Kei-ai South Bay Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Gardena, California.
- Location
- 15115 S Vermont Ave, Gardena, California 90247
- CMS Provider Number
- 555306
- Inspections on file
- 53
- Latest survey
- March 11, 2026
- Citations (last 12 mo.)
- 19
Citation history
Health deficiencies cited at Kei-ai South Bay Healthcare Center during CMS and state inspections, most recent first.
A resident with a history of falls, femur fracture, gait abnormalities, muscle weakness, moderate cognitive impairment, poor standing balance, and impaired safety awareness was identified as high risk for falls through a Morse Fall Risk Screen, PT evaluation, and MDS assessment. The initial fall risk care plan included general assistance with ADLs, transfers, ambulation, and toileting but did not specify staff monitoring or supervision. After multiple unwitnessed falls in which the resident slid from the bed, the IDT documented that the resident perceived themself as independent and forgot to call for help, and added measures such as a falling star program, post-fall assessments, education to use the call light, and environmental adjustments. Despite these repeated falls and documented risk factors, the care plans created after each incident did not define the frequency or level of staff supervision or monitoring, contrary to facility expectations described by nursing leadership.
Two residents with cognitive impairment and significant medical conditions were involved in a physical altercation after one became verbally aggressive and struck the other. A CNA present attempted to verbally de-escalate but did not immediately separate the residents or call for help, contrary to facility policy. This lack of prompt intervention resulted in one resident being hit.
A resident with severe cognitive impairment and a history of wandering was not accurately assessed on the MDS, despite multiple progress notes, care plans, and staff interviews confirming frequent wandering and the need for redirection. The MDS assessment failed to reflect this behavior, and staff acknowledged the inaccuracy.
Surveyors identified that call light buttons were not placed within reach for four residents with significant medical and cognitive needs, including those with a history of falls and mobility limitations. Staff interviews and documentation review confirmed that call lights were either left out of reach or not provided due to assumptions about residents' abilities, contrary to facility policy.
The facility failed to provide written transfer notifications to three residents and their representatives, as required by policy. A resident with a subdural hematoma, another with hemiparesis, and a third with quadriplegia were transferred to hospitals without written notice, although their representatives were informed by phone. The facility lacked a process for issuing written notices, potentially violating residents' rights.
A facility failed to ensure that a physician performed the initial face-to-face visit and signed admitting orders for a resident with complex medical conditions, as required by policy and federal regulations. Instead, all documentation was signed by an NPP, with no evidence of physician involvement, raising concerns about the adequacy of care.
A resident with an indwelling catheter was not provided with a privacy bag, compromising their dignity. The resident, who was cognitively intact and dependent on staff for personal care, was observed without a privacy bag, which was confirmed by an LVN and a CNA. The facility's policy on dignity, which requires catheter bags to be covered, was not followed.
A resident with severe cognitive impairment and multiple health issues did not have their call light within reach on two occasions, as observed by surveyors. Facility staff acknowledged the oversight, which contradicted the facility's policy requiring call lights to be accessible to residents. This deficiency highlights a lapse in ensuring the resident's ability to request assistance.
A resident with COPD and fluctuating decision-making capacity was found with dirty and untrimmed fingernails, contrary to the facility's policy requiring daily cleaning and trimming. Staff acknowledged the oversight, noting the potential for infection and self-injury due to the resident's nail condition.
A resident with severe cognitive impairment and a history of pressure ulcers had their low air loss (LAL) mattress incorrectly set at 400 pounds instead of their actual weight of 135 pounds. This discrepancy was observed by an LVN, who confirmed that the settings should match the resident's weight to prevent skin breakdown. The facility's policies lacked specific guidance on the correct use of LAL mattresses, contributing to the deficiency.
A resident with COPD was observed receiving oxygen therapy at 3 liters per minute, contrary to the physician's order of 2 liters. An LVN confirmed the discrepancy, noting potential risks due to the higher oxygen level. The facility's policy requires adherence to physician orders for safe oxygen administration.
A resident with a history of heart conditions did not receive their prescribed Metoprolol on time, as it was administered outside the facility's one-hour window policy. Both an LVN and the Administrator acknowledged the late administration and the associated risks, highlighting a failure to adhere to the medication schedule.
The facility failed to maintain a medication error rate below 5%, resulting in a 6.67% error rate. A resident with heart conditions received their Metoprolol late, and another resident with psychosis and dementia did not receive their Depakote on time due to it not being ordered. The facility's policy requires medications to be administered within one hour of the prescribed time, which was not followed.
A resident missed nine doses of Depakote due to the facility's failure to order the medication from the pharmacy. The resident, with diagnoses including psychosis and dementia, was dependent on staff for daily activities. The absence of the medication was discovered during an interview with an LVN, who found that the pharmacy had not received a faxed order. The facility's policy required documentation for withheld or delayed medications, but this was not followed.
The facility failed to label and date a Ziplock bag containing 52 Tylenol suppositories in the medication storage room, as observed by an LVN. The lack of labeling posed a risk of medication errors, as confirmed by the Administrator, who noted the importance of labeling to determine medication ownership and expiration. The facility's policy requires refrigerated medications to be stored securely and labeled, which was not followed.
A resident with dementia and other health issues experienced a delay in dental care due to the facility's failure to follow up on necessary denture realignment. Despite monthly visits from the dental service, the resident's loose dentures were not addressed for a year, as confirmed by the Social Services Director and the Administrator.
A facility failed to change a resident's oxygen tubing within the required seven-day period, as per their infection prevention and control policy. The resident, with chronic health conditions, was observed with tubing that had not been changed for over a week, placing them at risk for infection. Staff interviews confirmed the oversight and the importance of adhering to the policy.
A resident with multiple health issues experienced a significant change in condition when a new wound was identified, and new treatment orders were issued. The facility failed to notify the resident's representative within 24 hours, as required by policy, resulting in a violation of the resident's rights.
