Jacob Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in San Diego, California.
- Location
- 4075 54th St., San Diego, California 92105
- CMS Provider Number
- 055508
- Inspections on file
- 30
- Latest survey
- November 27, 2024
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Jacob Healthcare Center during CMS and state inspections, most recent first.
A facility failed to follow its policy for storing controlled medications, leading to a missing card of 60 Morphine tablets. The medication was signed in by a nurse but not found in the controlled drawer, with no count sheet for reconciliation. The issue was discovered when reordering, and despite a search, the medication was not located. The incident was reported to the pharmacy and law enforcement.
Two residents in an LTC facility did not receive timely assistance with activities of daily living. A resident with quadriplegia was left in a soiled state due to delayed incontinence care, while another resident with paraplegia had untrimmed toenails despite requesting assistance. The facility's policy requires providing necessary services for residents unable to perform ADLs independently.
The facility failed to implement non-pharmacological interventions (NPIs) before administering PRN pain medications to three residents, as ordered by physicians. Despite orders for NPIs like repositioning and dimming lights, the MAR showed no evidence of NPIs being attempted prior to administering medications such as Oxycodone and Tramadol. Interviews with staff confirmed the lack of consistent NPI implementation and documentation, contrary to the facility's policy and physician's plan of care.
The facility failed to provide sufficient staffing, resulting in delayed call light responses and unmet resident needs. Residents reported long wait times for assistance, particularly during evening shifts and weekends. Staffing shortages were exacerbated by call-offs without replacements, and the facility struggled to meet the required direct care service hours. Observations on subacute and subskilled units further highlighted the impact of inadequate staffing on resident care.
The facility failed to conduct PASARR II assessments for two residents, one with schizophrenia and another with a new diagnosis of schizoaffective disorder. The Minimum Data Set Nurse did not resubmit the assessment for a resident returning from the hospital and was not informed of a new diagnosis for another resident, leading to missed evaluations. This oversight potentially affected the residents' care and placement.
A facility failed to develop a resident-centered care plan for a resident with dementia. Despite the resident's diagnosis, the care plan did not address dementia care, as confirmed by the DON. This omission was against the facility's policy, which requires comprehensive care plans to meet all resident needs.
A resident's care plan was not updated after their G-tube was discontinued, despite the resident being observed eating by mouth and having a physician's order for a soft diet. Interviews with the RD, LN, and DON confirmed the oversight, which could lead to staff confusion.
The facility failed to follow professional standards for three residents, leading to potential unnecessary medication side effects. Two residents were diagnosed with schizophrenia without meeting DSM criteria and were prescribed Seroquel without documented non-pharmacological interventions. Additionally, a nurse did not check a resident's heart rate before administering blood pressure medications, risking adverse effects.
A resident with functional quadriplegia and epilepsy was found without side rails on her bed, despite a physician's order and assessment indicating their necessity for safety and mobility assistance. The DON confirmed the oversight occurred during a room change, and the facility's policy required periodic safety checks for side rail use.
A resident with End Stage Renal Disease did not receive appropriate dialysis care as the facility failed to remove the pressure dressing from the dialysis access site within the required timeframe. The dressing, which should have been removed four hours post-dialysis, remained in place since the resident's last treatment, increasing the risk of infection and impaired blood flow. Both a licensed nurse and the DON confirmed the oversight, acknowledging the potential complications of not following the established care protocol.
Two residents were prescribed Seroquel for schizophrenia without clear indications, despite having diagnoses of anxiety and major depressive disorders. Interviews revealed no symptoms of schizophrenia, and non-pharmacological interventions were not attempted prior to medication use. The facility's policy requiring consistency with DSM and behavioral interventions before medication was not followed, and attempts to contact the prescribing physician for clarification were unsuccessful.
A resident did not receive prescribed cyanocobalamin and calcium due to unavailability during a medication pass. The nurse did not inform the physician or the resident about the missing medications, contrary to facility policy. The DON emphasized the importance of administering all medications and clarifying orders with the physician.
