Jurupa Hills Post Acute
Inspection history, citations, penalties and survey trends for this long-term care facility in Riverside, California.
- Location
- 6401 33rd Street., Riverside, California 92509
- CMS Provider Number
- 055581
- Inspections on file
- 51
- Latest survey
- January 14, 2026
- Citations (last 12 mo.)
- 6
Citation history
Health deficiencies cited at Jurupa Hills Post Acute during CMS and state inspections, most recent first.
A resident with a left shoulder RCT and neuropathy did not receive a timely orthopedic follow-up as ordered, because staff did not schedule the consult within the specified timeframe, did not document the reason for the consult, and did not incorporate the order into the care plan. The same resident’s gabapentin dose for neuropathy was increased from 100 mg to 300 mg TID without a documented nursing assessment or rationale, despite ongoing documentation of zero pain scores. Later, a neurology referral was obtained after the resident requested to see a neurologist, but staff did not document the assessment or reason for the referral and did not add the referral to the care plan, leaving other nurses unaware of the consult’s purpose.
The facility did not ensure that an area was free from accident hazards and failed to provide adequate supervision to prevent accidents. Surveyors observed environmental hazards and insufficient staff monitoring, increasing the risk of resident accidents.
A resident with a fractured right arm did not receive timely physical therapy after an orthopedic consultation due to the facility's failure to follow up on new medical orders. The resident returned from the appointment without an AVS, and staff did not document or act on the orthopedic doctor's therapy recommendations for seven days, resulting in a delay in care.
Surveyors observed that kitchen staff did not wear hairnets properly, with hair escaping from the top, sides, and nape of their necks. Additionally, a staff member responsible for dishwashing failed to change gloves after handling dirty kitchenware before touching clean, sanitized pans, and rinsed soiled kitchenware near clean beverage cups and glasses. The facility's policies lacked clear procedures for transitioning between dirty and clean tasks, contributing to these deficiencies.
The facility did not provide the required transfer/discharge notices to the State LTC Ombudsman before two residents, one with pneumonia and sepsis and another with heart failure, were discharged home. Notices were only sent after the residents had left, contrary to facility policy and regulatory requirements.
A resident with chronic pain and multiple pain medication orders did not receive pain management in accordance with physician instructions. Hydrocodone was administered for higher pain levels instead of Percocet as ordered, and staff did not match the pain scale to the correct medication. The DON confirmed that the orders were not followed and that staff did not notify the physician to adjust the medication regimen despite frequent PRN use.
Nursing staff did not follow manufacturer-specified contact times when disinfecting shared blood pressure cuffs and stethoscopes for two residents, and a CNA failed to wear a disposable gown during high-contact care for a resident on Enhanced Barrier Precautions due to wounds and medical devices. These actions were not in accordance with facility policy or infection prevention protocols.
A resident with asthma was found to be self-administering an albuterol inhaler without proper assessment or authorization, despite facility policy requiring an interdisciplinary team determination and physician order. The inhaler was kept unsecured at the bedside, and staff were unaware of its presence or use by the resident.
A resident with significant height and multiple mobility-related diagnoses was not provided with a bed long enough to accommodate his stature, despite repeated requests and staff awareness. Instead, a makeshift cardboard footrest was used, causing ongoing discomfort and requiring the resident to bend his knees or position his feet awkwardly.
A resident with a history of peripheral arterial disease was observed with dirty, uncleaned fingernails, which had not been attended to for about a month. The resident was alert and able to express needs, and staff interviews confirmed that CNAs are responsible for daily nail care but failed to notice or address the issue. This resulted in a lack of necessary hygiene care as required by the resident's care plan and facility policy.
A resident with diabetes mellitus, who was cognitively intact, received Insulin Lispro from a nurse even though their blood sugar was below the physician-ordered hold parameter. The DON confirmed that the insulin should have been withheld and that the nurse did not follow the physician's order or document the reason for administration, contrary to facility policy.
A resident receiving enteral nutrition via gastrostomy tube was observed on multiple occasions lying flat in bed while tube feeding was running, despite physician orders, care plan instructions, and facility policy requiring the head of bed to be elevated to at least 30 degrees during and after feeding. Both an LVN and the DON confirmed the necessity of proper positioning to prevent complications, but the required care was not provided.
A resident with significant respiratory and cardiac conditions was observed receiving oxygen at rates higher than the physician-ordered 2 LPM via nasal cannula. Both an LVN and the ADON confirmed the discrepancy, acknowledging that the physician's order was not followed, contrary to facility policy.
A resident with multiple diagnoses and prescribed CNS-acting medications experienced several unwitnessed falls, including one requiring hospital evaluation. Despite changes in the resident's condition and medication regimen, the consultant pharmacist did not identify or report the potential for medication-related fall risk during monthly reviews, and the facility did not request additional medication reviews after each fall, contrary to facility policy.
A resident's wheelchair was found to be unsafe due to broken brakes and an improper fit, posing a safety risk. The resident, with hemiplegia and hemiparesis, struggled with mobility and comfort. The Director of Rehabilitation Services confirmed the safety concern, highlighting the need for operable brakes, especially during transfers. The facility's maintenance policy requires equipment to be safe and operable, but this was not upheld, resulting in the deficiency.
A facility failed to follow its grievance policy when a family representative raised concerns about a resident's injury. The resident, with major depressive disorder, Parkinsonism, and dementia, had a wound on the right forearm. Conflicting accounts of the injury's cause were given, and the facility did not respond promptly to the family's request for incident details and corrective actions. The grievance policy, which requires staff to guide residents and representatives on filing complaints, was not adhered to.
A resident with severe cognitive impairment experienced 16 falls due to inadequate evaluation and implementation of fall prevention interventions. Despite being at high risk, the facility failed to consistently conduct post-fall reviews and IDT meetings, leading to repeated falls and injuries, including head lacerations and fractures.
