow prevention. These deficiencies were confirmed by staff and affected the majority of residents receiving food from the kitchen.
The facility did not consistently follow its policies for the storage and handling of food brought in by family or visitors, as staff gave conflicting accounts of procedures and used an unmonitored employee refrigerator for storage. Staff interviews revealed a lack of training and awareness regarding safe food handling of outside food, and facility leadership could not provide documentation of staff education on this topic.
Staff failed to follow hand hygiene protocols while assisting multiple residents with meals and during medication administration. CNAs were observed feeding more than one resident at a time and touching bibs without performing hand hygiene between residents. An LVN administered oral medications and then prepared a nebulizer treatment for a resident without hand hygiene in between, despite facility policy requiring it. Staff interviews confirmed these lapses in infection control practices.
Several residents, including those lacking decision-making capacity, did not have informed consents for psychotropic medications renewed every six months as required, and consent forms often lacked specific details such as dose, frequency, and indication. The process for obtaining consent did not consistently involve direct communication between the prescribing physician and the responsible party, and facility policies were not updated to reflect current regulations. These deficiencies were confirmed by interviews and record reviews with nursing staff and the DON.
The facility did not create care plans for 23 residents who smoked, nor for two residents involved in repeated disputes over their shared room door. Despite documentation and staff awareness of these issues, no individualized care plans were developed to address the residents' needs or manage the ongoing conflicts.
The facility did not follow its posted menu by serving mashed potatoes instead of roasted red potatoes to residents on regular diets, and this change was not communicated in advance as required by policy. The substitution was confirmed during a trayline observation, and facility staff acknowledged the menu should have been followed.
A facility failed to provide necessary psychiatric services for a resident with senile dementia and psychosis, as ordered by a physician. Despite a documented order for psychiatric evaluation and treatment, the resident was neither scheduled nor seen for these services. Interviews with the resident, an LVN, and the DON confirmed the oversight.
The facility failed to complete post-fall assessments for two residents, leading to potential delays in identifying neurological changes. One resident had an unwitnessed fall with no neuro checks documented, while another had incomplete neuro assessments after a fall. The DON acknowledged these lapses in following the facility's policy.
The facility failed to meet sanitary requirements in the kitchen, including improper drying of a blender, unclean kitchen hood, unsanitary ice machine, heavily marred cutting boards, and dirty or damaged utensils. These issues were confirmed by the Dietary Supervisor and had the potential to cause foodborne illnesses.
The facility failed to maintain its infection control program, including inaccurate infection surveillance documentation, improper storage of soiled and clean linens, and staff not performing proper hand hygiene during medication administration. These deficiencies were confirmed by the Infection Preventionist and observed during inspections.
The facility failed to offer PCV15/PCV20 immunizations to sampled and nonsampled residents in accordance with CDC recommendations. The Infection Preventionist admitted that the type of vaccine administered depended on the physician's order and was not aware of the current CDC guidelines, leading to the deficiency.
A resident with suspected mental illness did not receive a timely Level II Mental Health Evaluation due to the facility's failure to conduct a new Level 1 PASRR screening after the resident's isolation period. The delay resulted in the resident not receiving necessary specialized services for over a year.
The facility failed to coordinate hospice care, administer Lantus solution as ordered, and complete a fall risk assessment after an unwitnessed fall. These deficiencies were confirmed by the LVN, Social Services Director, and DON, posing risks to the residents' well-being.
The facility failed to attempt alternatives before using elevated side rails for a resident with limited mobility, impaired cognition, and a high risk for falls. The medical record showed no evidence of attempted alternatives, and staff confirmed this oversight.
The facility failed to have an RN on duty for at least eight consecutive hours a day, as required. Document reviews and interviews revealed multiple instances where RNs did not work the required hours, and the recorded hours did not match the actual hours worked. The Administrator confirmed the discrepancy and acknowledged the lack of an RN staffing waiver.
The facility failed to provide necessary pharmacy services, as discrepancies were found in the documentation and handling of discontinued controlled medications. Observations revealed that the quantities documented did not match the actual quantities, and some medications were not documented at all. Both the SNF DON and TRC DON acknowledged these findings.
A resident was administered Norvasc despite having a pulse rate below the physician-prescribed parameter. The resident's medical record indicated that Norvasc should be held if the pulse rate was less than 60 beats per minute, but it was given when the pulse rate was 56 beats per minute. This was confirmed by the DON during a review.
The facility failed to ensure that three residents were free from unnecessary psychotropic medications. Two residents were not properly monitored for orthostatic blood pressures while on Seroquel, and another resident did not have required monthly behavior summaries completed for multiple psychotropic medications. These deficiencies were confirmed by facility staff and had the potential to result in adverse consequences.
The facility failed to ensure safe and secure medication storage, including improperly labeled insulin pens, unreported removal of a medicated patch, expired sanitizing wipes, and an unlocked medication cart. These deficiencies compromised medication safety and security.
The facility failed to ensure that a TSH blood test was completed for a resident as ordered by the physician. The resident, who lacked decision-making capacity, had a physician's order for a TSH test every three months. However, the test due in April 2024 was not completed, as confirmed by the DON.
The facility failed to maintain accurate medical records for two residents. One resident was transferred to an acute care hospital without documentation of the change of condition, and another resident's POLST form lacked information on advance directives.
The facility failed to appoint a designated IDT member to coordinate care between the facility and the hospice agency for a resident on hospice services. Interviews with staff confirmed the absence of a specific hospice coordinator, and no care conference was held with the resident's family, facility IDT, and hospice provider.