A resident with multiple health conditions developed a new wound, but the facility failed to implement a care plan despite new treatment orders. The absence of a care plan meant the resident might not receive proper care, as confirmed by an LVN.
A facility failed to provide a resident with a physician-ordered CT scan and general surgeon referral. The resident, with a history of multiple myeloma, ulcerative colitis, and end-stage renal disease, required these services due to ascites and localized swelling. Despite physician orders, the facility did not follow up with the necessary medical providers after initial contact, leading to a delay in care. Interviews revealed that desk nurses and the resident's assigned nurse were responsible for organizing these services, but failed to do so, contrary to the facility's policy on referrals.
A resident with multiple health conditions, including MRSA, did not receive proper infection control measures in an LTC facility. The resident's soiled wound dressing was not changed, and a CNA failed to wear required PPE while providing care. These actions were against the facility's infection prevention policies and physician's orders.
A resident with multiple health conditions experienced a change of condition, including wheezing and vomiting, but the LVN failed to reassess the resident or notify the physician, leading to the resident's death. The care plan required prompt reporting of such symptoms, but the LVN prioritized other tasks, neglecting to follow the facility's policy for reassessment and documentation.
A resident with complex medical needs experienced shortness of breath, wheezing, vomiting, and sweating. An LVN administered treatment but failed to document follow-up vital signs, which was required by the facility's policy. Interviews with staff indicated that the resident's symptoms were a change of condition, necessitating reassessment and documentation, which were not performed. This lack of documentation potentially contributed to the resident's death.
A nurse in an LTC facility failed to perform hand hygiene between glove changes during wound care for three residents, potentially leading to cross-contamination. The residents had various conditions, including sepsis, dementia, and pressure ulcers. The facility's policy requires hand washing between glove changes, which was not followed.
A resident with acute respiratory failure, metabolic encephalopathy, and a UTI refused to participate in the RNA program due to pain. Despite documentation of the resident's refusal over several dates, the facility failed to timely develop a comprehensive care plan addressing this issue. The ADON acknowledged the delay in creating a care plan, which was against the facility's policy requiring updates for significant changes in a resident's condition.
A facility failed to monitor a resident's elevated skin condition as per physician's orders and facility policy. The resident, with multiple diagnoses, had a lump on the left posterior thigh that required monitoring for changes in size, pain, and drainage. However, staff did not document measurements of the lump, preventing proper assessment of its progression. Interviews with staff confirmed the lack of documentation, which was against the facility's policy requiring a full wound assessment.
A resident with multiple health conditions experienced unmanaged pain due to the facility's failure to conduct a pain assessment and administer prescribed medication. Despite complaints of pain and refusal to participate in activities, there was no documentation of pain management interventions, contrary to the facility's policy.
A resident with a history of acute respiratory failure, metabolic encephalopathy, and UTI experienced a delay in treatment due to the facility's failure to promptly notify the physician of abnormal urinalysis results. The urinalysis showed abnormal findings, but the physician was not informed until several days later, contrary to the facility's policy requiring timely communication in cases of acute illness or condition change.
The facility failed to report the misappropriation of funds for a resident within the required two-hour window, leading to a delay in investigation. Despite being informed by the resident's family and the Ombudsman, the staff did not take prompt action, violating the facility's abuse policy.
The facility failed to investigate unauthorized charges on a resident's credit card after the Ombudsman reported the issue. Despite the resident's family notifying the administrator and social worker, no investigation was conducted, and the Ombudsman's emails went unanswered. The facility's policy on investigating theft and misappropriation of resident property was not followed.
The facility failed to accurately document the provision of Restorative Nursing Assistant (RNA) services for three residents, potentially affecting their care. Despite residents confirming they received RNA services, documentation was missing on multiple dates. The Director of Nursing emphasized the importance of consistent documentation for patient well-being.
The facility failed to report an abuse incident where a resident threw water at another resident within the required 2-hour timeframe. Despite the incident being reported internally, it was not communicated to the CDPH as mandated by the facility's policy.
The facility failed to investigate an allegation of abuse and separate two residents after one reported throwing water at the other. Despite the incident being reported to an LVN, no further action was taken, and the residents were not separated until much later when the DON was informed.
Failure to Revise Fall Care Plan to Include Supervision and Monitoring
Penalty
Summary
The deficiency involves the facility’s failure to revise and individualize a resident’s care plan to include person-centered safety measures such as staff supervision and monitoring, despite multiple indicators of high fall risk. The resident was admitted with a history of falls and a left femur fracture, anxiety disorder, gait and mobility abnormalities, and muscle weakness. A Morse Fall Risk Screen identified the resident as high risk for falls, and a PT evaluation documented decreased strength, functional mobility, postural alignment, poor standing balance, and impaired safety awareness, with risk factors including falls and further functional decline. An MDS assessment showed moderate cognitive impairment and a need for substantial/maximal assistance with ADLs and partial/moderate assistance with transfers and walking. The initial care plan for high risk of falls, dated shortly after admission, included general interventions such as assistance with ADLs, transfers, ambulation, and toileting, but did not specify monitoring or supervision parameters. After an unwitnessed fall in which the resident slid off the bed while using a urinal, an IDT meeting documented that the resident perceived himself as independent and forgot to call for assistance, and added a falling star program as a new intervention. A care plan for this actual fall focused on assessing for pain or injury and educating the resident to call for help, but again did not address monitoring or supervision. Subsequent unwitnessed falls occurred with similar circumstances of the resident sliding from the bed, and IDT documentation again cited the resident’s perception of independence and forgetting to use the call light. Following each of the additional unwitnessed falls, new care plans were created that emphasized post-fall assessments such as checking range of motion, neuro checks, PT consults, vital signs, and reinforcing the need to call for assistance, as well as environmental measures like keeping areas free of clutter. However, none of these care plans specified the frequency or level of staff monitoring or supervision for this high-risk resident. Interviews with an LVN, the ADON, and the DON confirmed that the care plans did not include clear directions on monitoring or supervision, despite facility practice and policy indicating that high fall-risk residents should receive frequent monitoring and that care plans must be revised when resident condition changes or when desired outcomes are not met.