A resident with a history of COPD and bipolar disorder caused harm to two other residents due to inadequate supervision while smoking. The facility failed to enforce its smoking policy, allowing residents to keep smoking materials and lacking consistent staff supervision on the smoking patio. This led to incidents where one resident was burned with a cigarette and another was hit in the face.
Two residents in an LTC facility experienced inadequate pain management due to the facility's failure to administer medications in accordance with physician orders and care plans. One resident with pemphigus vulgaris received pain medication inconsistently with her reported pain levels, while another resident reported irregular administration of her pain and muscle relaxant medications, affecting her sleep. The facility's policies on pain management and medication administration were not followed, leading to this deficiency.
A resident with pemphigus vulgaris experienced a delay in receiving new medications after a specialist appointment due to the facility's failure to promptly obtain and implement new physician orders. The resident returned without necessary paperwork, and despite attempts by staff and family to contact the consulting physician's office, the new orders were not started until four days later, leading to a lack of continuity of care.
A resident was not properly assessed for bladder and bowel incontinence, leading to inadequate care. Initially documented as continent, the resident experienced prolonged periods in soiled diapers, causing skin redness. The MDS coordinator later corrected the error, acknowledging the resident's incontinence status.
A resident with anxiety, major depressive disorder, and Alzheimer's disease reported financial abuse by a caregiver, but the LTC facility failed to document the allegation or develop a care plan. Staff, including an RN, CNA, and LVN, were unaware of the incident, and the facility's policy for handling abuse allegations was not followed, leaving the resident at risk for further abuse.
A resident with Alzheimer's disease reported unauthorized withdrawal of $70,000 by a caregiver. The facility failed to report the financial abuse allegation to CDPH within the required two-hour timeframe, as the DON received the report on May 13, 2024, but the initial report was made on May 12, 2024. The facility's policy requires immediate reporting of such allegations.
The facility failed to implement a system to quickly and accurately identify code status in an emergency, leading to staff initiating CPR on a resident with a DNR order. The resident endured painful resuscitation procedures, sustained injuries, was hospitalized, and expired the following day. The deficiency was due to the use of an outdated POLST form and failure to maintain accurate records.
The facility failed to prevent potential cross-contamination during food preparation. A cook did not wear a beard restraint while preparing drinks, and another cook did not wash hands or change gloves between tasks. These actions had the potential to affect all 125 residents receiving meals from the dietary department.
The facility failed to test staff identified via contact tracing for COVID-19 and did not document staff testing, leading to a lapse in infection control. Additionally, a CNA performed perineal care in an unsanitary manner, contaminating clean washcloths. The facility lacked detailed policies and proper training for these procedures.
The facility failed to ensure accurate Level I PASRR screenings for two residents, leading to discrepancies in their mental health diagnoses and required evaluations. Staff did not thoroughly review PASRRs completed at hospitals, resulting in incorrect assessments of serious mental illnesses.
A facility failed to update a Level I PASRR for a resident following a new diagnosis of anxiety. Despite the resident's history of schizophrenia and the new diagnosis, the required PASRR update was not completed, as confirmed by staff interviews and record reviews.
A resident with a history of schizophrenia and anxiety had a PRN order for lorazepam that was not re-evaluated after 14 days, contrary to facility policy. The resident's care plan included antianxiety medication, but the facility failed to ensure the PRN order had a stop date or duration, leading to unnecessary medication use.
The facility failed to follow vital sign parameters when administering amiodarone to a resident with hypertension and heart failure, resulting in the medication being given despite low systolic blood pressure readings. Staff interviews revealed awareness of the importance of these parameters, but no clear explanation for the error was provided.
A resident was inaccurately documented with schizophrenia, leading to the inappropriate administration of Seroquel. The error was discovered through record reviews and staff interviews, revealing the resident actually had psychosis related to Parkinson's Disease.
Failure to Implement Orthopedic Follow-Up and Document Assessments for Pain Management and Neurology Referral
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care according to physician orders and to conduct and document appropriate assessments for a resident with a left shoulder rotator cuff tear and neuropathy. The resident was admitted with diagnoses including a left shoulder rotator cuff tear and neuropathy and reported limited movement and pain in the left shoulder. Hospital records from an acute stay documented that orthopedics had recommended an outpatient follow-up after an MRI confirmed a rotator cuff tear, with discharge instructions specifying an orthopedic surgery follow-up in 2–3 weeks. A physician order dated October 10, 2025, directed an orthopedic follow-up in 2–3 weeks, but the order did not specify the reason for the consult, it was not incorporated into the care plan, and there was no documentation that an orthopedic appointment was scheduled within the ordered timeframe. Record review and staff interviews confirmed that the orthopedic follow-up order was not implemented as written. The care plan addressing the resident’s musculoskeletal disorder and left shoulder rotator cuff tear did not include the physician’s order for an orthopedic consult. The RN acknowledged that there was no record of an appointment being scheduled within 2–3 weeks of the October 10 order and that the appointment was not scheduled until February 2026. The DON stated that staff were expected to call and set up such appointments within 72 hours of the order, that no one from the facility made the call, that the reason for the orthopedic consult was not documented in the order, and that the order was not added to the care plan. These omissions resulted in a delay in the resident being seen by an orthopedic physician for the rotator cuff tear. The deficiency also includes failures related to pain management and specialty referral for the resident’s neuropathy. The resident had an admission order for gabapentin 100 mg three times daily for neuropathy, with an order to monitor pain every shift. Pain level documentation from late October to November 10, 2025, showed pain levels of 0 each shift. On November 10, 2025, the gabapentin dose was increased to 300 mg three times daily, but there was no documented nursing assessment prior to obtaining this order and no documented rationale for the dose increase in the progress notes. LVN 1, who obtained and carried out the order, stated that the resident reported the medication was not working and requested the physician be called, but LVN 1 did not perform or document a pain assessment before obtaining the increased dose, despite facility policy requiring pain assessment and management steps. Additionally, on December 12, 2025, an order for a neurology referral was carried out for the same resident, who had neuropathy and had requested to be seen by a neurologist. There was no documented assessment indicating the need for the neurology referral and no documentation in the progress notes explaining why the referral was needed. The order for the neurology referral was also not added to the resident’s care plan. RN 1 stated that LVN 2 did not document the reason for the neurology consult, so the RN did not know what it was for. LVN 2 confirmed that he called the physician after the resident requested to see a neurologist but did not document the reason for the referral or add it to the care plan. These actions and omissions occurred despite facility policies requiring that referrals for medical services be based on physician evaluation and orders, coordinated with appropriate disciplines, and that comprehensive, person-centered care plans describe the services to be furnished and be revised as resident conditions and information change.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
The facility failed to ensure that an area was free from accident hazards and did not provide adequate supervision to prevent accidents. Surveyors observed that the environment contained hazards that could lead to resident accidents, and staff did not implement sufficient measures to monitor or protect residents from these risks. This deficiency was identified based on direct observations and findings during the survey, which indicated lapses in maintaining a safe environment and in providing necessary supervision to prevent accidents.
