Marin Post Acute
Inspection history, citations, penalties and survey trends for this long-term care facility in San Rafael, California.
- Location
- 234 N. San Pedro Rd, San Rafael, California 94903
- CMS Provider Number
- 055310
- Inspections on file
- 31
- Latest survey
- January 8, 2026
- Citations (last 12 mo.)
- 24
Citation history
Health deficiencies cited at Marin Post Acute during CMS and state inspections, most recent first.
Two residents were not adequately supervised near unsecured exits, leading to one resident in a wheelchair leaving the building unnoticed through unlocked front doors and traveling down a steep, uneven driveway to a lower parking lot, where paramedics later found the resident unresponsive, and another cognitively impaired resident with gait and vision issues wandering alone in a second-floor common area adjacent to unlocked doors to a wet deck, steep incline, and parking lot. The front lobby reception desk, which the DON stated was responsible for monitoring residents and intervening if they attempted to leave, was repeatedly observed to be unstaffed, and staff acknowledged that no one was actively monitoring the front doors. The eloped resident had a history of suicidal ideation, a care plan requiring continuous monitoring and hourly checks, and a physician order limiting outings to passes with a responsible party for medical appointments only, while the second resident was supposed to be supervised by activity staff who could not see her from their location. Facility policies on wandering, elopement, and safety required identification of at-risk residents and targeted interventions, including adequate supervision and locked doors, but these measures were not effectively implemented at the time of the incidents.
A resident was found slumped over in a wheelchair in the facility’s lower parking lot, and 911 was called. Paramedics performed CPR, pronounced the resident dead in the driveway, and then notified on-duty nurses. The Administrator stated he did not report the death to the Department because he did not consider it an unusual occurrence and had not completed his investigation or staff interviews. However, the DSD and DON both stated that the sudden death was an unusual occurrence that should have been reported. The facility’s Unusual Occurrence Reporting policy required reporting deaths from unnatural causes and submitting a written report within 48 hours, but this was not done for this event.
A resident’s assessments were not accurately completed, leading to incorrect documentation of cognitive status and an incomplete fall risk evaluation. The BIMS score recorded in the quarterly assessment was 1, despite the DSD and MDS nurse stating the resident was alert, oriented, and capable of making decisions, and a POLST form signed by the resident indicating capacity. The MDS nurse reported that social services staff had completed and mis-scored the BIMS. Additionally, a fall risk assessment documented a high-risk score but was not fully completed, even though it was signed by the MDS nurse. Elopement and wandering risk assessments showed the resident could propel in a wheelchair with some assistance, had no communication, hearing, or vision deficits, and had expressed plans to leave, with documentation that care plan interventions for unsafe wandering or elopement had been initiated or updated.
Nursing staff left medications at the bedside for four residents with varying cognitive abilities and complex medical conditions, without staying to ensure the medications were taken. Facility leadership confirmed this practice was not allowed and contradicted policy requiring staff to remain with residents until all medications were ingested.
A resident with severe cognitive impairment was physically struck in the face by another resident with no cognitive impairment in the hallway near the nurse's station. The incident was witnessed by the HRD, immediately intervened, and confirmed by video surveillance. This event demonstrated a failure to protect a resident from abuse as required by facility policy.
A resident struck another resident in the face during a hallway altercation witnessed by the HRD, who separated them and notified nursing leadership. Despite the incident being captured on video and observed by management, there was no documentation in the residents' records or care plans, and the event was not reported to the Department as required by policy. The failure to report and document the incident prevented timely investigation by authorities.
A resident with severe cognitive impairment and bed confinement was physically struck in the face with a hanger by another resident with moderate cognitive impairment and Parkinson's disease. The incident resulted in new scratches on the victim's cheek, and staff interviews confirmed the event and the facility's responsibility to prevent such abuse.
A resident with hemiplegia and hemiparesis did not receive restorative nursing services as ordered by her physician, receiving therapy only twice weekly instead of three times. This occurred because the RNA responsible for these services was frequently reassigned to CNA duties due to staffing shortages, with no replacement provided, resulting in missed restorative care for multiple residents.
A licensed nurse left a cup of nine pills unattended on a resident's bedside table without a physician's order for self-administration. The resident, who had hemiplegia and hemiparesis but no memory impairment, reported the incident and noted a medication was missing. Facility policy and staff confirmed that no residents had orders for self-administration, and that leaving medications unattended was not permitted.