The facility failed to ensure that garbage was properly stored in three dumpsters, with lids propped open by garbage, preventing them from fully closing. This was confirmed by the Maintenance Supervisor.
The facility failed to ensure appropriate respiratory care for a resident by not preventing the oxygen tubing from touching the floor and not formulating a care plan for oxygen therapy. The resident, who had severe cognitive impairment, was observed with nasal cannula oxygen tubing on the floor, and the care plan did not address the use of oxygen therapy. The DON confirmed these findings.
The facility failed to ensure the medication storage room refrigerator was free of ice buildup. The freezer compartment, containing e-kits, vaccines, and insulins, had significant ice buildup. An LVN confirmed it was the nursing staff's responsibility to report such issues to maintenance, but this was not done.
Failure to Obtain Informed Consent for Bed Exit Alarms
Penalty
Summary
The facility failed to obtain informed consent for the use of bed exit alarms for three residents. Medical record reviews showed that two residents lacked capacity to make decisions due to dementia, while one resident was determined to have decision-making capacity. Despite physician orders for bed exit alarms to prevent falls and injuries, there was no documentation of informed consent from either the residents or their responsible parties for the use of these devices. The facility's policy requires that residents or their responsible parties be informed and provide consent for treatments or procedures, but this was not followed in these cases. Interviews with nursing staff and the Director of Nursing confirmed that bed exit alarms were in use for all three residents and that the facility had never obtained informed consent for their use. The absence of consent was verified through both medical record review and staff statements, indicating a consistent failure to adhere to the facility's own policy regarding informed consent for the use of bed exit alarms.
Failure to Promote Dignity During Meal Assistance
Penalty
Summary
Staff failed to provide care that promoted dignity and respect for multiple residents who were dependent on assistance with eating. Certified Nursing Assistants (CNAs) were observed feeding two residents at the same time by alternating spoonfuls and beverages between them, rather than focusing on one resident at a time. This practice was observed with several residents who had severe cognitive impairment and were fully dependent on staff for eating, as documented in their Minimum Data Set (MDS) assessments. Specifically, CNA 1 was seen feeding two residents simultaneously, then later feeding another pair of residents at the same time. CNA 2 and CNA 3 were also observed feeding two residents at once. Interviews with the CNAs confirmed that this was a common practice in the facility. The facility's policy on Assistance with Meals required that residents who cannot feed themselves be fed with attention to safety, comfort, and dignity, and that staff should minimize interactions with others while assisting residents with meals. Further interviews with the Director of Staff Development (DSD) and a Licensed Vocational Nurse (LVN) revealed that CNAs were trained to feed only one fully dependent resident at a time, and that feeding two fully dependent residents simultaneously was not in accordance with facility policy. The DSD acknowledged the need to monitor seating arrangements and staff availability to ensure proper assistance during meals.
Failure to Prevent Unnecessary Psychotropic Medication Use and Inadequate Monitoring
Penalty
Summary
The facility failed to prevent the use of unnecessary psychotropic medications and did not ensure proper monitoring and documentation for residents prescribed antipsychotic drugs. In several cases, standing orders for injectable antipsychotics, such as Haldol, were implemented without documentation of nonpharmacological interventions being attempted prior to administration. For example, a resident with bipolar disorder, anxiety disorder, and substance use disorder had a standing order for Haldol IM if oral psychotropic medications were refused, but the medical record and facility policy did not specify or document any nonpharmacological interventions prior to use. Staff interviews confirmed the absence of such documentation and the lack of evidence that alternatives were considered before administering the medication. Additionally, the facility did not consistently monitor for orthostatic hypotension in residents receiving antipsychotic medications, as required by physician orders and facility policy. Multiple residents on medications such as Seroquel, Clozaril, and risperidone had orders for regular orthostatic blood pressure monitoring, but records showed either identical blood pressure readings for different positions (lying, sitting, standing), or readings taken hours apart, which is not consistent with proper orthostatic assessment. In some cases, significant drops in blood pressure were not reassessed or reported to the physician, and there was no documentation of resident assessment following abnormal readings. Staff interviews revealed a lack of understanding regarding the parameters for orthostatic hypotension and the appropriate steps to take when abnormal readings were identified. The facility's policies required monitoring for side effects and adverse consequences of antipsychotic medications, including orthostatic hypotension, but these were not followed in practice. Documentation failures included not recording nonpharmacological interventions, not obtaining or documenting informed consent with specific medication details, and not accurately or consistently monitoring and documenting orthostatic blood pressure as ordered. These deficiencies were verified by staff and the DON during interviews and record reviews.
Failure to Provide Individualized Cultural Activities for Non-English Speaking Resident
Penalty
Summary
The facility failed to provide an individualized and ongoing activity program to meet the needs and interests of a resident with severe cognitive impairment who only spoke a foreign language. Despite documented assessments and care plans specifying the need for cultural music and TV programs in the resident's primary language to promote therapeutic stimulation, observations on multiple occasions revealed that the resident's TV was set to English-language programming and no radio was present in the room. Communication cards in the resident's primary language were observed, but no other individualized activities reflecting the resident's cultural preferences were provided in the room. Interviews with staff, including the Activities Director and a CNA, confirmed that while group cultural music and events were offered in the activities room, the resident did not receive cultural music or TV programming in their room as required by their care plan. The Activities Director acknowledged the lack of appropriate TV channels and was unsure why a radio was not available in the resident's room. Documentation of activity participation indicated general activities such as socialization and entertainment, but did not reflect the provision of individualized cultural activities as outlined in the resident's assessments and care plan.
