Hemet Valley Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Hemet, California.
- Location
- 371 North Weston Pl, Hemet, California 92543
- CMS Provider Number
- 555623
- Inspections on file
- 21
- Latest survey
- December 10, 2025
- Citations (last 12 mo.)
- 18
Citation history
Health deficiencies cited at Hemet Valley Healthcare Center during CMS and state inspections, most recent first.
A resident with significant physical and cognitive impairments was transferred from bed to a shower gurney by a CNA and RT when the gurney's brakes failed to lock, causing the gurney to slip and the resident to slide to the floor. Both staff members were aware of the malfunctioning brakes but proceeded with the transfer and did not report the equipment issue as required by facility policy.
The facility did not report a COVID-19 outbreak to CDPH as required and failed to implement Enhanced Barrier Precautions (EBP) for residents with indwelling devices, wounds, or colonized MDROs. Staff were observed providing care without proper PPE, lacked awareness of EBP, and the facility's infection control policy was outdated and not aligned with current guidelines.
Four residents with significant health conditions, including respiratory and kidney failure, tested positive for COVID-19, but no care plans were developed to address their infection. Staff interviews revealed confusion about care plan responsibilities and timing, and record reviews confirmed the absence of required care plans despite facility policy mandating timely updates after a change in condition.
A resident with complex medical needs was placed in the activity room for several days due to a Covid-19 outbreak and lack of available rooms. The room remained cluttered with furniture, supplies, and equipment, and staff continued to access the space for activities, with no privacy curtains provided. Facility staff confirmed the environment was not appropriate for residential care and did not meet the standard for a homelike setting.
The facility did not submit staffing information to the CMS database for the second fiscal quarter. The DON stated that the IP, responsible for the submission, was transitioning into their role and the facility faced staffing issues, leading to the delay. The DON acknowledged the data should have been submitted timely, as per CMS guidelines.
The facility failed to provide and document information on Advance Directives (AD) for two residents and did not have an AD readily available for another resident. One resident with severe cognitive impairment and another who was unresponsive did not have documented evidence of AD information being provided to their representatives. Additionally, an alert and oriented resident's AD was not found in their medical record, despite facility policy requiring such documentation.
The facility failed to document the rationale for extended use of lorazepam for a resident and did not consistently monitor the effectiveness of quetiapine for another resident. The lack of documentation and monitoring could lead to unnecessary use of psychotropic medications.
The facility failed to ensure food safety and sanitation in the kitchen, with unlabeled and improperly stored food items, cleanliness issues, and equipment not maintained according to standards. Observations included open and unlabeled food in refrigerators, wet-stacked pans, and ice buildup in freezers, risking foodborne illness.
The facility failed to implement proper infection control practices, including a nurse using a gloved finger to check water temperature for medication dilution, and two nurses not performing hand hygiene before administering eye drops. Additionally, a suction canister was found unlabeled and undated, contrary to facility policy.
A resident with severe cognitive impairment and skin conditions frequently refused showers, leading to recurring redness in various areas. Despite having physician's orders for antifungal and antibacterial treatments, the facility failed to implement interventions to address the resident's shower refusals. The Infection Preventionist acknowledged the refusals, but the care plans lacked necessary interventions, as confirmed by the DON.
The facility failed to develop and implement written policies and procedures for the monthly drug regimen review by a licensed pharmacist. During an interview and record review with the Director of Pharmacy (DOP), it was found that there was no documented evidence of such policies. The DOP confirmed the absence of a current policy, potentially delaying the identification of harmful drug interactions and side effects, impacting residents' well-being.
A survey found a medication error rate of 9.68% in an LTC facility. Errors included an LVN administering tobramycin eye drops to both eyes instead of just the right eye, and holding fludrocortisone based on incorrect blood pressure parameters. An RN also improperly diluted Phos-NaK powder for a resident's feeding tube. These actions led to medications not being given as per orders or specifications.
The facility failed to ensure a safe and sanitary environment, as air vents above the beds of two residents with respiratory failure were found stained with dark dust particles. This was confirmed by the DON and DRD during a survey. The facility's policy requires immediate correction of such hazards, which was not followed.
A resident with lower extremity contractures sustained a left hip fracture due to improper positioning during urine sample collection. Despite hearing an abnormal sound, the staff continued the procedure. Additionally, the facility failed to monitor and address a bluish discoloration on the resident's left eyelid, resulting in delayed treatment.
