Huntington Valley Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Huntington Beach, California.
- Location
- 8382 Newman Avenue, Huntington Beach, California 92647
- CMS Provider Number
- 055888
- Inspections on file
- 42
- Latest survey
- February 5, 2026
- Citations (last 12 mo.)
- 9
Citation history
Health deficiencies cited at Huntington Valley Healthcare Center during CMS and state inspections, most recent first.
Surveyors found that staff stopped CPR on a full-code resident who remained unconscious, barely breathing, and without a blood pressure, resulting in a period without compressions before paramedics arrived and resumed resuscitation. A resident with severe cognitive impairment and post-fall hip pain did not have a PT-recommended hip/femur and knee x-ray promptly communicated to the physician, and when imaging was ordered, only hip films were completed; the same resident’s critically low Hgb was not promptly reported to the physician or family, and transfer to the ER was delayed. For this resident, staff also failed to obtain a urine specimen after a physician recommendation despite lethargy and sediment in the urine, and the resident was later hospitalized with AKI and catheter-associated UTI. In addition, several residents did not receive ordered wound, skin, and device care on multiple days, as shown by missing nurse initials on TARs and MARs, with one family member reporting a visibly cloudy catheter and filthy dressing; staffing records showed that treatment nurse coverage was missing or unsigned on some days.
A resident with full-code status was found on the floor unresponsive, pulseless, and not breathing. Nursing staff with documented BLS/CPR competencies initiated CPR, with one LVN performing chest compressions and an RN providing ventilations via Ambu bag. After approximately 18–20 minutes, staff believed a carotid pulse had returned and stopped compressions, even though the resident remained unconscious, was barely breathing, and had no blood pressure while they waited several minutes for paramedics. When the fire department arrived, they found the resident pulseless, apneic, and without compressions in progress, and they restarted manual compressions and advanced resuscitative measures. This conduct did not follow the facility’s CPR policy or BLS standards requiring continuous CPR for an unresponsive, non-breathing person until help takes over.
A resident was transferred from the facility to an acute care hospital, but staff did not complete the required Notification of Transfer/Discharge or send a copy to the State LTC Ombudsman. During record review, an RN confirmed that the electronic medical record lacked the notice and any documentation of Ombudsman notification, despite acknowledging that a change of condition form, transfer form, and notice of transfer are required for resident transfers. The interim DON later acknowledged that staff should have completed the transfer notice and provided it to the LTC Ombudsman.
A resident with no capacity for medical decisions and a history of confusion was allowed to leave for an outpatient appointment without being accompanied by a responsible person, as required by the care plan for elopement risk. The resident did not return directly to the facility and the responsible party was not informed or present, which was verified by the DON and confirmed by the responsible party.
A resident did not receive and have documented intravenous fluids (IVF) as ordered by a physician. Nursing staff failed to document the administration, monitoring, and removal of normal saline IVF from the emergency kit, and there was no evidence that the physician was notified if the IVF was not given. The required documentation was missing from the medical record, and both the administrator and DON confirmed these findings.
A resident who lacked decision-making capacity was found with an expired tube of diclofenac sodium 1% topical gel stored at the bedside, without a physician's order, care plan, or authorization for self-administration. Facility staff confirmed the medication was not permitted to be stored at the bedside and that required procedures for unauthorized medications were not followed.
A resident did not receive stat CBC and CMP laboratory tests as ordered by the physician, with no evidence in the medical record that the tests were completed. Nursing staff and laboratory interviews confirmed that the stat order was not processed or communicated as required, and there was no documentation of follow-up or notification to the physician regarding the delay. The DON and Administrator acknowledged the deficiency.
A resident with an indwelling urinary catheter did not have required monitoring of urine characteristics documented on two shifts, despite physician orders and facility policy. LVNs confirmed the lack of documentation in the TAR, and the DON acknowledged that licensed nurses are expected to follow physician orders.
Surveyors found that POLST forms for three residents were incomplete or inaccurate, missing required signatures, contact information, and documentation of consent. In some cases, verbal consents were not properly witnessed, and sections regarding artificially administered nutrition were left blank. These deficiencies were confirmed by nursing staff and the DON.
Surveyors found multiple sanitation and equipment failures in the kitchen, including a greasy stove hood, chipped and melted utensils, dirty and improperly dried kitchenware, heavily marred cutting boards, and rusted equipment such as a can opener and microwave. The Dietary Services Supervisor confirmed these deficiencies and acknowledged that items were not maintained or cleaned according to policy.
Surveyors identified multiple failures in infection prevention and control, including inaccurate infection surveillance logs, lack of Enhanced Barrier Precautions for a resident with a central line, and repeated lapses in hand hygiene by staff during resident care activities such as feeding, medication administration, and wound care. These deficiencies were confirmed by staff and leadership, and involved both direct care and documentation practices.
A resident was found self-administering Systane eye drops without being assessed as able or willing to do so, and without a physician's order or care plan documentation. Facility staff confirmed the resident should not have had the medication at the bedside, and required assessments and documentation were missing.
The facility did not maintain copies of executed advance directives in the medical records for two residents and failed to provide written information or assistance on formulating advance directives to two other residents or their responsible parties, as confirmed by staff interviews and record reviews.
A nurse administered insulin to a resident without allowing the alcohol at the injection site to air dry, contrary to facility policy and manufacturer guidelines. The nurse and DSD confirmed that proper training was provided, and both acknowledged the importance of letting the site dry before injection.
A resident with limited ROM had a physician's order for a left knee extension splint, but staff failed to document the times of application and removal, and did not perform or record required skin assessments during splint use. This omission was confirmed by staff interviews and review of the care plan and medical record.
A resident with an indwelling urinary catheter was repeatedly observed with cloudy urine and sediments in the catheter tubing, but nursing staff did not complete required change of condition documentation, progress notes, or care planning in the EHR, despite facility policy and physician orders. Staff interviews confirmed the lack of follow-up and documentation for the resident's condition.
Two residents receiving enteral feeding did not receive proper care as required by facility policy: one resident's intake and output were not monitored or documented, and another resident's enteral feeding formula and water bag were not changed or labeled according to protocol. Staff interviews and record reviews confirmed these lapses in care and documentation.
The facility did not ensure proper respiratory care for four residents, including failure to administer oxygen as ordered, improper storage of nasal cannula tubing, lack of care planning and maintenance for a CPAP device, and oxygen tubing left on the floor. Staff did not consistently follow physician orders or infection control policies, and there was no documentation of communication with physicians regarding changes in respiratory care.
A resident did not receive appropriate pain management when staff failed to accurately document pain assessments and administered oxycodone outside of the prescribed pain level parameters. Non-pharmacological interventions were not consistently implemented or documented prior to medication administration, and staff interviews confirmed these lapses in following physician orders and facility policy.
Two residents with ESRD did not receive appropriate dialysis care, as the facility failed to complete dialysis communication records, maintain an emergency dialysis kit at the bedside, and ensure licensed nurses assessed and documented dialysis access sites or maintained transparent dressings. These deficiencies were confirmed by both nursing staff and the DON.
A resident with severe cognitive impairment and a diagnosis of dementia did not receive the required monitoring and documentation of mood and behavioral symptoms as outlined in their care plan. Staff interviews and medical record reviews confirmed that assessments for altered mood and related dementia symptoms were not performed or documented, despite facility policy and care plan directives.
Two residents received controlled medications that were dispensed and signed out, but the administration was not documented on the EMAR as required by facility policy. This lack of documentation was confirmed through medical record review and staff interviews, and involved both pain and anxiety medications.
A resident with hypertension and congestive heart failure was given amlodipine and two diuretics despite physician orders to hold these medications when blood pressure was below specific thresholds. The MAR showed the medications were administered outside of the prescribed parameters, and staff confirmed that reminders about these parameters were present in the MAR.
Surveyors found that medications were not properly stored or labeled, with oral and external medications mixed in medication carts, a topical antibiotic missing an open date, and two residents' creams stored at the bedside without proper orders or documentation. Staff confirmed these practices did not follow facility policy.
Surveyors observed that hot food items, including meats, vegetables, and potatoes, were served at temperatures significantly below facility policy requirements. During a test tray evaluation, the Dietary Services Supervisor confirmed that food temperatures ranged from 75.3 to 101 degrees Fahrenheit, which did not meet the standard for hot meal service. Residents had also reported concerns about receiving cold food.
A resident with severe cognitive impairment and under hospice care for cerebral infarction did not receive scheduled hospice aide visits as required by the hospice provider's calendar. Documentation and interviews confirmed that multiple visits were missed and there was no communication from the hospice provider regarding these changes, contrary to facility policy and contractual obligations.
The facility failed to ensure proper assessment, documentation, and communication of care for three residents: one resident's foot conditions were not addressed or documented as recommended by a podiatrist; another resident did not receive complete post-fall neurological assessments and monitoring; and a third resident was assisted with thickened liquids using a straw instead of a spoon, contrary to hospital discharge instructions, with no evidence these instructions were communicated to the physician.
The facility failed to obtain and document required baseline measurements for PICC and midline catheters, did not label a PIV site with date, time, and nurse initials, and did not secure a physician's order for a PIV, as confirmed by staff interviews and medical record reviews for four residents receiving IV therapy.
The facility's assessment was not developed with active involvement from direct care staff, residents, or their representatives, and failed to address necessary staffing resources for weekends, recruitment and retention strategies, or a contingency plan for staffing needs, as confirmed by the Administrator.
Three resident rooms were found with environmental deficiencies, including a rusted and soiled vent cover, a ceiling hole above a bed, and multiple bed footboards with ripped corners exposing inner materials. These issues were confirmed by the Maintenance Director and IP during facility observations.
The facility did not ensure that medical records and inventories of personal effects were accurate and complete for several residents. Inventories were missing required signatures from residents' representatives, and POLST forms lacked essential information such as physician contact details and resident or responsible party signatures. The DON confirmed these omissions during record review.
A facility failed to report an allegation of resident-to-resident abuse involving a resident who was verbally abusive and threatening towards their roommate. The incident was not reported to the CDPH, L&C Program, or the local ombudsman, resulting in the allegation going uninvestigated. The facility's Administrator and DON confirmed the failure to report.
A facility failed to investigate a reported incident of verbal abuse by a resident towards their roommate, as required by their abuse P&P. The incident, documented by the SSD, involved a resident threatening their roommate throughout the night, causing fear. Despite the Administrator being informed and contacting the physician, no investigation was conducted, as confirmed by interviews with the DON and Administrator.
A facility failed to obtain informed consent for a resident's use of lorazepam and increased dosage of citalopram, and did not provide non-pharmacological interventions for psychotropic medication use. The resident was on buspirone, citalopram, and quetiapine, with lorazepam as needed. The absence of informed consent and non-pharmacological interventions was confirmed by the LVN and DON.
A resident with a documented fish allergy was served a fish sandwich due to a menu change that was not properly communicated or identified by staff. Despite the facility's policy for tray identification, the nursing staff relied on an incorrect dinner slip, leading to the resident experiencing an allergic reaction and requiring hospital transfer.
The facility failed to maintain sanitary conditions in a shared bathroom and a dirty laundry bin. Used washcloths and an unlabeled pitcher were found in a shared bathroom, posing a risk of accidental use by residents. Additionally, a CNA was observed handling a dirty laundry bin with bare hands, which had a brown residue suspected to be a bowel movement stain. The DON acknowledged the need for cleaning and glove use to prevent infection spread.
The facility failed to provide timely care and conduct required assessments for two residents. One resident experienced multiple falls without proper assessment or care plan updates, and ordered lab tests were not performed. Another resident did not receive ordered neuro checks after an unwitnessed fall. These deficiencies highlight lapses in following protocols and ensuring resident safety.
Two residents in an LTC facility were prescribed psychotropic medications without appropriate diagnoses. One resident received lorazepam PRN for anxiety without a documented diagnosis, and the medication was renewed beyond 14 days without evaluation. Another resident was given risperidone for psychosis without a documented diagnosis. Observations noted both residents were at risk of falls and exhibited aggressive behavior.
A resident did not receive prescribed medications, including Senna, enoxaparin, acetaminophen, gabapentin, and nystatin, as per physician's orders. The medications were not documented in the MAR, and the resident experienced increased pain, requiring stronger medication. Interviews with the DON and LVNs confirmed the lack of documentation and administration.
A resident experienced a decline in health, including a productive cough, poor meal intake, and refusal of medications. The resident's oxygen saturation dropped to 81%, but this was not communicated to the charge nurse. The resident was later found unresponsive, leading to emergency intervention. The facility failed to initiate a care plan or monitor the resident's condition as required.
