Lemon Grove Care And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Lemon Grove, California.
- Location
- 8351 Broadway, Lemon Grove, California 91945
- CMS Provider Number
- 055182
- Inspections on file
- 42
- Latest survey
- December 18, 2025
- Citations (last 12 mo.)
- 27
Citation history
Health deficiencies cited at Lemon Grove Care And Rehabilitation Center during CMS and state inspections, most recent first.
A resident with hearing loss was inaccurately assessed as having adequate hearing in the facility's MDS assessments. Despite being deaf and preferring written communication, the assessments indicated no difficulty in normal conversation. Staff interviews revealed discrepancies in the assessment process, with the Case Manager and MDS Coordinator Nurse acknowledging errors in coding.
A resident on parole with an ankle monitor was admitted to a facility without sufficient information to determine if appropriate care could be provided. The facility lacked specific admission criteria and did not screen for parole status, leading to the resident being sent back to the hospital without a medical need. The DON acknowledged the lack of information and screening criteria in the admission process.
A resident on parole with an ankle monitor was improperly discharged from an LTC facility to a hospital without a valid clinical reason. The resident was admitted, given a room, and provided dinner, but was sent back to the hospital the next day after an administrative staff member questioned their parole status. Interviews with staff revealed the facility admitted the resident without proper screening and later decided they were uncomfortable providing care, despite no documentation of danger or medical need for hospital evaluation.
A resident with early onset Alzheimer's and muscle weakness experienced a fall in the shower while assisted by one CNA, despite requiring two staff members for ADLs. The facility failed to update the care plan with interventions to prevent further falls, as identified by the DON.
A resident's clinical records were inaccurately documented, showing administration of Lithium when it was unavailable and misrepresenting behavior monitoring related to Risperidone. Nurses recorded the medication as given despite pharmacy errors and misinterpreted the resident's actions, leading to incorrect behavior documentation.
The facility failed to develop and implement comprehensive care plans for residents, leading to deficiencies in care. A resident was not assessed for activities, resulting in boredom, while another with PTSD had a care plan lacking trigger identification. A resident requiring dialysis had an inaccurate care plan referencing a non-existent fistula, and a resident at risk for skin breakdown was not repositioned as required. Staff were unaware of critical care needs, and the facility lacked necessary policies.
The facility failed to ensure safe medication storage and handling, with issues including incomplete temperature logs, food in a medication cart, a discontinued medication not removed, an unlocked medication cart, and a medication left unattended at a resident's bedside. These actions violated facility policies and posed risks to resident safety.
A resident was fed in a manner lacking dignity, as a speech therapist stood above her while feeding, contrary to the facility's policy of maintaining eye-level contact. The therapist, in her clinical fellowship, was unaware of this practice, and no training documentation was found.
A resident with Alzheimer's disease was left exposed in a brief and socks, visible from the hallway, due to a CNA not drawing the curtain or closing the door during personal care. Both the CNA and LN acknowledged the lack of privacy, and the DON confirmed that privacy should have been maintained.
A facility failed to provide activities of interest for a resident with a thoracic vertebra fracture, leading to potential impacts on her well-being. The resident expressed dissatisfaction with the activities, and an activity/interest assessment was not completed as required. The facility's policy to plan activities according to residents' preferences was not followed.
A resident with PTSD did not receive trauma-informed care due to the facility's failure to identify and manage the resident's triggers. Staff interviews revealed a lack of awareness regarding the resident's specific triggers, leading to an inadequate care plan. The facility's policy requires trauma-informed care, but the necessary steps to explore and address the resident's needs were not taken.
A licensed nurse in a LTC facility failed to competently administer medications to a resident, leaving the medication cart unlocked and unattended, and using unlabeled cups for crushed medications. The nurse did not verify vital signs before administering Amlodipine, leading to potential safety risks. The Director of Nursing and Director of Staff Development acknowledged the nurse's incompetence in medication administration.
A facility's medication error rate was 8.33%, exceeding the acceptable limit. An LPN made errors during medication administration for two residents, including incorrect dosages and incomplete administration. The LPN acknowledged not following physician's orders, and the DON confirmed the expectation for adherence to prescribed orders.
A resident was served pureed food and nectar thick beverages without a physician's order, despite being on a mechanical soft diet with thin liquids. The resident expressed dissatisfaction with the meals, and facility staff confirmed the inconsistency. The facility's policy lacked guidance on food texture and beverage consistency.