A resident with chronic respiratory failure and in a persistent vegetative state was found with a bruise on the left eyelid, which was not reported to CDPH within the required timeframe. The injury was documented on December 14, 2023, but not reported until March 15, 2024, 81 days later. The DON acknowledged the reporting delay, which could have delayed appropriate action and protection for the resident and others.
Failure to Ensure Shower Gurney Brakes Functioned Properly During Resident Transfer
Penalty
Summary
The facility failed to ensure that the shower gurney's wheel brakes were locking properly, resulting in an accident during the transfer and bathing of a resident who was dependent on staff for all transfers and showers. The resident, who had acute respiratory failure, contractures of both lower extremities, and no discernible consciousness, was being transferred from bed to a shower gurney by a CNA and a respiratory therapist. During the transfer, the gurney's brakes did not lock properly, causing the gurney to slip away and the resident to slide to the floor. Staff present managed to prevent the resident's head from hitting the floor, but the resident's buttocks and legs did make contact with the floor. Interviews with the CNA and respiratory therapist confirmed that they were aware the gurney's brakes were not functioning correctly at the time of use. The CNA acknowledged that she should not have used the malfunctioning equipment and should have reported the issue to the charge nurse. The DON stated that staff are expected to immediately report malfunctioning equipment and remove it from service, but was not informed of the issue until after the incident. Facility policy requires that any equipment suspected of malfunctioning be removed from service and reported, but this procedure was not followed in this case.
Failure to Report COVID-19 Outbreak and Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to adhere to infection prevention and control practices, specifically by not reporting a COVID-19 outbreak to the California Department of Public Health (CDPH) when one staff member and four residents tested positive. The Infection Preventionist (IP) acknowledged the outbreak and reported it only to the county public health officer, omitting the required notification to CDPH. Facility policy and state guidance both require such outbreaks to be reported to both local and state health authorities, but this was not followed. Additionally, the facility did not implement Enhanced Barrier Precautions (EBP) as required by CDC and CDPH guidelines for residents with indwelling medical devices, wounds, or colonized multidrug-resistant organisms (MDROs). Observations revealed that staff were not using gowns and gloves during high-contact care activities for these residents, and there was no signage indicating EBP in the rooms of affected residents. Interviews with staff, including CNAs and LVNs, indicated a lack of awareness and training regarding EBP, and the Infection Preventionist and DON confirmed that EBP was not being practiced or included in facility policy. Record reviews showed that multiple residents with tracheostomies, feeding tubes, urinary catheters, and wounds did not have physician orders or care plans for EBP. The facility's infection control policy was outdated and did not reflect current EBP requirements. Staff interviews further confirmed that EBP was not being implemented, and staff were unclear about the appropriate use of PPE for residents at risk of MDRO transmission.
Removal Plan
- Members of the Governing Board and MEC (Medical Executive Committee) were notified of the findings by the COO (Chief Operating Officer).
- The DON identified all residents with colonized MDROs, those at increased risk to acquire MDRO infection, and those that require high contact care activities for which EBP should be used.
- The DON validated the facility had appropriate and adequate levels of PPE to use for EBP. The DON contacted central supply to ensure levels were justified and supplies were available at all times.
- All residents currently on the unit were evaluated by the DON to ensure no adverse effects occurred. EBP was implemented for all residents if applicable by the DON/designee.
- Appropriate signage for EBP was created by the DON and placed by the room entrances of residents for whom EBP should be used to aid in identifying and reminding staff to use EBP when providing high contact care activities to the residents.
- The DON rounded on all resident's rooms to ensure the appropriate signage for EBP is in place as per facility policy. Any missing signage was placed in applicable rooms.
- The Medical Director (MD) of the subacute unit was notified of the IJ and was advised of the findings. The MD will continue to collaborate with the leadership team to create and implement the appropriate infection control measure.
- The resident and/or resident representatives of all residents impacted by the deficiency were notified of the incident via phone by the DON/designee.
- The DON/RN Charge Nurse started staff education on EBP and hand hygiene using 1:1 education and group education during huddles. The staff will receive the education before the start of their next shift.
- Providers for the residents impacted by this deficiency were contacted and orders obtained to include the use of EBP. The care plans of the affected residents impacted by this deficiency were updated by the DON/RN to include the use EBP.
- The DON reviewed the policy on EBP and revised it to ensure compliance with current regulations and best practices. The policy reviewed and approved by the Medical Director of the subacute unit and Medical Director of infection control.
