Holiday Manor Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Canoga Park, California.
- Location
- 20554 Roscoe Blvd, Canoga Park, California 91306
- CMS Provider Number
- 555578
- Inspections on file
- 64
- Latest survey
- March 13, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Holiday Manor Care Center during CMS and state inspections, most recent first.
The facility failed to ensure that a resident's Advance Directive was available in their medical record and did not provide two residents with written information about their rights to refuse or accept medical treatments and formulate an Advance Directive upon admission. This oversight could lead to the residents' healthcare wishes not being honored.
The facility failed to create comprehensive care plans for residents with PTSD, mobility issues, vaccination refusals, activity preferences, and oxygen therapy needs. This lack of planning led to deficiencies in addressing the specific needs of these residents, contrary to the facility's policy requiring person-centered care plans.
A facility failed to ensure nonpharmacological interventions were attempted before administering PRN morphine to a resident with severe pain. Despite having an order for such interventions, the Medication Administration Record showed multiple instances of morphine administration without documentation of attempted nonpharmacological methods. Interviews with staff confirmed the oversight, which contradicted the facility's pain management policy.
The facility failed to ensure nonpharmacological interventions were attempted before administering PRN lorazepam to a resident with anxiety disorder, as documented in their medication administration record. Additionally, another resident's PRN lorazepam order lacked a stop date, contrary to facility policy requiring a 14-day limit. These deficiencies were confirmed through interviews and record reviews.
A resident admitted with acute respiratory failure, hypoxia, and dementia did not have a complete baseline care plan within 48 hours of admission. The plan lacked sections on oxygen use, pain, safety risks, and skin risk, despite the resident's need for oxygen therapy and assistance with daily activities. The ADON acknowledged the oversight, and the DON confirmed the plan was incomplete, potentially affecting the resident's immediate care needs.
A resident with type 2 diabetes, paranoid schizophrenia, and encephalopathy experienced a change in behavior, including throwing things and banging doors. Despite this, the facility did not update the resident's care plan to address these new behavioral symptoms, as required by their policy. This oversight was confirmed by both an LVN and the DON, highlighting a failure to provide adequate care and supervision.
A facility failed to set a low air loss mattress (LALM) correctly for a resident, risking discomfort and pressure ulcer development. The resident, with severe cognitive impairment and dependence on assistance, had a care plan noting potential skin integrity issues. The LALM was set for 300 lbs, while the resident weighed 236 lbs, contrary to the physician's order and facility policy.
A resident with multiple health conditions did not receive the prescribed Restorative Nursing Assistant (RNA) program due to a failure in transferring the physician's order to the RNA task flowsheet. This oversight led to the RNA being unaware of the order, resulting in the program not being initiated and a care plan not being created. The resident was at risk for further decline in range of motion.
A resident with PTSD was admitted to the facility, but the staff failed to complete a timely trauma-informed care assessment or conduct an IDT meeting to address the resident's needs. The assessment was only completed after a medical records audit, and staff interviews revealed a lack of experience and adherence to the facility's policy on trauma-informed care.
A facility failed to conduct a social service assessment for a resident within 14 days of admission, as required by policy. The resident, admitted with type 2 diabetes, paranoid schizophrenia, and encephalopathy, had moderately impaired cognitive skills. The Social Services Designee acknowledged the oversight, and the Director of Nursing confirmed the requirement for timely assessments to address psychosocial concerns and assist with adjustment.
The facility failed to document the administration of PRN medications on the MAR for two residents, leading to potential risks of double dosing. A resident with polyneuropathy and osteoarthritis did not have tramadol administration recorded on the MAR, and another resident with neuropathy and a chronic ulcer had oxycodone administration missing from the MAR. This discrepancy was noted during record reviews, highlighting a failure to follow the facility's medication administration policy.
A resident with schizophrenia was not administered clozapine correctly, as a nurse did not follow the prescribed method of allowing the orally disintegrating tablets to dissolve in the mouth. The nurse was unaware of the correct administration method, which was confirmed by the ADON and facility policy.
Two residents' unopened insulin pens were improperly stored in medication carts instead of being refrigerated, as required by the manufacturer's guidelines. This failure was confirmed by nursing staff and contradicted the facility's medication storage policy.
A dietary aide was observed wearing an uncovered, dangling bracelet in the kitchen while handling food, contrary to the facility's dress code policy. This practice had the potential to place 89 out of 90 residents at risk for foodborne illnesses. The Dietary Supervisor confirmed that the dress code should be followed to maintain cleanliness.
The facility failed to implement Enhanced Barrier Precautions (EBP) for a resident with a colostomy bag, as required by their policy, and did not label a resident's urinal, risking cross-contamination. The Infection Preventionist was unaware of the need for EBP, and the Director of Nursing acknowledged the lack of a specific policy for urinal labeling, highlighting lapses in infection control practices.
A resident in an LTC facility was verbally abused by another resident, who used derogatory language during an altercation. Additionally, another resident was physically abused when pushed by a fellow resident, resulting in a fall. Both incidents were witnessed by staff and other residents, and the facility's policies on abuse prevention were not effectively implemented.
A resident with metabolic encephalopathy and Alzheimer's disease experienced a fall, and the facility failed to complete Fall Risk Evaluations accurately. The evaluations had incomplete sections and incorrect information regarding recent falls, which placed the resident at risk of not receiving appropriate care. The DON highlighted the importance of accurate evaluations for effective care.
A facility failed to document a resident's monthly behavior and side effects for psychotropic medications, Trazodone and Risperdal, over two months. The resident, with severe cognitive impairment and multiple diagnoses, was at risk of receiving unnecessary medications. Staff confirmed the lack of documentation, which impeded the evaluation of medication effectiveness and potential dose reduction.