Failure to Provide Supervision and Implement Fall Prevention Measures
Penalty
Summary
The facility failed to ensure the safety and supervision of residents in two key areas: smoking supervision and fall prevention. Four residents were observed smoking unsupervised in the designated outdoor smoking area, which lacked essential safety equipment such as a fire extinguisher, smoking apron, or smoking blanket. The facility's policy did not require staff-supervised smoke breaks, and residents were not assessed for their ability to smoke safely without supervision. Both the Assistant Administrator and TRC Program Director confirmed that residents were allowed to smoke unsupervised and that no safety equipment was present in the area. In the case of one resident, the facility did not implement or monitor fall prevention interventions as outlined in the care plan. After an unwitnessed fall, the care plan required monitoring of vital signs and blood pressure in lying, sitting, and standing positions, but the medical record showed this was not done. Additionally, following a witnessed fall, the resident was to have bilateral floor pads in place and undergo 24-hour neurochecks. Observations revealed that only one floor pad was in place, and the care plan interventions were not fully individualized or implemented as required. The facility also failed to notify the physician when the resident's neurological status changed, specifically when the resident's speech changed from clear to rambling during neurochecks after a fall. This change was documented in the medical record, but there was no evidence of physician notification or further monitoring of the resident's speech. Interviews with nursing staff and the DON confirmed these lapses in care plan implementation and communication.
Failure to Accurately Label and Store GT Feeding Formulas
Penalty
Summary
The facility failed to provide necessary gastrostomy tube (GT) care and services for two residents receiving enteral feeding. Observations revealed that the GT feeding formulas for both residents were not labeled accurately according to the physician's orders, with discrepancies in the feeding rates written on the labels compared to the orders in the medical records. Additionally, the date and time when the formula was hung were missing from the labels. Both residents had unopened bags of their respective feeding formulas stored at their bedsides, contrary to facility policy, which requires unopened formulas to be stored in temperature and light-controlled conditions within a locked utility room. Interviews with nursing staff and the Director of Nursing (DON) confirmed that the labels on the GT feeding formulas did not match the physician's orders and that the storage of unopened formula at the bedside was not in accordance with facility policy. The DON stated that proper labeling is necessary to ensure the correct resident, rate, and formula are administered, and that unopened formulas should be stored in the utility room. The observed practices did not align with the facility's written policies and procedures for enteral feeding safety precautions and error prevention.
Failure to Provide Safe and Appropriate Pain Management
Penalty
Summary
The facility failed to provide adequate and appropriate pain management for two of three residents reviewed for pain management. For one resident, the facility did not administer pain medication according to the physician's orders. The resident, who lacked capacity to make decisions, was given Tylenol for a pain level that was considered moderate, despite the physician's order specifying Tylenol only for mild pain. Both the LVN and the DON confirmed that the medication administered did not match the resident's pain level and that the physician should have been contacted to obtain an appropriate order for moderate pain. For another resident, the facility did not implement or document non-pharmacological pain interventions prior to administering PRN Tylenol for reported pain. The resident, who also lacked decision-making capacity, received Tylenol multiple times for pain levels ranging from moderate to severe. However, there was no documentation in the medical record that non-pharmacological interventions were attempted or their effectiveness assessed before giving the medication, as required by facility policy. Staff interviews confirmed that such interventions should have been tried and documented before administering PRN pain medication. The facility's policy on pain assessment and management requires that pain be managed according to the resident's clinical condition and treatment goals, with non-pharmacological interventions attempted and documented prior to pharmacological measures. In both cases, the facility did not follow its own policy, resulting in residents not receiving pain management services as ordered or documented.
Failure to Ensure Staff Competency in Orthostatic Hypotension Monitoring
Penalty
Summary
The facility failed to ensure that licensed nurses and nurse aides possessed the necessary competencies to properly obtain and evaluate orthostatic hypotension in residents. The Director of Nursing (DON) and Assistant Administrator confirmed that annual competency evaluations specific to orthostatic hypotension monitoring were not conducted or documented for the staff, including LVNs and LPTs. The facility's policy defined orthostatic hypotension and required reporting significant changes to a physician, but there was no evidence that staff were trained or assessed on this procedure. Interviews with staff revealed a lack of knowledge regarding the correct parameters for orthostatic hypotension and inconsistent practices in monitoring and documentation. Medical record and facility document reviews showed multiple instances where residents had significant drops in blood pressure readings between sitting and standing positions, consistent with orthostatic hypotension, but these were not properly identified, documented, or reported. For example, one resident had a diastolic blood pressure drop of 19 mmHg, and another had a drop of 12 mmHg, yet there was no evidence of appropriate follow-up or physician notification. Additionally, medication administration records and change of condition logs indicated that blood pressure readings were sometimes recorded incorrectly or not compared as required by policy. Interviews with nursing staff further demonstrated gaps in knowledge and competency. Some staff were unable to state the correct criteria for orthostatic hypotension or the appropriate actions to take when significant changes were observed. Others relied on CNAs to obtain vital signs but did not verify or interpret the results according to policy. The DON acknowledged that staff had not been specifically trained or evaluated on orthostatic hypotension monitoring, and this lack of competency assessment was confirmed by the DSD and other administrative staff.