The facility failed to prevent and manage pressure ulcers for two residents. One resident was not repositioned every two hours as required, while another resident's pressure ulcer was not assessed weekly, leading to worsening conditions. Staff interviews confirmed these deficiencies, highlighting a lack of adherence to care plans and assessment schedules.
The facility failed to follow Enhanced Barrier Precautions (EBP) for a resident, as staff did not wear gowns during high-contact care activities, including wound care. Additionally, hand hygiene was not performed between glove changes, and unused medical supplies were improperly handled, increasing the risk of infection spread.
A resident with intact cognition and limited range of motion had their call light blinking for an extended period without response from RN 1, who passed by twice. The call light was eventually answered by the Activity Director, who assisted the resident with marking her clothes.
A facility failed to maintain accurate medical records for a resident, including discrepancies in oxygen saturation documentation and oxygen administration orders. The resident's POLST form lacked proper signatures and advance directives were not documented in the medical record. Interviews with staff confirmed these deficiencies.
A facility failed to report an alleged staff-to-resident abuse incident to the appropriate authorities, as required by policy and federal regulations. The incident involved a resident with moderate cognitive impairment who expressed fear of a male CNA. Despite being reported internally, the incident was not documented or reported to external agencies.
The facility failed to conduct a comprehensive investigation into an alleged abuse incident involving a resident with hemiplegia and hemiparesis. Despite reports from a family member and the Activity Director, only the alleged perpetrator was interviewed, and the incident was not documented, violating the facility's abuse policy and procedure.
A facility failed to provide necessary foot care services for a resident with severe cognitive impairment and Type 2 Diabetes Mellitus. After receiving podiatry care for a fungal infection, the facility did not ensure proper skin checks, assessments, or monitoring of the resident's feet. No care plan was developed for the fungal infection, and a subsequent change in the resident's condition led to hospitalization. The DON confirmed the lack of documentation for monitoring and care planning.
A facility failed to provide non-pharmacological interventions for a resident prescribed Lexapro for depression, despite multiple episodes of tearfulness. The facility's policy requires minimizing medication use through non-pharmacological approaches, but no such interventions were documented or included in the care plan. The DON confirmed the lack of documentation for these interventions.
The facility failed to prevent and manage pressure injuries for three residents by not conducting weekly wound assessments and improperly setting low air loss mattresses. A resident's pressure injuries were not measured or photographed weekly, and their mattress was set too firm for their weight. Two other residents also had mattresses set too firm, increasing the risk of pressure injuries. The DON acknowledged these deficiencies.
The facility failed to maintain its infection control program, as evidenced by staff not wearing disposable gowns during wound care and resident transfers, and not establishing clean fields for wound supplies. These lapses involved two residents with wounds and indwelling devices, posing a risk of infection spread.
Failure to Provide Ordered CPR, Diagnostic Follow-Up, Lab Response, and Wound Care
Penalty
Summary
The deficiency involves multiple failures to provide treatment and care according to physician orders, facility policies, and residents’ needs and conditions. For one resident with a documented full code status and POLST indicating CPR and full treatment, staff initiated CPR after the resident was found unresponsive, pulseless, and not breathing. Staff reported that after approximately 18–20 minutes of CPR, a carotid pulse was obtained, but the resident remained unconscious, barely breathing, and without a blood pressure reading. Despite this, staff stopped chest compressions and rescue breathing while waiting approximately 5–7 minutes for paramedics to arrive. When the fire department arrived, they found the resident pulseless, apneic, and without compressions being performed, and they restarted manual compressions and advanced resuscitation efforts. The facility’s DON stated the expectation was that licensed nurses continue CPR until the fire department arrives and takes over. Another deficiency concerns a resident with severe cognitive impairment who experienced a fall and developed consistent right hip pain with a positive test noted by PT. The PT documented a recommendation for right hip/femur and knee x-rays, but the medical record did not show that nursing staff notified the physician of this recommendation at that time. A later physician order was written for bilateral hip/femur to knee x-rays, but the record only contained results for bilateral hip x-rays and no results for femur-to-knee imaging as ordered. The resident was later found at the hospital to have markedly displaced fractures of the distal femur requiring ORIF surgery. For the same resident, a STAT BMP, CBC, and magnesium were ordered, and lab results showed a hemoglobin of 6.3 g/dL, but the record did not show timely physician or family notification of this abnormal result. The resident was transferred to the ER later with low hemoglobin and received a blood transfusion. The resident’s family member reported not being notified of the low hemoglobin until the following day and that transfer to the hospital occurred two days after the low result. Additional deficiencies for this resident involved failure to follow through on a physician recommendation to obtain a urine sample after a change in condition. The family reported lethargy and sediment in the urine, and the physician recommended collecting a urine sample, but the record contained no physician order, no lab requisition, and no urine test result. The resident, who had a suprapubic catheter and was care planned as at risk for catheter-related complications, was later transferred to the hospital and diagnosed with acute kidney injury and catheter-associated UTI. The family member stated the facility resisted transferring the resident to the hospital until the resident was eventually sent. The facility also failed to provide ordered wound and skin treatments for several residents. For one resident with multiple treatment orders for bilateral upper and lower extremity discoloration, a left thumb lesion, MASD with excoriation to the buttocks, and suprapubic catheter site care and monitoring, the Treatment Administration Record and MAR for specific days lacked nurse initials, indicating treatments and monitoring were not completed. The resident’s family member reported the catheter was visibly cloudy and the split gauze dressing was filthy. For another resident with a gastrostomy tube, the TAR showed no nurse initials on a day when the daily order to cleanse the G-tube site and apply dressing should have been completed. For a third resident with mild cognitive impairment and multiple skin and wound treatment orders, including monitoring lower extremity discoloration, treating facial and shin scabs, managing MASD, and caring for surgical incisions and pressure injuries, the TAR lacked nurse initials for several ordered treatments on a specific day. Staffing assignment records showed that on some days there was no signed or assigned treatment nurse for certain stations, and LVN staff confirmed that missing initials indicated treatments were not completed.
Failure to Continue CPR for Full-Code Resident Until EMS Arrival
Penalty
Summary
The deficiency involves the facility’s failure to ensure that nursing staff with documented BLS/CPR competencies provided appropriate and continued emergency care to a full-code resident. Facility policies required that all nursing staff meet competency requirements per state law and that staff certified in CPR/BLS initiate and continue CPR for unresponsive individuals without normal breathing unless a DNR order exists or there are obvious signs of irreversible death. The facility’s CPR policy and cited clinical references emphasized that chest compressions are the cornerstone of CPR, that compressions and ventilations should continue in cycles until an AED is available or additional help arrives, and that compressions should only be stopped when the person speaks, moves, or breathes normally or when help takes over. Resident 7 was admitted with orders indicating full code status, including a POLST specifying “Attempt Resuscitation/CPR” and “Full Treatment” as the primary goal. On the date of the event, documentation in the resident’s eInteract SBAR and progress notes showed the resident was found on the floor next to the bed, unresponsive to verbal and tactile stimuli, with asystole and absence of respirations. CPR was initiated and 911 was called. The notes indicated that after approximately 20 minutes of CPR, return of spontaneous circulation was achieved and care was assumed, and that the fire department arrived and continued CPR and lifesaving measures for another 20 minutes. The resident’s medical record did not contain documentation of vital signs at the time staff believed spontaneous circulation had been achieved. The fire department’s electronic patient care report documented that responders arrived to find the resident on the ground, pulseless, apneic, and without compressions being performed, and that manual compressions were then initiated, BVM with high-flow oxygen was administered, and defibrillation pads were applied, with the rhythm noted as PEA. The emergency department record later documented that the resident died in the ED. In interviews, the Fire Captain stated that staff reported they had provided CPR for about 20 minutes, believed the heart rate had returned, and stopped compressions while waiting for paramedics. In interviews with facility staff, LVN 4 stated the resident was unresponsive with no pulse, and that CPR was started immediately, with LVN 5 performing compressions and RN 3 providing ventilations via Ambu bag. LVN 4 reported that after about 20 minutes of CPR, the resident’s pulse returned and RN 3 instructed staff to stop CPR while waiting for paramedics. RN 3 stated that she and LVN 5 initiated CPR when they found the resident unresponsive and pulseless, with LVN 5 doing compressions and RN 3 providing breaths, and that a pulse was achieved before the fire department arrived; however, she also stated the resident had no blood pressure and remained unconscious. LVN 5 reported finding the resident on the floor, with no pulse oximeter reading, and that RN 3 confirmed no pulse or respirations; he described performing compressions while RN 3 provided breaths, then stopping compressions after 18–20 minutes when a carotid pulse was obtained, even though the resident remained unconscious, was barely breathing, and had no blood pressure for approximately 5–7 minutes while they waited for paramedics. Review of staff records showed that LVN 4 and LVN 5 had documented competencies for emergency equipment and current BLS Provider certification, and RN 3 had documented competencies in emergency equipment, emergency responses, and CPR, along with an RQI Healthcare Provider BLS certificate demonstrating competence in high-quality CPR skills. Despite these documented competencies and the facility’s CPR policy, LVNs 4 and 5 and RN 3 did not continue life-saving measures for the resident, as they stopped chest compressions while the resident remained unconscious, barely breathing, and without a blood pressure reading, and before EMS personnel arrived and took over resuscitation. The facility acknowledged through the DON’s interview that the expectation was for licensed nurses to continue CPR until the fire department arrived and assumed care.
Failure to Notify State LTC Ombudsman of Resident Transfer/Discharge
Penalty
Summary
The deficiency involves the facility’s failure to provide the Office of the State LTC Ombudsman with a copy of a required notice of transfer/discharge for one sampled resident. The resident was admitted to the facility and later transferred to an acute care hospital. During a closed medical record review initiated on 12/23/25, surveyors found no documented evidence that the LTC Ombudsman had been notified of this transfer. Review of the resident’s electronic medical record did not contain a completed Notification of Transfer/Discharge form or any documentation indicating that the Ombudsman had been informed of the transfer to the hospital. In an interview and concurrent record review on 1/8/26, RN 3 explained that a change of condition form, transfer form, and notice of transfer were required when transferring a resident and confirmed that all resident information was maintained in the electronic medical record. When asked to locate the Notification of Transfer/Discharge for this resident, RN 3 verified that no such notice had been completed and that there was no documentation of Ombudsman notification. In a subsequent interview on 1/12/26, RN 2, acting as interim DON, acknowledged that facility staff should have completed the resident’s notice of transfer and sent a copy to the LTC Ombudsman.
Failure to Follow Elopement Care Plan for Resident Lacking Capacity
Penalty
Summary
The facility failed to implement and follow the individualized care plan for a resident who lacked capacity to make medical decisions and had a history of mild, intermittent confusion. The resident's care plan, initiated due to elopement risk, specified that the resident was not to leave the facility without being accompanied by a responsible person. Despite this, the resident was allowed to leave the facility for an outpatient medical appointment without accompaniment from a responsible party or the resident's responsible person, as required by the care plan and physician orders. Medical records indicated that the resident left the facility under approved authorization for an appointment but did not return directly afterward, instead going to his apartment before eventually returning to the facility. Documentation did not show that the responsible party was informed or present, and the responsible party later confirmed she was not notified of the appointment or the need to accompany the resident. The DON verified that the care plan was not followed and that the responsible party was not informed, resulting in the resident leaving unaccompanied and eloping after the appointment.
Failure to Administer and Document IV Fluids per Policy
Penalty
Summary
The facility failed to provide necessary treatment and services related to the administration and documentation of intravenous fluids (IVF) for one resident. According to the facility's policy and procedure (P&P) for intravenous administration, staff are required to monitor residents receiving continuous fluids for signs of complications, document specific details of the infusion, and notify the provider of any issues. For the resident in question, a physician's order was received for STAT labs and normal saline IVF at a specified rate. Although a nurse documented that the orders were noted and carried out, there was no evidence in the resident's progress notes or medication administration record (MAR) that the IVF was actually administered or that the IV site was monitored as required. Additionally, there was no documentation that the physician was notified if the IVF was not given. Further review revealed that the required physician's order for the IVF was missing from the resident's order summary and MAR. Interviews with nursing staff confirmed the lack of documentation regarding the insertion of the IV, administration of fluids, and monitoring of the IV site. There was also no record of the removal of the normal saline IVF from the facility's emergency kit, as required by protocol. Both the facility's administrator and director of nursing acknowledged these findings, and the pharmacy supplying the IV fluids confirmed that no documentation was provided by facility staff to show the IVF was removed from the emergency kit for the resident.