A resident with severe cognitive impairment and multiple health conditions had incomplete documentation on their ADL Flow Sheet, with several care activities left blank and missing CNA initials. This lack of documentation was confirmed by a CNA and the DON, highlighting gaps in maintaining accurate medical records.
A facility failed to notify a resident's physician and family about a skin discoloration on the coccyx, reported by a CNA. The resident, with severe cognitive impairment and requiring total assistance, had a history of hip fracture, osteoporosis, and diabetes. Despite the facility's policy for prompt notification, the physician and family were informed only after several days, confirmed by the Treatment Nurse and DON, who found no documentation of timely notification.
A resident with a history of encephalopathy and schizophrenia experienced an unwitnessed fall, but the required neurological assessment was not completed according to the facility's policy. The resident's care plan included interventions for falls, yet the Neurological Assessment Flow Sheet was incomplete, potentially risking the resident's care due to missing medical information.
Two residents were found on low air loss mattresses (LALM) set to static mode instead of the ordered alternating mode, with excessive linen layers, increasing the risk of skin breakdown. CNAs admitted to not adjusting the settings and forgetting to remove extra linen, contrary to facility policy.
The facility did not post actual nursing hours worked by staff daily, displaying projected hours instead. Interviews with the DON and Payroll staff revealed that actual hours were calculated the following day, contrary to the facility's policy requiring daily posting of actual hours within two hours of each shift's start.
A resident with severe cognitive impairment and multiple health conditions had zinc oxide cream applied without a physician's order, contrary to facility policy. The CNA reported skin discoloration, but the physician was not notified, and an order was not obtained until a week later. The DON confirmed the deficiency in following medication order protocols.
A resident with a history of hip fracture and severe cognitive impairment experienced a delay in care due to the facility's failure to promptly notify the physician of STAT X-ray results. The X-ray was performed after the resident slid from a chair, but results were not communicated to the physician until several hours later, despite multiple attempts by the diagnostic company to contact the facility. This delay was attributed to inadequate communication and follow-up between nursing staff during shift changes.
A facility failed to report an alleged sexual abuse incident involving two residents within the required two-hour timeframe. A CNA found both residents half-naked in a room but did not report the incident until 11 days later. The delay in reporting prevented timely investigation by the SSA, compromising resident safety. Both residents had cognitive impairments and required assistance with daily activities.
The facility failed to implement infection control practices by improperly storing a nebulizer mouthpiece and tubing without a protective bag, and by not reporting suspected scabies cases for two residents. These actions were against the facility's policies, posing a risk of cross-contamination and infection spread.
Two residents experienced changes in their skin conditions, including dry, flaky skin and itchiness, but their physicians were not notified in a timely manner. The facility's staff failed to complete the necessary documentation, leading to a delay in medical care and treatment, contrary to the facility's policy.
A resident with complex medical and behavioral needs was discharged from a locked SNF to an unlocked facility without proper procedures, including a physician's order, necessary documentation, and appropriate communication. The resident was transported using a non-medical service, despite being a danger to himself and others, leading to increased risk and subsequent death shortly after arrival at the new facility.
A resident was unsafely discharged from a locked facility to a non-locked facility without proper physician orders, necessary documentation, or communication between facilities. The resident, who required one-to-one supervision and was a danger to himself and others, was transported using a non-medical service, compromising his safety.
A resident with multiple health issues fell and sustained a fracture, but the incident was not reported by the LVN on duty, leading to delayed care. The resident was later found to have a fracture and was transferred to a hospital. The facility lacked a specific policy on quality of care.
A resident with atrial fibrillation and heart failure did not receive documented assistance with activities of daily living (ADLs) during a specific day shift. The CNA Functional Abilities Flowsheet was blank, indicating no ADL care was recorded, which the Director of Staff Development confirmed as a failure to provide necessary care.
Failure to Provide and Document Advance Directive Information
Penalty
Summary
The facility failed to ensure that a copy of Resident 49's Advance Directive was readily available in the resident's medical record. Despite the resident's admission record indicating the presence of an Advance Directive, the document was not found in the medical record during a review. Interviews with the Registered Nurse and Social Services Designee confirmed the absence of the document and the lack of follow-up to obtain it. This oversight could lead to the facility not being aware of or able to carry out the resident's healthcare wishes in an emergency. Additionally, the facility did not provide two residents, Resident 20 and Resident 291, with written information concerning their rights to refuse or accept medical or surgical treatments and to formulate an Advance Directive upon admission. Resident 20's Advance Directive Acknowledgement form was blank, and there was no evidence that the resident or their conservator was informed of their rights. Similarly, Resident 291's form was also blank, and there was no documentation that the resident received the necessary information upon admission. The facility's policy and procedure on Advance Directives require that residents or their representatives be provided with written information about their rights concerning medical treatment and Advance Directives upon admission. The failure to adhere to this policy for the sampled residents could result in their healthcare wishes not being honored, as the necessary documentation and communication were not completed as required.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop comprehensive, person-centered care plans for several residents, leading to deficiencies in addressing their specific needs. Resident 49, diagnosed with PTSD, did not have a care plan that addressed her condition, despite the facility's policy requiring trauma-informed care plans. The Director of Nursing acknowledged the importance of identifying triggers for PTSD to avoid re-traumatizing the resident, yet no such plan was in place. Resident 47, who required RNA therapy for mobility issues, also lacked a care plan addressing his prescribed treatments. Despite having physician orders for passive range of motion exercises and ambulation assistance, the facility did not develop a care plan to ensure these treatments were provided consistently. The Director of Nursing confirmed that a care plan should have been created to address these needs. Additionally, Resident 85's refusal of Covid-19 and influenza vaccinations was not documented in a care plan, leaving the resident without monitoring for potential complications. Resident 63's activity preferences were not considered in his care plan, despite his expressed interest in watching television. Lastly, Resident 21, who required oxygen therapy, did not have a care plan addressing his oxygen use, which could lead to inadequate care. The facility's failure to develop these care plans was contrary to their policy, which mandates comprehensive, person-centered care plans for all residents.