Failure to Prevent Resident-to-Resident Altercation Due to Inadequate Supervision
Penalty
Summary
The facility failed to provide adequate staff supervision for two residents, resulting in a physical altercation. Both residents had moderately impaired cognitive skills and required varying levels of assistance with daily activities. One resident, who had end stage renal disease, COPD, and diabetes, was struck on the left side of the face by another resident with a history of urinary tract infection, bilateral below-knee amputation, and COPD. The incident occurred when the second resident, while sitting in his wheelchair and eating lunch, became verbally aggressive and called the first resident names, telling him to get out of the way. A certified nurse assistant (CNA) was present in the room and observed the verbal aggression. The CNA stood between the two residents and attempted to verbally de-escalate the situation by telling the aggressive resident to be nice. Despite this, the aggressive resident suddenly hit the other resident. The CNA later acknowledged that she should have separated the residents immediately or called for help, and that the incident could have been prevented with prompt action. Interviews with facility leadership, including the Director of Staff Development and the Director of Nursing, confirmed that the facility's policy requires immediate separation of residents during altercations to prevent harm. Review of facility policies also indicated that resident safety, supervision, and prompt intervention during altercations are priorities. The failure to separate the residents promptly and provide adequate supervision directly led to the physical altercation and the resulting deficiency.
Plan Of Correction
F689 Corrective action for residents found to have been affected by this deficiency: CNA 1 was provided a one-on-one in-service and education regarding immediate separation and de-escalation of potential resident-to-resident altercation on 8/4/25. Corrective action for residents that may be affected by this deficiency: On 7/31/25, the Director of Staff Developer/designee interviewed staff to identify any resident roommate incompatibility to ensure supervision and communication to prevent potential resident incidents. Measures that will be implemented to monitor the continued effectiveness of the corrective action taken to ensure that this deficiency has been corrected and will not reoccur: On 8/4/25 and 8/5/25, the DON/designee provided an in-service and education training to staff regarding the facility’s policies and procedures on resident-to-resident altercation; to act promptly and conscientiously to prevent and address recurrent altercations, separate immediately, and measures to calm or diffuse the situation. The Director of Staff Developer/designee will validate compliance during observation rounds daily, checking if staff are responding immediately to potential resident incidents. The Director of Staff Developer/designee will communicate findings to the DON. Measures that will be put into place to ensure that this deficiency does not reoccur: The above Plan of Correction (POC) will be reviewed in the QAPI committee for 3 months and as needed thereafter. The Administrator and/or Designee will report trends. Measures that will be implemented to monitor the continued effectiveness of the corrective action taken to ensure that this deficiency has been corrected and will not reoccur: On 8/4/25 and 8/5/25, the DON/designee provided an in-service and education training to staff regarding the facility’s policies and procedures on resident-to-resident altercation; to act promptly and conscientiously to prevent and address recurrent altercations, separate immediately, and measures to calm or diffuse the situation. The Director of Staff Developer/designee will validate compliance during observation rounds daily, checking if staff are responding immediately to potential resident incidents. The Director of Staff Developer/designee will communicate findings to the DON. Measures that will be put into place to ensure that this deficiency does not reoccur: The above POC will be reviewed in the QAPI committee for 3 months and as needed thereafter. The Administrator and/or Designee will report trends.
Inaccurate MDS Assessment of Wandering Behavior
Penalty
Summary
A deficiency was identified when the facility failed to ensure the accuracy of a resident's Minimum Data Set (MDS) assessment regarding wandering behavior. The resident in question had a history of Alzheimer's disease, anxiety, and dementia, with documentation indicating severe cognitive impairment and an inability to make decisions. Multiple progress notes and care plans described the resident as exhibiting wandering behavior, including entering other residents' rooms and taking their belongings, which required staff intervention and redirection. Despite this documented behavior, the MDS assessment completed for the resident did not indicate any wandering behavior. Interviews with facility staff, including a CNA, the MDS Coordinator Nurse, the Director of Nursing (DON), and the Social Service Assistant (SSA), confirmed that the resident did, in fact, wander and required frequent redirection. The DON and SSA both acknowledged that the MDS assessment was inaccurate and did not reflect the resident's actual behavior. The facility's policy and procedure on the Resident Assessment Instrument stated that each discipline assigned to complete a section of the MDS is responsible for the accuracy of the information. The failure to accurately document the resident's wandering behavior on the MDS assessment was confirmed through record review and staff interviews, resulting in a deficiency for not ensuring the assessment accurately reflected the resident's status.
Plan Of Correction
F641 Corrective action for residents found to have been affected by this deficiency: Resident number 1 was kept safe. Roommate that was involved was moved to another room immediately on 7/7/25. Resident 1 was monitored for any signs and symptoms of emotional distress, none noted. On 8/5/25, MDS consultant gave one-on-one in-service and education to SSA 1 regarding proper and accurate behavioral coding, i.e., resident exhibiting wandering behavior. Corrective action for residents that may be affected by this deficiency: On 8/5/25, MDS coordinator reviewed residents with behavior emphasizing on residents with wandering behavior. None were noted. Measures that will be implemented to monitor the continued effectiveness of the corrective action taken to ensure that this deficiency has been corrected and will not reoccur: On 8/5/25, MDS consultant provided in-service and education training to MDS nurses and Social Services staff in regards to proper and accurate behavior assessment and coding. MDS accuracy will be reviewed by IDT member to ensure behaviors were accurately captured and documented during admission record review and scheduled residents' care conference. MDS consultant will validate compliance twice a month as scheduled. Findings will be reported to DON for follow-up. Measures that will be put into place to ensure that this deficiency does not reoccur: The above POC will be reviewed in the QAPI committee for 3 months and as needed thereafter. Administrator and/or Designee will report trends.