Medication Administration and Controlled Substance Documentation Deficiencies
Penalty
Summary
The facility failed to ensure accurate administration of medications and proper reconciliation and documentation of controlled substances. During a medication administration observation, a registered nurse did not administer the complete dose of a resident's docusate sodium, as significant residue was left in the medication cup after administration. The nurse acknowledged that if residue is observed, more applesauce should be added to ensure the full dose is given, which was not done in this instance. The Director of Nursing confirmed that all medications should be administered as ordered and that the complete dose should be given if residue remains. Additionally, the facility did not accurately reconcile and document controlled medications for a resident. Review of records showed discrepancies between the removal of controlled substances, such as alprazolam and morphine sulfate, and their documentation on the Medication Administration Record (MAR). For example, doses of morphine sulfate were removed at two different times, but only one administration was documented on the MAR. The Director of Nursing verified these discrepancies and acknowledged that the documentation did not match the removal records, indicating a failure in the facility's process for tracking and documenting controlled substances.
Medication Storage, Labeling, and Temperature Monitoring Deficiencies
Penalty
Summary
The facility failed to ensure proper storage and separation of medications, as observed during an inspection of the medication room. Orally administered medications were stored together with externally used medications, such as suppositories and eye drops, without any physical separation. This was confirmed by staff present during the observation, who acknowledged that these medications should be stored separately to prevent errors in medication administration. Additionally, the facility did not consistently monitor and document the temperature of the refrigerator used to store medications requiring refrigeration, such as insulin pens and PPD test bottles. Although a daily monitoring sheet was present and the temperature was within the required range at the time of observation, there were missing temperature records for two consecutive days. Staff verified these omissions and acknowledged the requirement for daily temperature monitoring and documentation. The facility also failed to monitor the storage conditions of enteral formulas and oral nutritional supplements. Multiple bags and bottles of enteral formula and supplements were stored in a utility room without any temperature monitoring in place. The product provider's guidelines specify that these products should be stored at room temperature and not exposed to excessive heat or freezing. Staff confirmed the lack of temperature monitoring and verified the storage conditions at the time of inspection.
Multiple Sanitation and Food Safety Deficiencies Identified in Kitchen
Penalty
Summary
Surveyors identified multiple failures in the facility's kitchen related to food safety and sanitation. During an initial tour and interviews, it was observed that an opened bag of chicken nuggets in the walk-in refrigerator was not labeled or dated, and there was no box to identify when the bag was received or opened. The facility's policy required all food items in storage to be labeled and dated, and this was verified as a deficiency by staff. Additionally, the heated plate lowerator was found to be unclean, containing dirt, a fork, a foil, and later a spoon, with these findings confirmed by the Dietary Services Supervisor (DSS). The DSS stated that maintenance was responsible for cleaning and disassembling the lowerator monthly, but the equipment was not clean at the time of inspection. Further observations revealed a thick ice build-up on the interior plastic lining near the door of the walk-in freezer, which was verified by staff. The surveyors also found that the metal drainpipe under the dishwasher extended below the flood level rim and into the drainage inlet, lacking the required air gap for backflow prevention as outlined in both the FDA Food Code and the facility's own policy. These deficiencies were confirmed by both the DSS and the Maintenance/Housekeeping Director. The report notes that 91 of 98 residents received food prepared in the kitchen where these issues were identified.
Failure to Follow Policy for Storage and Handling of Food Brought by Visitors
Penalty
Summary
The facility failed to follow its own policies and procedures regarding the use and storage of food brought in by family members and visitors for residents. Observations and staff interviews revealed inconsistent practices and a lack of staff awareness about the facility's protocols for safe food handling of outside food. Specifically, staff provided conflicting information about where and how such food should be stored, with some indicating that food was kept in an unmonitored employee refrigerator, while others stated it was stored in a designated area in the kitchen. The employee refrigerator, which was not monitored for temperature or sanitation, was observed to have a temperature of 40 degrees F and visible rust on the freezer door. No resident food items were present in the refrigerator at the time of observation. Further interviews with nursing and dietary staff indicated a lack of training and documentation regarding the safe handling and storage of food from outside sources. Staff members were either unaware of the facility's policies or had not received specific training on the subject. The Director of Nursing and Dietary Services Supervisor were unable to provide evidence of any inservices or education provided to staff on this topic. These failures were identified through review of facility policies, staff interviews, and direct observation.
Failure to Implement Hand Hygiene Practices During Resident Care
Penalty
Summary
The facility failed to implement its infection prevention and control program as outlined in its policies and procedures, specifically regarding hand hygiene practices among staff during resident care. Certified Nursing Assistants (CNAs) were observed assisting multiple residents with meals without performing hand hygiene between residents. For example, one CNA assisted two residents with feeding at the same time, touching their bibs, and did not perform hand hygiene between assisting each resident. Similar observations were made with other CNAs who also failed to perform hand hygiene between assisting different residents during mealtime. Additionally, a Licensed Vocational Nurse (LVN) was observed administering oral medications to a resident, then preparing and administering a nebulizer treatment without performing hand hygiene between the two different routes of medication administration. The LVN handled the resident's bed controls and nebulizer equipment after administering oral medications, contrary to the facility's policy which requires hand hygiene before preparing and handling medications and after contact with objects in the resident's immediate vicinity. Interviews with the involved staff confirmed that hand hygiene was not performed as required by facility policy. The Director of Staff Development (DSD) and Director of Nursing (DON) both acknowledged that staff are expected to perform hand hygiene before and after assisting residents with meals and between different medication administration routes, but these practices were not followed during the observed incidents.