Failure to Attempt Nonpharmacological Interventions Before Administering Morphine
Penalty
Summary
The facility failed to ensure that licensed nurses attempted nonpharmacological interventions before administering PRN morphine sulfate to a resident with severe pain. The resident, who had moderately impaired cognition and was dependent on staff for most activities of daily living, was admitted with diagnoses including polyneuropathy and spinal enthesopathy in the lumbar region. Despite having an order for nonpharmacological interventions, the facility's Medication Administration Record showed multiple instances where morphine was administered without documentation of attempted nonpharmacological interventions. During interviews, the Registered Nurse and the Director of Nursing acknowledged the lack of documentation and the importance of attempting nonpharmacological interventions before administering opioid medications. The facility's policy on pain assessment and management, last reviewed in February 2025, indicated that nonpharmacological interventions might be appropriate alone or in conjunction with medications. This oversight had the potential to increase the resident's risk of experiencing adverse side effects from the medication.
Failure to Implement Nonpharmacological Interventions and Stop Dates for PRN Lorazepam
Penalty
Summary
The facility failed to ensure that licensed nurses attempted nonpharmacological interventions before administering PRN lorazepam to a resident with anxiety disorder. The resident, who had intact cognition and required supervision for most activities of daily living, received lorazepam on multiple occasions without documentation of nonpharmacological interventions being attempted first. This was confirmed during an interview with a registered nurse and a review of the resident's medication administration record. The facility's policy indicated that nonpharmacological approaches should be used to minimize medication use, but this was not followed. Additionally, the facility did not ensure that a physician's order for another resident's PRN lorazepam included a stop date. The resident, who had moderately impaired cognition and was dependent on staff for most activities of daily living, had an order for lorazepam without a stop date, contrary to the facility's policy that PRN orders for psychotropic medications should be limited to 14 days. The Director of Nursing confirmed that PRN lorazepam should have a stop date after 14 days, and the physician should reevaluate the need for continued medication use.
Incomplete Baseline Care Plan for Resident
Penalty
Summary
The facility failed to develop a complete and accurate baseline care plan for a resident within 48 hours of admission, as required. The baseline care plan for the resident, who was admitted with acute respiratory failure, hypoxia, difficulty in walking, dementia, and a history of falling, was missing critical information. Specifically, the sections on oxygen use, pain, safety risks, and skin risk were incomplete. This oversight was identified during a review of the resident's records and an interview with the Assistant Director of Nursing (ADON), who acknowledged the omission and stated it was a mistake on her part. The resident's Minimum Data Set (MDS) indicated moderate cognitive impairment and a need for partial assistance with daily activities, as well as the use of oxygen therapy. Despite these needs, the baseline care plan did not reflect the necessary care instructions. The Director of Nursing (DON) confirmed that the baseline care plan was not completed thoroughly, which could lead to an inability to meet the resident's immediate care needs. The facility's policy requires a comprehensive baseline care plan to be developed within 48 hours of admission to ensure effective and person-centered care, but this was not adhered to in this case.
Failure to Update Care Plan After Resident's Change of Condition
Penalty
Summary
The facility failed to update and revise a resident's care plan following a change in the resident's condition. The resident, who was admitted with diagnoses including type 2 diabetes mellitus, paranoid schizophrenia, and encephalopathy, experienced a change in behavior on February 17, 2025, as documented in the SBAR communication form. The resident exhibited behavioral symptoms such as throwing things and banging doors, which was a significant deviation from their baseline condition. Despite this change, the care plans for mood problems and behavioral symptoms related to schizophrenia, both initiated on February 12, 2025, were not updated to reflect the resident's new condition. The care plans initially included interventions such as administering medications, providing meaningful activities, and monitoring for signs of depression and anxiety. However, these plans were not revised to address the resident's new behavioral symptoms, as confirmed by Licensed Vocational Nurse 3 and the Director of Nursing during interviews. The facility's policy and procedure require that care plans be reviewed and revised following a resident's change of condition. However, this was not done for the resident in question, potentially leading to inadequate care and supervision. The Director of Nursing acknowledged that the care plans were not updated, which is contrary to the facility's policy that mandates prompt notification and revision of care plans in response to significant changes in a resident's condition.
Incorrect LALM Setting for Resident
Penalty
Summary
The facility failed to ensure the low air loss mattress (LALM) was set correctly for a resident, which had the potential to place the resident at risk for discomfort and development of pressure ulcers. The resident was admitted with diagnoses including metabolic encephalopathy, acute respiratory failure, and chronic kidney disease. The resident's Minimum Data Set indicated severely impaired cognition and dependence on assistance for various activities. The resident's care plan noted potential impairment to skin integrity due to fragile skin and incontinence, with an intervention to follow facility protocol for treatment of injury. During an observation, it was noted that the LALM setting was at seven for 300 lbs, while the resident's current weight was 236 lbs. The physician's order indicated the LALM should be set based on comfort and/or resident weight for skin management. The Treatment Nurse confirmed the correct setting for the resident's weight was five. The facility's policy on support surface guidelines emphasized the importance of appropriate pressure reducing and relieving devices for residents at risk of skin breakdown. The LALM user manual also indicated that the comfort setting controls the air pressure output based on the resident's weight.