The QAPI committee failed to identify concerns about unnecessary antipsychotic medication use due to a lack of indications. The psychotropic committee focused on gradual dose reductions and medication reviews but did not discuss the appropriateness of these medications. The review should have included residents with continued psychotropic use after hospital discharge and new schizophrenia diagnoses.
A facility failed to implement Enhanced Barrier Precautions (EBP) for a resident with a foley catheter, as observed when a nurse wore PPE without proper signage or availability of PPE outside the room. Interviews with the IPN and DON confirmed that EBP should have been applied immediately upon admission due to the resident's increased risk of MDROs, as per facility policy.
Failure to Properly Store and Account for Controlled Medications
Penalty
Summary
The facility failed to adhere to its policy regarding the receipt and storage of controlled medications, resulting in a medication card containing 60 tablets of Morphine being unaccounted for. The issue was discovered when the facility attempted to reorder the medication for a resident, only to be informed by the pharmacy that it had already been delivered. The delivery log confirmed the medication was signed in by a licensed nurse, but the medication was not found in the controlled medication drawer, and there was no accompanying count sheet to verify its reconciliation. Interviews with the Assistant Director of Nursing, licensed nurses, and the Director of Nursing revealed that the medication was supposed to be placed in a locked drawer and reconciled at each shift change. However, since there was no count sheet for the missing Morphine, the reconciliation process could not be verified. The Director of Nursing was notified of the missing medication, and despite a search of the facility, it was not located. The incident was reported to the pharmacy and law enforcement, as per the facility's policy on controlled substances.
Deficiencies in ADL Assistance for Two Residents
Penalty
Summary
The facility failed to provide timely assistance with activities of daily living (ADL) for two residents, leading to deficiencies in care. Resident 28, who was admitted with quadriplegia and a history of urinary tract infections, was found in bed on a foul-smelling, dark brown substance with a visibly wet brief. The CNA assigned to Resident 28 admitted to noticing the need for incontinence care during rounds but delayed attending to it due to other tasks. The Director of Nursing acknowledged that the delay in providing incontinence care placed Resident 28 at risk for skin breakdown, wounds, or infection. Resident 30, admitted with paraplegia and muscle weakness, was observed with long, jagged toenails, which she expressed embarrassment about and had requested staff assistance to trim. The CNA was unsure if she could trim the resident's nails, although nail clippers and files were available. The Director of Nursing stated that CNAs could trim nails depending on the resident's preference, but preferred a licensed nurse to perform the task. The facility's policy indicated that residents unable to perform ADLs independently should receive necessary services, including grooming and personal hygiene.
Failure to Implement Non-Pharmacological Interventions Before PRN Pain Medication
Penalty
Summary
The facility failed to implement non-pharmacological interventions (NPIs) as ordered by the physician before administering PRN pain medications to three residents. Resident 22, who was admitted with chronic pain syndrome, had a cognitive score indicating intact cognition. Despite physician orders requiring NPIs such as repositioning and dimming lights before administering Oxycodone, the Medication Administration Record (MAR) showed no evidence of NPIs being attempted prior to medication administration. Resident 99, admitted with orthopedic aftercare following surgical amputation, had a moderately impaired cognitive score. The physician's orders specified NPIs before administering Tramadol for severe pain. However, the MAR indicated that Tramadol was administered 17 times, with no documentation of NPIs being attempted, even when the recorded pain level was below the threshold for severe pain. Additionally, the pain assessment interview for Resident 99 was incomplete, lacking details on pain triggers and location. Resident 312, diagnosed with rectal cancer, also did not receive NPIs before the administration of Oxycodone for breakthrough pain, as per physician orders. The MAR showed multiple administrations of Oxycodone without documented NPIs. Interviews with staff, including a CNA, LN, DSD, and DON, confirmed that NPIs were not consistently attempted or documented, despite being part of the physician's plan of care and facility policy. The facility's policy emphasized the importance of NPIs in pain management, yet these were not implemented as required.