Delay in Implementing Therapy Orders After Orthopedic Consultation
Penalty
Summary
A deficiency occurred when the facility failed to implement new medical orders in a timely manner following an orthopedic consultation for a resident with a fractured right humerus. The resident, who was admitted with a broken right arm and had the capacity to make decisions, reported not receiving any physical therapy (PT) for his right arm since admission. Medical records showed that after a follow-up orthopedic appointment, there was no documentation or evidence that the facility followed up with the orthopedic doctor for new orders or recommendations. The resident returned from the appointment without an After Visit Summary (AVS), and staff interviews confirmed that no follow-up or documentation was completed regarding the consultation or any new therapy orders until several days later. Further review revealed that the orthopedic doctor had ordered physical therapy for the resident's right arm, but this order was not received or implemented by the facility until seven days after the consultation. Staff, including the Occupational Therapist Assistant and Social Service Assistant, confirmed that the lack of documentation and follow-up led to a delay in therapy services. The Director of Nursing acknowledged that the expected process for following up on specialty appointments was not followed, resulting in a delay in care. The facility was unable to provide a policy or procedure for following up on new orders or recommendations from consulting doctors for residents who attended specialty appointments.
Food Safety and Sanitation Deficiencies in Dietary Services
Penalty
Summary
Several deficiencies in food safety practices were observed during an unannounced visit to the facility's kitchen. Multiple kitchen staff, including the Dietary Supervisor and two Dietary Aides, were seen wearing hairnets that did not fully contain their hair, with hair escaping from the top, sides, and nape of their necks. The Dietary Supervisor confirmed that staff were expected to have all hair tucked into hairnets, and that hairspray was suggested during training to help keep hair in place. The facility's dress code policy required hats or hairnets to completely cover hair, depending on its length. Additionally, improper glove use and dishwashing procedures were observed. The staff member responsible for dishwashing was seen rinsing dirty kitchenware with gloved hands and then, without changing gloves, handling clean and sanitized stainless steel pans. The staff member acknowledged this lapse, and the Dietary Supervisor confirmed that gloves should have been changed to prevent cross-contamination. Furthermore, the dishwasher was observed rinsing kitchenware with crusted food residue above and beside beverage cups and glasses, which were placed upside down on racks. The Dietary Supervisor stated that kitchenware should be scraped and soaked prior to dishwashing and that items used for meal preparation should be washed before those from patient care areas. The facility's dishwashing policy did not specify procedures for transitioning between dirty and clean tasks.
Failure to Notify Ombudsman Prior to Resident Discharge
Penalty
Summary
The facility failed to provide a copy of the Notice of Proposed Transfer/Discharge to the State Long-Term Care Ombudsman prior to the planned discharge dates for two residents. Both residents were scheduled for discharge to home, with one having diagnoses including pneumonia and sepsis, and the other with heart failure. The notices were given to the residents and acknowledged, but the copies intended for the Ombudsman were only sent after the residents had already been discharged from the facility. Interviews with facility staff, including the Social Services Director, Director of Nursing, and Administrator, confirmed that the required notifications to the Ombudsman were not made before the residents left. The facility's own policy required that such notices be sent to the Ombudsman in advance of discharge, but this procedure was not followed for the two residents in question.
Failure to Follow Physician Orders for Pain Management
Penalty
Summary
The facility failed to provide pain management according to the physician's orders and the resident's care plan for one resident. The resident had orders for pain to be monitored every shift and for specific pain medications to be administered based on the pain scale: Percocet for severe pain (level 7-10) and Hydrocodone for moderate to severe pain as needed. However, a review of the Medication Administration Record (MAR) showed that Hydrocodone was administered for pain levels of 7 and above multiple times, which did not align with the physician's order specifying Percocet for those pain levels. The resident was receiving PRN pain medications multiple times daily without the pain scale being matched to the correct medication as ordered. Interviews with the resident confirmed frequent administration of pain medications, and the DON acknowledged that the physician's orders were not being followed as written. The facility's own pain management policy required appropriate assessment and treatment of pain, including reviewing the MAR to determine the frequency and effectiveness of PRN pain medication use. Despite these procedures, the staff did not ensure that pain medications were administered according to the prescribed pain scale, nor did they contact the physician to adjust the medication regimen when frequent PRN use was observed.