A resident's medication administration record inaccurately documented the administration of a Lactobacillus capsule, which was not given. LN 10 admitted to the error, acknowledging the active order for the capsule despite discussions of its discontinuation. The DON emphasized the expectation for accurate documentation.
A resident with a g-tube was at risk of infection when an LN attempted to administer medication that had been discarded in the trash. The LN initially failed to dissolve the medication properly, discarded it, and then retrieved it from the trash to administer. A surveyor intervened, and the DON and IPN confirmed the breach of infection control practices.
Inaccurate Resident Hearing Assessment
Penalty
Summary
The facility failed to accurately code the required resident assessment for a resident, which had the potential to not identify the resident's needs. The resident was admitted with health conditions requiring assistance with personal care and unspecified hearing loss. During an unannounced visit, it was found that the resident was deaf and preferred written communication, which she responded to verbally. However, the facility's MDS assessments inaccurately indicated that the resident's hearing was adequate, showing no difficulty in normal conversation or social interaction. Interviews with facility staff revealed discrepancies in the assessment process. The Case Manager acknowledged that the MDS assessments were expected to be completed in person, but a mistake was made in the coding of the resident's hearing ability. The MDS Coordinator Nurse confirmed signing off on the assessments but could not recall why the resident's hearing was coded as adequate. The Social Worker responsible for the most recent assessment was unavailable for comment, leaving the error unexplained.
Failure to Implement Admission Policy for Resident with Parole Status
Penalty
Summary
The facility failed to implement its admission policy when a resident was admitted without sufficient information to determine if appropriate care and services could be provided. The resident, who was on parole and wore an ankle monitor, was admitted to the facility and later sent back to the hospital without a medical need for hospital treatment. The facility's admissions coordinator stated that the facility did not have specific admission criteria and did not screen for parole status or criminal background, although they had previously admitted residents with similar backgrounds. The director of nursing acknowledged that the facility did not have sufficient information about the resident's parole status and that the hospital did not disclose this information. The facility's admission process lacked criteria to screen for residents with criminal history or those on parole, which led to the resident being admitted without proper screening. The facility's policy indicated that admission decisions should be based on the ability to meet the medical and psychosocial needs of the resident, but this was not followed in this case.
Improper Discharge of Resident Without Valid Clinical Reason
Penalty
Summary
The facility failed to ensure that a resident was permitted to remain in the facility when they were discharged to the hospital without a valid clinical reason. The resident, who was on parole and wearing an ankle monitor, was admitted to the facility, given a room and bed, and provided dinner. The next morning, an administrative staff member questioned the resident about their parole status and ankle monitor, subsequently informing the resident that they could not stay at the facility and would have to return to the hospital. The resident was then transported back to the hospital, despite not having a medical need that required hospital treatment. Interviews with facility staff, including the admissions coordinator, licensed nurse, and director of nursing, revealed that the facility had admitted the resident without properly screening them and later decided they were not comfortable providing care. The facility's policy states that a resident should not be transferred or discharged unless it is necessary for their welfare, their health has improved, or the safety and health of others in the facility are endangered. However, there was no documentation indicating that the resident posed a danger to themselves or others, nor was there a medical situation necessitating hospital evaluation.
Failure to Update Care Plan After Resident Fall
Penalty
Summary
The facility failed to update the care plan with resident-specific interventions for a resident who was reviewed for falls. The resident, who was admitted with diagnoses including muscle weakness, cognitive communication deficit, and early onset Alzheimer's disease, was dependent on staff for showering. The Minimum Data Set (MDS) indicated that the resident required the assistance of one staff member for activities of daily living (ADLs) prior to a fall incident. However, after the fall, it was determined that the resident required two staff members for assistance. The deficiency was identified when the resident reported a fall in the shower while sitting in a shower chair, with only one Certified Nursing Assistant (CNA) present. The Director of Nursing (DON) identified the root cause of the fall as a sudden movement by the resident and stated that interventions to prevent further falls included providing bed baths instead of showers and educating the resident and staff. Despite these findings, the resident's care plan was not updated with the necessary interventions to address the root cause of the fall, as required by the facility's Falls Prevention policy.