Failure to Implement RNA Program for Resident
Penalty
Summary
The facility failed to ensure that a resident received the necessary treatment and services to prevent a decline in range of motion (ROM). The resident, who was admitted with conditions including metabolic encephalopathy, type 2 diabetes mellitus, and difficulty in walking, had a physician's order for a Restorative Nursing Assistant (RNA) program. This program was intended to assist the resident with ambulation using a front wheel walker five times a week with two-person assistance. However, the Treatment Administration Record for the specified period showed no entries for the RNA treatment, indicating that the program was not implemented. Interviews and record reviews revealed that the RNA was unaware of the order due to a failure in transferring the physician's order to the RNA task flowsheet in the Electronic Health Record (EHR). Consequently, the RNA program was not initiated, and a care plan was not created. The Director of Rehabilitation confirmed that the resident had been discharged to the RNA program after reaching maximal potential with skilled services, but the licensed staff did not follow through with the physician's order. The Director of Nursing acknowledged the oversight and emphasized the importance of creating a person-centered care plan to monitor the resident's progress and prevent functional decline.
Failure to Provide Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to provide trauma-informed care to a resident diagnosed with post-traumatic stress disorder (PTSD). The resident was admitted on January 31, 2025, with a diagnosis of PTSD, and the Minimum Data Set (MDS) dated February 4, 2025, indicated moderately impaired cognition and a need for moderate assistance with activities of daily living. Despite these indicators, the facility did not complete a timely trauma-informed care assessment or conduct an interdisciplinary team (IDT) meeting to address the resident's specific needs related to PTSD. Interviews with facility staff revealed gaps in the process. A Licensed Vocational Nurse from the regional office completed the trauma-informed care assessment only after a medical records audit prompted it, indicating it should have been done upon admission. The Director of Nursing acknowledged that social services should have completed the assessment and facilitated an IDT meeting to discuss the resident's specific triggers. The Social Services Designee admitted to lacking experience in conducting these assessments, as her predecessor was responsible for them. The facility's policy on trauma-informed care emphasized the importance of minimizing triggers and re-traumatization, which was not adhered to in this case.
Failure to Conduct Timely Social Service Assessment
Penalty
Summary
The facility failed to conduct a social service assessment for Resident 18 within 14 days of admission, as required by their policy and procedure titled 'Social Assessment.' Resident 18 was admitted with diagnoses including type 2 diabetes mellitus, paranoid schizophrenia, and encephalopathy. Despite the resident's cognitive skills being moderately impaired, as indicated in the Minimum Data Set, no social service assessment was conducted from the time of admission on February 12, 2025, to March 12, 2025. The Social Services Designee (SSD) acknowledged the oversight, stating that although another social worker was initially responsible, she should have followed up to ensure the assessment was completed. The Director of Nursing confirmed that the social worker should have conducted the assessment within the specified timeframe to address psychosocial concerns and assist with the resident's adjustment to the facility. The facility's policy, last reviewed on February 26, 2025, mandates that a social assessment be completed within 14 days of admission to identify the resident's personal and social situation, needs, and problems. This deficiency had the potential to delay the delivery of care and services necessary for the resident's well-being.
Failure to Document PRN Medication Administration
Penalty
Summary
The facility failed to ensure that licensed nurses documented the administration of PRN medications on the Medication Administration Record (MAR) for two residents. For Resident 29, who was admitted with conditions including polyneuropathy and bilateral osteoarthritis, there was a failure to document the administration of tramadol on the MAR, despite it being recorded on the Record of Controlled Substances. This discrepancy was identified during a review of the resident's records, where it was noted that the tramadol was taken from the bubble pack but not documented as administered on the MAR. Similarly, for Resident 8, who had diagnoses including idiopathic peripheral autonomic neuropathy and chronic ulcer, the administration of oxycodone was not documented on the MAR, although it was recorded on the Record of Controlled Substances. This occurred on two separate occasions. The lack of documentation on the MAR for both residents posed a risk of double dosing, as subsequent nurses would not have a complete record of medication administration. The facility's policy requires that the individual administering the medication initials the MAR after each administration, which was not adhered to in these cases.
Failure to Administer Clozapine Correctly
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors by not administering clozapine as ordered. The resident, who was admitted with diagnoses including encephalopathy, paranoid schizophrenia, and major depression, was prescribed clozapine orally disintegrating tablets (ODT) 200 mg to be taken once daily. During a medication administration observation, a Licensed Vocational Nurse (LVN) administered two 100 mg tablets of clozapine to the resident without explaining the proper method of administration, which involves allowing the tablets to disintegrate in the mouth before swallowing. The LVN admitted to not knowing the meaning of the abbreviation ODT or the correct administration method for ODT medication. The Assistant Director of Nursing confirmed that the medication should dissolve in the mouth before swallowing, and emphasized that licensed staff should be knowledgeable about the correct route of medication administration. The facility's policy on medication administration, last reviewed in February 2025, also indicated that medications should be administered safely and as prescribed, including the correct method of administration.
Improper Storage of Insulin Pens
Penalty
Summary
The facility failed to properly store unopened insulin pens for two residents, Resident 80 and Resident 391, which could potentially lead to the insulin losing its efficacy. Resident 80, who was originally admitted on January 21, 2024, and readmitted on December 16, 2024, had a diagnosis of type 2 diabetes mellitus with ketoacidosis and required insulin glargine injections. During an observation on March 12, 2025, it was noted that Resident 80's unopened insulin pen was stored in Medication Cart A instead of the refrigerator, contrary to the manufacturer's guidelines. Licensed Vocational Nurse 1 confirmed that the insulin should be refrigerated and acknowledged the potential need to discard the medication if not stored properly. Similarly, Resident 391, who was originally admitted on January 30, 2020, and readmitted on January 26, 2025, also had a diagnosis of type 2 diabetes mellitus and required insulin glargine injections. On March 11, 2025, an observation revealed that Resident 391's unopened insulin pen was stored in Medication Cart B instead of being refrigerated. The Director of Nursing confirmed that unopened insulin should be stored in the refrigerator to maintain its efficacy, as per the manufacturer's guidelines. The facility's policy on medication storage also indicated that medications requiring refrigeration should be stored in a secured refrigerator, which was not adhered to in these cases.