Failure to Obtain and Renew Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to ensure that residents and their responsible parties were fully informed and provided with appropriate, timely, and specific informed consent regarding the use of psychotropic medications. Multiple residents, including those with significant mental health diagnoses and those lacking capacity to make their own medical decisions, did not have their informed consents renewed every six months as required. In several cases, the consent forms did not specify the exact dose, frequency, or reasons for prescribing the medications, and the process for obtaining consent did not consistently involve direct communication between the prescribing physician and the resident's conservator or responsible party. For one resident with bipolar disorder, anxiety disorder, and substance use disorder, who had conservators for medical decisions, the medication consent form only listed medication names and dosage ranges, omitting the specific dose, frequency, and indications as required. The conservator confirmed that the physician did not directly contact them to obtain informed consent, and the process relied on faxed forms or verbal consent via nursing staff, without adequate explanation of the medications. The physician acknowledged that their signature on the consent form only verified the medication list and dosage range, not that informed consent had been properly obtained. Other residents, including those with no capacity to make decisions, were also affected. Informed consents for psychotropic medications such as risperidone, Lexapro, Belsomra, Seroquel, and Remeron were not renewed after six months, and facility policy and procedure documents had not been updated to reflect the new regulatory requirements for six-month renewals. Nursing staff and the DON confirmed that the required renewals had not occurred, and that the facility's tracking and policy review processes were insufficient to ensure compliance. These failures were identified through interviews, medical record reviews, and policy reviews, and were acknowledged by facility staff.
Failure to Develop Comprehensive Care Plans for Smokers and Roommate Disputes
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for all residents with identified needs. Specifically, care plans were not created for 23 residents in the TRC unit who were identified as smokers, despite documentation confirming their smoking status. Medical record reviews for these residents, including two specific examples, showed no care plan problems were initiated to address their smoking habits or the associated risks. The TRC Program Director confirmed that these care plans were missing during an interview and record review. Additionally, the facility did not develop care plans to address ongoing disputes between two residents regarding whether their shared room door should be open or closed. Documentation showed repeated arguments and incidents between the two residents, including loud altercations and complaints, but no care plan was initiated to address or manage these recurring issues. Interviews with staff and the TRC Program Director confirmed that the disputes were known and discussed among staff, but appropriate care planning was not completed.
Failure to Follow Posted Menu and Communicate Food Substitution
Penalty
Summary
The facility failed to follow its posted menu and recipes by serving mashed potatoes instead of roasted red potatoes to residents on regular-textured diets. This substitution was not communicated in advance to the residents, as required by facility policy. Review of facility documents showed that seven out of 52 residents on the SNF side were to receive regular-textured food, and the weekly menu specified roasted red potatoes for those on regular, NCS, and low fat/low cholesterol diets. During a trayline observation, it was confirmed that mashed potatoes were served instead, and the Dietary Services Supervisor (DSS) acknowledged that the menu should have been followed and the correct item served. The facility's policy requires that any deviations from the posted menu be documented with reasons for the change, but this was not done in this instance.
Failure to Provide Psychiatric Services as Ordered
Penalty
Summary
The facility failed to provide necessary psychiatric services as ordered by the physician for a resident diagnosed with senile dementia with psychosis. The resident was admitted to the facility with a physician's order for a psychiatric evaluation and treatment, which was not fulfilled. The medical record review revealed no documentation of the resident being scheduled or seen for the required psychiatric evaluation and treatment. Interviews conducted with the resident, an LVN, and the DON confirmed the deficiency. The resident stated they had not seen the psychiatrist, and the LVN verified that the psychiatric follow-up had not occurred. The DON acknowledged the oversight, confirming that the psychiatric evaluation and treatment were not conducted as ordered by the physician.
Failure to Complete Post-Fall Assessments for Residents
Penalty
Summary
The facility failed to complete post-fall assessments for two residents, leading to potential delays in identifying and responding to neurological changes after falls. Resident 4 experienced an unwitnessed fall on 6/10/24, where they were found with their knees and legs on the floor. Despite the facility's policy requiring neuro checks after such incidents, there was no documented evidence of these assessments being completed for Resident 4. Interviews with LVN 2 and LVN 1 confirmed that neuro checks should have been conducted every 15 minutes for one hour, then every 30 minutes for two hours, and every two hours for 24 hours, but this was not done. Similarly, Resident 5, who was at high risk for falls, had an unwitnessed fall on 7/5/24. The neuro check sheet for Resident 5 was incomplete, with missing assessments at 0930, 1130, and 1330 hours on 7/6/24. The DON confirmed that the neurological assessments, including vital signs, should have been completed and filed in the resident's medical record. The failure to complete these assessments for both residents was acknowledged by the DON, indicating a lapse in following the facility's post-fall assessment policy.