- All staff present were educated on the revised EBP policy by the DON/designee. Staff not present will be educated on the revised policy before the start of their next shift. All staff will be educated to the policy.
Failure to Develop Care Plans for Residents with COVID-19
Penalty
Summary
The facility failed to develop and implement care plans for four residents who tested positive for COVID-19. During an unannounced visit, it was found that these residents, who had significant diagnoses such as respiratory failure and kidney failure, did not have care plans addressing their COVID-19 infection. Interviews with staff revealed uncertainty about the process and timing for updating care plans, with the Infection Preventionist and a Registered Nurse both acknowledging that care plans should have been created or updated following the residents' positive COVID-19 diagnoses, but this was not done. Record reviews confirmed that, despite documentation of positive COVID-19 test results in the residents' progress notes, there were no corresponding care plans developed to address the infection. The facility's policy required that an individual plan of care be initiated within 24 hours of admission or a change in condition, and updated as needed, but this procedure was not followed for the affected residents.
Resident Placed in Activity Room Fails Homelike Environment Standard
Penalty
Summary
The facility failed to provide a homelike environment for one resident who was readmitted following a hospital stay. Upon readmission, the resident, who had diagnoses including acute-on-chronic respiratory failure, hydrocephalus, psychosis, and a tracheostomy, was placed in the activity room for five days due to a lack of available female rooms during a Covid-19 outbreak. The activity room was not cleared of its usual furniture and supplies, and staff continued to access the room for activity materials while the resident was present. No privacy curtains were provided, and the room contained multiple large tables, chairs, carts, bins, cabinets, and emergency oxygen tanks, creating a cluttered and non-homelike environment. Interviews with facility staff, including the Infection Preventionist, LVN, and DON, confirmed that the resident remained in the activity room for five days, and that the room was not adequately prepared for residential use. The DON was unaware of the extent of the clutter and the duration of the resident's stay in the activity room. Staff acknowledged that the environment was not appropriate for a resident, and that the resident was alert and aware of her surroundings, though she had unclear speech and communicated through nonverbal means. The facility's own policy on resident rights, which emphasizes the right to a dignified existence and a homelike environment, was not followed in this instance. The resident's placement in a cluttered, shared activity space without privacy or proper accommodation for personal belongings did not meet the standard for a safe, clean, and comfortable environment as required by facility policy.
Failure to Submit Staffing Data to CMS
Penalty
Summary
The facility failed to electronically submit staffing information based on payroll data to the CMS database for the second fiscal quarter of the year. This failure was identified through a review of the CMS PBJ Staffing Data Report CASPER for fiscal year quarter 2, which indicated that the data was not submitted for the quarter. During an interview, the Director of Nursing Services (DON) explained that the Infection Preventionist (IP), who was responsible for submitting the report, was transitioning into their role during the reporting period. The facility was also experiencing staffing issues, which contributed to the delay in submission. The DON acknowledged that the data should have been submitted in a timely manner, as required by CMS' Electronic Staffing Data Submission Payroll-Based Journal: Long-Term Care Facility Policy Manual.
Failure to Provide and Document Advance Directive Information
Penalty
Summary
The facility failed to ensure that information regarding the formulation of Advance Directives (AD) was provided to the Resident Representatives (RR) for two residents, and that another resident's AD was readily available in their medical record. For Resident 18, who had severe cognitive impairment and required high complexity medical decision-making, there was no documented evidence that information on formulating an AD was provided to the RR. The Infection Preventionist and Social Services Liaison confirmed that there was no documentation of such information being offered, and the Director of Nursing acknowledged that it should have been provided upon admission. Similarly, for Resident 7, who was unresponsive and unconscious with a history of chronic respiratory failure and anoxic brain injury, there was no documented evidence of recent attempts to provide information on formulating an AD to the RR. The RR had previously declined to complete an AD, and the facility staff could not state any frequency for follow-ups regarding AD formulation, confirming no recent attempts were made to discuss or provide information to the RR. For Resident 11, who was alert and oriented, there was no documented evidence that information on formulating an AD was provided, nor was there an AD filed in the resident's record. The Social Services Liaison and Director of Nursing were unable to locate the AD in both paper and electronic records, despite the resident having an AD in their chart upon initial admission. The facility's policy indicated that AD information should be documented and scanned into the patient's medical record, but this was not adhered to in Resident 11's case.