Failure to Ensure Call Light Accessibility for Multiple Residents
Penalty
Summary
Surveyors found that the facility failed to ensure call light buttons were placed within reach for four out of six sampled residents. During inspection, call light buttons were observed to be inaccessible: one was behind a pillow at the head of a bed, another was on the floor, and two were on beds but out of reach. Interviews with residents confirmed they could not access their call lights, and staff interviews revealed that in some cases, the call lights were not placed within reach after care was provided or were not provided due to assumptions about residents' abilities to use them. The facility's policy requires call lights to be placed within reach before staff leave the room. The residents affected had significant medical conditions, including diabetes, heart failure, kidney failure, epilepsy, osteoarthritis, hypertension, encephalopathy, schizophrenia, dementia, dysphasia, and physical limitations such as a contracted hand. Some had a history of falls and required assistance with mobility and transfers. Documentation reviewed included admission records, MDS assessments, care plans, and nurse notes, which indicated the need for call lights to be accessible as part of fall prevention and to allow residents to communicate their needs.
Failure to Provide Written Transfer Notifications
Penalty
Summary
The facility failed to adhere to its policy and procedure regarding the provision of written notifications of transfer for three residents who were transferred to general acute care hospitals. Resident 1, who lacked the capacity to make medical decisions due to a subdural hematoma, was transferred to a hospital without written notification being provided to their representative. Similarly, Resident 2, who had the capacity to make medical decisions and a history of hemiparesis following a stroke, was transferred without written notification to their emergency contact, despite being informed via telephone. Resident 3, who had quadriplegia and the capacity to make medical decisions, was also transferred without written notification to their representative, although they were informed by phone. Interviews with the Registered Nurse and the Director of Nursing revealed that the facility did not have a process in place to provide written notices of transfer, as required by their policy. The policy, dated December 2016, mandates that residents and their representatives receive written notification detailing the reason, time, and location of the transfer, as well as information about their rights, including the right to appeal the transfer. The lack of written notification potentially violated the residents' rights and left their representatives uninformed about the transfer details.
Failure to Ensure Physician Face-to-Face Visits and Orders
Penalty
Summary
The facility failed to adhere to its policy and procedure regarding physician services, specifically in ensuring that physicians perform the initial face-to-face visit, sign admitting physician orders, and alternate visits with a non-physician practitioner (NPP). This deficiency was identified for one resident who was admitted with a history of subdural hematoma, end-stage renal disease requiring dialysis, and multiple myeloma. The resident's admission record and subsequent medical documentation, including the history and physical, physician orders, and progress notes, were all signed by an NPP, with no evidence of a physician's face-to-face contact. The Director of Nursing confirmed that the facility's policy required physician visits and documentation to comply with current regulations, which mandate that physicians must perform the initial comprehensive visit and sign admission orders. The review of the Code of Federal Regulations further supported that NPPs are not permitted to perform these initial tasks in skilled nursing facilities. The lack of physician involvement in the resident's care raised concerns about the thoroughness of assessments and the safety and adequacy of care provided.
Failure to Provide Privacy Bag for Catheter Compromises Resident Dignity
Penalty
Summary
The facility failed to ensure that a resident with an indwelling catheter had a privacy bag, which compromised the resident's dignity. The resident, who was cognitively intact and dependent on staff for personal care, was observed without a privacy bag for the catheter. This observation was confirmed by both a Licensed Vocational Nurse (LVN) and a Certified Nursing Assistant (CNA), who acknowledged that the absence of a privacy bag could lead to embarrassment and a loss of dignity for the resident. The facility's policy on Quality of Life-Dignity, which mandates that residents be cared for in a manner that promotes dignity and respect, was not adhered to in this instance. The policy specifically prohibits practices that compromise dignity, including the requirement to keep urinary catheter bags covered. The failure to provide a privacy bag for the resident's catheter was a direct violation of this policy, as confirmed by staff interviews and the facility's documentation.
Resident's Call Light Not Within Reach
Penalty
Summary
The facility failed to ensure that a resident, identified as Resident 45, had their call light within reach, which is a critical aspect of meeting the resident's needs and preferences. Resident 45, who was readmitted to the facility with diagnoses including heart failure, acute myocardial infarction, and a syndrome causing colon expansion, was observed on two separate occasions without the call light within reach. The resident's cognitive abilities were severely impaired, and they were dependent on staff for personal care, making the accessibility of the call light essential for their safety and ability to request assistance. During interviews with facility staff, both a Licensed Vocational Nurse (LVN) and a Certified Nursing Assistant (CNA) acknowledged that the call light was not within reach and emphasized the importance of having it accessible to prevent falls and ensure the resident could call for help. The facility's policy and procedure on call light answering, dated December 2023, clearly stated that the call device should be placed within the resident's reach before leaving the room, and staff should check its placement during care. The failure to adhere to this policy resulted in a deficiency in providing adequate care to Resident 45.
Failure to Maintain Resident's Nail Hygiene
Penalty
Summary
The facility failed to ensure that one of the sampled residents, Resident 144, had properly trimmed fingernails. This deficiency was observed during a room visit where Resident 144 was found to have dirty and long untrimmed fingernails. The resident's Minimum Data Set (MDS) indicated that they were dependent on staff for personal hygiene, including nail care. Interviews with the Licensed Vocational Nurse (LVN) and Certified Nursing Assistant (CNA) confirmed that the resident's fingernails were not maintained as per the facility's policy, which requires daily cleaning and regular trimming to prevent infections and skin injuries. Resident 144 had a medical history that included chronic obstructive pulmonary disease (COPD), respiratory failure, and pleural effusion, and was noted to have fluctuating decision-making capacity. The facility's policy on nail care, dated February 2018, outlines the importance of maintaining clean and trimmed nails to prevent infections and skin problems. Despite this policy, the staff acknowledged the oversight, noting that the resident's untrimmed and dirty fingernails could harbor bacteria and potentially cause self-injury or infection.