Two residents experienced significant delays in call light response, with one resident's call light going unanswered for 25 minutes while she waited for a missing medication, and another reporting frequent waits of up to an hour-and-a-half. Both residents, who had no memory impairment and required staff assistance, described feeling neglected due to these delays. Facility policy required prompt call light response, but staff failed to meet this standard.
A resident with a history of hemiplegia and hemiparesis was not kept free from significant medication errors when a nurse administered morning medications more than an hour late, left the medications unattended at the bedside, and omitted a required dose of metformin that was to be given with breakfast. The nurse later confirmed the errors, and facility policy indicated that such deviations from scheduled administration times are considered medication errors.
The facility employed two Social Service Directors who did not meet federal qualification requirements, with one holding a degree in communications and the other lacking a college degree, and neither having documentation of the required credentials in their personnel files.
Failure to Supervise Residents and Secure Exits Resulting in Elopement and Unsafe Wandering
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate supervision and a safe environment to prevent accidents, resulting in one resident leaving the building unnoticed and being found deceased outside, and another resident wandering unsupervised near unlocked exterior doors. The facility building is three stories high and located on a hillside, with a steep, uneven asphalt driveway and stairs connecting the main entrance to a lower-level parking lot near a busy street. There were no secured gates to prevent residents from leaving the sitting area outside the front doors and attempting to go down the steep driveway in wheelchairs. On one survey date, the reception desk at the main entrance was observed to be empty, and multiple individuals without visible employee identification entered through the front doors. One resident, admitted with diagnoses including cerebral infarction (stroke), ataxia, dysphagia, major depressive disorder, right above-the-knee amputation, muscle weakness, dysarthria, and anarthria, self-propelled his wheelchair from the second floor via the elevator to the lobby. Video surveillance reviewed by the Administrator and Director of Staff Development showed the resident moving down a long hallway to the front doors, waiting there, and then exiting when visitors opened the unlocked doors. The last video frame showed him leaving the sitting area and heading slowly down the steep driveway. Facility staff were unaware he had left the building until paramedics, called by a passerby who found him slumped over in his wheelchair in the lower parking lot near electric vehicle chargers, arrived around 5 p.m. and requested information. The Administrator acknowledged there was no receptionist at the front desk at the time, despite the usual practice of staffing that area from mid-afternoon to evening, and the Assistant DON confirmed that no one was actively monitoring residents or the front doors. The resident who eloped had a documented history of suicidal ideation. Progress notes indicated that on a prior date he had stated he wanted to die, attempted to go out a ramp door but was redirected, and later went out to a second-floor balcony and said he wanted to leave and would jump off the balcony. Nursing documentation described him as having suicidal thoughts and verbalizing wanting to die and jump off the balcony, after which he said he did not mean it and was upset about his roommate not receiving help. His care plan included a focus on behavior monitoring due to suicidal ideation, with instructions for continuous monitoring for suicidal thoughts and hourly checks per facility protocol. A physician order from admission stated that he may go out on pass with a responsible party for medical appointments only, with no documented end date. The resident’s physician stated he should only have left with a responsible party and that no one should have been able to leave alone, and the DON stated that residents could not “just walk out,” describing the front desk role as monitoring residents in the lobby and intervening if they attempted to leave. A second resident, admitted with dementia with behaviors, muscle weakness, abnormal gait and mobility, and glaucoma, was observed on the second floor in an unattended common area adjacent to unlocked sliding doors leading to a wet deck overlooking a steep incline and unlocked double doors leading to a parking lot via a ramp. This resident was awake, non-communicative, and continuously walking around the area and hallway for approximately 40 minutes, turning lights on and off, opening cabinets, and rearranging furniture without apparent reason, with no staff checking on or monitoring her behavior during that time. The Nurse Consultant stated that both the sliding doors to the deck and the doors to the parking lot ramp were supposed to be locked and acknowledged the risk that the resident could have gone onto the deck and slipped and fallen on wet leaves. He also stated that the resident was being monitored remotely by activity staff in the next room and that those staff were supposed to supervise her, but they could not see her from where they were seated. Facility policies on wandering, elopement, and safety and supervision required identification of residents at risk for wandering or elopement, inclusion of safety strategies in the care plan, and targeted interventions such as adequate supervision to address individual hazards, which were not effectively implemented in these instances. Additional interviews reinforced the lack of effective supervision and control of egress points. The Administrator defined elopement as a resident without capacity leaving without permission and asserted that the eloped resident had capacity, while other staff, including the DON and unlicensed staff, stated that residents could not leave on their own and should only leave with someone for safety. Unlicensed staff reported that the resident left the second floor without being noticed and questioned how he could have navigated the steep, uneven driveway in a wheelchair, describing it as too steep to manage safely. A roommate of the deceased resident described the driveway as steep and dangerous and expressed doubt that the resident could have returned up the hill once he went down. Weather records for the evening of the incident documented cold, rainy, and windy conditions. The facility’s own policies on safety and supervision emphasized an individualized, resident-centered approach, analysis of assessment information to identify accident risks, and targeted interventions including adequate supervision, which contrasted with the observed absence of monitoring at the front entrance and the unlocked access to hazardous exterior areas near wandering residents.
