Greenhaven Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Sacramento, California.
- Location
- 455 Florin Road, Sacramento, California 95831
- CMS Provider Number
- 555098
- Inspections on file
- 54
- Latest survey
- March 12, 2026
- Citations (last 12 mo.)
- 25
Citation history
Health deficiencies cited at Greenhaven Healthcare Center during CMS and state inspections, most recent first.
A resident with ESRD and DM was sent to the hospital for evaluation and treatment of a left big toe infection with suspected osteomyelitis. The resident’s bed-hold period expired while hospitalized, and the facility recorded a discharge at that time. When hospital case management later determined the resident was medically stable and began planning for return, the facility administrator, DON, and Admissions Coordinator all indicated the resident would not be readmitted due to an insurance lapse, despite a LTC bed being available. No 30-day discharge notice, appeal rights, or discharge planning were provided before the transfer, and the facility’s own policy required priority readmission from hospital and equal application of readmission procedures regardless of payment source.
A resident with significant cognitive and physical impairments, including a high risk for falls, was left unsupervised in an outdoor patio area. Despite care plans and assessments indicating the need for supervision and fall prevention, the resident accessed the area alone, resulting in a fall that caused a fatal head injury. Staff interviews confirmed that supervision was not provided at the time of the incident, and facility policies requiring individualized supervision were not followed.
A resident with severe cognitive impairment and a history of traumatic brain injury was admitted with a physician order for a CT scan, which was not entered or implemented until 15 days after admission. Staff interviews confirmed the delay, and facility policy required timely entry and follow-up of such orders. This resulted in a delay of ordered care.
A resident with multiple sclerosis and intact cognition was punched on the arm by another resident with vascular dementia and moderate cognitive impairment following a verbal altercation. Staff witnessed the incident, and records showed there was no care plan in place to address the aggressor's risk for aggressive behavior, resulting in a failure to protect residents from physical abuse.
A resident with cognitive impairment and a history of aggressive behavior physically struck another resident who had no cognitive deficits. Despite staff intervention and moving the victim to a different room, the aggressor continued to access the victim's new room, causing ongoing fear and distress. Staff interviews confirmed that increased supervision and separation were not implemented as required, resulting in the victim feeling unsafe and avoiding activities.
A resident with severe cognitive impairment physically struck another resident, who has multiple sclerosis, in a common area. Staff observed the altercation, which involved slapping and attempted punches, and intervened to separate the residents. Facility policy defines such actions as physical abuse.
A resident with severe cognitive impairment and a high fall risk was repeatedly found with their call light out of reach due to a broken clip, preventing them from calling for assistance as required by their care plan and facility policy. CNAs and the DON confirmed the deficiency during interviews.
A resident with multiple venous ulcers, lymphedema, and diabetes was discharged without a documented skin assessment, despite facility policy requiring this step. The Discharge Instruction Form and Discharge Summary lacked information on the resident's skin condition, and staff interviews confirmed the assessment was not completed or documented before discharge.
A resident with diabetes and total dependence for ADLs sustained a skin tear that was not assessed or treated according to facility policy. The wound was not reported to the treatment nurse, no physician orders were obtained, and no care plan was developed or implemented, as confirmed by both the treatment nurse and DON.
A resident with dysphagia was not provided with the ordered nectar thick liquids and no straw, as regular water with a straw was found at their bedside. The CNA confirmed providing the water and straw, contrary to the physician's orders. The DON acknowledged the risk of aspiration due to this oversight.
A resident with hemiplegia and severe cognitive impairment did not consistently receive the prescribed application of a left hand splint, as documented in their care plan. The facility failed to document the application and duration of the splint on several occasions, as confirmed by the Director of Rehabilitation and the Director of Staff Development. The Director of Nursing acknowledged that this inconsistency could lead to a decline in the resident's condition.
The facility failed to account for controlled medications for three residents, resulting in missing doses of Hydrocodone-Acetaminophen and Oxycodone. Despite procedures for handling these medications, audits revealed missing medication cards and count sheets, raising concerns about potential misuse. Additionally, two doses of Hydrocodone-Acetaminophen for a resident were unaccounted for, with no documentation of administration or disposal.
A resident with severe cognitive impairment was admitted without their representative signing the admission agreement, as required by facility protocol. This oversight meant the representative was not informed of the resident's rights, potentially affecting decision-making for the resident's care.
A resident reported that a nurse took her cell phone and call light, placing them out of reach after she refused a blood sugar check, leaving her unable to call for assistance. Despite being informed, the facility's Administrator did not initiate an investigation or document any actions, failing to follow the policy for investigating allegations of abuse or mistreatment.
The facility failed to maintain proper food temperatures, with uncalibrated thermometers and milk served above acceptable temperatures. Multiple residents complained of cold food, and observations confirmed that meals were often not palatable. The removal of a microwave further hindered the ability to reheat food, as acknowledged by staff.
The facility failed to follow the recipe for pureed bread rolls for 25 residents on a pureed diet, resulting in bread that was dry and lumpy instead of the required pudding-like consistency. The Dietary Director and Registered Dietician acknowledged the issue, noting the importance of achieving the correct consistency to prevent aspiration risks.
The facility failed to follow proper infection control practices for four residents, including not wearing gowns during care, and not cleaning enteral feeding equipment and CPAP/BiPAP masks as required. These actions increased the risk of infection spread among residents.
A resident with a history of inappropriate behavior was not adequately monitored, leading to an incident where he allegedly touched another resident's breast. Despite care plans requiring supervision, the resident was moved to a less monitored area, resulting in the failure to protect the victim, who has cerebral infarction and aphasia, from abuse.
The facility failed to treat residents with dignity by referring to those needing meal assistance as 'feeders.' Staff, including an LN and a CNA, used this term, contrary to the facility's policy, which emphasized treating residents with respect and avoiding such labels. The DON stated that residents should be referred to as 'assisted diners.'