Failure to Follow Infection Control Protocols for Equipment Disinfection and Enhanced Barrier Precautions
Penalty
Summary
Nursing staff failed to follow proper infection control practices when disinfecting shared blood pressure cuffs and stethoscopes for two residents during medication administration. Specifically, staff did not adhere to the manufacturer's specified contact time for the disinfectant wipes used on the equipment. One nurse used a Micro-Kill One wipe but did not ensure the equipment remained wet for the required one minute, while another used a Micro-Kill Bleach wipe but did not maintain the necessary three-minute contact time. Both the Infection Preventionist and Director of Nursing confirmed that staff are expected to follow the manufacturer's instructions for disinfecting shared equipment, as outlined in facility policy and the product labeling. Additionally, a certified nursing assistant failed to use a disposable gown while providing high-contact care to a resident who required Enhanced Barrier Precautions (EBP) due to multiple medical conditions, including burns, a pressure ulcer, a colostomy, and an indwelling urinary catheter. The resident's care plan and physician's orders specified the use of gown and gloves during high-contact activities, but the CNA provided care without donning a gown, later stating she forgot to do so. The Infection Preventionist confirmed that a gown should have been used during direct care for this resident. Facility policies reviewed indicated that reusable or shared equipment must be disinfected according to manufacturer instructions before reuse, and that EBP, including gown and glove use, is required for residents with wounds or indwelling devices during high-contact care. The observed failures to follow these protocols resulted in deficiencies related to infection prevention and control practices.
Failure to Assess and Authorize Self-Administration of Albuterol Inhaler
Penalty
Summary
The facility failed to ensure that an appropriate assessment and evaluation for self-administration of medication was completed for a resident who possessed and used an albuterol inhaler. The resident, who had a history of asthma and was alert and oriented, was observed retrieving an albuterol inhaler from his pocket and later keeping it on his bedside table. The resident stated he had been using the inhaler for a long time, obtained it from his own doctor, and wanted it accessible in case of an asthma attack. However, the resident's admission records and a self-administration assessment indicated he did not want to self-administer medication, and there was no documentation or physician order authorizing self-administration of the inhaler. Licensed staff, including the LVN, MDS Coordinator, RN Supervisor, and DON, were unaware that the resident had the inhaler at his bedside or was self-administering it. The facility's policy required an interdisciplinary team determination and physician order for self-administration, as well as secure storage of self-administered medications. The inhaler was not stored securely, and staff confirmed that the resident should not have been self-administering the medication without proper assessment and authorization.
Failure to Provide Appropriate Bed for Tall Resident
Penalty
Summary
The facility failed to accommodate the needs and preferences of a resident who was significantly taller than average, measuring 6 feet 8 inches in height. Despite the resident's repeated requests over several months for a longer bed to fit his height, the facility did not provide an appropriate bed. Instead, a makeshift cardboard footrest was placed at the foot of the bed by the maintenance director at the resident's request. Observations confirmed that the resident had to keep his feet on either side of the footrest or bend his knees to fit in the bed, resulting in discomfort while lying down. Multiple staff members, including a CNA, the maintenance director, the central supplies director, and the assistant director of nursing, acknowledged that the current bed was inadequate and that the cardboard footrest was not an appropriate solution. The resident's medical record indicated a history of cervical disc degeneration, inclusion body myositis, polyneuropathy, and difficulty walking, all of which increased his need for comfort and proper positioning in bed. The care plan documented the resident's risk for pain, discomfort, and complications of immobility, and specified that his needs should be anticipated and met by staff. The facility's own policy required adaptations to the physical environment, such as providing appropriately sized furniture, to accommodate individual resident needs and preferences. Despite these requirements, the facility did not provide a suitable bed for the resident, resulting in ongoing discomfort.
Failure to Maintain Resident Nail Hygiene
Penalty
Summary
The facility failed to provide necessary care and services to maintain the cleanliness and hygiene of a resident's fingernails. During observation, the resident was found with blackish material under all fingernails and reported that his nails had not been cleaned for about a month. The resident was alert, oriented, and able to verbalize needs, and stated he would not mind if staff cleaned his nails. Interviews with a CNA, the Infection Preventionist, and nursing leadership confirmed that CNAs are responsible for daily hygiene, including nail care, and acknowledged that dirty fingernails could be a source of bacteria and infection. The CNA who cared for the resident did not notice the dirty fingernails. The resident's care plan indicated an actual risk for decline in activities of daily living (ADL) and required staff assistance to meet needs. The facility's policy stated that residents unable to perform ADLs independently should receive services to maintain grooming and personal hygiene. Despite these requirements, the resident's fingernails were not cleaned as needed, resulting in a failure to meet the standard of care outlined in the facility's policy and the resident's care plan.
Insulin Administered Below Hold Parameter
Penalty
Summary
A nurse administered Insulin Lispro to a resident with diabetes mellitus despite the resident's blood sugar being below the physician-ordered hold parameter. The resident, who was cognitively intact and had decision-making capacity, reported that the nurse gave him insulin when his blood sugar was low, specifically noting a blood sugar reading of 32 at the time of the incident. Record review confirmed that on a separate occasion, the resident received 3 units of Insulin Lispro subcutaneously for a blood sugar of 89, which was below the prescribed threshold of 90 for holding the medication. The Director of Nursing confirmed that the nurse did not follow the physician's order, as the insulin should have been held and the reason for not administering it should have been documented. Facility policy requires medications to be administered safely and as prescribed, in accordance with prescriber orders. The failure to adhere to these standards resulted in the resident receiving insulin when it should have been withheld according to the order.
Failure to Maintain Proper Head of Bed Elevation During Tube Feeding
Penalty
Summary
A resident with a history of dysphagia following a stroke, who was admitted with orders for enteral feeding via gastrostomy tube, was observed on multiple occasions receiving tube feeding while lying flat in bed. Observations on two separate days showed the resident's head of bed (HOB) was not elevated as required during active tube feeding. During one observation, a Licensed Vocational Nurse confirmed that the HOB was too low and should be elevated to at least 45 degrees. The Director of Nursing also stated that the HOB should be elevated between 30-45 degrees during and for 30 minutes after feeding. Review of the resident's care plan and physician orders confirmed the requirement for HOB elevation to at least 30 degrees during and after tube feeding to prevent complications such as aspiration. Facility policy also addressed the need for proper positioning during enteral nutrition. Despite these documented requirements, the resident was not positioned appropriately during tube feeding, constituting a failure to provide care in accordance with physician orders, care plan, and facility policy.