Unauthorized Medication Storage at Bedside Without Physician Order
Penalty
Summary
A deficiency occurred when a tube of diclofenac sodium 1% topical gel, which had expired, was found stored at the bedside of a resident who lacked the capacity to understand and make decisions. The medication was not authorized for self-administration, and there was no physician's order, care plan, or documentation permitting the resident to store or self-administer the medication. The facility's policy required that any medications found at the bedside without authorization for self-administration be turned over to the nurse in charge, but this procedure was not followed in this instance. The resident's medical record indicated that the resident did not wish to self-administer medications and had no assessment or order allowing for self-administration. Facility staff, including an RN and the DON, confirmed that the medication should not have been left at the bedside and that it may have been brought in by the resident's family. The medication was accessible in the resident's room, and staff verified that there was no documentation or physician's order supporting its presence or use at the bedside.
Failure to Complete Stat Laboratory Orders as Prescribed
Penalty
Summary
The facility failed to ensure that a physician's order for stat laboratory tests, specifically a Complete Blood Count (CBC) and Comprehensive Metabolic Panel (CMP), was completed for one resident. The physician ordered these tests on 9/5/25 at 1315 hours due to the resident's decreased urine output and increased lethargy. However, a review of the resident's medical record did not show any documented evidence that the stat laboratory tests were performed as ordered. Interviews with nursing staff revealed that stat laboratory orders should be processed as soon as possible, typically within two to four hours, and require both entry into the facility's electronic system and direct communication with the laboratory. The laboratory's records confirmed that no stat order was received for the resident, and the last blood work on file was from a previous date. Further interviews with staff indicated that the expected protocol for stat laboratory orders includes notifying the laboratory by phone, documenting follow-up actions, and informing the physician if there are delays. In this case, the nurse who received the order did not see the laboratory technician arrive before the end of the shift, and there was no documentation of follow-up or communication regarding the delay. The Director of Nursing and Administrator acknowledged these findings during the survey.
Incomplete Documentation of Urine Monitoring for Catheterized Resident
Penalty
Summary
The facility failed to ensure that the medical record for one of six sampled residents was complete, specifically regarding documentation of urine characteristics for a resident with an indwelling urinary catheter. According to the facility's policy and procedure for catheter care, information such as urine color, clarity, and odor should be recorded in the resident's medical record to prevent catheter-associated complications. Medical record review revealed that the Treatment Administration Record (TAR) for August was incomplete, with missing documentation on two shifts where monitoring of urine characteristics was required by physician order. Interviews with two LVNs confirmed that the TAR entries for the specified dates and shifts were left blank, indicating that documentation was not completed. Both LVNs acknowledged that monitoring may have been performed but was not recorded as required. The Director of Nursing stated that the expectation was for licensed nurses to follow physician orders, and both the Administrator and DON acknowledged the findings during the survey.
Incomplete and Inaccurate POLST Documentation for Multiple Residents
Penalty
Summary
The facility failed to ensure that medical records, specifically the Physician Orders for Life-Sustaining Treatment (POLST) forms, were accurate and complete for three of eight sampled residents. For one resident with dementia and moderate cognitive impairment, the POLST form was missing the physician's phone number, license number, signature, and the responsible party's signature, address, and telephone number. The responsible party's signature was entered by a nurse without indicating it was a verbal consent, and the nurse practitioner’s name was incorrectly entered in the section for the supervising physician. These omissions were verified during a medical record review with a registered nurse. For another resident with moderate cognitive impairment, the POLST form lacked the nurse practitioner's phone number, license number, date signed, and the supervising physician's name. The form also did not indicate whether the information was discussed with the resident, and the resident's address, telephone number, and signature date were missing. A third resident, who was cognitively intact, had a POLST form that did not document a second nurse witnessing the verbal consent from the responsible party, omitted the resident's wishes regarding artificially administered nutrition, and left the responsible party's address and phone number blank. These findings were confirmed by both a registered nurse and the Director of Nursing.
Widespread Kitchen Sanitation and Equipment Failures
Penalty
Summary
Surveyors identified multiple failures in the facility's kitchen related to food safety and sanitation. The kitchen hood over the stove was found to have black, greasy residue, despite facility policy requiring it to be cleaned every two weeks and kept free of dust and grease. The Dietary Services Supervisor (DSS) confirmed that the hood was only cleaned once a week and acknowledged the presence of dirt and grease. Additionally, several kitchen utensils, including spatulas, ladles, whisks, and dough cutters, were observed to be chipped, cracked, melted, discolored, or otherwise worn out, contrary to facility policy and USDA Food Code requirements that utensils be maintained in good repair and have smooth, cleanable surfaces. Further observations revealed that numerous kitchen utensils and equipment were not properly cleaned. Items such as ladles, spoons, cake slicers, spatulas, scoops, measuring cups, and dough cutters were found with dry, crusted food residue, watermarks, and bristle-like debris. The DSS acknowledged that these items should have been cleaned and washed to prevent bacteria growth. Cutting boards used for food preparation were heavily marred, fuzzy, and had deep grooves, making them difficult to clean and sanitize. The DSS confirmed that these cutting boards should have been replaced. Additional deficiencies included improper drying and storage of kitchenware. A heavy-duty blender, several ladles, scoops, and clear plastic bins were stored while still wet, and some scoops were also dirty with food residue. The DSS acknowledged that all utensils and equipment should have been air dried before storage. The countertop-mounted can opener and the microwave were both found to have yellowish discoloration resembling rust, with the microwave also having white residue inside the door. The DSS confirmed that these items were old, unsanitary, and needed replacement. These findings were observed during an initial kitchen tour, and the DSS verified all deficiencies.
Infection Control Deficiencies and Failure to Follow Protocols
Penalty
Summary
The facility failed to implement and maintain effective infection prevention and control practices as outlined in its own policies and procedures. Surveyors found that the monthly Infection Prevention and Control Surveillance Logs for January and February did not accurately match the Infection Control Monthly Summary reports, resulting in inaccurate reporting of healthcare-associated infections (HAIs) and community-acquired infections (CAIs). The Infection Preventionist (IP) confirmed that the discrepancies were due to the volume of infections and acknowledged that the numbers should have matched to provide accurate information for infection control monitoring. Additionally, the facility did not follow Enhanced Barrier Precautions (EBP) for a resident with a central line, as there was no signage or personal protective equipment (PPE) available at the doorway, and no physician's order for EBP was documented. Staff also failed to adhere to hand hygiene protocols during resident care activities. For example, an occupational therapist did not perform hand hygiene between assisting multiple residents during mealtime, and a licensed vocational nurse (LVN) did not don a gown when providing enteral feeding care to a resident on EBP. Another LVN failed to perform hand hygiene and change gloves prior to administering insulin to a resident, despite facility policy requiring these steps to prevent infection. Furthermore, improper hand hygiene was observed during wound care treatment for a resident with stage 4 pressure injuries. The LVN performing the wound care did not sanitize hands immediately after removing gloves throughout the procedure, only washing hands at the end of the treatment. These failures were acknowledged by the staff involved and confirmed by the IP and Director of Nursing (DON) during interviews, demonstrating a lack of consistent adherence to infection control protocols designed to prevent the development and transmission of diseases and infections within the facility.
Failure to Ensure Safe Self-Administration of Medication
Penalty
Summary
A deficiency occurred when a resident was found to be self-administering Systane eye drops, despite not being assessed as able or willing to self-administer medications. During an observation, two bottles of Systane eye drops were found on the resident's bedside table, and the resident confirmed self-administration. A licensed vocational nurse (LVN) verified the presence of the medication at the bedside and stated that the resident was not able to self-administer the eye drops and should not have had them at the bedside. Review of the resident's medical record showed no physician's order for the Systane eye drops or for self-administration, and the care plan did not address the resident's eye condition or ability to self-administer medication. The facility's policy requires an assessment, physician's order, and care plan documentation for self-administration, none of which were present for this resident. The Director of Nursing (DON) confirmed that the necessary documentation and orders were missing.
Failure to Maintain and Provide Advance Directive Documentation and Information
Penalty
Summary
The facility failed to obtain and/or maintain copies of advance directives and provide written information regarding the formulation of advance directives for four residents. For two residents who had executed advance directives, the facility did not ensure that copies of these documents were available in their medical records or electronic health records. Interviews with nursing and social services staff confirmed that there was no documented follow-up to obtain these documents, despite facility policy requiring such actions and quarterly checks. For another resident who had not executed an advance directive, the facility did not provide written information or assistance on how to formulate one to the resident or their responsible party. Medical record review and staff interviews confirmed the absence of documentation showing that the required information and assistance were offered, as outlined in facility policy. The responsible staff acknowledged that this step was missed during the admission process and subsequent follow-up. A fourth resident, who lacked decision-making capacity, also did not have documentation in the medical record that the responsible party was provided with information on how to formulate an advance directive. The social services director and DON confirmed that, according to policy, this information should have been offered and documented, but there was no evidence of this in the resident's records. These failures were verified through interviews and concurrent record reviews with facility staff and administration.
Failure to Follow Proper Insulin Administration Procedure
Penalty
Summary
LVN 1 failed to follow the facility's policy and procedure for insulin administration for one resident. During a medication administration observation, LVN 1 was seen wiping the resident's left upper abdominal area with an alcohol wipe and immediately injecting Lantus insulin while the area was still visibly wet. The facility's policy, as well as the manufacturer's administration guide, require that the injection site be cleaned with alcohol and allowed to air dry before injection. LVN 1 did not wait for the alcohol to dry before administering the insulin. Interviews with LVN 1 and the Director of Staff Development (DSD) confirmed that LVN 1 had been trained to allow the injection site to air dry after cleaning with alcohol. Both LVN 1 and the DSD acknowledged that injecting insulin into a site that is still wet with alcohol could cause stinging and potentially alter the effect of the medication. The deficiency was identified through observation, interview, and review of facility policies and training records.
Failure to Document and Assess Skin During Splint Use for Resident with Limited ROM
Penalty
Summary
The facility failed to follow a physician's order for the application of a left knee extension splint for a resident with limited range of motion (ROM). The order specified that the splint should be applied to the resident's left knee five times a week for up to five hours a day or as tolerated. However, there was no documentation of the exact times when the splint was applied and removed. Additionally, the care plan and medical record did not include or document any skin assessments when the splint was in use, despite the resident having hardware (screws) in the leg and being at risk for skin issues. Interviews with staff confirmed that while the splint was applied as ordered, there was no record of skin assessments being performed or documented during its use. The facility's policy on restorative nursing services required care to promote safety and independence, but the lack of documentation and omission of skin assessments represented a failure to provide appropriate care to prevent a decline in ROM and potential skin complications. The Director of Nursing verified these findings during the survey.
Failure to Document and Respond to Change in Condition for Catheterized Resident
Penalty
Summary
A deficiency occurred when a resident with an indwelling urinary catheter did not receive appropriate care and services as required by facility policy and physician orders. The resident, who had moderate cognitive impairment, was observed on multiple occasions with cloudy urine and sediments in the catheter tubing. Despite these findings, which were recognized by nursing staff as a change in condition and potential sign of infection, there was no documentation of a change of condition (COC) assessment, progress notes, or care plan in the resident's electronic health record (EHR) for several days. Interviews with licensed nursing staff confirmed that the facility's policy required immediate reporting and documentation of unusual findings such as cloudy urine with sediments. However, staff acknowledged that no COC documentation, progress notes, or care plan had been completed for the resident's condition during the relevant period. One nurse stated that the change was reported to other staff, but those staff members did not follow up with the required documentation or care planning. The administrator was informed and acknowledged these findings.
Failure to Monitor and Document Enteral Feeding Care and Adherence to Protocols
Penalty
Summary
The facility failed to provide necessary gastrostomy tube (GT) care and services for two residents receiving enteral feeding. For one resident, staff did not monitor or document intake and output as required by both the resident's care plan and the facility's policy. The resident had a history of dysphagia and was receiving Glucerna via GT at a prescribed rate. Despite a care plan intervention to monitor intake and output, there was no evidence in the medical record that this was being done. Interviews with staff, including an LVN and the DON, confirmed that intake and output monitoring was not consistently performed or documented for residents on tube feeding, contrary to facility protocol and care plan requirements. For another resident, the facility did not ensure that the enteral feeding formula was changed within 24 hours, nor was the formula bottle properly labeled with the start time and nurse's initials. Additionally, the water bag used for enteral feeding was not labeled with the date and time it was prepared. This resident also had a history of dysphagia and was receiving Jevity 1.2 via feeding pump, along with scheduled water flushes. Observation and interviews confirmed that the labeling and timely changing of the formula and water bag were not performed as required by facility policy. These deficiencies were identified through observation, interviews, medical record review, and review of facility policies and procedures. Both the DON and Administrator acknowledged the findings related to the lack of intake and output monitoring, as well as the failure to follow protocols for changing and labeling enteral feeding supplies.