Inaccurate Documentation of Medication and Behavior Monitoring
Penalty
Summary
The facility failed to ensure accurate documentation in the clinical record for a resident who was prescribed Lithium, a mood stabilizing medication. The resident's medication administration record (MAR) inaccurately indicated that Lithium was administered on multiple occasions when the medication was not available due to a pharmacy error. The pharmacy had not dispensed the medication because they believed the resident was allergic to it. Despite this, licensed nurses documented that the medication was given, which was later acknowledged as an error by the nurses involved. Additionally, the facility failed to accurately document the resident's behavior monitoring associated with the administration of Risperidone, an antipsychotic medication. The MAR inaccurately recorded episodes of the resident striking out toward others, which was not observed by the nurses. Instead, the resident was seen swinging his amputated arm in a manner that was misinterpreted as aggressive behavior. The nurses admitted to documenting these actions inaccurately, which did not reflect the true nature of the resident's behavior. The director of nursing acknowledged the inaccuracies in the documentation and confirmed that the Lithium was not dispensed until a later date. The facility's policy on charting and documentation did not provide guidance on ensuring the accuracy of documentation, contributing to the deficiencies observed in the resident's clinical records.
Deficiencies in Resident-Centered Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive, resident-centered care plans for several residents, leading to deficiencies in care. Resident 47, who was admitted with a fracture of the thoracic vertebra, was not assessed for activities, resulting in a lack of engagement and boredom. The Activity Director admitted that an activity/interest assessment was not completed within the required timeframe, and the care plan did not address the resident's preferences for activities. This oversight was acknowledged by the facility's consultant, who noted the need for a more thorough assessment. Resident 42, diagnosed with Post-Traumatic Stress Disorder (PTSD), had a care plan that failed to identify specific triggers for re-traumatization. Interviews with various staff members, including the Assistant Director of Nursing and a Certified Nursing Assistant, revealed that none were aware of the resident's triggers, which were crucial for providing appropriate care. The facility's consultant recognized the inadequacy of the care plan, noting that the resident's triggers should have been explored more thoroughly. Resident 32, who required dialysis, had a care plan that inaccurately referenced an arteriovenous fistula, despite the resident having a permacath for dialysis access. Licensed nurses were incorrectly documenting care related to a fistula, which the resident did not have. The Director of Nursing confirmed the inaccuracies in the care plan, emphasizing the importance of having resident-specific and accurate care plans to prevent miscommunication and errors. Additionally, Resident 43, who was at risk for skin breakdown, was not turned and repositioned every two hours as required by their care plan, with staff failing to implement this critical intervention. The facility lacked a policy on turning and repositioning, further contributing to the deficiency.
Medication Storage and Handling Deficiencies
Penalty
Summary
The facility failed to ensure the safe storage and handling of medications, as evidenced by several observations and interviews. The medication refrigerator temperature log was found to be incomplete, with missing entries for two consecutive days. This lack of documentation raised concerns about whether medications were stored at the correct temperature, potentially affecting their efficacy. Additionally, a food product was discovered in a medication cart, which could lead to cross-contamination with medications. The facility's policy on medication storage emphasizes the importance of maintaining clean and clutter-free storage areas, which was not adhered to in this instance. Further deficiencies were noted when a discontinued medication was not removed from a medication cart, posing a risk of accidental administration. A medication cart was also left unlocked and unattended by a licensed nurse, which could allow unauthorized access to medications. The facility's policy requires medication carts to be locked when out of sight, a protocol that was not followed in this case. These lapses in medication management highlight a failure to adhere to the facility's policies and procedures, potentially compromising resident safety. In another incident, a medication was left unattended at a resident's bedside, which is against the facility's policy of keeping medications secure. The licensed nurse involved acknowledged the mistake, noting that other cognitively impaired residents in the room could have accessed the medication. The Director of Nursing confirmed that medications should not be left unattended at any resident's bedside, underscoring the importance of maintaining control over medication administration to prevent potential harm.