A resident's room had a large hole in the wall above the bed, which had been present since admission. The resident, with a history of stroke and depression, confirmed the disrepair. A nurse acknowledged the issue, and the Maintenance Supervisor emphasized the importance of a homelike environment. However, only one maintenance request was logged, with no follow-up, contrary to the facility's policy.
A resident with Type 2 Diabetes Mellitus did not receive care in accordance with professional standards due to the facility's failure to accurately document blood glucose readings and notify the physician of readings below 100 as ordered. This issue persisted for nine days, potentially compromising the resident's care. The licensed nurse confirmed a documentation error, and the DON emphasized the importance of following physician orders and accurate documentation.
A resident with muscle weakness and unsteadiness was not assisted to his wheelchair for meals, contrary to physician orders and facility policy. This oversight was confirmed by staff and linked to the resident's recent weight loss and difficulty in eating. The facility's policy on supporting ADLs was not followed, impacting the resident's ability to feed himself.
A resident with a tongue ulcer, under palliative and hospice care, did not receive proper coordination of care when the ulcer was not communicated to the physician. Despite the resident's complaints and requests for evaluation, there was no evidence of notification to the physician or hospice, leading to potential pain and discomfort.
A facility failed to ensure clear and consistent documentation for a resident's left hand splint, leading to potential misuse. The resident had conflicting orders for the splint's duration, with staff unaware of the updated order. Observations showed the splint was applied daily, but the duration was not documented, and the resident's family noted it was only occasionally seen. The facility's policies on individualized care plans and documentation were not effectively implemented, resulting in a deficiency.
The facility failed to document daily glucometer calibration, with only six entries recorded for two machines in September. Interviews with staff confirmed missing entries and emphasized the importance of daily checks for accurate blood glucose readings. The facility's policy mandates daily calibration by night shift nurses, monitored monthly by the DON or Unit Manager.
Two residents were prescribed Seroquel without adequate indication or target behaviors. Resident 18, with Alzheimer's, showed no aggressive behavior or psychosis, yet was on Seroquel. Resident 117, with dementia, was given Seroquel for sleep issues, despite no aggressive behavior. Facility policy required specific conditions and non-pharmacological attempts before antipsychotic use, which were not documented.
Expired medications, including glucose tablets and an inhaler, were found in a medication cart, indicating a failure to follow the facility's medication storage policy. A licensed nurse confirmed the expiration, and the DON acknowledged that expired medications should not be in the cart. The facility's policy requires outdated drugs to be returned or destroyed.
A resident's medical records were found to be inaccurate, with discrepancies in the documentation of a PICC line and surgical site status. Observations and interviews revealed that the resident did not have a PICC line, and the surgical site details were outdated. The DON acknowledged the importance of accurate documentation to prevent misleading care decisions.
The facility's QAPI Committee failed to include the Medical Director (MED) in its meetings from November 2023 to October 2024, as required by policy. The DON confirmed the MED's absence, and the ADM emphasized the importance of the MED's role in guiding healthcare decisions.
A loose round plate with a large bolt in the D wing hallway posed a trip hazard, potentially endangering residents. Both a Licensed Nurse and a Maintenance Assistant acknowledged the hazard, noting the plate covers a drain used for pipe maintenance. The facility's maintenance policy requires all areas to be safe and operable, which was not met in this case.
A resident with Alzheimer's disease eloped from the facility due to inadequate supervision and monitoring. Despite being on elopement protocol and wearing a wander guard, the resident exited through the front door, triggering an alarm that was not heard by staff. The resident was found in a nearby apartment complex courtyard by a former employee. Video footage showed the resident leaving the facility before staff responded.
A resident with diabetes experienced multiple instances of low blood glucose levels, falling below the ordered threshold of 70 mg/dl. Despite the facility's policy requiring notification of the physician in such cases, there was no documentation that the physician was informed. The Director of Nursing confirmed the lack of notification, which could have delayed necessary medical care.
A resident with Alzheimer's Disease and a history of altercations slapped another resident at the nurse's station due to inadequate supervision and lack of behavior monitoring in the care plan. The CNA present was unaware of the resident's aggressive history, and the incident could have been prevented with proper care plan updates and monitoring.
A facility failed to report an allegation of abuse within the required timeframe. A resident reported inappropriate touching by another resident to an LPN, who did not document or report the incident. This led to a four-day delay in the investigation, causing the resident to feel fearful and unsafe.
A resident was not treated with dignity and respect when a CNA did not honor her wish to be changed later, resulting in the resident being accidentally hit on the face with a dirty diaper. The resident, who had speech impairment following a stroke, communicated the incident through writing and gestures, expressing fear and upset. The facility's policies on resident rights and dignity were reviewed, indicating that residents should be treated with respect and dignity at all times.
A resident with multiple diagnoses, including diabetes and a below-knee amputation, experienced an unwitnessed fall resulting in injuries due to the facility's failure to install ordered bed rails. Despite the resident's care plan and physical therapist's recommendation, the bed rails were not in place, leading to the fall and subsequent hospitalization.
Failure to Readmit Hospitalized Resident Due to Insurance Lapse
Penalty
Summary
The facility failed to allow a resident to return after a hospital transfer, despite the resident being medically stable and a bed being available. The resident had been admitted with ESRD and DM and was transferred to the emergency department on 2/18/26 for evaluation and treatment of a left big toe infection with suspected osteomyelitis, as documented in the IDT note. The resident’s admission record showed a discharge date of 2/25/26 at 10:30 a.m., coinciding with the expiration of a seven-day bed-hold period while the resident remained hospitalized. Hospital case management correspondence on 3/9/26 indicated the resident was medically stable and ready to leave the hospital, and planning began for the resident to return to the facility. According to an online complaint to CDPH, the facility administrator stated the facility was refusing to readmit the resident after hospitalization due to an insurance lapse. In interviews, the DON confirmed the resident was still considered a resident at the time of transfer to the hospital, that the facility refused readmission due to insurance issues, that there was a LTC bed available, and that there was no 30-day discharge notice, no appeal rights provided, and no discharge planning prior to hospitalization. The Admissions Coordinator also confirmed the resident was not readmitted because of lack of insurance. The facility’s own policy on readmission stated that residents discharged to the hospital would be given priority for readmission, that residents whose hospitalization exceeded the state bed-hold period would be readmitted upon first bed availability if they required the facility’s services, and that readmission procedures would apply equally regardless of payment source.