Failure to Provide Safe and Appropriate Respiratory Care and Maintain Infection Control
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for four residents who required oxygen therapy or CPAP support. For two residents, staff did not ensure oxygen was administered as per physician orders and failed to store nasal cannula tubing in a sanitary manner. One resident was observed with a nasal cannula left on the bed and not in a plastic bag, while another had the tubing wrapped around a bed rail. In both cases, the oxygen concentrator was running, but the residents were not using the oxygen as ordered, and there was no documentation of communication with the physician regarding changes in oxygen use or need. Another resident using a CPAP machine did not have a care plan addressing the use of the device, and there was no physician's order for the cleaning and maintenance of the CPAP as directed by the manufacturer's guidelines. The CPAP mask was left on top of a drawer, and the tubing was stored in a plastic bag, but staff could not provide the user guide for the device and confirmed that cleaning instructions were not being followed or documented. Additionally, a resident receiving continuous oxygen therapy was observed with oxygen tubing touching the floor, which was verified by the infection preventionist. The facility's policies required proper storage and regular changing of oxygen tubing and cannulas, as well as adherence to infection control practices, but these were not consistently followed for the residents reviewed.
Failure to Provide and Document Appropriate Pain Management
Penalty
Summary
The facility failed to provide appropriate pain management for one resident by not accurately documenting pain assessments and not administering pain medication according to the physician's orders. Specifically, the medical record review showed that the resident was given oxycodone, a narcotic opioid, even when the documented pain level was zero, which was outside the ordered parameters that required administration only for moderate to severe pain (pain levels 6-10). Additionally, pain assessments were not consistently documented each shift as required, and there were discrepancies between the administration of pain medication and the recorded pain levels. The facility also did not ensure that non-pharmacological interventions were implemented and documented prior to administering pain medication, as required by both physician orders and facility policy. On several occasions, the non-pharmacological interventions were either not documented or were marked as 'none' before the administration of oxycodone. This was confirmed through review of the Medication Administration Record (MAR) and interviews with both the LVN and the DON, who acknowledged that non-pharmacological interventions should have been attempted and documented prior to medication administration. Interviews with facility staff, including the LVN and DON, confirmed that the expected process was not followed. Both staff members verified that pain medication should not be administered when the pain level is documented as zero, and that non-pharmacological interventions should not be marked as 'none' if pain medication is given. The DON also stated that pain assessments should be accurately documented each shift and updated if the resident's pain status changes after initial documentation.
Failure to Provide Safe and Appropriate Dialysis Care and Documentation
Penalty
Summary
The facility failed to provide appropriate dialysis care for two residents with end-stage renal disease (ESRD) who required dialysis services. For one resident, the dialysis communication records, which serve as a communication tool between the dialysis center and the facility, contained multiple blank entries for the dialysis access site assessment on several dates. Both the LVN and the DON confirmed that these records should have been fully completed prior to the resident going to the dialysis center, as per facility policy. For another resident, the facility did not ensure that an emergency dialysis kit was kept at the bedside, as required by physician's order and facility policy. During an interview and observation, the LVN was unable to locate the emergency dialysis kit at the resident's bedside, despite acknowledging that it should be present even if the resident was no longer receiving dialysis treatments but still had a dialysis access in place. The DON also confirmed that the kit should have been readily available for any resident with a dialysis access. Additionally, the facility failed to ensure that licensed nurses assessed and documented the resident's dialysis access site and maintained a transparent dressing over the site. Medical record review showed no documentation of assessment of the dialysis catheter, and the resident's care plan did not address the care of the dialysis catheter. Observation confirmed that the resident's dialysis access site was not covered with a transparent dressing, and the DON was unable to find documentation of the last dressing change. These failures were verified by both the LVN and the DON during interviews and record reviews.
Failure to Implement and Document Dementia Care Interventions
Penalty
Summary
The facility failed to implement and document dementia care interventions for one resident diagnosed with dementia. According to the facility's own policy, staff and physicians are required to evaluate, monitor, and document the cognitive and behavioral status of residents with dementia, including signs of altered mood, loss of interest in activities, and other related symptoms. For the resident in question, the care plan specifically called for monitoring and reporting of mood changes and symptoms of depression or anxiety. However, medical record review revealed no documented evidence that these assessments or monitoring activities were being performed as required. Observations and interviews with staff confirmed that the resident exhibited severe cognitive impairment, was dependent for most ADLs, and displayed behaviors such as confusion, aggression, and lack of interaction. Despite these symptoms and the care plan directives, both CNAs and LVNs were unable to provide documentation of behavior or mood monitoring for the resident. The DON also verified that no such documentation existed, confirming that the required interventions and monitoring for dementia-related symptoms were not being carried out as outlined in the resident's plan of care.
Failure to Document Administration of Controlled Medications
Penalty
Summary
The facility failed to provide necessary pharmaceutical services in accordance with its policies and procedures for two residents. For one resident with the capacity to make decisions, a physician's order was in place for oxycodone-acetaminophen to be administered as needed for moderate to severe pain. The medication was dispensed and signed out, but there was no documentation of its administration on the Medication Administration Record (MAR) for the specified date and time. This omission was verified during a medical record review and interview with a registered nurse. Similarly, for another resident who was unable to make decisions, a physician's order was in place for lorazepam to be administered as needed for anxiety. The medication was dispensed and signed out, but again, there was no documentation of its administration on the MAR for the specified date and time. This finding was also confirmed through medical record review and staff interviews. The facility's policies require that the administration of controlled substances be documented on the MAR, including the date, time, dosage, route, and the signature of the administering nurse, which was not followed in these instances.
Failure to Adhere to Blood Pressure Parameters for Medication Administration
Penalty
Summary
The facility failed to ensure that a resident’s drug regimen was free from unnecessary medications by not adhering to physician-prescribed blood pressure parameters for three medications: amlodipine, spironolactone, and ethacrynic acid. The physician’s orders specified that amlodipine should be held if the systolic blood pressure was less than 115 mmHg or the heart rate was less than 56 bpm, and that both diuretics should be held if the systolic blood pressure was less than 110 mmHg or the heart rate was less than 60 bpm. Despite these parameters, the resident was administered amlodipine when their systolic blood pressure was 113 mmHg and both diuretics when their systolic blood pressure was 104 mmHg, as documented in the Medication Administration Records (MAR) for January and March. The resident had a history of hypertension and congestive heart failure and was determined to have the capacity to understand and make decisions. During interviews, the LVN confirmed that reminders regarding medication parameters were present on the MAR prior to administration, and both the DON and Administrator acknowledged the findings. The facility’s policy required medications to be administered in accordance with prescribed orders, but this was not followed in the instances identified.
Deficiencies in Medication Storage, Labeling, and Documentation
Penalty
Summary
Surveyors identified multiple deficiencies in the facility's medication management practices. During inspections of two medication carts, it was observed that orally administered medications were not stored separately from externally used medications, such as ointments, creams, and eye drops, contrary to facility policy. Staff, including the ADON and an RN, verified these findings. Additionally, a gentamicin ointment used for a resident's skin infection was found without an open date on its label, which was confirmed by both the LVN and the DON as a requirement for proper labeling. Further review revealed that a resident's Preparation H and Lidocaine creams were stored at the bedside without a physician's order or care plan authorizing bedside storage. The LVN responsible for administering these medications admitted to storing them at the bedside and failing to document their administration on the Treatment Administration Record (TAR) for several days. The DON and Administrator acknowledged these findings during interviews. The report also notes that the resident had the capacity to make decisions, as documented in their medical record.
Failure to Serve Hot Food at Required Temperatures
Penalty
Summary
Surveyors found that the facility failed to serve food items at appetizing and safe temperatures, as required by facility policy and best practices. During a meal service observation, residents expressed concerns that hot food items were being served cold. A review of the facility's policies indicated that hot foods, including meats, vegetables, and potatoes, should be served at or above 140 degrees Fahrenheit, with specific service temperatures for certain items ranging from 160-180 degrees Fahrenheit, and a minimum delivery temperature of 120 degrees Fahrenheit for hot entrees, starches, and vegetables. On the day of the survey, a test tray was evaluated in the presence of the Dietary Services Supervisor (DSS) and surveyors. The measured temperatures of various hot food items, including roast turkey, vegetables, and potatoes, ranged from 75.3 to 101 degrees Fahrenheit, all of which were below the recommended serving temperatures. The DSS confirmed that these temperatures did not meet the facility's standards for hot food service and acknowledged that the food was not hot as required. This failure affected the majority of residents who consumed meals prepared in the kitchen.
Failure to Provide Scheduled Hospice Aide Visits and Communication
Penalty
Summary
The facility failed to ensure that a resident receiving hospice care was provided with the scheduled hospice aide (HA) visits as outlined by the hospice provider's calendar. According to the medical record and hospice documentation, the resident was to receive HA visits every Tuesday and Thursday, but there were no documented visits on 3/25, 3/27, 4/1, and 4/3, with the last recorded visit occurring on 3/20. Interviews with facility staff, the resident's family member, and hospice personnel confirmed that the scheduled visits did not occur and that there was no communication from the hospice provider regarding changes to the visit schedule. The resident in question had severe cognitive impairment, as indicated by a BIMS score of three, and was under hospice care for a cerebral infarction. Facility policy and the hospice contract required timely delivery of hospice services and communication between the hospice provider, facility staff, and the resident's family. However, the lack of scheduled HA visits and absence of communication about missed visits demonstrated a failure to provide necessary care and services as required by both facility policy and the hospice agreement.
Failure to Provide and Document Appropriate Care and Services
Penalty
Summary
The facility failed to provide necessary care and services to three residents, resulting in deficiencies related to assessment, documentation, and communication of care needs. For one resident, a black scab under the second right toenail and dryness on both feet were observed, but these conditions were not addressed in the comprehensive skin assessment. Although a podiatry visit had recommended applying lotion to restore moisture, the wound care nurse was unaware of these additional foot conditions, and there was no documentation that the recommendations were followed. Another resident experienced a fall, and the facility did not complete or accurately document the required post-fall neurological assessments and monitoring. Several neurological assessment components, such as pupil response, extremity motor function, and pain response, were missing or not completed at multiple required intervals. Additionally, progress notes did not reflect post-fall monitoring during several shifts, contrary to facility policy that mandates such monitoring every shift for 72 hours post-fall. A third resident, who had specific swallowing and diet recommendations from an acute care hospital, was observed being assisted with thickened liquids using a straw, despite discharge instructions specifying that liquids should be given by spoon only. There was no evidence that these recommendations were communicated to the attending physician or incorporated into the resident's care plan. Staff interviews confirmed the lack of documentation and awareness regarding the required feeding method.
Failure to Document and Monitor IV Line Care and Orders
Penalty
Summary
The facility failed to provide necessary care and services related to the administration and monitoring of intravenous (IV) lines for four residents. For two residents with peripherally inserted central catheters (PICC lines), baseline external catheter length and arm circumference measurements were not obtained or documented upon admission, as required for proper monitoring. In one case, a resident with a midline catheter did not have arm circumference and external catheter length measured on admission or during dressing changes, despite physician orders specifying these requirements. Documentation of these measurements was also missing from the medical records and IV medication administration records. Additionally, a resident with a peripheral intravenous (PIV) line did not have the site labeled with the date, time, and nurse's initials, and there was no physician's order for the PIV, contrary to facility policy and standard practice. Observations confirmed the absence of labeling and orders, and interviews with nursing staff verified that these steps had not been completed. The lack of documentation and assessment could delay the identification of IV catheter-related complications, as noted in the findings. Medical record reviews and staff interviews consistently revealed that required assessments, documentation, and care planning for IV lines were not performed according to facility policy and physician orders. The Director of Nursing (DON), Assistant Director of Nursing (ADON), and other nursing staff acknowledged these deficiencies during interviews and record reviews. The failures were observed across multiple residents and types of IV access, including PICC lines, midlines, and PIVs.
Facility Assessment Lacks Required Input and Staffing Plans
Penalty
Summary
The facility failed to ensure its Facility Assessment was developed with the active involvement of required individuals, including direct care staff, direct care representatives, residents, residents' representatives, and family members. The assessment did not document participation from these groups, as verified by the Administrator during an interview and document review. Additionally, the assessment did not address the resources necessary to care for residents during weekends, nor did it include a plan to maximize recruitment and retention of direct care staff or a contingency plan for staffing needs. The deficiency was identified through a review of the Facility Assessment and confirmed by the Administrator, who acknowledged that the assessment was not updated to reflect the latest CMS guidance. The lack of comprehensive input and planning in the assessment process had the potential to result in unmet care needs for residents, particularly if the facility's population needs and available resources were not fully identified and addressed.