Failure to Follow Safe Food Handling Practices
Penalty
Summary
The facility failed to adhere to safe food handling practices when a dietary aide was observed wearing an uncovered, dangling bracelet in the kitchen. This observation was made during a concurrent interview and record review with the Dietary Supervisor. The dietary aide was seen taking plates from the steam table and placing them into a delivery cart while wearing the bracelet, which was not covered by the gloves. The facility's policy, titled 'Dress Code for Women and Men' and dated 2018, specifies that no excessive jewelry should be worn in the kitchen, allowing only wedding rings, non-dangling earrings, and wristwatches, which must be covered with gloves when handling food. The Dietary Supervisor acknowledged that the dress code should be followed to maintain cleanliness in the kitchen. This deficiency had the potential to place 89 out of 90 residents at risk for foodborne illnesses.
Infection Control Deficiencies in EBP and Urinal Labeling
Penalty
Summary
The facility failed to implement its Enhanced Barrier Precautions (EBP) policy for a resident with a colostomy bag, which is a medical device that collects stool from a surgical opening in the abdomen. The resident, who was admitted and readmitted with diagnoses including metabolic encephalopathy and urinary tract infections, was not placed on EBP despite the facility's policy indicating that residents with indwelling medical devices require such precautions. Observations revealed no EBP signs or personal protective equipment (PPE) outside the resident's room, and the Infection Preventionist (IP) was unaware of the need for EBP in this case. Additionally, the facility did not ensure that a resident's urinal was labeled with a resident identifier, which is crucial for infection control. The unlabeled urinal was observed at the resident's bedside, and the Certified Nursing Assistant confirmed the lack of labeling. The Director of Nursing (DON) acknowledged the absence of a specific policy for labeling urinals, while the IP emphasized the importance of labeling to prevent cross-contamination among residents. The facility's policies on Enhanced Barrier Precautions and Standard Precautions were reviewed, indicating the necessity of using standard precautions in all situations to prevent the transmission of infectious diseases. However, the failure to adhere to these policies in the cases of the resident with a colostomy bag and the unlabeled urinal highlights lapses in infection control practices within the facility.
Verbal and Physical Abuse Incidents in LTC Facility
Penalty
Summary
The facility failed to protect a resident's right to be free from verbal abuse when one resident verbally abused another. Resident 50, who had intact cognition and was dependent on staff for most activities of daily living, was subjected to verbal abuse by Resident 15. The incident occurred when Resident 50 attempted to stop Resident 15 from moving a personal protective equipment bin outside his room, leading to Resident 15 responding with derogatory language. This incident was witnessed by several staff members, including a Registered Nurse and the Director of Staff Development, who confirmed the verbal exchange. In another incident, the facility failed to protect a resident from physical abuse when Resident 18 pushed Resident 61, causing her to fall. Resident 61, who had moderately impaired cognitive skills and required assistance for daily activities, was pushed by Resident 18 in the hallway. This incident was witnessed by another resident, Resident 53, who reported the altercation to the nursing staff. The facility's records indicated that Resident 18 had a history of behavioral symptoms and was known to exhibit aggressive behavior. The facility's policies on abuse prevention and resident-to-resident altercations were not effectively implemented, as evidenced by these incidents. The Administrator and Director of Nursing acknowledged the incidents as abuse, with the verbal abuse being confirmed by the facility's policy definition. The physical altercation was substantiated by witness accounts and the facility's own investigation, highlighting a failure to maintain a safe environment for residents.
Incomplete Fall Risk Evaluations Lead to Deficiency
Penalty
Summary
The facility failed to ensure that Fall Risk Evaluations were completed accurately for a resident, which placed the resident at risk of not receiving appropriate care and services after a fall incident. The resident, who was originally admitted on 9/3/2021 and readmitted on 2/1/2025, had diagnoses including metabolic encephalopathy, Alzheimer's disease, and generalized muscle weakness. The Minimum Data Set (MDS) indicated that the resident was dependent on staff for most activities of daily living. On 3/11/2025, the resident was found on the floor next to her bed, and she stated she did not know what happened and was just trying to get comfortable. During a review of the resident's Fall Risk Evaluations, it was found that the evaluation dated 2/1/2025 had incomplete sections, specifically the Gait/Balance and Medications sections. Treatment Nurse 1 acknowledged that these sections should have been completed. Additionally, the Fall Risk Evaluation dated 3/11/2025 incorrectly indicated that the resident had no falls within the past three months, despite the fall occurring on the morning of 3/11/2025. The Director of Nursing emphasized the importance of accurately completing Fall Risk Evaluations to assess the resident's risk of falling and to provide effective care. The facility's policy on managing falls and fall risk, last revised on 2/26/2025, requires staff to identify interventions based on evaluations and current data to prevent falls.
Failure to Document Psychotropic Medication Effects
Penalty
Summary
The facility failed to ensure a resident was free of unnecessary psychotropic drugs by not summarizing the resident's monthly behavior and side effects. This deficiency was identified for a resident who had been admitted with diagnoses including a left hip fracture, schizoaffective disorder, and major depressive disorder. The resident's Minimum Data Set indicated severely impaired cognitive skills and a need for total assistance with daily activities. Physician orders included Trazodone for depression and Risperdal for schizoaffective disorder. However, the Behavior Summary Side Effects forms for these medications were blank for two months, lacking documentation of episodes of sadness or adverse reactions. Interviews with facility staff, including an LVN and the DON, confirmed that the monthly behavior summaries for the resident's psychotropic medications were not completed. The staff acknowledged that without this data, it would be challenging to assess the effectiveness of the medications or proceed with a gradual dose reduction. The facility's policy on psychotropic medication use emphasized the need for comprehensive review and documentation to ensure medications are clinically indicated and to monitor for adverse consequences. The lack of documentation hindered the facility's ability to evaluate the necessity and impact of the psychotropic drugs administered to the resident.