Failure to Provide Adequate Supervision Resulting in Resident Fall and Death
Penalty
Summary
A deficiency occurred when a resident with significant medical and cognitive impairments was left unsupervised outdoors, resulting in a fall that led to hospitalization and subsequent death. The resident had a history of hemiplegia, hemiparesis, aphasia, impaired vision, cognitive dysfunction, and was assessed as being at high risk for falls. Care plans and assessments indicated the need for supervision, cues, and fall prevention interventions due to the resident's impaired mobility, cognition, and vision, as well as a history of falls and other risk factors. Despite these documented needs, the resident was able to access the outdoor patio area alone and without supervision. Staff interviews confirmed that the resident frequently went outside by himself, and on the day of the incident, no staff were present to supervise him in the patio area. The resident was found on the ground with his wheelchair tipped backwards, having struck his head on the concrete. Staff acknowledged that supervision was required, especially when the resident was outside, but no evidence was found that supervision was provided at the time of the fall. Facility policies required individualized supervision and interventions based on assessed risks, including fall prevention for high-risk residents. However, the facility failed to implement these interventions, as there was no documentation or evidence that the resident was considered safe to be alone in the patio, nor were frequent checks or supervision provided. This lack of supervision directly contributed to the resident's unwitnessed fall and subsequent fatal injury.
Delayed Implementation of Physician-Ordered CT Scan
Penalty
Summary
The facility failed to ensure that physician orders were followed in accordance with professional standards of care and facility policy for a resident who was admitted with multiple diagnoses, including a traumatic hemorrhage of the cerebrum and severe cognitive impairment. Upon admission, the resident had a physician order for a CT scan of the head to be completed within two weeks. However, the order for the CT scan was not entered into the system until 15 days after admission, despite the expectation that all orders and follow-up appointments for new admissions be entered on the day of admission. Interviews with facility staff, including the DON and Unit Secretary, confirmed that the CT scan order was present in the admission documents but was not processed in a timely manner. The Unit Secretary acknowledged the delay and stated that not entering orders on time could potentially result in delayed care. Review of facility policy indicated that nurses are responsible for gathering information and contacting outside services, such as diagnostic services, upon admission. The failure to timely implement the physician's order for a CT scan resulted in a delay of ordered care for the resident.
Failure to Protect Resident from Physical Abuse by Another Resident
Penalty
Summary
A deficiency occurred when a resident with multiple sclerosis and intact cognition was physically abused by another resident diagnosed with vascular dementia and moderate cognitive impairment. The incident took place when the resident with dementia punched the other resident on the left arm after a verbal altercation, which was witnessed by staff. The assaulted resident reported being punched, and the aggressor admitted to the action, stating it was in response to perceived disrespect toward his deceased wife. Record review revealed that there was no documented evidence of a person-centered care plan addressing the potential risk of aggressive behavior for the resident with vascular dementia prior to the incident. The facility's policy states that residents have the right to be free from all forms of abuse, including physical abuse, but this right was not upheld in this case.
Failure to Prevent Resident-to-Resident Abuse and Ensure Resident Safety
Penalty
Summary
A deficiency occurred when a resident with no cognitive impairment was physically struck on the arm by another resident who had significant mental and cognitive impairment and a documented history of aggressive behaviors and resident-to-resident altercations. The incident took place in the resident's shared room, where a CNA witnessed the aggressor sitting on the victim's bed and attempting to make physical contact. The CNA intervened immediately, and the resident was assessed with no visible injuries. However, the victim expressed fear and concern for her safety following the incident. Despite being moved to a different room on a separate unit, the victim reported that the aggressor entered her new room on multiple occasions after the initial altercation. This ongoing access caused the victim to feel unsafe, leading her to request that her door be kept closed and to express fear that the aggressor would find her again. The victim became too fearful to leave her room or participate in activities, and staff interviews confirmed that the aggressor had further contact with the victim after the incident. Interviews with facility staff, including the Social Services Director and the DON, revealed that there was a lack of increased supervision and separation between the two residents following the altercation. Staff acknowledged that the abuser should have been separated from the victim to prevent further emotional distress and that residents have the right to feel safe. The facility's policy also required protection of residents from further harm during investigations, which was not fully implemented in this case.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect a resident from physical abuse when one resident, who had severe cognitive impairment due to Alzheimer’s disease, slapped another resident on the left cheek and head. The incident occurred in a common area, where the cognitively impaired resident was observed swinging and making contact with the other resident, who was attempting to defend himself by blocking the hits. Staff, including the activities director and a certified nursing assistant, witnessed the altercation and intervened to separate the residents. The resident who was struck had multiple sclerosis and was cognitively intact at the time of the incident. Documentation and interviews confirmed that the altercation involved physical contact, including slapping and attempted punches. The facility’s policy defines such actions as physical abuse, including slapping and punching, and staff acknowledged that resident-to-resident altercations are not tolerated.
Call Light Not Accessible for High-Risk Resident
Penalty
Summary
A deficiency was identified when a resident with severe cognitive impairment and a high risk for falls was found to have their call light placed out of reach on multiple occasions. The resident, who had a history of Alzheimer’s disease and a low BIMS score indicating severe cognitive impairment, was observed in their room with the call light on the floor atop a fall mat, rather than within easy reach as required by their care plan. The resident expressed an inability to call for assistance without the call light. Certified Nursing Assistants (CNAs) confirmed during interviews that the call light was not accessible to the resident and noted that the clip used to attach the call light was broken. The Director of Nursing acknowledged that the expectation was for call lights to be within reach and recognized the risk if this was not maintained. Facility policy also required that call lights be accessible to residents when in bed, but this was not followed in this instance.