Failure to Maintain Safe and Homelike Resident Rooms
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment in three resident rooms. In Room A, a vent cover was found with rust and a black substance around it, and a hole approximately one inch in diameter was observed on the ceiling above a resident's bed. In Room C, the footboard of a resident's bed had ripped corners, exposing the inner cardboard surface. In Room B, the footboards of three residents' beds were also found with ripped corners, exposing the inner cardboard. These conditions were confirmed by the Maintenance Director and the Infection Preventionist during observations and interviews.
Incomplete Medical Records and Personal Effects Inventories
Penalty
Summary
The facility failed to ensure that medical records and inventories of personal effects for four residents were accurate and complete, as required by facility policy and accepted professional standards. Specifically, for three residents, the Inventory of Personal Effects forms were not reviewed with or signed by the residents' representatives upon admission, with signature sections left blank and undated on multiple occasions. The Director of Nursing (DON) confirmed that these inventories were completed by CNAs at admission but acknowledged that the forms should have been fully completed to account for all personal belongings. Additionally, two residents had incomplete Physician Orders for Life-Sustaining Treatment (POLST) forms. The missing information included the physician's telephone number, license number, and the resident's or responsible party's signature, address, and phone number, as well as the date the POLST was completed. The DON verified these omissions and stated that the POLST forms were completed by RNs at admission and followed up by social services staff, but should have been fully filled out as they contain relevant medical information.
Failure to Report Resident-to-Resident Abuse
Penalty
Summary
The facility failed to adhere to its policy and procedure for reporting suspected abuse, neglect, or theft, as required by section 1150B. Specifically, the facility did not report an allegation of resident-to-resident abuse involving Resident 5 to the California Department of Public Health (CDPH), Licensing and Certification (L&C) Program, or the local ombudsman. This oversight resulted in the abuse allegation going unreported and uninvestigated. Resident 5, who was admitted to the facility with the capacity to understand and make decisions, was documented as being verbally abusive and threatening towards their roommate on 7/31/24. The situation was brought to the attention of the facility's Administrator, who contacted the physician but failed to report the incident to the appropriate authorities. Interviews with the Director of Nursing (DON) and the Administrator confirmed that the required reporting did not occur.
Failure to Investigate Resident-to-Resident Abuse
Penalty
Summary
The facility failed to implement its abuse policy and procedure (P&P) related to the investigation of resident-to-resident abuse for one of the sampled residents. Specifically, the facility did not conduct a thorough investigation when Resident 5 was reported to be verbally abusive to their roommate. This incident was documented in a progress note by the Social Services Director (SSD), indicating that Resident 5 was threatening the roommate throughout the night, causing the roommate to feel scared. Although the Administrator was made aware of the situation and contacted the physician, no investigation was initiated. Interviews with the Director of Nursing (DON) and the Administrator confirmed that the facility did not investigate the abuse allegation, which was a requirement according to the facility's P&P revised in September 2022.
Failure to Obtain Informed Consent and Provide Non-Pharmacological Interventions
Penalty
Summary
The facility failed to ensure that a resident was free from unnecessary psychotropic medications. Specifically, the facility did not obtain informed consent from the resident or their surrogate decision maker for the use of lorazepam and for an increase in the dosage of citalopram. The resident was on a regimen of buspirone, citalopram, and quetiapine, with lorazepam prescribed as needed. However, there was no documentation of informed consent for the increased dosage of citalopram or the renewed order for lorazepam. Additionally, the facility did not provide or document non-pharmacological interventions for the resident's use of psychotropic medications, as required by the facility's policy. Interviews with the LVN and DON confirmed the absence of informed consent and non-pharmacological interventions. These deficiencies were acknowledged by the facility's administrator.
Failure to Adhere to Resident's Food Allergy Leads to Adverse Reaction
Penalty
Summary
The facility failed to ensure that Resident 4's food allergies were considered and adhered to, resulting in the resident being served food containing fish, to which they were allergic. This incident occurred despite the facility's policy and procedure for tray identification, which mandates the use of appropriate identification to ensure correct diets are served. The dietary services supervisor (DSS) had changed the menu from grilled chicken to breaded fish due to a vendor issue, and this change was communicated to the nursing staff. However, the nursing staff relied on the dinner slip, which incorrectly listed grilled chicken, leading to the resident being served fish. Resident 4, who had a documented allergy to fish, experienced an allergic reaction after consuming the fish sandwich. The resident's medical records and care plan clearly indicated the allergy, and the resident was capable of understanding and making decisions. After taking a bite of the sandwich, the resident experienced symptoms of an allergic reaction, including difficulty breathing and a heavy feeling in the throat. The resident was subsequently transferred to an acute care hospital for treatment. Interviews with facility staff, including the DSS, RN, and DON, revealed that the process for checking meal trays involved comparing the meal ticket with the diet list and visually inspecting the tray. However, the fish was shredded and mixed with other ingredients, making it difficult to identify visually. The failure to correctly identify the sandwich protein as fish, despite the documented allergy, led to the adverse reaction experienced by Resident 4.
Sanitation Deficiencies in Shared Bathroom and Laundry Bin
Penalty
Summary
The facility failed to maintain sanitary environmental conditions, as evidenced by observations in a shared toilet/bathroom and a dirty laundry collection bin. In the shared bathroom for Rooms A and B, several used washcloths were found by the sink, on top of the paper towel dispenser, and hanging on the toilet seat lid. Additionally, a yellow and pink pitcher without a label was observed by the sink. RN 3 acknowledged that the used washcloths should have been collected by the CNA and placed in the dirty linen, and the pitcher should have been labeled and not left in the bathroom. These items posed a risk of being accidentally used by another resident. Furthermore, a dirty laundry collection rolling bin was observed with a brown residue on the top corner, which was touched multiple times with bare hands by a CNA while pushing the bin. The CNA speculated that the residue could be a bowel movement stain from dirty linen and acknowledged that the bin should have been cleaned and gloves should have been worn to prevent the spread of infection. The DON confirmed that the bin should have been cleaned and gloves should have been used to maintain hygiene and prevent infection spread.
Failure to Provide Timely Care and Conduct Required Assessments
Penalty
Summary
The facility failed to provide necessary care and services for two residents, leading to deficiencies in their treatment and well-being. Resident 2 experienced multiple falls, and the facility did not conduct timely assessments or update the care plan to reflect these incidents. On 12/24/24, Resident 2 fell from a wheelchair due to a slipping seat cushion, and although neuro checks were recommended, there was no evidence of a comprehensive assessment or notification to the physician and resident's representative. Another fall occurred on 12/26/24, but the facility did not document the incident properly or update the care plan, as confirmed by the Director of Nursing (DON) and Licensed Vocational Nurse (LVN) 1. Additionally, the facility failed to perform ordered laboratory tests for Resident 2. On 12/24/24, a physician ordered a CBC, CMP, and UA with culture due to a change in condition, but there was no documentation that these tests were completed. The DON was unable to provide evidence that the tests were conducted, indicating a lapse in following physician orders and ensuring necessary diagnostic evaluations. Resident 1 also suffered from inadequate care following an unwitnessed fall on 11/23/24. Despite a physician's order for neuro checks every shift for 72 hours post-fall, there was no documented evidence that these checks were performed. The fall resulted in skin tears, and the resident was sent to an acute care hospital for evaluation. Upon return, the facility did not conduct the required neuro checks, as verified by LVN 2 and the DON. This oversight in monitoring and documentation highlights a failure to adhere to post-fall protocols and ensure resident safety.
Failure to Document Appropriate Diagnoses for Psychotropic Medications
Penalty
Summary
The facility failed to ensure that two residents were free from unnecessary psychotropic drugs. Resident 1, diagnosed with dementia, was prescribed lorazepam PRN for anxiety manifested by restlessness without a documented diagnosis of anxiety prior to the medication's initiation. The physician's orders for lorazepam were continuously renewed beyond the standard 14-day period without documented evaluation or rationale from the prescribing practitioner. Observations revealed that Resident 1 was often asleep for extended periods after medication administration, and staff noted the resident's high fall risk and aggressive behavior. Resident 8, also diagnosed with dementia, was prescribed risperidone for psychosis manifested by inconsolable episodes of calling out, despite lacking a documented diagnosis of psychosis prior to the medication's initiation. The facility's records did not provide evidence of a diagnosis of psychosis, and staff were unable to clarify the origin of this diagnosis. Observations indicated that Resident 8 was a fall risk and exhibited wandering and aggressive behavior. The facility's failure to document appropriate diagnoses and evaluations for the use of psychotropic medications placed the residents at risk for receiving unnecessary medications and potential adverse reactions. The lack of documented clinical rationale for extending PRN orders beyond 14 days and the absence of proper diagnoses for the prescribed medications were significant deficiencies identified during the survey.
Failure to Administer and Document Medications
Penalty
Summary
The facility failed to administer necessary medications to a resident as per the physician's orders, which included Senna, enoxaparin, acetaminophen, gabapentin, and nystatin suspension. These medications were not given on a specific date, and there was no documentation in the Medication Administration Record (MAR) to indicate if they were withheld for any reason. The resident, who had an intact cognition with a BIMS score of 14, reported not receiving the enoxaparin injection and other pain medications, which led to increased pain levels, requiring stronger pain medication. Interviews with the Director of Nursing (DON) and Licensed Vocational Nurses (LVNs) revealed that the medications were not documented as administered in the MAR. LVN 3 mentioned time constraints as a possible reason for the lack of documentation, while LVN 4 confirmed that there was no report of the resident refusing the medication. The DON acknowledged the failure to document the administration of medications, which was expected to be done as per the facility's policy and procedures.
Failure to Monitor and Communicate Resident's Condition
Penalty
Summary
The facility failed to provide necessary care and services to ensure a resident attained and maintained the highest practicable physical well-being. The deficiency involved a resident who was admitted and later readmitted to the facility, and subsequently transferred to an acute care hospital. On a specific date, a family member reported the resident had a productive cough and appeared slightly weak. The following day, the resident's poor meal intake was noted, and several medications were refused by the resident. Despite these observations, there was no care plan initiated for the change in condition, and the resident was not monitored every shift as expected. Additionally, the resident's oxygen saturation level was recorded at a critically low 81%, but this information was not communicated to the charge nurse by the CNA who took the measurement. The charge nurse only became aware of the resident's deteriorating condition when the resident was found unresponsive with abnormal vital signs, prompting a call to emergency services. Interviews with the LVN and CNA involved confirmed the lack of communication and monitoring, and the DON acknowledged the expectation for monitoring and documentation of the resident's condition every shift for at least 72 hours.
Failure to Prevent and Manage Pressure Ulcers
Penalty
Summary
The facility failed to provide necessary care and services to prevent the development of new pressure injuries and promote healing of existing pressure ulcers for two residents. Resident 8 was not turned and repositioned at least every two hours as per the facility's policy and plan of care. Observations on multiple occasions showed Resident 8 lying on her right side for extended periods, contrary to the facility's turning schedule. Interviews with staff confirmed the lack of adherence to the turning schedule, which posed a risk for the development of new pressure ulcers and worsening of existing ones. For Resident 11, the facility failed to conduct weekly assessments of a pressure ulcer on the coccyx, which was initially a Stage 2 ulcer upon admission. The medical record review revealed a lack of a care plan for managing the resident's pressure ulcers, and no assessments were documented between 9/19/24 and 10/11/24. When the ulcer was finally assessed, it had worsened, with the stage being undetermined and significant slough present. Interviews with staff confirmed the lack of timely assessments and the absence of a care plan, which hindered proper intervention for the resident's pressure ulcers.
Infection Control Lapses in EBP for Resident
Penalty
Summary
The facility failed to adhere to its infection prevention and control program, specifically regarding Enhanced Barrier Precautions (EBP) for Resident 9. Staff members, including LVN 4 and a wound consultant, did not wear disposable gowns while performing wound care on Resident 9, despite the presence of an EBP sign indicating the requirement for gown and glove use during high-contact care activities. This oversight was confirmed through interviews with the involved staff and the Infection Preventionist (IP), who acknowledged the lapse in following the facility's policy. Additionally, during a wound treatment observation, LVN 5 and CNA 2 did not wear gowns while providing care to Resident 9, who was on EBP. LVN 5 also failed to perform hand hygiene between glove changes during the wound care process. Furthermore, LVN 5 returned unused gauze and a bottle of normal saline to the treatment cart without proper disposal, acknowledging the mistake in an interview. These actions were contrary to the facility's infection control policies and had the potential to contribute to the spread of infections within the facility.