Sanitary Failures in Kitchen
Penalty
Summary
The facility failed to meet sanitary requirements in the kitchen, as evidenced by multiple observations and interviews. The heavy-duty blender used for puree preparation was not air-dried prior to use, contrary to the facility's policy and USDA Food Code 2022. Instead, it was dried using a paper towel, which the Dietary Supervisor acknowledged was incorrect and could lead to contamination. Additionally, the kitchen hood was found to have blackish dirt residue, indicating it had not been cleaned as frequently as required by the facility's policy and USDA guidelines. The Dietary Supervisor confirmed that the hood should be cleaned every three weeks by staff and every three months by an outside company, but the last service was in December 2023, well beyond the recommended interval. The ice machine used for residents and staff was also found to be in an unsanitary condition. The interior of the ice machine bin had yellowish/blackish residue, and the last recorded cleaning by dietary staff was in April 2024, with the maintenance staff last cleaning it in January 2024. The Maintenance Supervisor admitted uncertainty about the residue and confirmed that the ice was not safe for use. Furthermore, the cutting boards in the kitchen were heavily marred with deep grooves, making them difficult to clean and sanitize, as required by the USDA Food Code 2022. The Dietary Supervisor acknowledged that these cutting boards should have been replaced to prevent bacterial contamination. Several kitchen utensils were found to be in poor condition and not clean. Four rubber spatulas were cracked and chipped, and other utensils like stainless spatulas and a basting brush were partially melted and worn off. The Dietary Supervisor confirmed that these utensils were unsafe for use and should have been replaced. Additionally, multiple scoops and a peeler were observed with dry, crusted food residue, indicating they had not been properly washed after use. The Dietary Supervisor verified these findings, acknowledging that the utensils should have been cleaned to prevent contamination.
Infection Control Program Deficiencies
Penalty
Summary
The facility failed to maintain its infection control program, which is designed to prevent the development and transmission of diseases and infections. Specifically, the facility did not implement its infection control surveillance program for January through March 2024. The Infection Preventionist (IP) was responsible for conducting surveillance of residents' infections using the McGeer's Criteria. However, the Monthly Antimicrobial/Infection Control Surveillance forms for several residents were inaccurately documented, failing to classify infections as community-acquired (CAI) or healthcare-associated infections (HAI) and incorrectly stating that antibiotic use met McGeer's criteria. This led to inaccurate monthly and quarterly infection surveillance reports, as verified by the IP during the review process. For example, Resident 72's form did not classify the infection, and the criteria for a urinary tract infection (UTI) were not met, among other similar discrepancies for other residents. The facility also failed to maintain proper infection control practices in the laundry room area. During an inspection, it was observed that soiled and clean linens were not stored separately, and items such as slings, socks, and blankets were improperly placed, posing a risk of cross-contamination. The Laundry Supervisor confirmed these findings. Additionally, crates containing residents' shoes and clothing were stored on the floor, and a bottle of lotion was found with folded pillowcases in the clean laundry area, further indicating lapses in maintaining a sanitary environment. Furthermore, the facility did not ensure that staff performed proper hand hygiene during medication administration. Two Licensed Vocational Nurses (LVNs) were observed failing to perform hand hygiene after touching contaminated surfaces and before administering medications. One LVN touched a trash bin lid and then handled a resident's insulin pen injector without washing hands, while another LVN had long fingernails and did not perform hand hygiene between touching a resident and administering medications. These actions were verified by the LVNs themselves, highlighting a significant breach in infection control practices as per the facility's policies and procedures.
Failure to Offer PCV15/PCV20 Immunizations
Penalty
Summary
The facility failed to offer PCV15/PCV20 immunizations to 11 of 19 sampled residents and 47 nonsampled residents in accordance with CDC recommendations. This failure was identified through interviews, medical record reviews, and facility policy and procedure reviews. The facility's policy stated that all residents should be offered pneumococcal vaccines upon admission, but this was not consistently followed. The Infection Preventionist (IP) admitted that the pneumococcal vaccine was always offered upon admission, but the type of vaccine administered depended on the physician's order. The IP also mentioned that she had started using the California Immunization Registry (CAIR) to track residents' immunizations only four months ago. Despite this, the residents' immunization reports did not show records of the pneumococcal vaccination, and the IP confirmed that she did not offer PCV15 or PCV20 to residents who had never received any pneumococcal vaccine. Further review of the residents' medical records showed that the facility did not offer a dose of PCV15 or PCV20 a year after residents received PPSV23, as per CDC guidelines. The IP verified these findings and stated that she only offered what was ordered by the physician. She was not aware of the current CDC guidelines for pneumococcal vaccines, leading to the deficiency in offering the appropriate vaccines to the residents.
Failure to Ensure Timely Level II Mental Health Evaluation
Penalty
Summary
The facility failed to ensure a timely Level II Mental Health Evaluation for a resident with suspected mental illness. The initial Level 1 PASRR screening conducted on 3/20/23 indicated the need for a Level II evaluation, but the resident was unavailable due to isolation for health and safety reasons. Despite the requirement to submit a new Level 1 screening after the isolation period, the facility did not conduct another Level 1 PASRR screening until 3/29/24, approximately a year later. This delay resulted in the resident not receiving the necessary Level II evaluation and the accompanying specialized services until 4/3/24. The Director of Nursing (DON) confirmed that the initial positive Level 1 screening required a Level II evaluation, which was not performed due to the resident's isolation. The DON also verified that the facility failed to conduct another Level 1 PASRR screening for over a year, leading to a significant delay in the resident receiving the required mental health evaluation and specialized services. This oversight posed a risk of failing to incorporate the recommendations from the PASRR Level II determination into the resident's care plan and transition of care.