Failure to Follow Physician's Order for Oxygen Administration
Penalty
Summary
A deficiency occurred when a resident with multiple respiratory and cardiac diagnoses, including heart failure, chronic pulmonary edema, acute respiratory failure with hypoxia, pleural effusion, pneumonia, and anemia, was not provided respiratory care in accordance with the physician's order. The resident was observed on two separate occasions receiving oxygen via nasal cannula at rates of 3.5 and 4 liters per minute (LPM), despite a physician's order specifying oxygen administration at 2 LPM. Both a Licensed Vocational Nurse (LVN) and the Assistant Director of Nursing (ADON) confirmed that the oxygen was being administered at a higher rate than ordered and acknowledged that the physician's order was not followed. The facility's policy on oxygen administration requires verification and adherence to physician orders, which was not done in this case.
Failure to Conduct Timely Medication Regimen Review After Resident Falls
Penalty
Summary
The facility failed to ensure that a licensed pharmacist performed a thorough monthly medication regimen review (MRR) for a resident who experienced multiple falls and changes in condition. Despite the resident being prescribed several medications known to have sedating effects—Prozac (fluoxetine), Valproic Acid, and Risperdal (risperidone)—the consultant pharmacist did not identify or report the potential for these medications to contribute to increased fall risk during the monthly MRRs. Additionally, after each fall and change in the resident's condition, the facility did not request an additional medication review as outlined in their own policies and procedures. The resident in question had a complex medical history, including contracture of the right upper arm, spastic hemiplegia, cerebral palsy, dementia, major depressive disorder, anxiety, and psychosis. Over a period of several months, the resident experienced at least five unwitnessed falls, one of which resulted in a hospital transfer for evaluation and treatment of a right knee abrasion. The resident's medication regimen was adjusted during this time, with increases in Valproic Acid dosage and the addition of Risperdal, both of which have documented sedating effects and potential to impair cognitive and motor function, especially when combined with other CNS-acting drugs. Despite these significant changes in the resident's condition and medication regimen, the consultant pharmacist's monthly reviews for December, January, and February did not include any recommendations regarding the potential contribution of these medications to the resident's falls. Interviews with facility staff, including the DON and ADON, confirmed that the consultant pharmacist was not notified after the resident's falls and that no additional medication review was requested. The facility's policy specifically states that an acute change of condition may prompt a request for a medication regimen review, but this procedure was not followed.
Wheelchair Maintenance Deficiency
Penalty
Summary
The facility failed to maintain a resident's wheelchair in a safe and operable condition, which was identified during an unannounced visit. The resident, who was admitted with hemiplegia and hemiparesis following a stroke, was observed attempting to use the wheelchair brakes, which were broken and non-functional. Additionally, the wheelchair was too small for the resident, causing discomfort and limiting mobility. This issue was confirmed through observation and interview with the resident, who expressed difficulty in using the wheelchair due to its size and malfunctioning brakes. The Director of Rehabilitation Services acknowledged the safety concern, emphasizing the importance of having a wheelchair with operable brakes, especially during transfers. The facility's maintenance policy, dated December 2009, mandates that equipment be maintained in a safe and operable manner at all times. However, the failure to adhere to this policy resulted in the resident using a wheelchair that posed a safety risk. The maintenance department is responsible for ensuring equipment safety, but in this instance, the necessary maintenance was not performed, leading to the deficiency.
Failure to Follow Grievance Policy for Resident's Injury
Penalty
Summary
The facility failed to adhere to its grievance policy and procedure when a family representative expressed concerns about a resident's care. The resident, who was admitted with diagnoses including major depressive disorder, Parkinsonism, and dementia, was observed with a wound on the right forearm. The family representative reported receiving conflicting accounts of how the injury occurred, initially being told it was due to arm-to-arm contact with staff, and later that it was caused by hitting a side rail. The Director of Nursing (DON) was informed of the incident during a change of condition discussion with the Interdisciplinary Team. The DON reviewed the situation based on a statement from a Certified Nursing Assistant (CNA) who was not assigned to the resident but responded to an alarm. The CNA reported that the resident became aggressive and hit the CNA's arm, leading to the injury. Despite the family representative's concerns and request for a copy of the incident report and corrective actions, the facility did not respond promptly. The facility's grievance policy, which encourages staff to guide residents and their representatives on how to file complaints, was not followed. The family representative's email to the DON and other staff members regarding the incident and the lack of response highlights the facility's failure to address the grievance appropriately. This lack of action may have contributed to a delay in addressing the concerns raised by the family representative.
Failure to Prevent Repeated Falls in Resident
Penalty
Summary
The facility failed to ensure the effectiveness of interventions to prevent falls for a resident, resulting in 16 falls over a period of several months. The resident, who had a history of falls and severe cognitive impairment, experienced multiple falls due to behaviors such as getting up unassisted. Despite being at high risk for falls, the facility did not consistently evaluate the effectiveness of interventions or implement new strategies to prevent further incidents. The resident's care plan included interventions such as keeping the bed in a low position, using fall mats, and encouraging the resident to call for assistance. However, these measures were insufficient as the resident continued to fall, sustaining injuries including a laceration to the head, a skin tear, and multiple fractures. The facility's documentation revealed that post-fall reviews and interdisciplinary team (IDT) meetings were not consistently completed after each fall, and new interventions were not always implemented. Interviews with staff indicated that the resident's falls could have been minimized with a 1:1 sitter, which was not consistently provided. The Director of Nursing acknowledged that the falls were not properly evaluated to address their causes and implement appropriate interventions. The facility's policy required post-fall reviews and IDT meetings to discuss and document the resident's plan of care, but these were not consistently conducted, contributing to the repeated falls and injuries.