Delayed Response to Call Light for Resident
Penalty
Summary
The facility failed to accommodate the needs of Resident 12, who was part of a sample of 12 residents. Resident 12, who has intact cognition and a limitation in the range of motion on one side of both upper and lower extremities, was observed to have their call light blinking outside Room C for an extended period. Despite the call light being on, RN 1 passed by the room twice without responding, as he was heading to another station. The call light was eventually answered by the Activity Director, who found that Resident 12 needed assistance to mark her clothes. This delay in responding to the call light had the potential to prevent the resident from having her needs met in a timely manner.
Incomplete and Inaccurate Medical Records for Resident
Penalty
Summary
The facility failed to maintain complete and accurate medical records for a resident, which could negatively impact the delivery of services. The resident's Medication Administration Record (MAR) for September 2024 indicated that oxygen saturation should be checked each shift. However, on the evening shift of September 28, 2024, the recorded oxygen saturation level was 76%, while it should have been documented as 96% according to the Licensed Vocational Nurse (LVN) interviewed. Additionally, discrepancies were found in the documentation of oxygen administration. The Interact SNF/NF to Hospital Transfer Form indicated the resident was provided with oxygen at 4 LPM, while a late entry nurse's note stated the resident received high flow oxygen at 15 LPM via a non-rebreather mask. There was no physician's order for either 4 LPM or 15 LPM oxygen administration. Furthermore, the facility failed to properly document the resident's advance directives. The resident's POLST form dated June 14, 2024, indicated verbal consent was obtained from a family member but lacked the signature of the resident or a legally recognized decision maker. The POLST form from October 6, 2023, marked no advance directives, and the resident's medical record did not contain any advance directive documentation. Interviews with the LVN, Medical Records Director, and Social Worker confirmed the absence of advance directives in the resident's electronic and paper medical records. The Social Worker noted that the POLST from October 6, 2023, should have been carried forward upon the resident's readmission.
Failure to Report Alleged Abuse to Authorities
Penalty
Summary
The facility failed to implement its policy and procedure for reporting a reasonable suspicion of a crime, as required by section 1150B of the Act. This deficiency occurred when the facility did not report an allegation of staff-to-resident abuse involving a certified nursing assistant (CNA) and a resident with moderate cognitive impairment. The incident was initially reported by the Activity Director and a family member to the Director of Nursing (DON) and the Administrator, but no report was made to the California Department of Public Health Licensing and Certification Program, law enforcement, or the Ombudsman office. The alleged abuse was also not documented by the facility. The resident involved, who had a diagnosis of hemiplegia and hemiparesis affecting the right side, expressed fear and distress when recounting the incident. The resident indicated that a male staff member had been abusive, which was corroborated by the family member who identified the CNA when the resident showed signs of fear upon the CNA's presence. Despite these reports, the facility's management acknowledged that the incident was not reported to the appropriate authorities, as required by their policy and federal regulations.
Failure to Conduct Comprehensive Abuse Investigation
Penalty
Summary
The facility failed to implement its abuse policy and procedure (P&P) related to the investigation of physical abuse for one of the sampled residents. The facility's P&P, revised in November 2017, requires a thorough investigation involving interviews with the person(s) reporting the incident, any witnesses, the resident, staff members from different shifts, the resident's roommate if appropriate, family members, and other residents to whom the accused employee provides care. Additionally, the findings of the investigation must be reported to the appropriate agencies within five working days. However, in this case, the facility did not conduct a comprehensive investigation as required. The deficiency involved a resident who was admitted with a diagnosis of hemiplegia and hemiparesis affecting the right dominant side. An anonymous complainant alleged that a Certified Nursing Assistant (CNA) abused the resident. The incident was reported to the Administrator and Director of Nursing (DON) by a family member and the Activity Director. Despite this, the DON confirmed that only the alleged perpetrator, CNA 1, was interviewed, and the alleged abuse was not documented. This failure to conduct a thorough investigation posed a risk for potential abuse to remain unidentified and for residents to go unprotected.
Failure to Provide Adequate Foot Care and Monitoring
Penalty
Summary
The facility failed to provide necessary foot care services for a resident with severe cognitive impairment and Type 2 Diabetes Mellitus, who was at risk for altered skin integrity. The resident had received podiatry care for a fungal infection, which included debridement and nail trimming. However, the facility did not ensure proper skin checks, accurate assessments, or monitoring of the resident's feet following the podiatry care. There was no documentation of a care plan addressing the fungal infection or monitoring of the debridement site and pain assessment. On a subsequent date, a change in the resident's condition was observed, including swelling, redness, and minimal drainage of the right foot and second toe. This change was reported by a CNA, and the resident was transferred to an acute care hospital as ordered by the physician. During an interview, the DON confirmed the absence of documentation for monitoring, assessment, and care planning related to the resident's foot care following the podiatry procedure.
Failure to Implement Non-Pharmacological Interventions for Psychotropic Medication Use
Penalty
Summary
The facility failed to provide non-pharmacological interventions for a resident who was prescribed Lexapro, a psychotropic medication, for depression characterized by tearful episodes. Despite the facility's policy, which emphasizes minimizing medication use through non-pharmacological approaches, there was no documented evidence of such interventions being implemented for the resident. The resident's medical records showed multiple episodes of tearfulness across various shifts in August and September, yet no non-pharmacological strategies were recorded or included in the care plan. During an interview and medical record review, the Director of Nursing (DON) confirmed that the resident was monitored for side effects and tearfulness but acknowledged the absence of documentation for non-pharmacological interventions. The care plan also lacked any mention of non-pharmacological measures related to the use of Lexapro. This oversight had the potential to lead to adverse complications for the resident due to the continued reliance on medication without exploring alternative interventions.
Failure to Prevent and Manage Pressure Injuries
Penalty
Summary
The facility failed to provide necessary care and services to prevent the development or worsening of pressure injuries for three residents. Resident 2's pressure injuries were not measured and assessed weekly, and no pictures were taken as per the facility's protocol. Resident 2 had multiple infected wounds, including a Stage 4 pressure injury to the sacrum and right lateral knee, and unstageable pressure injuries to various parts of the body. Despite receiving daily wound treatments, there was no documented evidence of weekly wound assessments, including measurements and photos, between 7/22/24 and 9/2/24. Additionally, the facility did not properly adjust the low air loss mattresses for Residents 2, 4, and 5 according to their weights, as required by the facility's policy. Resident 2's mattress was set at levels 8-9, which was too firm for their weight of 166-173 lbs, potentially increasing pressure on the sacral area. Similarly, Resident 4's mattress was set at levels 7-8, which was appropriate for a person weighing 250 lbs, while Resident 4 weighed 182.1 lbs. Resident 5's mattress was also set at levels 7-8, despite their weight being 160-165.4 lbs, and a label on the control panel indicated the correct setting should have been 5-6. These failures posed a risk for the residents to develop new pressure injuries or for existing injuries to worsen. The facility's Director of Nursing (DON) was informed and verified the findings, acknowledging the discrepancies in mattress settings and the lack of documented weekly wound assessments for Resident 2.
Infection Control Lapses in Wound Care and Resident Handling
Penalty
Summary
The facility failed to implement and maintain its infection control program for two of six sampled residents, as evidenced by several lapses in following Enhanced Barrier Precautions (EBP) during wound care and resident handling. Licensed Vocational Nurse (LVN) 1 did not wear a disposable gown as required by EBP when performing wound care on Resident 2, who had multiple infected wounds. Additionally, LVN 1 failed to establish a clean field for wound care supplies, placing them directly on Resident 2's bed, which is against the facility's policy. LVN 1 acknowledged these oversights, citing an allergy to gowns as a reason for non-compliance, although no allergic reaction was observed during the procedure. LVN 3 also failed to adhere to EBP by not wearing a disposable gown while performing wound care on Resident 2, despite the presence of EBP signage indicating the necessity of gown and glove use. LVN 3 admitted to placing wound care supplies on the bed instead of using the overbed table, which was occupied by Resident 2's personal items. This practice contradicts the facility's policy, which requires the use of a clean field for wound care supplies to prevent cross-contamination. Certified Nursing Assistant (CNA) 1, along with a student, did not wear disposable gowns while transferring Resident 6, who was on EBP due to an indwelling urinary catheter and wounds. The Infection Preventionist (IP) confirmed that staff should wear gowns during high-contact activities such as transferring residents on EBP. These failures in following infection control protocols pose a risk of spreading disease-causing microorganisms and infections among residents.
Latest citations in California
Two residents with dementia, schizoaffective disorder, and major depressive disorder, both with moderately impaired cognition and needing moderate ADL assistance, were found unclothed together in one resident's bed. One resident later stated she did not want sexual activity and did not consent, while the other resident could not recall the encounter. An LVN reported that both residents verbally consented at the time but acknowledged no assessment had been done to determine their capacity to consent to sexual activity. The DON identified the incident as sexual abuse and confirmed that allowing sexual activity without prior capacity assessment was inconsistent with facility policy and that the resident was not protected from sexual abuse.
Two residents with dementia, schizoaffective disorder, major depressive disorder, and moderately impaired cognition, both needing moderate assistance with ADLs, were found unclothed together in one resident’s bed. The resident later stated she did not consent to sexual contact, while the other resident did not recall any sexual activity. An LVN documented the incident and acknowledged it constituted sexual abuse that should have been reported immediately to the abuse coordinator and appropriate agencies, but did not report it. The administrator, who serves as the abuse coordinator, stated she relies on staff to notify her immediately of such allegations so they can be reported to CDPH, law enforcement, and the Ombudsman, but this did not occur, resulting in the allegation not being reported as required.
A resident with Parkinson’s disease, osteoporosis, and osteoarthritis reported being punched in the face by another resident, resulting in facial bruising. The resident’s MDS showed intact cognition, and a change in condition evaluation documented the assault; however, the MD was not notified until more than a day later. The care plan directed licensed nurses to assess the resident’s body, and staff observed a purplish bruise on the right lower eyelid/orbital area, but this was not documented in the progress notes. Required every-shift monitoring for 72 hours after the change in condition was not documented on multiple day shifts. The DON confirmed lack of awareness of the bruise and acknowledged missing documentation and monitoring, despite facility policies requiring immediate provider notification and complete, accurate charting of changes in condition.
A nurse left a medication cart unlocked and unattended in the hallway while administering insulin to a resident with diabetes, cardiac, and post-surgical conditions. The cart was out of the nurse's direct line of sight, contrary to facility policy requiring medication carts to be locked when not in use. The DON confirmed that medications should be secured to prevent unauthorized access.
A resident’s legal representative requested copies of the resident’s medical records through a faxed request from a law office’s third-party service, but the records were not provided within the required timeframe. The MRD confirmed receiving the request and stated he had forwarded the documents to the DON for review over a month earlier and had not received them back to release. Upon review of federal requirements for record access, the ADON acknowledged that the facility did not comply with the regulation requiring provision of copies within two working days of request.
Two CNAs violated privacy and confidentiality requirements when one CNA used a personal cell phone to record and photograph two residents during a perceived altercation and then sent the video to another CNA. The residents, who had significant medical conditions including paraplegia, seizures, dysphagia, and severe cognitive impairment, were dependent on staff for ADLs. The second CNA reported that a family member later took her phone without permission, accessed the contents, and transmitted the videos and photos to facility leadership. Facility staff, including an LVN, the DSD, and the administrator, stated that HIPAA rules and facility policies prohibit staff from recording residents on personal devices and allow resident photographs only with consent and for medical purposes as part of the chart, and that the facility’s "Stop and Watch" process requires observation and reporting, not filming.
A resident with a stage 4 sacrococcygeal PI, Parkinson’s disease, hypertension, moderate cognitive impairment, and high assistance needs was not provided care consistent with the facility’s pressure injury prevention policy. Although the care plan included daily wound treatment and use of a LAL mattress, it lacked an individualized repositioning schedule and did not document education or reminders about repositioning. Facility documentation showed only that the resident was assisted to roll each shift, with no evidence of q2h turning in bed or of how often incontinence briefs were checked and changed. After the resident refused Foley catheter reinsertion, the IDT did not identify incontinence as a risk factor or add new wound-protective or moisture-preventive interventions, and the subsequent care plan for non-compliance omitted such measures. The TXN and DON confirmed that repositioning and protection of the wound from incontinence were not clearly implemented or reflected in the care plan, despite policy requirements.