Deficiencies in Hospice Coordination, Medication Administration, and Fall Risk Assessment
Penalty
Summary
The facility failed to coordinate the care of a resident with the contracted hospice provider. The hospice calendar and sign-in/out forms did not show complete skilled nursing and CHHA visits as per the physician's orders. Additionally, the nursing clinical notes and hospice aide notes were not updated, which was verified by the LVN, Social Services Director, and DON. These failures had the potential for the resident to not receive appropriate hospice care and services. The facility did not ensure that a resident's medication order for Lantus solution was administered per the physician's order. The MAR for May showed that the Lantus solution dose for a specific date was not administered or documented as held for any reason. The DON verified that the insulin was not administered as ordered, posing a risk for the resident to have a hyperglycemic episode and to receive unnecessary short-acting insulin doses. The facility also failed to complete a fall risk assessment after a resident had an unwitnessed fall and was transferred to the acute care hospital for evaluation. The resident's medical record did not show a completed Fall & Skin Risk Summary after the fall, which was confirmed by the LVN and DON. The facility's P&P required a fall risk assessment to be done within 24 hours of a fall, but this was not completed, posing a risk of not receiving immediate care based on the evaluation.
Failure to Attempt Alternatives Before Using Bed Rails
Penalty
Summary
The facility failed to ensure that alternatives were attempted before using elevated side rails for Resident 20, who was at risk for entrapment and serious injury. The FDA has issued a Safety Alert regarding entrapment hazards with hospital bed side rails, particularly for frail or elderly residents or those with conditions that may cause them to move about the bed. The facility's policy requires that alternatives to bed rails be attempted and documented before their use, but this was not done for Resident 20. Resident 20, who had limited physical mobility, impaired cognition, and a high risk for falls, was observed using an elevated side rail during ADL care and repositioning. However, a review of the medical record showed no documented evidence that alternatives were attempted before the use of the elevated side rail. Interviews with facility staff confirmed that alternatives were not tried prior to the implementation of the side rail for Resident 20.
Failure to Ensure RN Coverage for Required Hours
Penalty
Summary
The facility failed to have a registered nurse (RN) on duty for at least eight consecutive hours a day, as required. This deficiency was identified through interviews and document reviews. The facility's Nursing Sign-in sheets and Employee Time Cards for October and November 2023 showed multiple instances where RNs did not work the required eight hours. For example, on several dates, the sign-in sheets indicated that an RN worked eight hours, but the actual hours worked were less, ranging from 6.17 to 7.75 hours. The Social Worker and the receptionist confirmed that the hours recorded on the sign-in sheets did not match the actual hours worked by the RNs. The receptionist admitted to entering eight hours for RNs based on instructions from the Director of Staff Development (DSD) or Director of Nursing (DON), even when the RNs did not work the full eight hours. The Administrator confirmed that the facility did not have an RN staffing waiver and acknowledged the discrepancy in RN hours. The Administrator also mentioned that the facility did not have a Skilled Nursing Facility (SNF) DON at the time and that the Transitional Care (TRC) DON was on duty since the facility had less than 120 beds. The Social Worker, who was responsible for submitting the staffing report, did not review the actual RN hours worked and relied on the receptionist to enter the hours. This failure to ensure that an RN was on duty for the required hours has the potential to impact the clinical needs of the residents, either directly or indirectly through the oversight of licensed nurses.
Discrepancies in Documentation and Handling of Discontinued Controlled Medications
Penalty
Summary
The facility failed to provide the necessary pharmacy services to meet the needs of the residents, as evidenced by discrepancies in the documentation and handling of discontinued controlled medications. During an observation and interview with the SNF DON, it was found that the quantities documented for discontinued controlled medications did not match the actual quantities in the medication bubble packs or bottles. Specifically, discrepancies were noted in the quantities of lorazepam, alprazolam, and morphine sulfate for three residents. Additionally, one resident's lorazepam was not documented on the Discontinued Controlled Drug Log sheet. The SNF DON acknowledged these findings and attributed the errors to not wearing eyeglasses while documenting the quantities. Similarly, an observation and interview with the TRC DON revealed that two discontinued controlled medications were not documented on the Discontinued Controlled Drug Log sheet. The medications in question were clonazepam and lorazepam for two residents. The TRC DON admitted to forgetting to add these medications to the log sheet. Both the Administrator and the respective DONs were informed of and acknowledged these findings, which had the potential for drug diversion.
Failure to Monitor Medication Parameters
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary medications. Specifically, Resident 18 was administered Norvasc, a medication used to treat high blood pressure, despite the resident's pulse rate being below the parameter prescribed by the physician. The medical record review showed that the physician's order required Norvasc to be held if the pulse rate was less than 60 beats per minute. However, on 5/10/24, Norvasc was administered when Resident 18's pulse rate was 56 beats per minute. This was verified by the Director of Nursing (DON) during a concurrent interview and medical record review on 5/22/24. Resident 18 had no capacity to understand and make decisions, as noted in the history and physical examination dated 1/18/24.