Failure to Maintain Dignity During Meal Assistance
Penalty
Summary
The facility failed to ensure that a resident was assisted with a meal in a dignified manner. Resident 106, who was readmitted with a diagnosis including epilepsy, was observed being fed by a staff member in a manner that did not maintain eye-level contact. The staff member, identified as Speech Therapist 1 (ST 1), was standing approximately two feet above the resident's head while feeding her a pureed diet. ST 1 was conducting a swallowing skills assessment and admitted to not being informed about the importance of feeding residents at eye level. Interviews with other staff members, including Licensed Nurse 31 (LN 31) and Physical Therapy Assistant 1 (PTA 1), confirmed that maintaining eye-level contact while feeding is a standard practice to promote resident dignity. It was revealed that ST 1 was in her clinical fellowship and there was no documented evidence of her receiving training on proper feeding techniques. The Director of Nursing (DON) also emphasized the expectation for staff to maintain eye level during meal assistance, aligning with the facility's policy on dignity and privacy.
Failure to Ensure Resident Privacy During Personal Care
Penalty
Summary
The facility failed to ensure privacy for a resident during personal care, as observed by surveyors. The resident, who was admitted with Alzheimer's disease and was severely cognitively impaired, was left visible from the hallway while wearing only a brief and socks on the lower half of his body. This occurred when a certified nursing assistant (CNA) left the room carrying a bag of soiled items without drawing the curtain or closing the door, leaving the resident exposed to passers-by. Interviews with the licensed nurse (LN) and the CNA involved confirmed that privacy should have been provided by drawing the curtain and closing the door. Both staff members acknowledged that the resident was unable to verbalize his feelings due to confusion, and they expressed that the situation was undignified. The director of nursing (DON) also confirmed that privacy should have been maintained during the resident's personal care, in accordance with the facility's policy on dignity and privacy.
Failure to Provide Resident-Centered Activities
Penalty
Summary
The facility failed to provide activities of interest for a resident, identified as Resident 47, which had the potential to impact her physical, mental, and psychosocial well-being and independence. Resident 47 was admitted with a diagnosis of a fracture of the thoracic vertebra. During an observation and interview, Resident 47 expressed boredom and dissatisfaction with the activities offered, describing them as suitable for young children. The Activity Director admitted that an activity/interest assessment was not completed within the required five days after admission. The resident's activities care plan indicated minimal involvement in activities and a stated wish not to participate, which was not adequately addressed. The facility's policy requires activities to be planned according to residents' preferences, needs, and abilities, but this was not followed in Resident 47's case.
Failure to Provide Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to provide trauma-informed care for a resident diagnosed with Post-Traumatic Stress Disorder (PTSD), as required by professional standards of practice. The resident, identified as Resident 42, was admitted with a diagnosis of PTSD, which necessitates careful management to prevent re-traumatization. However, the facility did not identify the resident's triggers, which are crucial for providing appropriate care. Interviews with various staff members, including the Assistant Director of Nursing, a certified nursing assistant, a registered nurse, and the Director of Staff Development, revealed that none of them were aware of the resident's specific triggers. This lack of knowledge indicates a failure to implement a comprehensive care plan tailored to the resident's needs. The facility's policy on Behavioral Health Services emphasizes the importance of providing trauma-informed care to prevent re-traumatization. Despite this policy, the care plan for Resident 42 was found to be inadequate, as acknowledged by the facility's consultant and administrator. The consultant noted that the facility should have explored the resident's diagnosis and potential triggers more thoroughly, especially since the resident and their family were unable to provide this information. This oversight resulted in the potential for the resident to lack a sense of emotional and physical safety, as the facility did not take necessary steps to identify and mitigate possible triggers.
Medication Administration Deficiency
Penalty
Summary
The facility failed to ensure that a licensed nurse (LN 10) was competent in medication administration, which led to several deficiencies during the administration of medications to Resident 43. LN 10 left the medication cart unlocked and unattended, which is against the facility's policy. During the medication administration, LN 10 crushed several medications into powder and placed them in unlabeled cups, leading to confusion about which medication was which. LN 10 attempted to administer a medication that had been discarded in the trash, which was stopped by the surveyor due to infection control concerns. Resident 43, who had a history of hemiplegia, hemiparesis, hypertension, dementia, and a gastrostomy, was at risk due to LN 10's actions. LN 10 did not verify the resident's vital signs before administering Amlodipine, which had specific hold parameters based on blood pressure and heart rate. The vital signs were recorded after the medication administration had begun, indicating a lack of adherence to the physician's order. Additionally, LN 10 did not fully dissolve the medications in water, resulting in incomplete administration, and inaccurately documented the administration of Lactobacillus, which was not given. The Director of Nursing (DON) and the Director of Staff Development (DSD) acknowledged that LN 10's medication administration was not competently done. The DON confirmed that the medication cart should have been locked and that medications should not have been left unattended. The DSD noted that LN 10 should have contacted the physician after the error with the unlabeled medication cups. LN 10 admitted to not recalling any training or competency evaluation related to administering medications via a g-tube, highlighting a gap in the facility's competency evaluation process.