Incomplete Documentation of Resident Care
Penalty
Summary
The facility failed to maintain complete and accurate medical records for a resident, identified as Resident 1, by not documenting on the resident's Activities of Daily Living (ADL) Flow Sheet. This deficiency was identified during a review of Resident 1's records, which showed multiple instances in December 2022 where essential care activities such as bowel function, personal hygiene, bathing, transfer, and locomotion were left undocumented. Additionally, there were no initials from Certified Nursing Assistants (CNAs) on several dates, indicating a lack of accountability for the care provided. Resident 1, who was readmitted to the facility with a history of a left hip fracture, osteoporosis, and diabetes mellitus, was assessed to have severely impaired cognitive skills and required total assistance with daily activities. The absence of documentation on the ADL Flow Sheet meant that there was incomplete information regarding the care provided to the resident, which could lead to confusion about the resident's care needs. Interviews with CNA 3 and the Director of Nursing confirmed the importance of proper documentation and acknowledged the gaps in the records, emphasizing that without documentation, it is unclear what services were provided to the resident.
Failure to Notify Physician and Family of Skin Discoloration
Penalty
Summary
The facility failed to notify the physician and the resident's family about a skin discoloration on a resident's coccyx, which was reported by a CNA on 9/9/2022. The resident, who had a history of a left hip fracture, osteoporosis, and diabetes mellitus, was severely cognitively impaired and required total assistance with daily activities. Despite the CNA's report, the facility did not inform the physician or the family until 9/16/2022, when a physician order was received to treat the skin condition. This delay in communication was confirmed during interviews with the Treatment Nurse and the Director of Nursing, who were unable to find documentation of timely notification. The facility's policy requires prompt notification of changes in a resident's condition to the physician and family, ideally within 24 hours. However, in this case, the notification was delayed by several days, which could have impacted the resident's care. The Director of Nursing acknowledged the lack of documentation and stated that the physician and family should have been notified on the same day the skin discoloration was observed. The facility's failure to adhere to its policy on notifying changes in a resident's condition led to this deficiency.
Failure to Complete Neurological Assessment After Unwitnessed Fall
Penalty
Summary
The facility failed to complete a neurological assessment for a resident after an unwitnessed fall, which is a requirement according to the facility's policy. The resident, who had a history of encephalopathy, lack of coordination, and schizophrenia, was found on the floor near the dietary department. The resident's Minimum Data Set indicated moderately impaired cognitive skills for daily decision-making, and the care plan included interventions for falls, such as frequent neurological and bleeding evaluations. However, the Neurological Assessment Flow Sheet for the resident was incomplete, with no documented evidence of an assessment being done at the specified time. Licensed Vocational Nurse 1 confirmed during an interview and record review that the neurological assessment was not completed as required. The facility's policy, reviewed in July 2024, mandates neurological assessments following an unwitnessed fall, but this was not adhered to in this instance. The lack of documentation and completion of the neurological assessment could lead to confusion in care and services, potentially placing the resident at risk of not receiving appropriate care due to incomplete medical information.
Improper Use of Low Air Loss Mattresses
Penalty
Summary
The facility failed to ensure proper use of low air loss mattresses (LALM) for two residents, leading to potential risks of skin breakdown. Resident 2, admitted with diagnoses including gangrene and dementia, was observed on a LALM set to static mode instead of the ordered alternating mode. The resident was also lying on multiple layers of linen, contrary to the facility's policy of using no more than two layers. Certified Nursing Assistant 1 (CNA 1) admitted to forgetting to remove the extra cloth incontinence pad, which contributed to the improper setup. Similarly, Resident 3, who was readmitted with chronic obstructive pulmonary disease and dementia, was found on a LALM set to static mode with multiple layers of linen. CNA 2 acknowledged the oversight of not removing the extra cloth incontinence pad, resulting in four layers of linen. Both CNAs stated that they were instructed not to adjust the LALM settings, which were supposed to be checked every shift according to the physician's orders. The facility's policies and procedures emphasized the importance of using the LALM correctly to prevent pressure ulcers, including maintaining the alternating mode and limiting linen layers. The failure to adhere to these guidelines for both residents increased the risk of skin breakdown, as the LALM's effectiveness was compromised by the static setting and excessive linen layers.
Failure to Post Actual Nursing Hours Daily
Penalty
Summary
The facility failed to ensure that the actual hours worked by licensed and unlicensed nursing staff responsible for resident care were posted daily, as required. On two consecutive days, the facility displayed projected nursing hours instead of actual hours worked. Observations and interviews revealed that the posted nursing hours in the facility's lobby were based on expected staffing rather than the actual hours worked by the staff. The Director of Nursing (DON) and Payroll personnel confirmed that the actual nursing hours were calculated the day after the shifts occurred, which led to the posting of projected hours instead of actual hours. Interviews with the DON and Payroll staff indicated a lack of adherence to the facility's policy, which mandates the posting of actual nursing hours within two hours of the beginning of each shift. The DON acknowledged that the posted hours were projections and not actual hours, and Payroll staff confirmed that the actual hours for the days in question had not been calculated at the time of the survey. This practice potentially kept residents and visitors unaware of the actual staffing levels in the facility.
Failure to Obtain Physician's Order for Medication Application
Penalty
Summary
The facility failed to obtain a physician's order before applying zinc oxide cream to a resident's skin, which is a requirement for medication administration. The resident, who was admitted with conditions including a left hip fracture, osteoporosis, and diabetes mellitus, had severely impaired cognitive skills and required total assistance for daily activities. On 9/9/2022, a CNA reported skin discoloration on the resident's coccyx, and zinc oxide cream was applied without a physician's order. A physician's order for the cream was not obtained until 9/16/2022. During interviews and record reviews, it was confirmed that there was no documentation of notifying the resident's physician or family about the skin discoloration on 9/9/2022. The facility's policy requires that medications and treatments be administered only upon a written order from a licensed practitioner. The Director of Nursing acknowledged the lack of a physician's order and the absence of documentation regarding the notification of the physician or family, confirming the deficiency in following the facility's medication and treatment order policy.