Staffing Deficiencies Lead to Delayed Resident Care
Penalty
Summary
The facility failed to provide sufficient staffing to meet the care needs of residents, as evidenced by delayed responses to call lights. Interviews and record reviews revealed that call lights were not answered timely for three of six confidential residents interviewed. Specifically, one resident with a left heel wound and vision impairment reported that staff ignored his call light, and it took a long time for it to be answered, especially during the evening shift. Another resident stated that while staff assisted with bathroom needs, they were made to wait for other assistance. The Resident Council minutes from June to August 2024 repeatedly identified issues with call light response and insufficient staffing. The facility's staffing issues were particularly pronounced on weekends, with several instances of staff calling off without replacements. Interviews with the Staffing Coordinator and Director of Nursing confirmed awareness of these issues, and attempts were made to call in off-duty staff. However, the facility struggled to maintain adequate staffing levels, particularly on weekends, due to staff preferences for time off and infrequent use of registry staff. The facility's policy required a minimum of 3.5 direct care service hours per patient per day, but there were instances where this was not met, leading to licensed nurses performing CNA duties. Additional observations on the subacute and subskilled units highlighted further staffing challenges. A resident's call light went unanswered while respiratory therapists engaged in conversation nearby, and a CNA reported difficulties in timely call light responses due to the high acuity of residents and the need for additional staff. The subskilled unit was under the supervision of a nurse from another unit, complicating communication and assistance requests. These staffing deficiencies were documented in the facility's policy, which mandated 24-hour availability of licensed nurses and CNAs to provide direct resident care services.
Failure to Conduct PASARR II Assessments for Residents
Penalty
Summary
The facility failed to ensure that Preadmission Screening and Resident Review II (PASARR II) assessments were conducted for two residents, which is a federal requirement to prevent inappropriate placement of individuals with mental disorders in nursing homes. Resident 6, who was diagnosed with schizophrenia, was admitted to the facility and had a positive PASARR I screening, indicating the need for a Level II Mental Health Evaluation. However, the PASARR II assessment was not conducted after Resident 6 returned from a hospital stay, as the Minimum Data Set Nurse (MDSN) did not resubmit the assessment to the state. Resident 99 was admitted with a diagnosis of unspecified psychosis and initially had a negative PASARR I screening, indicating no need for a Level II evaluation. However, after a new diagnosis of schizoaffective disorder was made, which would have triggered a PASARR II assessment, no reassessment was conducted. The MDSN stated that she was not informed of the new diagnosis, which led to the oversight. As a result, it was undetermined if Resident 99 qualified for additional services or if the placement was appropriate. The facility's policy requires all new admissions and readmissions to be screened for mental disorders through the PASARR process. The policy mandates a Level I PASARR screen for all potential admissions and a referral to the state PASARR representative for a Level II evaluation if the criteria for a mental disorder are met. The failure to conduct the necessary PASARR II assessments for Residents 6 and 99 indicates a lapse in following these procedures, potentially affecting the residents' care and placement.
Failure to Develop Dementia Care Plan for Resident
Penalty
Summary
The facility failed to develop a resident-centered care plan for a resident diagnosed with dementia. Despite the resident's admission records indicating diagnoses of major depressive disorder and anxiety disorder, a subsequent History and Physical examination revealed the resident also had dementia and lacked the capacity to understand and make decisions. This critical information was not incorporated into the resident's care plan, which is a requirement to ensure all care needs are addressed. During a joint interview and record review with the Director of Nursing, it was acknowledged that the care plan for the resident did not include provisions for dementia care. This omission was contrary to the facility's own policy, which mandates the development of a comprehensive, person-centered care plan that includes objectives to meet the resident's physical, psychosocial, and functional needs. The failure to include dementia care in the resident's care plan had the potential for the resident's needs to be unmet.
Failure to Revise Care Plan After Discontinuation of G-tube
Penalty
Summary
The facility failed to revise the care plan for a resident when their gastrostomy tube (G-tube) was discontinued. The resident, who was admitted with a diagnosis of traumatic subdural hemorrhage, was observed feeding himself in the dining hall, indicating a change in his nutritional intake method. Despite a physician's order for a soft textured diet, the care plan still included instructions for managing tube feeding, such as checking residuals every shift and holding feedings if residuals exceeded 250 milliliters. Interviews with the Registered Dietitian and a Licensed Nurse confirmed that the resident was no longer receiving tube feedings and was exclusively eating by mouth. The Director of Nursing acknowledged that the care plan interventions were outdated and could lead to confusion among staff. The facility's policy on care plans emphasized the need for ongoing assessments and revisions as residents' conditions change, highlighting the oversight in updating the resident's care plan.