Medication Administration Errors Observed
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, with an observed rate of 8.33 percent. During the medication administration process, three errors were noted out of 36 opportunities. Specifically, LN 10 was observed administering medications to two residents, where errors were made in the dosage and administration of medications. For Resident 43, LN 10 dispensed medications into unlabeled cups and attempted to dissolve crushed tablets in cold water, which did not fully dissolve, resulting in a significant portion of the medication being discarded. LN 10 acknowledged that nearly a full dose of Vitamin D remained in the cup, indicating a failure to administer the complete prescribed dose. Additionally, LN 10 administered an incorrect dosage of Lactulose to Resident 43, providing 25 ml instead of the prescribed 30 ml. For Resident 10, LN 10 used a facility supply of Calcium with Vitamin D that contained 200 IU more than the physician's order. These actions were contrary to the physician's orders, as confirmed by LN 10 during an interview. The Director of Nursing stated that it was expected for medications to be administered as prescribed, highlighting a deviation from the facility's policy on administering medications safely and timely.
Inappropriate Dietary Consistency for Resident
Penalty
Summary
The facility failed to provide Resident 122 with food and drink that were palatable, appetizing, and appropriate for her dietary needs. Despite the resident's admission record indicating a mechanical soft-ground texture diet with thin liquids, she was served pureed food items and nectar thick beverages without a physician's order or clear indication. This inconsistency led to the resident expressing dissatisfaction with the meals, describing them as resembling cat food and bland, and resulted in her altering the consistency of her drinks by adding water from her bedside pitcher. Observations and interviews revealed that the resident had no diagnosis of dysphagia or swallowing issues, and the registered dietitian and speech therapist confirmed that the resident should have been on a mechanical soft diet. The facility's policy did not provide guidance on food palatability, texture, or beverage consistency, contributing to the oversight. The director of nursing acknowledged the error, stating that the resident's diet texture and fluid consistency should have been clearly understood and adhered to.
Inaccurate Medication Administration Documentation
Penalty
Summary
The facility failed to ensure accurate documentation of medication administration for one of its residents, identified as Resident 43. During an observation of medication administration, LN 10 was seen dispensing medications into individual, unlabeled cups and administering them through the resident's g-tube. The medications included Amlodipine, Apixaban, Lactulose, Keppra, Polyethylene glycol, Multivitamins, and Vitamin D. However, the administration of a Lactobacillus capsule, which was ordered by the physician, was not observed. Despite this, the medication administration record (MAR) inaccurately indicated that the Lactobacillus capsule had been given. Upon review, it was confirmed that LN 10 did not administer the Lactobacillus capsule and had erroneously documented it as administered. LN 10 acknowledged the mistake, noting that there had been a discussion about discontinuing the Lactobacillus order, but the order was still active at the time of administration. The Director of Nursing stated that it was expected for the clinical record to accurately reflect the care and treatment provided, which was not the case in this instance.
Infection Control Breach During Medication Administration
Penalty
Summary
The facility failed to ensure proper infection control practices during medication administration for one resident, identified as Resident 43. The resident, who had a g-tube for medication administration and feeding, was at risk of infection due to the actions of LN 10. During a medication administration observation, LN 10 attempted to administer a medication that had been disposed of in the trash can. Initially, LN 10 prepared the medication by dissolving crushed tablets in cold water, which did not fully dissolve, leaving a significant amount of medication in the cup. After discarding the cup in the trash, LN 10 retrieved it and considered administering the remaining medication to the resident. The incident was observed by a surveyor who intervened, preventing LN 10 from administering the medication from the trash. LN 10 acknowledged the infection control concern and decided to obtain a new dose of medication. Interviews with the DON and the IPN confirmed that the practice of administering medication from the trash can was unacceptable and not in line with infection control standards. The facility's policy on administering medications emphasized the importance of safe and timely administration, which was not adhered to in this instance.
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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