Failure to Monitor Psychotropic Medication Use and Document Behavioral Summaries
Penalty
Summary
The facility failed to ensure that three residents were free from unnecessary psychotropic medications. Specifically, Residents 3 and 54 were not properly monitored for orthostatic blood pressures as ordered by their physicians while on Seroquel. The medical records showed that the orthostatic blood pressure readings were either incomplete or inaccurately recorded, with only the systolic blood pressure being noted. This was confirmed by an LVN and the SNF DON, who acknowledged the importance of accurate monitoring due to the potential for hypotension caused by the medications. Additionally, the facility did not complete the required monthly behavior summaries for Resident 18, who was on multiple psychotropic medications including Abilify, Seroquel, Zyprexa, Lithium carbonate, Buspar, and Prozac. The monthly summaries, which are essential for assessing the need for gradual dose reductions, were last completed in March 2024. This lapse was confirmed by both an LPT and the DON, who stated that the summaries should be updated monthly to assess the resident's behaviors. These deficiencies indicate a failure to adhere to the facility's policies and procedures regarding the monitoring and documentation of psychotropic medication use. The lack of proper monitoring and documentation had the potential to result in adverse consequences for the residents involved.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure the medications were safely and securely stored, leading to several deficiencies. Resident 32's insulin pen was not properly labeled, with a gray stain making the label hard to read. Additionally, the insulin pen was left unattended near the foot of the resident's bed while the LVN went to the restroom, despite the LVN claiming she could see it from the mirror. This compromised the safe storage of the medication and posed a risk of unauthorized access or misuse. For Resident 53, the facility failed to ensure that the staff reported to the licensed nurse when the resident's medicated patch came off. The CNA admitted to throwing the Exelon patch in the trash without informing her supervisor, citing being busy as the reason. This lack of communication could lead to improper medication administration and affect the resident's treatment for dementia. The facility also failed to maintain the medication storage areas properly. An inspection of the medication room revealed expired containers of Sani-Hands sanitizing wipes, which should not have been stored there. Additionally, a medication cart was found unlocked and unattended in a hallway, accessible to residents and staff passing by. These lapses in securing medication storage areas and ensuring the proper labeling and reporting of medication issues highlight significant deficiencies in the facility's medication management practices.
Failure to Complete Ordered TSH Blood Test
Penalty
Summary
The facility failed to ensure that a TSH blood test was completed for Resident 18 as ordered by the physician. The facility's policy and procedure (P&P) titled Lab and Diagnostic Test Results - Clinical Protocol, revised in September 2012, mandates that the physician will identify and order diagnostic and lab testing based on diagnostic and monitoring needs, and the staff will process test requisitions and arrange for tests. Resident 18, who had no capacity to understand and make decisions, was admitted and readmitted to the facility on unspecified dates. A physician's order dated January 11, 2024, required a TSH laboratory test to be completed every three months. However, a review of Resident 18's medical record on May 22, 2024, revealed that the laboratory blood test result for the TSH level, which was due in April 2024, was missing. The Director of Nursing (DON) confirmed that the TSH test was not completed as ordered.
Incomplete Medical Records for Two Residents
Penalty
Summary
The facility failed to ensure the medical record was accurately maintained for two residents. Resident 40 was transferred to an acute care hospital due to shortness of breath, but the medical record did not document the change of condition that necessitated the transfer. An interview with the LVN assigned to Resident 40 confirmed that the change of condition was not documented at the time of the transfer. Resident 20's medical record was also found to be incomplete. The POLST form for Resident 20 did not include documentation regarding whether the resident had formulated an advance directive. The Director of Nursing verified this omission during a concurrent medical record review and interview.
Failure to Designate Hospice Care Coordinator
Penalty
Summary
The facility failed to ensure a designated Interdisciplinary Team (IDT) member was appointed to coordinate care between the facility and the hospice agency for a resident receiving hospice services. The medical record review for the resident showed a physician's order for hospice services, but the facility's policy and procedure for the hospice program did not have a designated hospice coordinator. The hospice service agreement also lacked a designated IDT member responsible for coordinating care with the hospice agency. Interviews with facility staff, including an LVN, the Social Services Director, and the Director of Nursing (DON), confirmed that there was no specific staff member assigned to coordinate hospice care. The DON acknowledged that no care conference had been conducted with the resident's family, the facility's IDT, and the hospice provider. This lack of coordination had the potential to result in uncoordinated medical care for the resident on hospice services.
Improper Garbage Storage
Penalty
Summary
The facility failed to ensure that garbage was properly stored in three of three garbage dumpsters. During an observation on 5/20/24 at 1439 hours, it was noted that the lids of the dumpsters were propped open by garbage, preventing them from fully closing. This was confirmed in a subsequent observation and interview with the Maintenance Supervisor at 1502 hours, who verified that the dumpsters' lids were indeed propped open by garbage. According to the 2022 FDA Food Code, outside garbage receptacles must have tight-fitting lids or covers to prevent the scattering of garbage, the breeding of flies, or the entry of rodents.
Failure to Ensure Appropriate Respiratory Care
Penalty
Summary
The facility failed to ensure appropriate respiratory care for a resident, specifically by not preventing the resident's oxygen tubing from touching the floor and not formulating a care plan for the use of oxygen therapy. During an initial facility tour, the resident was observed with nasal cannula oxygen tubing on the floor, which was verified by an LVN present in the room. The medical record review showed that the resident had severe cognitive impairment and had a physician's order for oxygen therapy at 2 liters per minute as needed for comfort. However, the resident's care plan did not address the use of oxygen therapy. The DON confirmed these findings during an interview.
Medication Storage Refrigerator Ice Buildup
Penalty
Summary
The facility failed to ensure that the medication storage room refrigerator was free of ice buildup. During an inspection, the freezer compartment of the refrigerator, which contained e-kits, vaccines, and insulins, was observed with significant ice buildup. An ice pack used for the residents was also found inside the freezer compartment. The Licensed Vocational Nurse (LVN) confirmed the findings and acknowledged that it was the nursing staff's responsibility to report such issues to the maintenance team. However, the staff did not report the ice buildup to the maintenance staff, leading to the deficiency.
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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