Failure to Conduct Required Skin Assessment Prior to Discharge
Penalty
Summary
The facility failed to provide professional standards of care for a resident when a required skin assessment was not conducted prior to discharge. The resident, who had a history of chronic venous hypertension with ulcers on both lower extremities, lymphedema, and type 2 diabetes mellitus, was discharged without documentation of their skin condition or management. Both the Discharge Instruction Form and Discharge Summary lacked information regarding a skin assessment at the time of discharge. Interviews and record reviews revealed that the Treatment Nurse was aware of the resident's multiple venous ulcers, fragile skin, and a deep tissue injury on the left heel, which was later classified as unstageable. Despite these significant skin issues, the Unit Manager did not perform the required skin assessment before the resident left the facility, and there was no documentation explaining the missed assessment. The Director of Nursing confirmed that the facility's process for conducting a skin assessment prior to discharge was not followed in this case. The facility's policy, revised in December 2016, requires an assessment and documentation of the resident's condition, including a skin assessment, at discharge. The lack of a documented skin assessment and omission of skin condition details on discharge forms directly contributed to the deficiency identified by surveyors.
Failure to Assess and Treat Skin Tear According to Standards
Penalty
Summary
A resident with a history of diabetes, memory impairment, and respiratory failure was admitted in mid-2024 and was totally dependent on activities of daily living. The resident sustained a skin tear on the right forearm, which was documented in the SBAR summary and nurse progress notes. Despite this, there were no physician treatment orders or a nursing care plan developed or implemented for the skin tear. The treatment nurse was not made aware of the injury and therefore did not assess the wound, develop a treatment plan, or submit it to the physician. The Director of Nursing confirmed that the standard protocol was not followed, as the care plan for the skin tear was not initiated and treatment orders were not obtained. Facility policy required that any new skin tear be reported, assessed, and managed according to professional standards, including obtaining a physician's order and updating the care plan. Interviews with staff revealed a breakdown in communication and failure to follow established procedures for wound care. The absence of a care plan and treatment orders for the resident's skin tear was verified by both the treatment nurse and the Director of Nursing, in direct contradiction to facility policy and professional standards of practice.
Failure to Follow Liquid Consistency Orders for Resident with Dysphagia
Penalty
Summary
The facility failed to provide necessary care for a resident with dysphagia, as the ordered liquid consistency was not followed according to the physician's orders. The resident, who was admitted with a diagnosis of dysphagia following a stroke, had a physician's order for nectar thick liquids and no straw due to aspiration precautions. However, during an observation, the resident was found with regular water and a straw at their bedside, which was confirmed by a CNA who provided the water and straw, stating it was to prevent dripping from the resident's mouth. Further interviews revealed that the Licensed Nurse and the Speech Therapist confirmed the resident's diet order for nectar thick liquids and no straw, which was not adhered to. The Director of Nursing stated that the expectation was for staff to follow the physician's orders, and acknowledged the potential risk of aspiration if the ordered liquid consistency was not provided. The facility's policy on dysphagia emphasized the importance of identifying and addressing swallowing disorders, which was not followed in this instance.
Inconsistent Documentation and Application of Hand Splint
Penalty
Summary
The facility failed to ensure consistent documentation and application of a left hand splint for a resident with hemiplegia and hemiparesis following a nontraumatic intracerebral hemorrhage. The resident, who also had severe cognitive impairment, was admitted with a care plan that included the application of a left resting hand splint by a Restorative Nursing Assistant (RNA) seven times a week for up to four hours a day. However, there was no documented evidence that the splint was applied on several days, and when it was applied, the duration was often not recorded. This inconsistency in documentation and application was confirmed by the Director of Rehabilitation and the Director of Staff Development. The deficiency was further highlighted during interviews and record reviews, where it was confirmed that there was no documentation of the splint being applied on specific dates, and the RNA program was not consistently followed. The Director of Nursing stated that the expectation was for the RNA program to be adhered to and documented, and acknowledged that failure to do so could result in a decline in the resident's condition. The facility's policy on Restorative Nursing Services emphasized the importance of individualized and resident-centered care plans, which were not consistently implemented in this case.
Controlled Medication Accountability Failure
Penalty
Summary
The facility failed to ensure accurate accountability of controlled medications for three residents, resulting in missing and unaccounted medications. Controlled medications delivered by the pharmacy for three residents were reported missing, including Hydrocodone-Acetaminophen for two residents and Oxycodone for another. The medications were signed for upon delivery by the nursing staff, indicating receipt, but subsequent audits revealed the absence of medication cards and count sheets, leaving the facility unable to track the medications' whereabouts. The Director of Nursing (DON) and Assistant Director of Nursing (ADON) confirmed the procedures for handling controlled medications, which include signing delivery receipts and storing medications in a locked narcotic box. Despite these procedures, the facility was unable to locate the controlled drug sheets for the medications delivered to the residents. The lack of documentation and accountability raised concerns about potential misuse or diversion of these medications. Additionally, the facility's Controlled Drug Record (CDR) for one resident indicated that two doses of Hydrocodone-Acetaminophen were missing, with no documentation of administration or disposal. The facility's policy on controlled substances requires reconciliation upon receipt, administration, and at the end of each shift, but the absence of records for the missing doses suggests a failure to adhere to these protocols.
Failure to Inform Resident Representative of Rights
Penalty
Summary
The facility failed to ensure that the resident representative for a resident with severe cognitive impairment was informed of the resident's rights due to the admission agreement not being signed. The resident, who was admitted in early December 2024 with a diagnosis of spine fusion, had a Brief Interview for Mental Status (BIMS) score indicating severe cognitive impairment. The Health Information Manager confirmed that the resident lacked capacity, and the admission packet was not signed by the resident's representative. The Admissions Manager stated that the protocol required the admission packet to be signed by the third day of admission, but this was not completed before the resident was sent to the hospital 14 days later. The facility's policies on admission criteria and resident rights emphasize the importance of informing residents and their representatives about their rights and responsibilities. However, the failure to obtain the representative's signature on the admission agreement meant that the representative was not adequately informed, potentially impacting their ability to make informed decisions regarding the resident's care.