Incorrect LAL Mattress Settings for Resident
Penalty
Summary
The facility failed to ensure that a low air loss (LAL) mattress was set correctly for a resident, leading to a potential risk of skin breakdown. The resident, who was severely cognitively impaired and dependent on staff for personal care, had a history of pressure ulcers and was using a LAL mattress to prevent further skin damage. During an observation, it was noted that the LAL mattress was set at 400 pounds, while the resident's actual weight was 135 pounds. A Licensed Vocational Nurse (LVN) confirmed that the mattress settings should be adjusted to match the resident's weight to effectively prevent and treat pressure ulcers. The facility's policies on support surfaces and pressure ulcer prevention did not provide specific guidance on the correct use of LAL mattresses. The policy outlined the need for pressure-reducing devices based on various risk factors, but lacked detailed instructions on setting the LAL mattress according to the resident's weight. This oversight in policy and practice contributed to the deficiency, as the incorrect mattress settings could compromise the resident's skin integrity and impede the healing of existing pressure ulcers.
Failure to Follow Physician Orders for Oxygen Therapy
Penalty
Summary
The facility failed to ensure that a resident received oxygen therapy according to the physician's orders. Resident 143, who was admitted with diagnoses including chronic obstructive pulmonary disease (COPD), respiratory failure, and pleural effusion, was observed receiving oxygen therapy set at 3 liters per minute. However, the physician's order specified that the resident should receive 2 liters of oxygen via nasal cannula continuously every shift. This discrepancy was confirmed during an observation and interview with a Licensed Vocational Nurse (LVN), who acknowledged that the physician's orders were not being followed. The LVN expressed concern that administering oxygen at 3 liters could be dangerous for the resident, particularly given their COPD diagnosis, as it could lead to discomfort or oxygen poisoning. The facility's policy and procedure for oxygen administration, dated October 2010, requires verification of a physician's order and adherence to the specified guidelines for safe oxygen administration. The failure to follow these orders and procedures had the potential to impact the resident's medical care adversely.
Late Administration of Blood Pressure Medication
Penalty
Summary
The facility failed to administer blood pressure medication in a timely manner for one resident, identified as Resident 36. This resident had a history of atrial fibrillation, atherosclerotic heart disease, and hypertensive heart disease, and was dependent on staff for various activities of daily living. The physician's order for Metoprolol, a medication used to manage hypertension, specified a daily dose of 25 milligrams to be administered at 7:30 a.m. However, during an interview and record review, it was revealed that the medication was administered late, outside the one-hour window before or after the scheduled time, as per the facility's policy. Licensed Vocational Nurse 1 confirmed that the medication was considered late and acknowledged the potential risks associated with delayed administration, such as fluctuations in blood pressure. The facility's Administrator also confirmed the late administration and reiterated the importance of adhering to the prescribed medication schedule to avoid adverse side effects and maintain consistency with the resident's medication regimen. The facility's policy on medication administration emphasized the importance of administering medications within the specified time frame, which was not adhered to in this instance.
Medication Error Rate Exceeds 5% Due to Late and Unavailable Medications
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in a combined error rate of 6.67% during the observation of medication administration. Two residents were affected by this deficiency. Resident 36, who has a history of atrial fibrillation, atherosclerotic heart disease, and hypertensive heart disease, did not receive their prescribed Metoprolol on time. The medication was scheduled for 7:30 a.m. but was administered late, which could potentially affect the resident's blood pressure and heart condition. Resident 148, diagnosed with psychosis, dementia, urinary tract infection, and dehydration, did not receive their prescribed Depakote as it was not available in the medication cart or facility. The medication had not been ordered, and the pharmacy was contacted to deliver it later in the day. This delay in medication administration could lead to medication errors and affect the resident's behavior. The facility's policy requires medications to be administered within one hour of the prescribed time, which was not adhered to in these cases.
Failure to Order Medication Results in Missed Doses
Penalty
Summary
The facility failed to ensure that medication was ordered from the pharmacy for one of the residents, resulting in the resident missing nine doses of Depakote, a medication used to treat aggression. The resident, who was admitted with diagnoses including psychosis, dementia, urinary tract infection, and dehydration, had severely impaired cognitive skills and was dependent on staff for various activities of daily living. The absence of the medication was discovered during an observation and interview with a Licensed Vocational Nurse (LVN), who stated that the pharmacy had not received a faxed order for the medication, leading to the missed doses. The facility's Administrator confirmed that licensed staff were responsible for calling and faxing new physician orders to the pharmacy, and that medications could be delivered the same day or the following day if ordered late. However, there was no explanation provided for why the medication was not ordered and filled. The facility's policy required documentation if a drug was withheld, refused, or given at a different time, but this was not adhered to in this case. The deficiency had the potential to result in the resident exhibiting physical aggression, restlessness, and manic behavior, creating an unsafe environment.
Unlabeled Tylenol Suppositories in Medication Storage
Penalty
Summary
The facility failed to ensure that Tylenol suppositories stored in a clear Ziplock bag in the Station 1 Medication Storage room were labeled and dated. During an observation and interview with an LVN, it was noted that the bag containing 52 rectal Tylenol suppositories was unlabeled and undated. The LVN acknowledged that the bag should have been labeled with an open date and expiration date, and expressed concern that the lack of labeling could lead to medication errors. The LVN was unable to determine if the medication was expired, if it belonged to a resident, or even what the medication was. The facility's Administrator confirmed that all medications in the storage room should be labeled and dated with open and expiration dates. The Administrator also highlighted the risk of medication errors due to the presence of unlabeled medication in the storage refrigerator, noting that it would be unclear whether the medication belonged to a resident or was a house medication, and whether it was expired. The facility's policy on medication storage requires that medications needing refrigeration be stored in a secured location and labeled accordingly, which was not adhered to in this instance.