A resident with Parkinson’s disease, cognitive impairment, and significant assistance needs for mobility and toileting experienced two early-morning falls resulting in head injuries. After the first fall, the IDT documented potential interventions such as a bed alarm and floor mat but did not identify the cause of the fall, did not obtain a physician order for the floor mat, and did not ensure the care plan addressed supervision or bed alarm function. Before and after the falls, the care plan lacked interventions for supervision despite poor safety awareness and failure to use the call light, and the second fall occurred when the resident slid from bed while reaching for a snack bag placed on the bedside table. IDT follow-up documentation for the second fall was incomplete, and staff acknowledged that fall causes were not identified and resident-centered interventions were not fully implemented.
A resident with severe cognitive impairment and multiple neurological diagnoses was dependent on staff for hygiene and mobility. During an IDT meeting, the resident’s family member communicated specific care preferences, but facility staff did not develop or update a comprehensive person-centered care plan to include these preferences. Review of care plans over several months showed no documentation of the communicated preferences, despite facility policy requiring the IDT to create a measurable, time-framed care plan based on assessed needs and expressed preferences.
A resident with COPD and severely impaired cognition, dependent on staff for all ADLs and mobility, had a physician order for continuous supplemental O2 at a fixed rate of 2 L/min. During observations, the resident was found receiving O2 at 3 L/min. An LVN recognized the discrepancy and reported it to an RN supervisor, but there was no documentation of any clinical rationale for the increased flow, no physician notification, and no order change. The care plan directed staff to administer O2 as ordered, and facility policy required verification of the order, documentation of flow rate and rationale, and appropriate reporting, which were not followed.
Failure to Protect Cognitively Impaired Resident From Sexual Abuse
Penalty
Summary
The facility failed to ensure a resident was free from sexual abuse when two cognitively impaired residents were found unclothed together in one resident's bed without prior assessment of their capacity to consent to sexual activity. One resident had dementia, schizoaffective disorder, and major depressive disorder, with documentation of fluctuating capacity to understand and make decisions and a Minimum Data Set (MDS) indicating moderately impaired cognition and a need for moderate assistance with ADLs. During an interview at her bedside, this resident stated she did not want to engage in sexual activity and did not consent to sexual contact with the other resident. The second resident involved also had dementia, schizoaffective disorder, and major depressive disorder, with an MDS showing moderately impaired cognition and a need for moderate assistance with ADLs. In an interview, he stated he liked women and liked to socialize with women but could not recall whether he engaged in sexual activity with the first resident. An LVN reported observing both residents unclothed in the first resident's bed and stated that, at the time of the incident, both residents verbally consented to sexual activity, but she was not aware of any assessment having been performed to determine either resident's capacity to consent. The DON stated the incident was considered sexual abuse, that it was not the facility's practice to allow sexual activity without appropriate assessment, and that the facility failed to ensure the resident was protected from sexual abuse, contrary to the facility's abuse prevention policy.
Failure to Report Alleged Sexual Abuse Between Cognitively Impaired Residents
Penalty
Summary
The deficiency involves the facility’s failure to report an allegation of sexual abuse between two residents to the State Survey Agency, Ombudsman, and local law enforcement as required by federal regulations and the facility’s own abuse reporting policy. A nurse documented that one resident (Resident 2) and another resident (Resident 4) were found unclothed together in Resident 2’s bed, and the nurse acknowledged that this situation constituted sexual abuse and should have been reported immediately to the abuse coordinator and appropriate agencies, but she did not report the incident. The facility’s policy stated that all staff are mandated reporters and must notify appropriate authorities within two hours of becoming aware of abuse and immediately notify the Abuse Prevention Coordinator and their supervisor. Resident 2 had dementia, schizoaffective disorder, major depressive disorder, fluctuating capacity to understand and make decisions, and moderately impaired cognition, and required moderate assistance with ADLs. During an interview at her bedside, Resident 2 stated she did not consent to sexual contact with Resident 4. Resident 4 also had dementia, schizoaffective disorder, major depressive disorder, moderately impaired cognition, and required moderate assistance with ADLs, and stated he did not recall engaging in sexual activity with any residents. The Administrator, who served as the abuse coordinator, stated she was responsible for reporting all abuse allegations to CDPH, law enforcement, and the Ombudsman, and that staff were responsible for notifying her immediately of sexual abuse allegations so they could be reported and investigated. The failure of staff to notify the Administrator and report the incident resulted in the sexual abuse allegation not being reported as required, causing a delay in an onsite investigation by CDPH.
Failure to Assess, Notify, and Monitor Resident After Facial Trauma
Penalty
Summary
The deficiency involves the facility’s failure to follow professional standards of nursing practice in assessing and monitoring a resident after a reported change of condition related to facial trauma. The resident was admitted with Parkinson’s disease, age-related osteoporosis, and osteoarthritis, and had intact cognitive skills for daily decision-making per a recent MDS. On the evening of 3/26/2026, a Change in Condition Evaluation documented that another resident hit this resident on the nose and both cheeks. The evaluation showed that the attending physician was not notified until 10 p.m. on 3/27/2026, approximately 26.5 hours after the reported incident, and the physician’s recommendation was to monitor the resident’s nose and cheeks for any changes and pain. The resident’s care plan, initiated on 3/26/2026, documented the report that another resident hit him on the nose and both cheeks and included an intervention for licensed nurses to check and assess the resident’s body. In an interview, the resident described that the other resident came into the room, stood on the left side of the bed, and punched him in the face. A photograph taken two days after the alleged incident showed a purplish-blue bruise on the right lower orbital area, although the resident declined to provide a copy of the picture. A CNA later reported observing a purple bruise on the resident’s right lower eyelid on 3/27/2026, described as extending from the inner to the middle lower eyelid and about the size of the tip of her fifth digit. During record review and interviews, an LVN stated that on 3/27/2026 the resident’s right lower eyelid had a dime-sized purplish bruise, but there was no documentation of this bruise in the progress notes. The LVN also stated that the resident should have been monitored every shift for 72 hours after the change of condition, yet there was no documented evidence of monitoring on the 7 a.m. to 3 p.m. shifts on 3/27/2026, 3/28/2026, and 3/29/2026. The DON reported not being made aware of the right eyelid bruise, confirmed that the resident should have been monitored every shift for at least 72 hours following the change of condition, and acknowledged there was no confirmed documentation of monitoring on the identified shifts. Facility policies required immediate physician consultation for significant changes in condition and complete, accurate documentation of changes and services provided, but the facility failed to identify, document, and monitor the resident’s change of condition in accordance with these policies.
Plan Of Correction
Facility Response Submission of the Plan of Correction does not constitute admission or agreement by the Provider of the truth of the facts alleged or conclusion set forth in this statement of deficiencies. The Plan of Correction is prepared and/or executed solely because it is required by the provision of Federal and State laws. This Plan of Correction constitutes the facility's credible allegation of compliance Corrective Action On 4/7/2026 Resident 1 was reassessed by LVN 3 and no skin issue was identified. On 4/7/2026 LVN 3 received one-on-one in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. Identification of other residents and corrective action On 4/8/2026 DON and/or designee reviewed audits provided by medical records for all change of condition in month of April to ensure proper documentation and monitoring are in place. No other deficient practice noted. Measures to prevent recurrence On 4/7/2026 LVN 3 received one-on-one in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. On 4/8/2026 Licensed nurses received in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. Monitoring and incorporation into the QA system HID will audit change of conditions using Change of Condition Audit form daily Monday-Friday and will report any finding during daily stand-up meeting Monday-Friday on-going. DON or designee will review change of conditions from prior day during daily clinical meetings (Monday -Friday) on going to ensure the nurse notified the attending physician regarding resident's significant change of condition and documented. Any deficient finding will be reported to DON and/or administrator for further corrective action/recommendation. Any trend of deficient finding(s) will be documented on Change of Condition Audit Form and will be reviewed during the monthly QA meeting for further review and/or recommendation(s). Administrator who will then report to the Quality Assurance (QA) team during monthly Quality Assurance (QA)/Quality Assurance and Performance Improvement (QAPI) for further evaluation/recommendation and to provide feedback and program modification if needed x3 months or until compliant. Date Corrective action to be completed: 4/8/2026
Medication Cart Left Unlocked During Medication Pass
Penalty
Summary
During a medication pass for a resident with a history of surgical aftercare, cardiac arrest, heart failure, and type 2 diabetes mellitus, a licensed nurse prepared and administered Novolog insulin using a pen-injector. The nurse left the medication cart unlocked and unattended in the hallway, approximately two feet outside the resident's bedroom doorway, while administering the injection inside the room. The cart was out of the nurse's direct line of sight during this time. The nurse acknowledged that the cart was left unlocked and should have been secured when not in direct view. Facility policy and procedure documents reviewed indicated that medication carts must be kept closed and locked when out of sight of the medication nurse or aide, and that compartments containing drugs and biologicals are to be locked when not in use. The Director of Nursing confirmed that medications should be locked and secured to prevent unauthorized access by unlicensed staff and residents. The failure to lock the medication cart during the medication pass was observed and confirmed through interviews and record review.
Plan Of Correction
From 4/4/2025 through 4/7/2025, the DON, DSD, and ADSD completed 1:1 inservices with licensed staff regarding the facility policy and procedure titled Storage of Medications. Medication carts must be kept locked when unattended. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 3 times a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 2 times a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 1 time a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will random monitor medication carts being locked when unattended for 1 month. System effectiveness will be evaluated during the facility's monthly Quality Assurance Performance Improvement Committee meetings for three (3) months.
Failure to Timely Provide Resident Medical Records Upon Request
Penalty
Summary
The facility failed to provide timely access to medical records as required under 42 CFR 483.10(g)(2) for one resident. The resident’s face sheet showed an admission date of November 18, 2025, with multiple diagnoses, but no additional clinical details were provided. A legal representative’s office faxed an initial request for the resident’s medical records on February 26, 2026. As of March 26, 2026, the legal representative’s staff reported that the office had not yet received the requested records from the facility. On April 2, 2026, the Medical Record Director (MRD) confirmed documentation that a third-party service for the law office had requested the resident’s medical records on February 26, 2026. The MRD stated he had submitted the requested documents to the Director of Nursing (DON) for review over a month prior but had not received them back to proceed with releasing the records. During a concurrent interview and record review, the Assistant Director of Nursing (ADON) reviewed the State Operations Manual Appendix PP guidance on residents’ rights to access personal and medical records, which requires that copies be provided within two working days of request. The ADON acknowledged that this regulatory requirement was not followed by the facility.
Plan Of Correction
F0573 Right to Access/Purchase Copies of Records What corrective action(s) will be accomplished for those Residents found to have been affected by the deficient practice? Medical Records Director (MRD) released medical records for Resident 1 as requested by the legal representative (Legal Staff) on April 21, 2026. How will other individuals with the potential to be affected by this deficient practice be identified and protected? No other Resident was identified to have been effected by the deficient practice. What systemic changes will be implemented to ensure that the deficient practice does not recur? The Quality Assurance Committee met on April 14, 2026 to review the Policy and Procedure which was then forwarded to the Knolls West Post Acute legal team for further evaluation. Revision of the policy will be discussed and approved by the Quality Assurance Committee to ensure the facility meets all Federal and State Regulations. F0573 Right to Access/Purchase Copies of Records (CONT.)The Administrator and the Medical Records Director (MRD) are responsible for informing the requesting party for the demand for payment for the requested medical documentation being provided and until payment is received the facility will hold the chart copies.How corrective action(s) will be monitored to ensure solutions are being achieved and sustainedThe Resident's Responsible Party will be notified upon receipt of the Medical Records Request and review in the presence of the facility representative. Records will be provided if it does not pertain to any legal matters after payment is received. The Administrator and/or Designee is responsible for reporting to the Quality Assurance Committee on a monthly basis and monitoring to ensure that corrective action is implemented and evaluated for its effectiveness. The same will be reviewed on a quarterly basis to the Quality Assurance Committee meeting x 3 quarters or until 100% compliance is achieved and sustained.Date of CompletionApril 23, 2026
Unauthorized Resident Recording and Disclosure Violating Privacy and Confidentiality
Penalty
Summary
The deficiency involves a failure to protect residents’ privacy and confidentiality when a CNA used a personal cell phone to record and photograph two residents without their knowledge or consent, and then shared that content with another CNA. One resident had paraplegia, depression, muscle weakness, dorsalgia, and polyneuropathy, was cognitively intact, and dependent on staff for ADLs. The other resident had diagnoses including seizures, dysphagia, acute kidney dysfunction, and muscle weakness, was able to make needs known but could not make medical decisions, had severely impaired decision-making, and was also dependent on staff for ADLs. Both residents were therefore in a position of dependence on staff for care at the time of the incident. According to CNA 2, on a specific date she recorded a video of the two residents because one resident started an altercation with the other. She stated she recorded the incident for “evidence” and to show CNA 1, acknowledging that recording residents was not part of facility policy and that she should not have recorded or taken photographs of them. CNA 1 confirmed that she received the video on her personal cell phone from CNA 2 and stated that the recording was made for “safety purposes” due to a situation that was perceived as potentially escalating to physical aggression. CNA 1 reported that she did not share or post the video on social media or distribute it to others, but that a family member took her phone without permission and accessed its contents. CNA 1 further stated that this family member sent the video and pictures of the two residents to the facility, and that she notified the facility that her phone had been taken but did not disclose that it contained videos or photographs of the residents because she was unaware that the family member had accessed or distributed them. The DSD reported receiving a text message from an unknown number containing approximately two videos and an undetermined number of photographs of the two residents, along with the names of CNA 1 and CNA 2. The DSD, LVN 2, and the Administrator each stated that staff were required to follow HIPAA regulations, that staff were not permitted to record or possess videos or photographs of residents on personal devices, and that any photographs of residents required consent and had to be for medical purposes as part of the medical record. Facility policies on confidentiality, residents’ rights, and dignity stated that unauthorized release, access, or disclosure of resident information, including video or audio, was prohibited and that staff must protect resident privacy and treat residents with dignity and respect. The videos received by the DSD did not show an altercation between the residents, and staff interviews confirmed that filming residents was not part of the facility’s “Stop and Watch” process, which instead required observation, intervention, and reporting of changes in condition or behaviors to nursing staff.