Failure to Investigate Allegation of Mistreatment
Penalty
Summary
The facility failed to adhere to its policy and procedure for investigating allegations of abuse or mistreatment when an allegation involving a resident was not investigated. The resident, who was cognitively intact and required substantial assistance with mobility, reported that a licensed nurse took her cell phone and call light, placing them out of reach after she refused a blood sugar check. This left the resident unable to call for assistance, which was reported to the Director of Nursing and the Administrator by the resident's family and the Ombudsman. Despite being informed of the allegation, the Administrator did not initiate an investigation or document any actions taken. The facility's policy requires that all allegations of abuse, neglect, or misappropriation be thoroughly investigated and documented, with specific steps outlined for the investigation process. However, the Administrator confirmed that no investigation had been started, and the resident had not been interviewed, indicating a failure to follow the established procedures for protecting residents and ensuring a safe environment.
Failure to Maintain Proper Food Temperatures
Penalty
Summary
The facility failed to ensure that food served to residents was maintained at proper temperatures and was palatable. The kitchen staff did not calibrate thermometers used to measure food temperature during meal tray assembly, and there was no documentation of when the last calibration occurred. The Dietary Director (DD) acknowledged the lack of records and stated that calibration should occur at least weekly. The Registered Dietician (RD) confirmed the importance of this step to ensure food safety and palatability. During observations, it was found that milk on residents' trays was not at acceptable holding temperatures, with readings of 46 and 43 degrees Fahrenheit, which were above the facility's policy of 40 degrees Fahrenheit or below. The DD acknowledged the milk temperatures were out of range and discarded the milk. Additionally, Resident 19's tray contained menu items not at the proper temperature, with pureed meatballs at 102 degrees Fahrenheit and milk at 53 degrees Fahrenheit, both of which were not palatable. The RD stated that food temperatures should be checked before leaving the kitchen to ensure they are appetizing and safe. Multiple residents, including Residents 75, 53, 77, 86, and 107, complained of cold food. During a resident council meeting, several residents expressed that cold food was a persistent issue, particularly for breakfast and lunch. Observations during meal service confirmed that food was often served cold, and residents reported that the removal of a microwave made it difficult to reheat food. Staff interviews corroborated these complaints, with both a Certified Nursing Assistant (CNA) and a Licensed Nurse (LN) acknowledging the issue of cold food and the lack of a microwave for reheating meals.
Failure to Follow Recipe for Pureed Bread Rolls
Penalty
Summary
The facility failed to ensure that the recipe for preparing pureed bread rolls was followed for 25 residents who had chewing or swallowing difficulties and were on a pureed diet. The pureed bread served to these residents was observed to be dry and lumpy, which did not meet the required pudding-like consistency. The facility's recipe for pureed breads directed kitchen staff to gradually add milk to achieve a consistency similar to applesauce. However, during the preparation, the staff member added milk but did not test or taste the mixture to ensure the correct consistency before serving it. The Dietary Director acknowledged that the pureed bread was too thick, dry, and lumpy, failing to meet the smooth consistency required. The Registered Dietician confirmed that the pureed bread rolls needed to be properly pureed with enough liquid to achieve the right consistency, emphasizing that residents on a pureed diet are at risk for aspiration if the food is not of the correct consistency. The facility's 'Standardized Recipes' policy indicated that standardized recipes should be developed and used in food preparation, which was not adhered to in this instance.
Infection Control Deficiencies in Resident Care
Penalty
Summary
The facility failed to adhere to proper infection control practices for four residents, leading to potential infection risks. A Certified Nursing Assistant (CNA) was observed changing a soiled brief for a resident without wearing a gown, despite the resident being on Enhanced Barrier Precautions (EBP) due to the presence of wounds. The CNA acknowledged the requirement to wear a gown to prevent the spread of germs and diseases, which was confirmed by the Infection Preventionist, who emphasized the importance of EBPs in preventing the spread of multi-drug resistant organisms (MDROs). Resident 97's enteral feeding pump and pole were found with multiple brown crusted spots, indicating they were very soiled. A Licensed Nurse confirmed the pump's condition and acknowledged that a dirty pump increases the risk of infection by potentially contaminating the tube feeding formula or lines. The facility's policy on infection prevention and control emphasizes maintaining a clean and sanitary environment, which was not adhered to in this instance. Additionally, Resident 79's CPAP nasal mask was observed with residue and discoloration, and the resident reported never seeing staff clean the mask. Licensed Nurses confirmed the mask was not cleaned as ordered, which could lead to respiratory infection or bacterial growth. Similarly, Resident 13's BiPAP mask was found hazy with condensation and had not been cleaned for weeks, as confirmed by the resident and a Licensed Nurse. The facility's policy requires daily cleaning of CPAP/BiPAP equipment, which was not followed, and there was no documentation of cleaning in the resident's records until after the surveyor's observation.
Failure to Protect Resident from Abuse
Penalty
Summary
The facility failed to protect a resident from abuse when another resident inappropriately touched her breast. Resident 14, who has cerebral infarction and aphasia, was admitted to the facility in October 2024. Resident 93, who has multiple sclerosis and cognitive intactness, was admitted in August 2022 and has a history of inappropriate behavior towards female residents. Despite this history, Resident 93 was moved to a wing with less staff monitoring, which led to the incident where he allegedly touched Resident 14's breast in the lobby. The incident was reported by a speech therapist after being informed by Resident 14's family member. Resident 14, who uses an electronic device for communication, identified Resident 93 as the perpetrator. Interviews with staff, including the Social Services Director, revealed that Resident 93's care plans, which required monitoring and not leaving him alone with female residents, were not followed. The facility's policy on abuse prevention was not effectively implemented, leading to this deficiency.