Failure to Provide Timely Dental Care
Penalty
Summary
The facility failed to ensure dental services were provided for a resident, identified as Resident 35, who had been experiencing issues with loose upper dentures for the past year. Despite the facility's dental service, Golden Age Dental Care, visiting residents monthly, there was no follow-up to address the resident's need for a denture realignment. The resident's son reported the issue, and it was confirmed by the Social Services Director (SSD) that the last dental appointment was on November 1, 2024, with no subsequent action taken to resolve the denture problem. The SSD acknowledged that the Social Services department was responsible for coordinating dental services, including setting appointments and follow-ups. The lack of follow-up was confirmed during an interview with the Administrator, who stated that the responsibility for dental service coordination lay with Social Services. The facility's policy, revised in December 2016, indicated that Social Services should assist residents with dental appointments and related arrangements, but this was not adhered to in the case of Resident 35.
Failure to Change Oxygen Tubing as Per Policy
Penalty
Summary
The facility failed to adhere to its infection prevention and control program by not changing the oxygen tubing for Resident 66 within the required seven-day period. Resident 66, who has chronic obstructive pulmonary disease, heart failure, and chronic kidney disease, was observed with oxygen tubing dated 12/18/2023, which had not been changed by 12/26/2023. This oversight was confirmed through interviews with the Licensed Vocational Nurse, Assistant Director of Nursing, and Infection Preventionist Nurse, all of whom acknowledged the importance of changing the tubing weekly to prevent infection. The facility's policy, as outlined in their Infection Prevention and Control Program and Respiratory Therapy-Prevention of Infection procedures, mandates the change of oxygen cannula and tubing every seven days to prevent infection. The failure to comply with this policy placed Resident 66 at risk for infection, as confirmed by the staff interviews and the facility's documented procedures.
Failure to Notify Resident's Representative of Significant Health Change
Penalty
Summary
The facility failed to notify a resident's representative within 24 hours of a significant change in the resident's health status, violating the resident's rights. The resident, who was unable to make medical decisions, had a history of multiple myeloma, type II diabetes mellitus, and end-stage renal disease. On 11/28/2024, a new wound was identified on the resident, and new physician orders for medications and a wound culture were issued. However, the resident's representative was not informed of these changes until 11/30/2024, two days later. Interviews with facility staff, including the Director of Nursing and a Registered Nurse, confirmed that the facility's policy required notifying a resident's representative of significant changes in condition within 24 hours. Despite this policy, the Licensed Vocational Nurse admitted that the representative was not notified promptly. The facility's policy on changes in a resident's condition was reviewed and indicated that significant changes requiring staff intervention must be communicated to the resident's representative within the specified timeframe.
Failure to Implement Care Plan for Resident's New Wound
Penalty
Summary
The facility failed to develop and implement a care plan for a resident after a new wound was identified. The resident, who was admitted with a history of multiple myeloma, type II diabetes mellitus, and end-stage renal disease, was found to have an abscess on the right buttock with copious pus drainage, indicating an infection. Despite receiving new physician orders for multiple antibiotics and a wound culture on November 28, 2024, there was no corresponding care plan created to address the resident's wound and treatment needs. During a review of the facility's records, it was noted that the resident's care plans dated December 2024 did not include any information related to the new wound or the treatment orders. A Licensed Vocational Nurse confirmed that a care plan should have been implemented when the wound was discovered and when the treatment was modified. The absence of a care plan meant that the resident had the potential to not receive proper care and services for the condition, as the facility's policy requires care plans to be revised as the resident's condition changes.
Failure to Provide Physician-Ordered CT Scan and Surgeon Referral
Penalty
Summary
The facility failed to provide a resident with a physician-ordered CT scan and a referral to a general surgeon. The resident, who was unable to make medical decisions, had a history of multiple myeloma, ulcerative colitis with rectal bleeding, and end-stage renal disease requiring dialysis. The physician orders dated 11/14/2024 and 11/20/2024 indicated the need for a general surgeon referral due to ascites and a CT scan of the right gluteus maximus area due to localized swelling, mass, and lump. However, the facility did not follow up on these orders, as there were no progress notes indicating contact with the general acute care hospital or the general surgeon after 11/25/2024. Interviews with licensed vocational nurses revealed that the facility's desk nurses and the resident's assigned nurse were responsible for organizing the CT scan orders and general surgery referrals. Despite this responsibility, there was a lack of follow-up communication with the necessary medical providers. The facility's policy and procedure on referrals indicated that social services should collaborate with nursing staff to arrange physician-ordered services, but this collaboration did not occur, leading to a delay in care for the resident.
Infection Control Deficiency in Resident Care
Penalty
Summary
The facility failed to implement proper infection prevention precautions for a resident with a history of multiple myeloma, type II diabetes mellitus, and end-stage renal disease. The resident's wound dressing was observed to be soiled with old, dried stool, and it was not changed as required by the physician's orders. The Licensed Vocational Nurse (LVN) acknowledged that the dressing was soiled and should have been changed to prevent infection. The facility's job description for charge nurses indicated that they must administer professional services such as applying and changing dressings, which was not adhered to in this instance. Additionally, the facility did not enforce the required contact isolation precautions for the resident, who had a wound infected with Methicillin-resistant Staphylococcus aureus (MRSA). A Certified Nursing Assistant (CNA) was observed not wearing a gown while providing care to the resident, contrary to the physician's orders and the facility's infection prevention and control program. The LVN confirmed that all staff and visitors must follow the contact precautions to prevent the spread of infection. The facility's policy indicated that infection prevention includes implementing measures to avoid complications, which was not followed in this case.
Failure to Reassess and Notify Physician Leads to Resident's Death
Penalty
Summary
The facility failed to provide necessary care and services for a resident, resulting in the resident's death. The resident, who had multiple diagnoses including hydrocephalus, diabetes mellitus, and was dependent on enteral feeding, experienced a change of condition characterized by wheezing, vomiting, and sweating. Despite these symptoms, the Licensed Vocational Nurse (LVN) did not reassess the resident after administering medications and failed to notify the physician of the change in condition. The resident's care plan required staff to observe and report symptoms such as shortness of breath, wheezing, and vomiting to the physician promptly. However, the LVN prioritized administering medications to other residents over reassessing the resident and notifying the physician. The LVN acknowledged that the resident's airway should have been the priority and that reassessment was crucial to determine the effectiveness of the interventions. Interviews with other staff members, including a Registered Nurse (RN) and the Assistant Director of Nursing (ADON), confirmed that the LVN did not follow the care plan's interventions, which included notifying the physician and reassessing the resident's condition. The facility's policy and procedure also required detailed documentation and physician notification in the event of a change in condition, which was not adhered to in this case.