Inadequate Supervision Leads to Resident Harm During Smoking
Penalty
Summary
The facility failed to provide adequate supervision for residents while smoking, leading to incidents involving Resident C, who caused physical harm to Resident A and Resident B. On June 9, 2024, Resident C burned Resident A's arm with a lit cigarette and hit Resident B in the face while they were at the smoking patio. Observations and interviews revealed that residents were allowed to keep their own cigarettes and lighters, contrary to the facility's policy, which required smoking materials to be stored by staff and residents to be supervised while smoking. Interviews with residents and staff indicated a lack of supervision on the smoking patio. Resident F, who witnessed the incident, stated that there was no staff present to supervise the residents while smoking. This was corroborated by Resident B, who mentioned that staff only came to the patio if they were looking for a resident. The Director of Staff Development and the Activities Director acknowledged that there was no formal schedule for monitoring residents on the patio, and supervision was inconsistent. Resident C's medical records showed a history of COPD and bipolar disorder, with a care plan indicating the need for supervision during smoking due to non-compliance with smoking rules. Despite this, Resident C was allowed to keep smoking materials, which led to the incidents on June 9, 2024. The facility's smoking policy required residents to be assessed for their ability to smoke safely and mandated staff supervision for those who were not independent smokers, but these protocols were not followed, resulting in harm to other residents.
Inadequate Pain Management for Two Residents
Penalty
Summary
The facility failed to manage the pain of two residents, Resident D and Resident E, in accordance with professional standards of practice and their comprehensive person-centered care plans. Resident D, who suffers from pemphigus vulgaris, reported experiencing significant pain from lesions on her arms and a sore mouth, which made eating difficult. A review of Resident D's Medication Administration Record (MAR) revealed that out of 51 doses of prescribed pain medication administered over a 25-day period, 24 doses were not given in accordance with the physician's orders. This included instances where the dosage did not match the pain level reported by the resident, and medications were administered outside the prescribed time frames. Resident E expressed concerns about not receiving her medications on time, particularly her muscle relaxant and pain medication, which affected her ability to sleep due to pain. Her MAR indicated that she received Tramadol, a medication for severe pain, 14 times over a 21-day period, with three instances where it was administered for a pain level of 6, contrary to the physician's orders. Resident E's care plan emphasized the need for administering medications as ordered and assessing pain every shift, but these directives were not consistently followed. Interviews with the Director of Nursing (DON) highlighted the need for adjusting medication times to better accommodate the residents' needs and the importance of reevaluating medication regimens if pain levels are not being controlled. The facility's policies on pain assessment and management, as well as medication administration, stress the importance of administering medications in accordance with prescribed orders and addressing unrelieved pain through a multidisciplinary approach. However, these policies were not adhered to, resulting in inadequate pain management for Residents D and E.
Delay in Implementing New Physician Orders for Resident with Skin Disease
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice. This deficiency occurred when new physician orders from a consulting physician's office were not initiated promptly after the resident returned to the facility. The resident, who has a rare skin disease called pemphigus vulgaris, was sent to the facility for 24-hour care and rehabilitation needs. After attending a specialist appointment, the resident returned without the necessary paperwork, and the facility did not follow up effectively to obtain the new orders. Interviews with the Director of Nursing (DON) and Licensed Vocational Nurse Two (LVN 2) revealed that the facility's process for handling new orders from external appointments was not followed. The DON stated that upon a resident's return from an appointment, the charge nurse or RN supervisor should review and enter any new physician orders. However, in this case, LVN 2, who was responsible for the resident on the day of the appointment, did not receive the necessary paperwork and attempted to contact the consulting physician's office twice without success. The resident's family member also tried to obtain the orders but faced difficulties. Consequently, the new medications were not started until four days after the appointment, leading to a delay in treatment. Further interviews with the Registered Nurse (RN) and Medical Records (MR) staff confirmed the delay in medication administration. The RN acknowledged that there was a delay in starting the new medications and that progress notes should have been written over the weekend to document the resident's care. The MR staff indicated that the facility received the documents on the day after the appointment, but the orders were not entered into the system until later. This delay in implementing the new treatment plan resulted in a lack of continuity of care for the resident, who was at risk for delayed healing and infection due to their skin condition.
Inadequate Assessment of Resident's Incontinence
Penalty
Summary
The facility failed to properly assess a resident, identified as Resident E, for bladder and bowel control, which led to inappropriate care. Upon admission on May 22, 2024, Resident E was noted to have bladder and bowel incontinence, with a toileting program set to check and change every two hours. However, the Minimum Data Set (MDS) assessment on June 4, 2024, inaccurately recorded Resident E as always continent for both urinary and bowel functions. This discrepancy in documentation resulted in Resident E not receiving the appropriate care for her incontinence. During an interview, Resident E reported sitting in soiled diapers for one to two hours before staff responded to her calls for assistance, leading to redness in her groin and peri-area. The MDS coordinator later acknowledged a data entry error in the MDS, which was subsequently corrected to reflect Resident E's incontinence status. Despite the correction, the initial failure to accurately assess and document Resident E's condition resulted in inadequate care and potential discomfort for the resident.