Delay in Notification of STAT X-ray Results
Penalty
Summary
The facility failed to promptly notify the physician of the results of a STAT X-ray for a resident, leading to a delay in necessary care. The resident, who had a history of a left hip fracture, osteoporosis, and diabetes mellitus, was readmitted to the facility with severe cognitive impairment and required total assistance for daily activities. On 9/29/2022, after the resident slid from a chair, a STAT X-ray was ordered to rule out a fracture in the left hip and femur. The X-ray was performed on the same day at 11:22 p.m., and the results were emailed to the facility at 12:50 a.m. on 9/30/2022. However, the facility staff did not promptly relay the results to the physician. The mobile diagnostic company attempted to call the facility multiple times during the early hours of 9/30/2022, but there was no answer. It was not until 7:35 a.m. that the results were communicated to the physician, who then ordered the resident to be transferred to the hospital for further evaluation. Interviews with the facility staff revealed that there was a lack of proper communication and follow-up between the nursing staff during shift changes. The Licensed Vocational Nurse acknowledged that the 11 p.m.-7 a.m. shift should have followed up on the STAT X-ray results and documented their attempts. The Director of Nursing, who was not present at the time of the incident, stated that the staff should have contacted the diagnostic company sooner to prevent the delay in care. The facility's policy required prompt communication of test results to the attending physician, especially for STAT orders, but this procedure was not adequately followed.
Failure to Timely Report Alleged Sexual Abuse
Penalty
Summary
The facility failed to report an allegation of sexual abuse involving two residents within the required two-hour timeframe, as mandated by Section 1150B of the Act. The incident involved Resident 1, who was found half-naked in their room with Resident 2, also half-naked, by a Certified Nursing Assistant (CNA 1) on 11/11/2024. Despite witnessing the situation, CNA 1 did not report the incident to any facility staff until 11/22/2024, leading to a significant delay in reporting the alleged abuse to the State Survey Agency (SSA). Resident 1, who has a history of epilepsy and schizoaffective disorder, was assessed to have moderately impaired cognitive skills and required assistance with daily activities. Resident 2, diagnosed with psychosis and mood disorder, was also cognitively impaired and needed maximum assistance with certain tasks. The failure to report the incident promptly resulted in a delay of an onsite inspection by the SSA, which was necessary to ensure the safety of other residents and to investigate the potential abuse. Interviews with facility staff revealed that CNA 1 and CNA 2, who also witnessed the incident, did not fulfill their responsibility to report the situation immediately. CNA 1 assumed nothing inappropriate had occurred and did not inform anyone until questioned by the Director of Nursing (DON) on 11/22/2024. CNA 2, believing CNA 1 had already reported the incident, also failed to notify any licensed nurse. The facility's policy requires all allegations of abuse to be reported within two hours, but this protocol was not followed, leading to the deficiency.
Infection Control Deficiencies in Equipment Storage and Disease Reporting
Penalty
Summary
The facility failed to implement proper infection control practices in two significant instances. Firstly, a resident with chronic obstructive pulmonary disease and Alzheimer's disease was found to have their nebulizer mouthpiece and tubing improperly stored in a nightstand without a protective bag or date label. This was against the facility's policy, which requires such equipment to be stored in a plastic bag with the resident's name and date to prevent the spread of germs. The Licensed Vocational Nurse acknowledged the oversight and confirmed that the equipment should have been stored correctly. In another instance, the facility did not report suspected cases of scabies for two residents. One resident, who was dependent on staff for personal care, exhibited dry, flaky skin and crusted palms, which were itchy. The Treatment Nurse confirmed there were no treatment orders in place and subsequently notified the physician. Another resident, also dependent on staff for personal care, had dry, flaky skin on the right palm and reported itching. The Certified Nursing Assistant had reported this condition to the Treatment Nurse two weeks prior, but no action was taken until the survey. The facility's failure to report these suspected scabies cases and to store medical equipment properly posed a risk of cross-contamination and infection spread among residents and staff. The facility's policies on infection control and outbreak management were not adhered to, as evidenced by the lack of timely reporting and appropriate storage practices.
Failure to Notify Physicians of Skin Condition Changes
Penalty
Summary
The facility failed to notify the physicians of two residents when there were changes in their skin conditions. Resident 2, who has chronic obstructive pulmonary disease and pruritis, was observed with dry, flaky skin and crusted palms, which he reported as itchy. Despite being dependent on staff for personal hygiene, there were no treatment orders in place for his condition, and the physician was not notified until the surveyor's visit. Similarly, Resident 3, diagnosed with Alzheimer's disease and type two diabetes mellitus, had dry, flaky skin on the right palm and reported itchiness. Although a CNA reported this change to a treatment nurse about two weeks prior, the nurse did not receive the report until the day before the surveyor's visit, delaying notification to the physician and treatment initiation. The Director of Nursing acknowledged that the facility's staff failed to complete the Stop and Watch form, an early warning tool for communicating changes in a resident's condition, which led to the omission of necessary follow-up actions. The facility's policy requires prompt notification of changes in a resident's condition to the resident, their physician, and their representative, but this was not adhered to in these cases. The lack of documentation and communication resulted in a delay in medical care and treatment for both residents, potentially impacting their well-being.