Failure to Follow Professional Standards in Diagnosing and Medication Administration
Penalty
Summary
The facility failed to adhere to professional standards of practice for three residents, leading to potential unnecessary medication side effects. Resident 5 was diagnosed with schizophrenia at the facility without meeting the criteria outlined in the DSM. Despite being admitted with anxiety and major depressive disorder, Resident 5 was prescribed Seroquel for schizophrenia based on behavior such as pulling at life-sustaining devices. Interviews with staff and the responsible party revealed no history or symptoms of schizophrenia, and the diagnosis did not align with DSM guidelines. Additionally, there were no documented non-pharmacological interventions attempted before administering Seroquel. Similarly, Resident 6 was diagnosed with schizophrenia without meeting DSM criteria. The resident, admitted with anxiety and major depressive disorder, was prescribed Seroquel for unprovoked agitation. Interviews indicated that Resident 6 was alert and oriented, with no hallucinations or paranoia documented in the medical record. The facility's DON acknowledged the lack of documentation supporting the schizophrenia diagnosis and the absence of non-pharmacological interventions prior to medication use. For Resident 18, a licensed nurse failed to obtain the heart rate before administering blood pressure medications, contrary to the facility's policy. The nurse acknowledged the oversight, which could have put the resident at risk for adverse effects due to the medications' potential to lower heart rate. The DON confirmed the expectation for nurses to check all pertinent vital signs before medication administration, highlighting a lapse in following established procedures.
Failure to Install Side Rails for Resident with Epilepsy
Penalty
Summary
The facility failed to maintain a safe environment for Resident 28, who was diagnosed with functional quadriplegia and epilepsy, by not installing side rails on her bed. The resident was admitted with a severe mental impairment, as indicated by a BIMS score of 3. Observations on 09/09/24 revealed that Resident 28's bed was pushed against the wall without side rails, despite a physician's order and a side rail assessment indicating the need for 1/2 bilateral side rails for safety and assistance with bed mobility and transfers. The Director of Nursing (DON) acknowledged that Resident 28 was moved to a different room without her side rails, which were intended for her safety, particularly in the event of a seizure. The DON stated that the licensed nurse should have ensured the side rails were installed according to the physician's order. The facility's policy on the proper use of side rails, revised in December 2016, required periodic safety checks relative to side rail use, which were not adhered to in this instance.
Failure to Remove Dialysis Pressure Dressing
Penalty
Summary
The facility failed to provide appropriate dialysis care for a resident with End Stage Renal Disease who was dependent on dialysis. The resident, identified as Resident 71, had a dialysis access site on the left upper arm, which was covered with a pressure dressing. According to the facility's policy and the resident's physician's orders, the pressure dressing should have been removed four hours after the resident returned from dialysis to allow for proper assessment of the site for any signs of redness or bleeding. However, during an observation and interview conducted on 9/9/24, it was found that the pressure dressing had not been removed since the resident's last dialysis treatment on 9/7/24. Licensed Nurse 35 confirmed that the pressure dressing should have been removed to prevent potential complications such as infection or impaired blood flow to the fistula. The Director of Nursing also acknowledged that the pressure dressing should have been removed by a licensed nurse within the specified timeframe to avoid risks of bleeding or infection. The facility's failure to adhere to the established protocol for post-dialysis care resulted in a deficiency in providing safe and appropriate dialysis services to the resident.