Failure to Treat Residents with Dignity
Penalty
Summary
The facility failed to treat residents with dignity and respect by referring to those who required assistance with eating as 'feeders.' This was observed during interviews with staff members, including a Licensed Nurse (LN 3) and a Certified Nursing Assistant (CNA 9), who used the term 'feeders' to describe residents needing help with meals. The Director of Nursing (DON) later clarified that the expectation was to refer to these residents as 'assisted diners.' The facility's policies on Assistance with Meals and Resident Rights emphasized the importance of treating residents with dignity and avoiding labels such as 'feeders.'
Failure to Maintain Homelike Environment for Resident
Penalty
Summary
The facility failed to provide a homelike environment for Resident 106, as evidenced by a large hole in the wall at the head of the resident's bed. This deficiency was identified during an observation and interview conducted on November 5, 2024, where Resident 106 confirmed that the wall had been in disrepair since his admission. The resident's medical history includes a stroke and depression, conditions that could be exacerbated by an unwelcoming environment. Licensed Nurse 6 verified the presence of the hole and acknowledged that it should be repaired to maintain a suitable environment for the resident. The Maintenance Supervisor indicated that maintenance concerns are documented in a binder and addressed promptly, emphasizing the importance of a comfortable and homelike setting for residents. However, a review of the Maintenance Log from July 9, 2024, to November 7, 2024, revealed only one request to repair the wall, submitted on July 25, 2024, with no subsequent follow-up requests. The facility's policy on providing a homelike environment, dated February 2021, underscores the importance of maintaining a clean and sanitary setting, which was not upheld in this instance.
Failure to Document and Notify Physician of Low Blood Glucose Levels
Penalty
Summary
The facility failed to ensure that a resident with Type 2 Diabetes Mellitus received treatment and care in accordance with professional standards of practice. The licensed staff did not accurately document the blood glucose (BG) readings and failed to notify the physician of BG readings below 100 as ordered. This issue persisted for a total of nine days, during which the resident's care could have been compromised due to the lack of necessary medication adjustments. The resident was cognitively intact, and the physician's order specifically required holding medication and notifying the physician if the BG was below 100. Interviews and record reviews revealed that the licensed nurse confirmed a documentation error in the medication administration records (MAR), where a BG reading was incorrectly recorded as 29 instead of 129. Additionally, there was no documentation to indicate that the physician was notified of BG readings below 100 on multiple occasions. The Director of Nursing confirmed the lack of documentation and emphasized the expectation for staff to follow physician orders and document accurately. The facility's policy and procedure on charting and documentation required complete and accurate records, including notifying the physician when indicated.
Failure to Assist Resident with Meal Positioning
Penalty
Summary
The facility failed to promote and maintain the ability to perform Activities of Daily Living (ADLs) for a resident, identified as Resident 348, who was not assisted to his wheelchair prior to meals. Resident 348 was admitted with diagnoses including muscle weakness, lack of coordination, and unsteadiness on feet, but had no cognitive impairment. Physician orders indicated that Resident 348 should be up in a chair or wheelchair for all meals and 30 minutes after meals to prevent pneumonia. However, during an observation, Resident 348 was found sitting in bed with his breakfast tray, expressing difficulty in eating due to his position. A Certified Nursing Assistant (CNA) confirmed that the resident was not in his wheelchair. Further interviews revealed that a Licensed Nurse acknowledged the resident's recent weight loss and the potential impact of meal positioning on food intake. The Director of Rehabilitation stated that repositioning was a CNA task, and they should assist Resident 348 to his wheelchair. The Registered Dietitian also indicated that not assisting the resident to his wheelchair could affect his food intake. The facility's policy on ADLs emphasized providing appropriate care to maintain or improve residents' ability to carry out ADLs, including mobility and dining, but this was not adhered to in Resident 348's case.
Failure to Coordinate Care for Resident's Tongue Ulcer
Penalty
Summary
The facility failed to ensure proper coordination of care for a resident with an ulcer on the tongue. The resident, who was receiving palliative and hospice care, had a care plan for an open area on the tongue and was previously treated with clobetasol cream. However, the treatment was discontinued, and the ulcer persisted. Despite the resident's complaints of pain and requests for a physician's evaluation, there was no documented evidence that the physician or hospice was notified about the ulcer from late October to early November. Observations and interviews revealed that the resident was alert and oriented, and had communicated the issue to staff, who failed to follow up appropriately. The Director of Nursing confirmed that the expectation was for the licensed nurse to notify the physician and hospice, but this did not occur. The lack of communication and follow-up increased the potential for the resident to experience pain and discomfort due to the unaddressed ulcer.
Inconsistent Documentation and Implementation of Splint Orders
Penalty
Summary
The facility failed to ensure clear and consistent documentation and implementation of orders and care plans for the use of a left hand splint for a resident with hemiplegia and hemiparesis due to a stroke. The resident, who was severely cognitively impaired, had conflicting orders regarding the duration the splint should be worn. One order indicated the splint should be worn for 7 hours a day, while another order specified 4-5 hours twice a day. This inconsistency was not addressed, leading to potential misuse of the splint. Observations and interviews revealed that the splint was applied daily, but the duration was not documented. The resident's family member noted the splint was only occasionally seen on the resident, and the CNA responsible for applying the splint was unsure of the exact duration it should be worn. The Director of Nursing and the Director of Staff Development acknowledged the conflicting orders and the lack of documentation regarding the splint's application duration. The Restorative Nurse Assistants (RNAs) were following the care plan, which indicated a 7-hour application, but were unaware of the updated order for a shorter duration. The facility's policies on resident mobility and restorative nursing services emphasized the need for individualized care plans and documentation of progress, but these were not effectively implemented in this case, leading to a deficiency in care for the resident.