Failure to Document Vital Signs After Treatment
Penalty
Summary
The facility failed to document vital signs after administering treatment for shortness of breath, wheezing, vomiting, and sweating for a resident. This resident had a complex medical history, including hydrocephalus, diabetes mellitus, aphasia, gastro-esophageal reflux disease, a gastrostomy, and right-sided hemiplegia and hemiparesis. The resident was dependent on staff for personal care and required tube feeding. On the day of the incident, the resident exhibited symptoms of vomiting and sweating, and was assessed by an LVN who noted shortness of breath and wheezing. The LVN administered medications but failed to document follow-up vital signs after the interventions. Interviews with facility staff revealed that the resident's symptoms were considered a change of condition, and the LVN should have reassessed the resident's condition at regular intervals after administering treatment. The facility's policy required documentation of all services provided, changes in the resident's condition, and the resident's response to care. However, the LVN did not document the necessary follow-up assessments, and the ADON confirmed that the lack of documentation indicated that the vital signs were not taken. This failure to document and reassess the resident's condition potentially contributed to the resident's death.
Failure in Hand Hygiene During Wound Care
Penalty
Summary
The facility failed to ensure proper hand hygiene practices were followed by a licensed nurse during wound care procedures for three residents. Observations revealed that the nurse did not perform hand washing or hand sanitizing between changing gloves while attending to the residents' wounds. This practice was noted during wound care for a gastric tube site, sacral area, and other skin treatments, which could potentially lead to cross-contamination and infection spread. Resident 2, who was admitted with diagnoses including sepsis and pressure ulcers, was observed receiving wound care without the nurse sanitizing hands between glove changes. Similarly, Resident 3, with a history of dementia and hemiplegia, also received wound care without proper hand hygiene. Resident 4, diagnosed with colon cancer and pressure ulcers, was another case where the nurse failed to sanitize hands between glove changes during wound care. The facility's policy on dressing changes requires hand washing between glove changes, which was not adhered to by the nurse. The nurse acknowledged the importance of hand hygiene in preventing infection spread and admitted to not following the protocol during the wound care procedures for the residents.
Failure to Develop Comprehensive Care Plan for Resident Refusing RNA Program
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident who was refusing to participate in the Restorative Nurse Assistant (RNA) program due to pain. The resident, who was admitted with acute respiratory failure, metabolic encephalopathy, and a UTI, was documented as having the capacity to understand and be understood according to the Minimum Data Set (MDS). Despite this, the resident consistently refused to walk with the RNA due to pain over several dates in March and April 2022, as noted in the RNA Documentation Survey Report and progress notes. The Assistant Director of Nursing (ADON) acknowledged that the resident's refusal to participate in the RNA program due to pain should have been addressed in a care plan. However, a care plan for noncompliance was only created on April 21, 2022, after a significant delay. The facility's policy and procedure required that individualized comprehensive care plans be developed and updated when there was a significant change in the resident's condition, which was not adhered to in this case.
Failure to Monitor Skin Condition
Penalty
Summary
The facility failed to thoroughly assess and monitor an elevated skin condition, described as a lump, on a resident's left posterior thigh according to the physician's order and the facility's Policy and Procedure (P&P). The resident was admitted with multiple diagnoses, including acute respiratory failure, metabolic encephalopathy, and a UTI. The physician's order required monitoring of the lump for pain, drainage, and increase in size every shift. However, the facility did not document measurements of the lump's size, which was necessary to determine any changes. Interviews with the Licensed Vocational Nurse (LVN) and the Assistant Director of Nursing (ADON) confirmed that the required measurements were not taken, preventing staff from assessing whether the lump was increasing in size. The facility's P&P required a full wound assessment, including size and description, to be documented in the resident's clinical records, which was not done. This oversight had the potential to delay necessary treatment and worsen the resident's skin condition.
Failure in Pain Management for a Resident
Penalty
Summary
The facility failed to provide appropriate pain management for a resident, leading to a deficiency in care. The resident, who was admitted with acute respiratory failure, metabolic encephalopathy, and a urinary tract infection, was noted to have complained of pain and refused to walk and stand with the Restorative Nursing Assistant (RNA) for several days. Despite the RNA reporting the resident's pain to the charge nurse, there was no documentation of a pain assessment being conducted by the Registered Nurse (RN) or any administration of the prescribed Norco medication for pain relief. The Assistant Director of Nursing (ADON) confirmed that the resident's progress notes and Medication Administration Record (MAR) did not indicate any pain assessment or administration of the prescribed pain medication. The facility's policy required a comprehensive pain assessment and documentation of interventions, which were not followed in this case. This oversight had the potential to impact the resident's activities of daily living and mobility due to unmanaged pain.
Delayed Physician Notification of Abnormal Urinalysis Results
Penalty
Summary
The facility failed to ensure timely notification to the physician for a resident's abnormal urinalysis results, leading to a delay in treatment for a urinary tract infection. The resident, who was admitted with diagnoses including acute respiratory failure, metabolic encephalopathy, and a UTI, had a urinalysis and culture ordered due to a change in condition. The urinalysis, collected and resulted on the same day, showed abnormal findings, but the physician was not notified until several days later. Interviews with the Infection Prevention Nurse and the Assistant Director of Nursing revealed that the urinalysis results were not promptly communicated to the physician, contrary to the facility's policy. The delay in notification was acknowledged by the ADON, who stated that the late reporting could lead to a delay in care and potential complications. The facility's policy required prompt notification of physicians in cases of acute illness or condition change, which was not adhered to in this instance.