Neglect in Resident Discharge Process
Penalty
Summary
The facility failed to protect a resident from neglect during a discharge process. The resident, who had a history of chronic obstructive pulmonary disease, type 2 diabetes mellitus, schizoaffective disorder, and psychosis, was discharged from a locked skilled nursing facility (SNF 1) to an unlocked facility (SNF 2) without proper procedures. The resident exhibited behaviors that made him a danger to himself and others, requiring one-to-one supervision. Despite this, the discharge was conducted without a physician's order, and the necessary discharge summary and recapitulation of stay were not provided to the receiving facility. The facility staff did not conduct a hand-off communication to ensure continuity of care for the resident. The receiving facility, SNF 2, was not informed of the resident's arrival and did not receive the necessary medical information to provide appropriate care. The resident was transported using a non-medical transport service, despite being identified as a danger to himself and others, which was against the facility's policy for safe and orderly discharge services. The facility's actions were deemed neglectful as they failed to provide the necessary care and services to ensure the resident's safety during the discharge process. The lack of communication, documentation, and appropriate transportation contributed to the resident's increased risk of harm, ultimately leading to the resident's death shortly after arriving at SNF 2.
Removal Plan
- Resident 1 was discharged to SNF 2 and is no longer a resident of the facility (SNF 1).
- The DON in-serviced RN 2 to enter physician orders for discharge only after speaking to the physician.
- The DON in-serviced the facility Marketer 1 (MTR 1) to no longer arrange resident transportation.
- The DON in-serviced RN 2 regarding giving report to the nurse at the receiving facility of SNF 2.
- Medical Director Medical Doctor 1 (MDMD 1) in-serviced the ADM, DON, Assistant Director of Nursing (ADON), SSD, and all other Department Heads regarding ensuring all residents are free of neglect related to discharge services to ensure resident's safety and promote their (resident) highest well-being from the time residents enter the facility to the time residents leave the facility.
- The DON continued providing in-services to admissions office staff, nursing staff, and social services staff regarding the facility's current policies and procedures for the prevention of Neglect related to Discharge/Transfer services.
Unsafe Discharge of Resident to Non-Locked Facility
Penalty
Summary
The facility failed to ensure a safe and orderly discharge for a resident who was a danger to himself and others. The resident was transferred from a locked facility to a non-locked facility without obtaining a proper physician order for discharge. The registered nurse entered a verbal order for discharge without actually speaking to the attending physician, which was a deviation from the standard procedure. This lack of communication and proper authorization contributed to the unsafe discharge process. Additionally, the facility did not provide the receiving facility with the necessary discharge summary and recapitulation of stay, only sending a summary of physician orders. The receiving facility was not informed in advance about the resident's arrival, and attempts to contact the discharging facility for more information were unsuccessful. This lack of communication and documentation transfer hindered the continuity of care and left the receiving facility unprepared to meet the resident's needs. Furthermore, the facility did not conduct a proper hand-off communication to ensure the receiving facility was aware of the resident's medical and behavioral needs. The resident, who required one-to-one supervision and was at risk for wandering and falls, was transported using a non-medical transport service, despite being identified as a danger to himself and others. This inappropriate mode of transportation further compromised the resident's safety during the discharge process.
Removal Plan
- Resident 1 was discharged to SNF 2 and is no longer a resident of the facility (SNF 1).
- The DON in-serviced RN 2 to enter physician orders for discharge only after speaking to the physician.
- The DON in-serviced the facility Marketer 1 (MTR 1) to no longer arrange resident transportation.
- The DON in-serviced RN 2 regarding giving report to the nurse at the receiving facility of SNF 2.
- Medical Director Medical Doctor 1 (MDMD 1) in-serviced the ADM, DON, Assistant Director of Nursing (ADON), SSD, regarding ensuring all residents receive all discharge services (providing and completed needed discharge documentations and conducting hand off report to receiving facility) needed to ensure the resident's safety and promote the resident's highest well being from the time of discharge.
Failure to Report Resident Fall Leads to Delayed Care
Penalty
Summary
The facility failed to provide resident-centered care for a resident who sustained a fall. On the morning of 6/15/2024, a Licensed Vocational Nurse (LVN 2) did not inform another nurse (LVN 1) or the Registered Nurse Supervisor (RNS 1) that the resident had fallen. This oversight led to a delay in the resident receiving necessary care and services. The resident, who had been admitted with multiple diagnoses including chronic obstructive pulmonary disease, chronic kidney disease, anxiety disorder, lack of coordination, and major depressive disorder, was found on the floor by a Certified Nursing Assistant (CNA 2) and was assisted back to bed by LVN 2 and CNA 2. Despite the resident's moderate cognitive impairment and requirement for supervision with activities of daily living, the fall was not immediately reported or documented by LVN 2. The resident later complained of leg pain, which led to an x-ray revealing an acute minimally displaced intertrochanteric fracture of the left femur. The resident's physician was eventually notified, and the resident was transferred to a General Acute Care Hospital. Interviews with the staff revealed that LVN 2 acknowledged the failure to report the fall due to being busy, and the facility lacked a specific policy related to quality of care.
Failure to Provide Documented ADL Assistance
Penalty
Summary
The facility failed to ensure that a resident was provided with activities of daily living (ADL) assistance, resulting in a delay in delivering necessary care and services. The resident, admitted with diagnoses including atrial fibrillation and heart failure, had the capacity to understand and make decisions. The resident's Minimum Data Set (MDS) indicated the need for setup or clean-up assistance for various ADLs, and the care plan specified that the resident's ADL needs should be met daily. However, the Certified Nurse Assistant (CNA) Functional Abilities Flowsheet for a specific day in April 2024 was found to be blank, indicating that no ADL assistance was documented as provided during the day shift. During an interview and record review, the Director of Staff Development (DSD) confirmed that CNAs are required to document on the CNA Functional Abilities Flowsheet after providing ADL assistance. The DSD emphasized the importance of documentation to ensure care is provided and to notify licensed nurses of any changes in the resident's needs. The facility's policy on ADLs, last revised in March 2018, stated that residents should be provided with care, treatment, and services to maintain or improve their ability to carry out ADLs. The lack of documentation suggested that the necessary care was not provided to the resident on the specified day.
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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