Failure to Implement Abuse Prevention Policy
Penalty
Summary
The facility failed to implement its policy and procedure on abuse for a resident who was a victim of financial abuse. The resident, who had been diagnosed with anxiety, major depressive disorder, and Alzheimer's disease, reported that a caregiver had withdrawn $70,000 from her bank account without her consent. Despite the resident's report to the police, the facility staff, including a registered nurse, a certified nurse assistant, and a licensed vocational nurse, were unaware of the incident. There was no documentation of the allegation in the resident's medical record, and no plan of care was developed to ensure the resident's safety. Interviews with facility staff revealed that the facility's process for handling such allegations was not followed. The Director of Nursing confirmed that there was no documentation of the financial abuse allegation and no care plan was initiated to address the issue. The facility's policy required the administrator to determine necessary actions for resident protection upon receiving any allegations of abuse, but this was not done. As a result, the staff was not informed of the necessary information to ensure the resident's safety and protection, placing the resident at risk for further abuse.
Failure to Timely Report Financial Abuse Allegation
Penalty
Summary
The facility failed to report an allegation of financial abuse involving a resident to the California Department of Public Health (CDPH) within the required timeframe. The incident involved a resident who had been admitted with diagnoses including anxiety, major depressive disorder, and Alzheimer's disease. The resident reported that a caregiver, whom she had known for over five months, had withdrawn $70,000 from her bank account without her authorization. The resident attempted to report the incident to the county's police department but was unsuccessful. The Director of Nursing (DON) acknowledged receiving the report of the financial abuse allegation from the Social Services Designee on May 13, 2024, although the initial report was made to a Registered Nurse (RN) by the General Acute Hospital (GACH) on the evening of May 12, 2024. The facility submitted the SOC 341 form and contacted CDPH on May 13, 2024, but this was not within the required two-hour timeframe. The facility's policy mandates immediate reporting of such allegations to the state licensing/certification agency, defined as within two hours if the allegation involves abuse or results in serious bodily injury.
Failure to Honor Resident's Advance Directive
Penalty
Summary
The facility failed to implement a system that allowed staff to quickly and accurately identify code status in the event of an emergency and failed to honor the advance directive of one resident. Specifically, staff initiated cardiopulmonary resuscitation (CPR) on a resident who was found unresponsive, despite the resident having a signed physician's order for life-sustaining treatment (POLST) and an advance directive on file that indicated the resident elected do not resuscitate (DNR). As a result, the resident endured painful resuscitation procedures, sustained injuries, was hospitalized, and expired in the hospital the following day. The deficiency was identified when staff could not locate the resident's most recent POLST form, which indicated DNR, and instead used an outdated POLST form that indicated full code. The resident's POLST form from 2016, which reflected full code, was in the POLST book at the nurse's station, while the updated POLST form from 2021, indicating DNR, was not readily accessible. This led to the initiation of CPR and subsequent hospitalization of the resident. Interviews with staff revealed that the process for maintaining and accessing POLST forms was not followed correctly. The Director of Nursing (DON) and the Administrator acknowledged that the POLST process was broken, and the resident's wishes were not honored due to the failure to update and maintain accurate records. The facility's non-compliance with the requirements of participation caused serious harm to the resident, resulting in injuries and prolonged death.
Failure to Prevent Cross-Contamination in Food Preparation
Penalty
Summary
The facility failed to ensure food was prepared and served in a manner to prevent potential cross-contamination. Specifically, Cook #6 was observed working in the kitchen with a full beard and did not wear a beard restraint while preparing drinks for the lunch meal service. Despite being reminded by the Dietary Director earlier that morning, Cook #6 completed the lunch meal service without wearing a beard restraint. During an interview, Cook #6 acknowledged the facility's expectation for dietary staff to wear hair restraints and admitted to forgetting to wear one due to being busy. The Dietary Director confirmed that staff were expected to restrain all hair before entering the kitchen and that beard restraints were available for staff use. Additionally, Cook #7 was observed plating food during the lunch meal service and then turning away from the meal service line to use a spatula to flip a quesadilla on the grill without washing hands or changing gloves between tasks. Cook #7 admitted, through a translator, that he was aware of the requirement to change gloves when changing tasks. The Director of Nursing (DON) and the Administrator both confirmed the facility's policy that dietary staff must wear hairnets or covers, including beard covers if applicable, and change gloves between tasks. These failures had the potential to affect all 125 residents who received meals from the dietary department.
Infection Control and Perineal Care Deficiencies
Penalty
Summary
The facility failed to test staff identified via contact tracing as having a high-risk COVID-19 exposure, which had the potential to affect all residents. The Infection Preventionist (IP) did not maintain a log or documentation of staff testing, and staff were instructed to self-test without proper follow-up. One staff member, CNA #11, did not complete the required testing and worked while symptomatic, leading to a positive COVID-19 test result. The Director of Nursing (DON) and the Administrator confirmed that staff testing should be documented and conducted on days one, three, and five, regardless of work schedule, and that symptomatic staff should not work without a test. However, these protocols were not followed, resulting in a lapse in infection control measures. The facility also failed to ensure that perineal care was performed in a sanitary manner for a resident with severe cognitive impairment and multiple diagnoses, including sepsis and a stage 4 pressure ulcer. During an observation, CNA #10 was seen placing soiled washcloths in the same bag as clean ones and then using another washcloth from the contaminated bag to continue cleaning the resident. This practice was confirmed by the IP, DON, and Administrator as improper, as it contaminated the clean washcloths. The facility lacked a detailed policy on the steps for performing perineal care, and the Director of Staff Development (DSD) indicated that there was no set procedure being taught to staff. These deficiencies highlight significant lapses in the facility's infection prevention and control program, as well as in the training and execution of basic care procedures. The lack of proper documentation, adherence to testing protocols, and clear guidelines for perineal care contributed to these failures, potentially compromising the health and safety of the residents.