Unnecessary Antipsychotic Medication Use Without Clear Indications
Penalty
Summary
The facility failed to ensure that two residents, Resident 5 and Resident 6, were free from unnecessary medications, specifically antipsychotic medications, without clear indications. Resident 6 was admitted with anxiety disorder and major depressive disorder but was prescribed Seroquel for schizophrenia based on unprovoked agitation. Interviews with staff and the resident revealed that Resident 6 was alert, oriented, and did not exhibit symptoms of schizophrenia such as hallucinations or paranoia. The Director of Nursing (DON) confirmed that there was no documentation supporting the use of Seroquel for schizophrenia and that non-pharmacological interventions were not attempted prior to medication use. Similarly, Resident 5 was admitted with anxiety disorder and major depressive disorder and was also prescribed Seroquel for schizophrenia, allegedly due to indifference to surroundings and pulling at life-sustaining devices. Interviews with staff and the resident's responsible party indicated that Resident 5 had no history of schizophrenia or hallucinations. The DON and Social Worker (SW) confirmed that there was no appropriate diagnosis of schizophrenia and that the behavior of pulling tubes was not a valid indication for the use of Seroquel. Non-pharmacological interventions were not documented as attempted before resorting to medication. The facility's policy on antipsychotic medication use, which requires consistency with the Diagnostic and Statistical Manual of Mental Disorders (DSM) and the attempt of behavioral interventions before medication, was not followed. Attempts to contact the prescribing physician, MD 1, for clarification on the schizophrenia diagnoses were unsuccessful. The lack of appropriate documentation and adherence to policy resulted in the unnecessary administration of antipsychotic medications to Residents 5 and 6.
Medication Error Due to Unavailable Medications
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, as evidenced by the unavailability of two routine medications for a resident during a medication administration observation. The resident, who was admitted with diagnoses including nutritional anemia and muscle weakness, was supposed to receive cyanocobalamin 5000 micrograms and Calcium 500 milligrams every morning at 9 A.M. However, these medications were omitted during the medication pass conducted by a licensed nurse. The nurse acknowledged the absence of the medications, stating that only Oyster Shell Calcium and cyanocobalamin 1000 micrograms were available, and did not inform the physician or the resident about the unavailability. The Director of Nursing confirmed the importance of administering all prescribed medications and stated that staff should have clarified the orders with the physician. The facility's policy on administering medications requires contacting the prescriber or attending physician if a dosage is believed to be inappropriate. However, this protocol was not followed, as the nurse did not seek guidance from the physician regarding the medication unavailability, leading to the deficiency.
QAPI Committee Fails to Address Unnecessary Antipsychotic Use
Penalty
Summary
The facility's Quality Assurance and Performance Improvement (QAPI) committee failed to identify concerns related to the unnecessary use of antipsychotic medications due to a lack of indications. During an interview with the Administrator, Director of Nursing (DON), and Administrator in Training (AIT), it was revealed that the psychotropic committee focused primarily on gradual dose reductions (GDR) and Medication Review Regimen (MRR) for residents on psychotropic medications. However, the committee did not discuss the indications for use or the appropriateness of these medications, which are crucial aspects of psychotropic review. The DON acknowledged that the review should have included residents who continued psychotropic medications after hospital discharge and those with new diagnoses of schizophrenia. The facility's policy on QAPI, revised in February 2020, aimed to establish and implement performance improvement projects to correct identified negative indicators. Despite this, the QAPI committee did not expand its review to thoroughly assess the necessity of psychotropic medication use, potentially leaving deficiencies uncorrected and exposing residents to unnecessary medication side effects.
Failure to Implement Enhanced Barrier Precautions for Resident with Foley Catheter
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) for a resident with an indwelling foley catheter, which is necessary to prevent the transmission of multi-drug resistant organisms (MDROs). During an observation, a Licensed Nurse (LN) was seen wearing full Personal Protective Equipment (PPE) while providing care to the resident, but there was no signage indicating the need for PPE, nor was PPE available outside the resident's room. The LN stated that she wore PPE to avoid urine splashing on her scrubs while emptying the resident's catheter bag. Interviews with the Infection Prevention Nurse (IPN) and the Director of Nursing (DON) revealed that residents with foley catheters should be placed on EBP immediately upon admission due to their higher risk of acquiring MDROs. The facility's policy on Enhanced Barrier Precautions, revised in June 2024, indicates that EBP should be applied to residents with wounds and/or indwelling medical devices, regardless of MDRO colonization, for the duration of their stay or until the discontinuation of the device. The failure to implement these precautions for the resident upon admission was a deficiency in infection control practices.
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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