Failure to Document Daily Glucometer Calibration
Penalty
Summary
The facility failed to document the calibration of glucometers, which are essential for measuring blood sugar levels accurately. Specifically, the Quality Control Record for two glucose machines on Unit C showed only six entries for the entire month of September 2024, indicating a lack of daily calibration checks. This was confirmed during interviews with a Licensed Nurse, the Infection Preventionist, and the Assistant Director of Nursing, all of whom acknowledged the missing entries and the importance of daily checks to ensure accurate blood glucose readings. The facility's policy requires that glucometer calibration be completed daily by the night shift nurse, with logs monitored monthly by the Director of Nursing or the Unit Manager for accuracy and compliance. However, the absence of documentation raised concerns about whether the checks were performed properly, potentially leading to inaccurate blood glucose management for residents. The staff interviewed emphasized the necessity of these checks to ensure the machines function correctly and provide reliable readings.
Unnecessary Use of Psychotropic Medications for Two Residents
Penalty
Summary
The facility failed to ensure that two residents, Resident 18 and Resident 117, were free from unnecessary psychotropic medications. Resident 18 was prescribed Seroquel for a disturbed thought process related to dementia, despite having no documented episodes of psychosis or aggressive behavior. Observations and interviews revealed that Resident 18 was calm, non-aggressive, and did not exhibit behaviors warranting the use of antipsychotic medication. The care plan included non-pharmacological interventions, but these were not documented in the Medication Administration Record (MAR) for the relevant months. Resident 117 was admitted with a diagnosis of dementia without behavioral disturbance and was initially prescribed Seroquel as needed for disturbed thought processes. The prescription was later changed to a routine dose at bedtime for inability to sleep. Despite this, there were no documented episodes of aggressiveness or behaviors that justified the use of Seroquel. Observations and interviews indicated that Resident 117 was nonverbal, communicated through body language, and was not combative when redirected. The facility's policy required that antipsychotic medications be used only when necessary to treat specific conditions and after non-pharmacological approaches had been attempted. The facility's policy and the nationally recognized drug reference, DailyMed, indicated that Seroquel is not approved for the treatment of dementia-related psychosis. The Pharmacy Consultant recommended reviewing the diagnosis and indication for the use of Seroquel, as the current justification was not specific enough. The facility's failure to adhere to its policy and the lack of documented non-pharmacological interventions contributed to the unnecessary use of psychotropic medications for both residents.
Expired Medications Found in Medication Cart
Penalty
Summary
The facility failed to adhere to its medication storage policy by not removing expired medications from a medication cart. During an observation and interview, a licensed nurse identified an expired bottle of glucose tablets and an inhaler that had been opened beyond its recommended use date. The nurse confirmed that these medications were expired and acknowledged that medications could lose effectiveness if used past their expiration or manufacturer's use-by date. The Director of Nursing and a Nurse Consultant confirmed that inhalers should be dated when opened and that expired medications should not be present in the medication cart. The facility's policy and procedure on medication storage, dated November 2020, stated that discontinued, outdated, or deteriorated drugs should be returned to the dispensing pharmacy or destroyed. However, the presence of expired medications in the cart indicated a failure to implement this policy, potentially compromising the safety and potency of medications administered to residents.
Inaccurate Medical Record Documentation for a Resident
Penalty
Summary
The facility failed to ensure the accuracy of medical records for one resident, identified as Resident 49, which could potentially lead to inappropriate care. Resident 49 was admitted with diagnoses including an infection following a procedure and sepsis. A review of the admission nursing note dated November 5, 2024, indicated that Resident 49 had a PICC line in the right upper arm and a surgical site with staples on the right hip. However, during an observation on November 6, 2024, it was noted that Resident 49 did not have a PICC line in either arm. Further interviews and record reviews revealed discrepancies in the documentation. Licensed Nurse 2 confirmed that the admission note inaccurately reflected Resident 49's current status, as the PICC line was not present. Additionally, Licensed Nurse 3 stated that the resident's hip incision was open to air and did not have staples, and the coccyx wound had resolved, contradicting the information in the admission note. The Director of Nursing acknowledged that the notes were expected to be accurate and that inaccurate documentation could mislead staff in providing care. The facility's policy on charting and documentation emphasized the need for complete and accurate records.
QAPI Committee Lacks Medical Director Attendance
Penalty
Summary
The facility failed to ensure that the Quality Assurance and Performance Improvement (QAPI) Committee met with the required members, specifically the Medical Director (MED), for a census of 134 residents. A review of the facility's QAPI monthly meeting sign-in sheets from November 2023 to October 2024 revealed that the MED or their designee were not present during these meetings. During an interview, the Director of Nursing (DON) confirmed that the MED did not attend the QAPI meeting in October 2024 or the last QAPI quarter meeting. The Administrator (ADM) acknowledged the importance of the MED's attendance to guide healthcare decisions in the facility. The facility's policy and procedure indicated that the Medical Director is a required member of the committee.
Unsafe Environment Due to Loose Plate in Hallway
Penalty
Summary
The facility failed to provide a safe environment for residents, staff, and the public due to a maintenance issue in the D wing hallway. A loose round plate, approximately 6 inches in diameter, with a large bolt extending from it, was observed in the center of the floor. This condition was identified as a potential trip hazard for residents, which could lead to falls and injuries. During an observation and interview, a Licensed Nurse and a Maintenance Assistant both acknowledged the hazard. The Maintenance Assistant explained that the drain underneath the plate is used for cleaning out clogs in the pipes, and confirmed the need for repair. The facility's Policy and Procedure for Maintenance Service, revised in December 2009, requires the maintenance department to keep the building, grounds, and equipment safe and operable at all times, which was not adhered to in this instance.