Plan Of Correction
This Plan of Correction is the facility's credible allegation of compliance. Preparation and/or execution of this plan of correction does not constitute admission or agreement by the provider of the truth or facts alleged, or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of federal and state law. F0583 Personal Privacy/Confidentiality of Records How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: Corrective actions were immediately implemented for Resident 1 and Resident 2 upon identification of the deficient practice. The facility initiated an investigation on 03/23/2026 and conducted immediate interviews with staff and residents utilizing structured interview tools to assess scope, impact, and additional potential concerns. Interviews confirmed the incident was isolated and no additional residents reported privacy violations or concerns. The staff members involved were removed from duty immediately. Following completion of the investigation, both employees were terminated in accordance with facility policy due to violation of resident rights, HIPAA, and facility confidentiality policies. Both employees completed formal Declarations and Attestations of Deletion of Unauthorized Recordings, confirming removal of all recordings and non-distribution of content. Documentation includes: Ashley Zelaya, CNA – Declaration executed 03/30/2026 at 9:21 AM, attesting deletion of all recordings and acknowledgment of policy violation Leslie Bram Reyes, CNA – Declaration executed 03/26/2026 at 10:42 AM, attesting deletion of all recordings and acknowledgment of policy violation Residents and/or responsible parties were notified. Social Services completed assessments with no identified psychosocial harm. All corrective actions were completed by 03/26/2026. How the facility identifies other residents having the potential to be affected by the same deficient practice and what corrective action will be taken. A facility-wide audit was initiated on 03/25/2026 using the Briarcrest Comprehensive Privacy, Recording, and Resident Rights Audit Tool. The audit included direct observation, staff interviews, and resident interviews to evaluate compliance with privacy practices, personal device use, and HIPAA requirements. Interviews were conducted using standardized staff and resident interview tools to ensure consistency and thoroughness in data collection. Findings from the audit confirmed that no additional residents were affected by the deficient practice and no additional incidents of unauthorized recording or disclosure were identified. Staff were immediately re-educated by Director and staff development on HIPAA Privacy Rule requirements, the facility's prohibition on personal device recordings, and the appropriate use of the Stop and Watch process for reporting changes in resident conditions. This corrective action was completed by 03/27/2026. What measures will be put into place or what systemic changes will the facility make to ensure that the deficient practice does not recur. The facility implemented systemic changes to prevent recurrence of the deficient practice by reinforcing a zero-tolerance policy for unauthorized recordings and strengthening staff accountability related to resident privacy and confidentiality. Staff completed mandatory re-training by the Director of Staff Development on Resident Rights, HIPAA, and Privacy/Confidentiality requirements. Staff were required to re-acknowledge facility policies related to confidentiality and personal device use. The facility implemented routine supervisory rounding to monitor compliance with personal device restrictions. In addition, the facility installed visible signage at the receptionist area clearly articulates that video recording is strictly prohibited inside resident rooms and in any facility areas where residents are present. The facility also posted signage throughout the entire facility, in both English and Spanish, indicating that video recording is not allowed to ensure clear communication to staff, visitors, and all individuals entering the facility. Privacy and HIPAA compliance were further integrated into new employee orientation, annual competencies, and ongoing in-service education. The Director of Staff Development completed initial re-education by 03/27/2026, and staff completed required training by 04/05/2026. How the facility plans to monitor its performance to make sure that solutions are sustained. To ensure sustained compliance, the facility incorporated privacy and confidentiality monitoring into its Quality Assurance and Performance Improvement (QAPI) program. The facility implemented an ongoing monitoring system beginning on 03/25/2026 utilizing the established audit tool, which confirmed that no additional residents were affected, and no further incidents occurred during the initial audit period. The facility will continue monitoring through weekly audits for four consecutive weeks, followed by monthly audits for three months. These audits will include direct observation of staff practices, verification of compliance with personal device policies, and evaluation of adherence to HIPAA and privacy requirements. Audit findings will be documented using standardized tools and reviewed by the Director of Nursing, with results reported to the Quality Assurance and Performance Improvement (QAPI) Committee for analysis and trending. If any issues are identified, immediate corrective action will be implemented, including re-education and progressive discipline as appropriate. If no trends or repeat deficiencies are identified after the monitoring period, the facility will discontinue routine auditing and remove the issue from active QAPI monitoring. Dates when corrective action will be completed. 4/17/2026
Failure to Implement Repositioning and Moisture Management for Stage 4 Pressure Injury
Penalty
Summary
The deficiency involves the facility’s failure to provide care and services to prevent deterioration of a stage 4 sacrococcygeal pressure injury in accordance with its own pressure injury prevention policy. The resident had a documented stage 4 PI of the sacral region, Parkinson’s disease, hypertension, moderate cognitive impairment, and required substantial/maximal assistance with toileting hygiene, rolling, and transfers. A Braden Scale score of 16 identified the resident as at risk for pressure injury. The Skilled Evaluation Nurse note indicated a pressure-reducing device for the bed but did not indicate that the resident was to be turned and repositioned every two hours. The resident’s care plan for the stage 4 sacrococcyx PI included cleansing with normal saline, applying Santyl ointment, and covering with dry and foam dressings daily, as well as providing pressure relief and a low air loss mattress to support body alignment and position. However, the care plan did not include an individualized repositioning schedule or education and reminders about the importance of repositioning. Documentation from the facility’s records showed that the resident was assisted to roll left and right every shift, but there was no documentation that the resident was turned and repositioned every two hours while in bed, nor was there documentation of the frequency of incontinence brief checks and changes after each episode. After the resident refused reinsertion of a Foley catheter, nursing progress notes documented the refusal but the IDT wound management conference record did not identify incontinence as a risk factor affecting healing of the stage 4 PI and did not document any new recommendations following the catheter refusal. A subsequent care plan addressing the resident’s potential for worsening condition related to non-compliance with Foley catheter reinsertion did not include wound protective measures or moisture-preventive interventions. During interviews, the treatment nurse acknowledged uncertainty about how often the resident was turned/repositioned or how frequently incontinence briefs were checked and changed, and confirmed that the care plan did not include measures to ensure turning at least every two hours or effective measures to protect the sacrococcyx PI. The DON stated that staff were supposed to ensure turning at least every two hours and protection of the wound dressing from incontinence, and that the IDT did not address this risk, so the care plan was not revised, despite facility policy requiring prompt cleaning after incontinence, use of barrier products, individualized repositioning schedules, and ongoing review of interventions for effectiveness.
Failure to Identify Fall Causes and Implement Supervision and Safety Interventions
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to keep the environment free from accident hazards and to provide adequate supervision and assistance devices to prevent accidents for a resident with significant fall risk. The resident had diagnoses including stage 4 sacral pressure ulcer, Parkinson’s disease, and hypertension, and was assessed as moderately cognitively impaired, with poor decision-making and a need for assistance with toileting, transfers, and ambulation. On one occasion, the resident was found on the floor at approximately 4:05 AM with a right forehead laceration requiring transfer to an acute care hospital for suturing. Following this first fall, the IDT Fall Management Follow-Up record listed interventions such as a medication regimen review, bed in lowest position, landing floor mat, and bed alarm, but there was no documented evidence identifying the cause of the fall. The resident’s care plan addressing strength and safety awareness deficits did not include supervision for safety despite poor safety awareness and not remembering to use the call light. The care plan for the actual fall with minor injury did not include ensuring that the bed alarm was functioning. Additionally, physician orders from 9/10/2025 to 1/29/2026 did not contain an order for a floor mat, despite this intervention being recommended in the IDT record. A second fall occurred at around 4:10 AM when the resident was again found on the floor next to the bed, holding a snack bag. The resident, described as alert but forgetful, stated that she had been trying to reach a snack bag on the bedside table and slid down from the bed, and redness was observed on the left side of the forehead after reportedly hitting the bedside table. The IDT Fall Management Follow-Up record for this second fall was incomplete, with no checked interventions. Interviews with the MDS nurse and DON confirmed that the IDT records should have identified the causes of the falls, that frequent monitoring and supervision were not care planned despite the resident’s cognitive impairment and poor safety awareness, and that the recommended floor mat was never ordered or applied, contrary to the facility’s own policies on assessing falls and developing comprehensive person-centered care plans.
Failure to Incorporate Resident Care Preferences Into Person-Centered Care Plan
Penalty
Summary
Surveyors identified a failure to develop a comprehensive person-centered care plan that incorporated a resident’s specific care preferences. The resident was readmitted on 8/31/2025 with multiple diagnoses, including metabolic encephalopathy, Alzheimer’s disease, blindness in the right eye, a history of TIA, and cerebral infarction without residual deficits. An MDS dated 10/30/2025 documented that the resident’s cognition was severely impaired and that the resident was dependent on staff for oral hygiene, toileting hygiene, personal hygiene, and movement. On 3/17/2026, the IDT met with a family member, who communicated specific care preferences for the resident. During interviews, the SSD and DSD confirmed that the family member had provided detailed care preferences at the 3/17/2026 IDT meeting, but a review of the resident’s care plans from 8/31/2025 to 3/31/2026 showed no documented care plan addressing those preferences. The DSD stated that a care plan should have been developed to reflect the resident’s care preferences, that it is the MDS nurse’s responsibility to develop the care plan, and that the absence of such a care plan could result in the preferences not being honored. The Administrator stated that the care plan is essential as it is used by staff as a guide to understand and implement the resident’s plan of care. The facility’s policy on Comprehensive Person-Centered Care Plans required the IDT to develop a comprehensive person-centered care plan with measurable objectives and time frames to meet identified needs, which was not done in this case.
Failure to Administer Oxygen Therapy as Ordered
Penalty
Summary
The deficiency involves the facility’s failure to administer oxygen therapy as ordered by the physician for a resident with COPD. The resident was admitted with chronic obstructive pulmonary disease and had severely impaired cognition, requiring total staff assistance for all ADLs and mobility. A physician’s order dated 3/27/2026 directed that the resident receive continuous supplemental oxygen at a fixed rate of 2 L/min, with no indication that staff could adjust the flow rate. The resident’s care plan for altered respiratory status related to COPD instructed staff to administer oxygen as ordered. On 3/31/2026, during observations at the bedside at 8:45 a.m. and 9:40 a.m., the resident was noted to be receiving oxygen at 3 L/min, which did not match the physician’s order. An LVN reported that the resident was on 3 L/min when he checked vital signs that morning and stated this was not the ordered rate; he said he reported this to the previous shift’s RN supervisor but was unsure what action was taken. Another RN supervisor confirmed there was no documentation in the record to support an increased flow rate or any notification to the physician about the change from 2 L/min to 3 L/min, and reiterated that the order was for a fixed rate of 2 L/min. During a concurrent observation and interview, the prior RN supervisor acknowledged the resident was on 3 L/min and that the flow rate needed to be corrected to match the order. The facility’s oxygen administration policy required staff to verify a physician order, document the flow rate and rationale, and report information per professional standards, which was not followed in this instance.
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