Failure to Document Rationale and Monitor Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that two residents were free from unnecessary psychotropic medications. For one resident, the facility did not have the prescriber-documented rationale for the extended use of as-needed lorazepam beyond 14 days. The resident's medical record showed multiple orders for lorazepam, but there was no documentation justifying the need for continued use. The Director of Nursing acknowledged the lack of documentation and stated that the expectation is for the physician to evaluate and document the rationale for extending such orders. For another resident, the facility did not consistently monitor the effectiveness of the antipsychotic medication quetiapine. The resident had a history of substance abuse, multiple injuries, and chronic respiratory failure, and was prescribed quetiapine to manage psychosis. However, the behavior monitoring documentation was inconsistent, with some days having less than the expected two entries per day. The Clinical Nurse Educator and Infection Preventionist confirmed the inconsistency, and the Director of Nursing noted issues with staff documentation practices.
Food Safety and Sanitation Deficiencies in Kitchen
Penalty
Summary
The facility failed to adhere to food safety requirements for food storage and sanitary food preparation in the kitchen. During an inspection, it was observed that multiple items in the walk-in refrigerator, freezer, and dry storage area were not labeled and/or left open to air. Specifically, bags of red grapes and heads of green leafy lettuce were stored without lids, a gallon of lime juice was opened and not labeled with an open date, and another gallon of lime juice was expired. Additionally, a large vacuum-sealed pork in the freezer was not labeled or dated, and containers of spices were not labeled with open dates. A bag of Cinnamon Strudel Topping Mix was left open to air, and stainless steel pans were stacked wet, risking cross-contamination. The kitchen also had cleanliness issues, with a used black rubber glove left on a cooking prep table, tattered oven mitts with exposed batting, and a stainless steel shelf with peeling plastic and loose particles. Freezers 2 and 3 had ice buildup on the floors, which was acknowledged as unacceptable by the Deputy Regional Director. The facility's policies and procedures for food storage, preventing disease transmission, and cleaning and sanitation were not followed, as confirmed by the Dietary Supervisor during interviews.
Infection Control Deficiencies in Medication Administration and Equipment Management
Penalty
Summary
The facility failed to implement proper infection control practices during medication administration and equipment management. One licensed nurse used her gloved finger to check the water temperature before using it to dilute medications and flush the feeding tube for a resident. This practice was confirmed by the nurse and identified as an infection control issue by both the Infection Preventionist and the Director of Nursing. Additionally, two nurses did not perform hand hygiene before administering eye drops to residents. One nurse used the same pair of gloves throughout the medication pass, including administering eye drops, due to a lack of gloves in the resident's room. Another nurse changed gloves but did not perform hand hygiene before administering eye drops, believing it was unnecessary unless hands were visibly soiled. The facility's policy required hand hygiene before clean/aseptic procedures, which was not followed. Furthermore, a suction canister for a resident with respiratory failure was found unlabeled and undated. The Respiratory Therapist confirmed the oversight, noting that suction canisters should be labeled and dated to ensure timely changes. The facility's policy required suction canisters to be changed every two weeks or as needed, which was not adhered to in this instance.
Failure to Address Resident's Shower Refusals and Skin Care
Penalty
Summary
The facility failed to implement interventions to address a resident's frequent refusals of showers, which could potentially delay the care and treatment of the resident's skin conditions. The resident, who was admitted with chronic respiratory failure and diabetes mellitus, had a BIMS score of zero, indicating severe cognitive impairment. The resident's Medication Administration Record included physician's orders for antifungal and antibacterial treatments for inflamed skin in various areas, including under the arms, breasts, and groin. Despite these orders, the resident frequently refused showers, leading to recurring redness in these areas. The Infection Preventionist, who also served as the Treatment Nurse, acknowledged the resident's frequent shower refusals and stated that bed baths were offered as an alternative. However, the resident's care plans did not include any interventions to address these refusals. The Director of Nursing confirmed that there should have been a plan of care or interventions developed to address the resident's skin issues related to shower refusals. The facility's policy on interdisciplinary care plans required individualized plans to be initiated upon admission and adjusted in response to identified problems, but this was not done in this case.