Resident Elopement Due to Inadequate Supervision
Penalty
Summary
The facility failed to provide adequate monitoring and supervision for a resident diagnosed with Alzheimer's disease, major depressive disorder, and age-related cataracts, who eloped from the facility. The resident, who was at high risk for elopement as indicated by a Wandering Risk Assessment score of 7, managed to exit the facility in a wheelchair through the front door. The alarm system was triggered, but staff did not respond promptly as the alarm was not heard in Station A, and there were no staff members present in the front office at the time. The resident was eventually found in the courtyard of a nearby apartment complex by a former employee who notified the facility. Interviews with staff revealed that the alarm was reset by a maintenance worker, and the staff assumed the resident exited through the front door. The Director of Nursing acknowledged that the staff did not meet expectations for monitoring residents at risk for elopement. Video surveillance confirmed that the resident exited the facility at 6:34 a.m., and staff followed at 6:55 a.m. The facility's policies on emergency procedures and wandering and elopements, which require monitoring of residents at risk, were not effectively implemented in this instance.
Failure to Notify Physician of Low Blood Glucose Levels
Penalty
Summary
The facility failed to notify a resident's physician when the resident's blood glucose levels fell below the ordered threshold of 70 mg/dl. This deficiency was identified for one resident who was admitted with diagnoses including protein-calorie malnutrition, muscle weakness, and diabetes. The resident was cognitively intact and able to communicate effectively. The physician's orders required notification if the blood glucose levels were below 70 mg/dl or above 300 mg/dl. However, on multiple occasions, the resident's blood glucose levels were recorded below 70 mg/dl, yet there was no documentation indicating that the physician was notified as required. The Director of Nursing confirmed during an interview that the physician was not notified on the specified dates when the resident's blood glucose levels were below the threshold. The facility's policy on acute condition changes required nursing staff to collect pertinent details and contact the physician based on the urgency of the situation. Despite this policy, the necessary communication with the physician did not occur, potentially delaying medical care and treatment for the resident.
Inadequate Supervision Leads to Resident Altercation
Penalty
Summary
The facility failed to provide adequate supervision to ensure the safety of residents, resulting in an incident where one resident slapped another at the nurse's station. Resident 1, who has severe cognitive impairment due to Alzheimer's Disease, was involved in the altercation with Resident 2. Despite having a history of altercations with other residents, Resident 1's care plan did not reflect this history, nor did it include behavior monitoring interventions. The incident occurred when Resident 1 blocked Resident 2's path and demanded payment to pass, subsequently slapping Resident 2 on the face. The Certified Nursing Assistant (CNA) present at the scene was unaware of Resident 1's history of aggressive behavior, although she had previously experienced Resident 1 hitting her with a broom. The Licensed Nurse (LN) and the Social Service Director (SSD) confirmed that Resident 1 had a history of altercations, but this information was not included in the care plan, which could have helped staff anticipate and prevent such incidents. The Director of Nursing (DON) acknowledged that Resident 1 should have been monitored more closely due to her history of altercations. The facility's policies on care plans and resident-to-resident altercations emphasize the need for ongoing assessments and revisions to care plans as residents' conditions change. However, these policies were not effectively implemented, as evidenced by the lack of behavior monitoring and care plan updates for Resident 1.
Failure to Report Allegation of Abuse
Penalty
Summary
The facility failed to ensure an allegation of abuse was reported to the authorities as required by their abuse policy and regulations. A Licensed Nurse (LN 2) did not report an incident where Resident 1 alleged that Resident 2 touched her inappropriately. This incident was reported to LN 2 by Resident 1 and her daughter on 4/20/24, but LN 2 did not document or report the incident to the administrator or authorities. The incident was only reported on 4/24/24 when Resident 1 inquired about the status of the report, leading to a four-day delay in the investigation. This delay caused Resident 1 to feel fearful and unsafe in the facility, resulting in her staying in her room to avoid further incidents with Resident 2. Interviews with the Director of Nursing (DON), Director of Staff Development (DSD), and Assistant Director of Nursing (ADON) confirmed that LN 2 did not follow the facility's policy, which mandates that such incidents be reported within two hours. The facility's policy, revised in September 2022, clearly states that any suspicion of abuse must be reported immediately to the administrator and other officials as per state law. The failure to report the incident promptly and the lack of documentation by LN 2 were identified as significant deficiencies in the facility's handling of the abuse allegation.
Failure to Treat Resident with Dignity and Respect
Penalty
Summary
The facility failed to ensure that a resident was treated with dignity and respect when a Certified Nursing Assistant (CNA) did not honor the resident's wish to be changed later and instead proceeded with the care, resulting in the resident being accidentally hit on the face with a dirty diaper. The resident, who was cognitively intact but had speech impairment following a stroke, communicated the incident by writing on a clipboard and through gestures. The resident expressed feeling scared and upset, and the Social Service Director confirmed that the resident had never been combative before and was tearful for hours after the incident. The CNA involved stated that the resident was combative during the diaper change and accidentally hit herself with the dirty diaper. However, the Director of Nursing indicated that the CNA should have called for assistance when the resident became combative and crying. The facility's policies on resident rights and dignity were reviewed, indicating that residents should be treated with respect and dignity at all times, and demeaning practices are prohibited.
Failure to Provide Adequate Supervision and Assistive Devices
Penalty
Summary
The facility failed to ensure adequate supervision and assistive devices were provided to prevent falls for a resident with multiple diagnoses, including diabetes mellitus and a below-knee amputation. Despite an order for bilateral bed rails to assist with mobility and transfers, the resident experienced an unwitnessed fall, resulting in injuries that required hospitalization. The resident's care plan and side rail assessment indicated the need for bed rails, and the physical therapist had recommended their use. However, the bed rails were not installed at the time of the fall, as confirmed by interviews with the licensed nurse and CNA on duty. The incident occurred when the resident fell off the bed during sleep, hitting the bedside table and sustaining injuries to the left side of the head, ribs, and hip. The CNA and licensed nurse both confirmed that the bed rails were not in place, despite the resident's repeated requests and the documented order. The Director of Nursing acknowledged that the facility's protocol required therapy assessment before installing bed rails and that the resident should have had bed rails if there was an order. The facility's policies on care plans and fall risk management were not followed, leading to the resident's fall and subsequent hospitalization.
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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