Failure to Report Misappropriation of Funds
Penalty
Summary
The facility failed to implement its abuse policy and procedure by not reporting the misappropriation of funds to the State Licensing Agency within two hours for one resident. Resident 2, who had a history of falling and was admitted with personal items including credit cards, experienced unauthorized charges totaling $2,286.57 over two billing periods. Despite being informed by the resident's family and the Ombudsman, the facility's staff, including the Administrator and the Director of Social Services, did not report the incident or investigate it promptly. The Director of Nursing was also unaware of the missing wallet and fraudulent charges. The facility's policy required immediate reporting of such incidents to local authorities, but this was not followed. The delay in reporting resulted in a delay in the investigation by the California Department of Public Health. The Director of Social Services admitted to not taking action because the report came from the Ombudsman and not directly from the resident or family members. This inaction led to a failure in addressing the misappropriation of Resident 2's funds in a timely manner, as required by the facility's abuse policy and procedure.
Failure to Investigate Unauthorized Charges on Resident's Credit Card
Penalty
Summary
The facility failed to conduct a thorough investigation after the Ombudsman reported unauthorized charges on a resident's credit card. Resident 2, who was admitted with a history of a left femur fracture, hypertension, and falls, had intact cognitive skills and required moderate assistance with daily activities. The resident's inventory list included personal items such as two cell phones, a charger, a wristwatch, clothing, dentures, and a wallet with identification, cards, and cash. Unauthorized charges totaling $928.18 and $1,358.39 were found on Resident 2's credit card statements for two different periods. Despite the Ombudsman notifying the facility's business office manager via email, the business manager was unaware of the issue, and the social worker and administrator did not investigate further or contact the resident or family members. The Director of Social Services admitted to receiving the email but did not act on it, assuming the Ombudsman would provide more information. The Director of Nursing was also unaware of the missing wallet and fraudulent charges and stated that a theft and loss report should have been opened and investigated by the administrator and social worker. Family member 1 reported the missing credit cards and cash to the administrator, who promised to investigate but did not follow through. The family member also left several voicemails for the social worker, which were not returned, leading them to report the issue to the Ombudsman. The Ombudsman confirmed sending two emails to the facility inquiring about an official investigation but received no response. The facility's policy on investigating theft and misappropriation of resident property, dated December 2006, mandates prompt and thorough investigations of such reports, which was not followed in this case.
Failure to Document Restorative Nursing Services
Penalty
Summary
The facility failed to accurately document the provision of Restorative Nursing Assistant (RNA) services for three residents, which had the potential to negatively affect their care. Resident 1, who was admitted with diagnoses including respiratory failure and hemiplegia, had physician orders for RNA to provide Active Assistance Range of Motion (AAROM) to both legs five times a week. However, there was no documentation of RNA services on several dates in April and May 2024. During an interview, Resident 1 confirmed receiving RNA services, but the RNA admitted that documentation was sometimes incomplete due to assisting as a Certified Nurse Assistant (CNA). The Director of Nursing (DON) emphasized the importance of consistent documentation for patient well-being. Resident 5, admitted with osteoarthritis and muscle weakness, had orders for RNA to ambulate using a platform walker and perform Active Range of Motion (AROM) to both arms five times a week. Similar to Resident 1, there was no documentation of RNA services on multiple dates in April and May 2024. Resident 5 confirmed receiving RNA services and noted improvements in mobility. However, the RNA responsible for documentation admitted to using a phone for documentation, which did not reflect on the RNA sheets. Resident 6, who had diagnoses including contracture of the right hand and major depressive disorder, had orders for RNA to provide AAROM to both arms, passive range of motion (PROM) to the right wrist and fingers, and apply a wrist hand splint. Again, there was no documentation of RNA services on several dates in April and May 2024. Resident 6 confirmed receiving RNA services and showed improvement. The facility's policy and procedure for charting and documentation emphasized the need for complete and accurate records to facilitate communication between the interdisciplinary team. The DON reiterated that lack of documentation could be interpreted as services not being provided as ordered.
Failure to Report Abuse Incident Timely
Penalty
Summary
The facility failed to implement its Policy and Procedure (P&P) titled, Abuse Reporting and Investigation, which required all allegations of abuse to be reported to the California Department of Public Health (CDPH) within 2 hours. This failure was observed in the case of two residents, where Resident 1 threw water towards Resident 4. Despite the incident being reported to a Licensed Vocational Nurse (LVN) by a Certified Nursing Assistant (CNA), the LVN did not report the incident to the CDPH, believing it was not physical abuse. The Director of Nursing (DON) was unaware of the incident until much later and confirmed that any kind of abuse should have been reported immediately to the CDPH. Resident 1, who had a history of respiratory failure, hemiplegia, and hemiparesis following a stroke, admitted to throwing water at Resident 4 due to being upset by the noise of the curtain. Resident 4, who had diagnoses including traumatic subdural hemorrhage and muscle weakness, was unable to understand or make medical decisions. The incident was not reported to the CDPH within the required timeframe, leading to a potential delay in the investigation and underreporting of abuse incidents.
Failure to Investigate and Separate Residents After Allegation of Abuse
Penalty
Summary
The facility failed to thoroughly investigate an allegation of abuse and separate two residents after one resident reported throwing water at the other. Resident 1, who has a history of respiratory failure, hemiplegia, and hemiparesis, admitted to throwing water at Resident 4 because of the noise from the curtain. Despite this admission, the incident was not reported or investigated by the Licensed Vocational Nurse (LVN) who was informed of the event. The LVN did not consider the act as physical abuse and did not take further action. Resident 4, who has a history of traumatic subdural hemorrhage and muscle weakness, was not separated from Resident 1 following the incident. The Director of Nursing (DON) was unaware of the incident until much later and only initiated an investigation and room change after being informed. The facility's policy requires thorough investigation and separation of residents involved in alleged abuse, which was not followed in this case.
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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