Lack of Policies for Monthly Drug Regimen Review
Penalty
Summary
The facility failed to develop and implement written policies and procedures for the monthly drug regimen review by a licensed pharmacist. This deficiency was identified during a concurrent interview and record review with the Director of Pharmacy (DOP) on July 31, 2024. The review revealed no documented evidence of such policies and procedures in place. During a subsequent interview, the DOP confirmed the absence of a current policy addressing the monthly drug regimen review. This lack of policy had the potential to delay the identification of harmful drug interactions, side effects, and inadequate monitoring, which could negatively impact residents' physical, mental, and psychosocial well-being.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility was found to have a medication error rate of 9.68% during a survey, with three medication errors occurring out of 31 opportunities. One error involved a Licensed Vocational Nurse (LVN) administering tobramycin eye drops incorrectly to a resident. The physician's order specified that the drops should be administered to the resident's right eye only, but the LVN administered them to both eyes. Additionally, the same LVN held a dose of fludrocortisone for the resident based on incorrect blood pressure parameters, contrary to the physician's order which specified holding the medication only if the systolic blood pressure was greater than 110. Another error involved a Registered Nurse (RN) administering Phos-NaK powder to a different resident via a feeding tube with insufficient dilution. The RN used only 40 ml of water instead of the required 75 ml per packet as indicated on the medication's labeling and in the drug information resource. The RN admitted to not having received training on the proper dilution of Phos-NaK for feeding tube administration. These errors resulted in medications not being administered according to the prescriber's orders and/or manufacturer's specifications, potentially affecting the therapeutic outcomes for the residents involved.
Failure to Maintain Safe and Sanitary Environment
Penalty
Summary
The facility failed to maintain a safe and sanitary environment, as evidenced by the presence of stained air vents with dark colored dust particles above the beds of two residents. This was observed during a survey conducted on July 30, 2024, at 10:30 a.m., with confirmation from the Director of Nursing and the Deputy Regional Director. The affected residents, identified as Resident 17 and Resident 170, both have diagnoses related to respiratory failure, which could be exacerbated by the dust particles. The Director of Facility acknowledged the issue and mentioned plans to place new covers on the vents. The facility's policy, revised in March 2021, requires that hazards posing imminent danger be corrected immediately, which was not adhered to in this instance.
Improper Positioning and Lack of Monitoring Lead to Resident Injury
Penalty
Summary
The facility failed to ensure proper positioning of a female resident with lower extremity contractures during urine sample collection using a straight catheter. The resident's hip and leg/thigh were lifted up six inches from the mattress, and despite hearing an abnormal sound from the resident's hip area, the licensed nurse continued to collect the urine sample. This improper positioning resulted in the resident sustaining a left hip fracture and being transferred to an acute hospital for a surgical procedure. Interviews with the staff involved revealed that they were aware of the resident's contractures and the abnormal sound but proceeded with the urine collection under the charge nurse's instructions. Additionally, the facility failed to assess, monitor, evaluate, and refer to the physician for appropriate treatment of a bluish discoloration to the resident's left eyelid. The discoloration was first noticed by the resident's family member and reported to the staff. Despite initiating a short-term care plan to monitor the discoloration, there was no documented evidence of further assessment, evaluation, or physician notification. The Director of Nursing acknowledged the lack of documentation and follow-up regarding the discoloration. The resident involved had a history of chronic respiratory failure, status post tracheostomy, and persistent vegetative state. The improper handling during the urine collection and the failure to monitor and address the discoloration on the resident's eyelid highlight significant deficiencies in the facility's care practices and adherence to protocols for resident safety and health monitoring.
Failure to Timely Report Injury of Unknown Origin
Penalty
Summary
The facility failed to report an injury of unknown origin for Resident A to the California Department of Public Health (CDPH) within the required timeframe. Resident A, who has a history of chronic respiratory failure and is in a persistent vegetative state, was found with a bruise on the left eyelid on December 14, 2023. Despite the bruise being documented and monitored, the facility did not report the injury to CDPH until March 15, 2024, which is 81 days after the initial identification. The Director of Nursing (DON) acknowledged that the injury should have been reported within 2 hours of its discovery, as per the facility's policy on abuse prevention and reporting procedures. The deficiency was identified during an announced visit on March 28, 2024, to investigate a facility-reported incident. Interviews with the DON revealed that the family of Resident A had noticed the bruise and believed it occurred during a shower given by the staff. The DON's assessment on December 25, 2023, indicated the bruise was old and healing, but neither the resident nor the staff could determine its cause. The facility's failure to report the injury promptly had the potential to delay appropriate action and protection for Resident A and other residents.
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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