Inaccurate PASRR Screenings for Mental Disorders
Penalty
Summary
The facility failed to ensure the accuracy of Level I PASRR screenings for two residents, leading to discrepancies in their mental health diagnoses and the required evaluations. Resident #12 was admitted with diagnoses including schizophrenia, major depressive disorder, and bipolar disorder. However, the Level I PASRR screening incorrectly indicated that the resident did not have a serious mental illness, resulting in a negative screening and no Level II evaluation. This was despite the resident's care plan and MDS indicating severe cognitive impairment and active diagnoses of serious mental illnesses, including the use of antidepressant and antipsychotic medications. Similarly, Resident #110 was admitted with diagnoses of bipolar disorder, major depressive disorder, and anxiety disorder. The Level I PASRR screening initially indicated a positive result due to suspected mental illness, but a subsequent review by the California Department of Healthcare Services concluded that the resident did not have a serious mental illness, negating the need for a Level II evaluation. This was inconsistent with the resident's care plan and MDS, which documented active diagnoses of anxiety disorder, depression, and bipolar disorder, along with the use of psychotropic, antianxiety, and antidepressant medications. Interviews with facility staff revealed a lack of clarity and responsibility in verifying the accuracy of PASRR screenings completed at hospitals. MDS nurses and the marketer responsible for new admissions did not thoroughly review the PASRRs for accuracy, leading to the discrepancies. The Director of Nursing and the Administrator both expected the PASRRs to accurately reflect the residents' clinical conditions, but this expectation was not met, resulting in the identified deficiencies.
Failure to Update PASRR Following New Mental Health Diagnosis
Penalty
Summary
The facility failed to submit a status change to a Level I PASRR following a new mental health diagnosis for a resident. Specifically, the resident had a prior positive Level I PASRR but was later diagnosed with anxiety, and the facility did not update the PASRR evaluation. The resident was admitted with a history of schizophrenia and later diagnosed with anxiety, receiving medications for both conditions. Despite the new diagnosis, the facility did not complete an updated PASRR as required by policy and state guidelines. Interviews with facility staff, including MDS nurses and the Director of Nursing, confirmed that a new Level I PASRR should have been completed when the resident received the new diagnosis. The Administrator was unaware of the need to update the PASRR for new mental health diagnoses. The failure to update the PASRR was identified during a review of the resident's medical records and facility policies, which indicated that all new psychiatric diagnoses should prompt a new PASRR evaluation.
Failure to Re-evaluate PRN Psychotropic Medication
Penalty
Summary
The facility failed to ensure that a resident's medication regimen was free from unnecessary medications. Specifically, a resident had an order for lorazepam, a benzodiazepine used to treat anxiety, that was started without a stop date or re-evaluation for continued use. The facility's policy required that PRN orders for psychotropic medications not be renewed beyond 14 days unless the healthcare practitioner evaluated the resident for the appropriateness of the medication and documented the rationale for continued use. However, this policy was not followed in the case of the resident, who had a PRN order for lorazepam that was not re-evaluated after 14 days, leading to a deficiency in medication management. The resident, who was admitted to the facility with a medical history that included schizophrenia and anxiety, had a BIMS score indicating cognitive intactness. The resident's care plan included the use of antianxiety medication due to anxiety manifested by verbalization of anxiousness. Despite the facility's policy and the expectations of the pharmacist and the Director of Nursing, the PRN order for lorazepam was not re-evaluated after 14 days, and there was no stop date or duration included in the order. Interviews with the pharmacist, DON, and Administrator confirmed that the facility did not adhere to the required re-evaluation process for PRN psychotropic medications, resulting in the resident receiving unnecessary medication.
Failure to Follow Vital Sign Parameters for Medication Administration
Penalty
Summary
The facility failed to follow vital sign parameters when administering medications to a resident with a history of hypertension and heart failure. Specifically, the staff did not hold the medication amiodarone when the resident's systolic blood pressure (SBP) was less than 110 mmHg, as outlined in the physician's order. This occurred six times in both February and March 2024, despite the clear instructions in the resident's medication administration record (MAR) and the facility's policy on administering medications safely and as prescribed. Interviews with the nursing staff revealed that they were aware of the importance of following vital sign parameters to prevent adverse effects such as hypotension. However, the staff members involved could not provide a clear explanation for why the medication was administered despite the low SBP readings. One nurse suggested it might have been a click error, while another nurse could not explain the discrepancy. The Director of Nursing (DON) and the facility's physician both emphasized the critical nature of adhering to these parameters to ensure resident safety. The resident involved was cognitively intact and had a documented history of heart failure and hypertension. The physician reiterated that administering amiodarone with a low SBP could exacerbate the resident's condition, potentially leading to severe hypotension and other complications. The facility's failure to follow the prescribed medication administration guidelines directly contradicted their own policies and the physician's orders, putting the resident at risk for adverse health events.
Inaccurate Medical Records and Unnecessary Medication
Penalty
Summary
The facility failed to maintain accurate medical records for a resident who was prescribed unnecessary medications. The resident was admitted with a diagnosis of schizophrenia, which was later found to be inaccurately documented by the MDS Nurse. The resident's medical records, including the Minimum Data Set (MDS), care plan, and Medication Administration Record (MAR), all reflected this incorrect diagnosis, leading to the administration of Seroquel for schizophrenia, a condition the resident did not have. The error was discovered during a review of the resident's records and interviews with facility staff. The MDS Nurse admitted to mistakenly entering the diagnosis of schizophrenia into the resident's medical record, believing it was supported by the psychiatry notes. However, further review revealed that the resident was actually experiencing psychosis related to Parkinson's Disease, not schizophrenia. The Consultant Pharmacist and Psychiatric Mental Health Nurse Practitioner (PMHNP) confirmed that the resident did not have a diagnosis of schizophrenia. Interviews with the Director of Nursing (DON) and the facility Administrator highlighted the importance of accurate diagnoses for residents. The DON emphasized that residents must have appropriate diagnoses based on psychiatric evaluations, and the Administrator stated that it was his expectation for resident diagnoses to be accurate. The facility's failure to ensure accurate documentation led to the inappropriate use of psychotropic medication for the resident.
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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