Failure to Report Unusual Resident Death to State Authorities
Penalty
Summary
The facility failed to timely report an event of unknown source that resulted in a resident’s death to the state Department, as required by regulation and by its own policy on unusual occurrence reporting. A resident was found slumped over in his wheelchair in the lower parking lot, and someone called 911. Paramedics arrived, performed CPR, and then pronounced the resident dead in the facility’s driveway. The Administrator stated that the facility first became aware of the resident’s death only after paramedics had completed CPR, pronounced the resident, and notified the nurses working in the facility. The Administrator further stated that he did not report this resident death to the Department because he did not consider it to be an unusual occurrence and believed he did not have to report it. The Administrator also stated he had not concluded his investigation and did not have interviews with staff who responded to the incident, and therefore did not report the event. In contrast, the Director of Staff Development stated that the resident’s death was an unusual occurrence and should have been reported to the Department. The DON stated that she understood an unusual occurrence to include events such as a fire, flood, or the sudden death of a resident, and confirmed that this resident’s death was definitely an unusual occurrence that should have been reported. The facility’s written policy on Unusual Occurrence Reporting specified that the death of a resident due to unnatural causes (e.g., suicide, homicide, accidents) must be reported to appropriate agencies, with a written report sent within 48 hours of reporting the event, but this process was not followed for this resident’s death in the driveway.
Inaccurate Cognitive and Incomplete Fall Risk Assessments for a High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure accurate resident assessments for one of three sampled residents. The Director of Staff Development reported that, during an investigation into this resident’s death, he reviewed the resident’s Brief Interview of Mental Status (BIMS) score and found the last quarterly summary showed a score of 1, which he could not understand because, as a licensed nurse familiar with the resident, he believed the resident was alert and oriented. In a concurrent interview and record review, the MDS nurse stated that when she assessed the resident during the last quarter, she would have scored the BIMS at 3, and on review of the documented BRIEF INTERVIEW FOR MENTAL STATUS form, she noted it showed a score of 1 and stated that social services staff had completed and scored it incorrectly. She further stated the resident had capacity to make his own decisions and was his own responsible party. A Physician Orders for Life-Sustaining Treatment (POLST) form in the record, signed by the resident, indicated that the patient had capacity. Record review also showed that the resident’s fall risk assessment was incomplete. A NURSING - FALL RISK OBSERVATION / ASSESSMENT form for the resident indicated a score of 18, which corresponded to high risk, but the assessment had not been completed and was signed by the MDS nurse. Additional documentation titled NURSING - ELOPEMENT AND WANDERING RISK OBSERVATION ASSESSMENT indicated the resident was able to move or propel himself in a wheelchair with some assistance, had no communication, hearing, or vision deficiencies, and that the care plan had been initiated or updated to reflect interventions aimed at reducing the risk of unsafe wandering or elopement. A subsequent elopement and wandering risk assessment documented that the resident had expressed plans to leave but had not attempted to leave the facility, again noting no communication, hearing, or vision deficiencies and that interventions were reflected in the care plan.
Medications Left Unattended at Bedside by Nursing Staff
Penalty
Summary
Nursing staff failed to follow professional standards of practice by leaving medications at the bedside for four residents. Observations and interviews revealed that medications, including oxycodone and gabapentin, were left in cups on residents' tray tables without supervision. Residents reported that nurses sometimes left pills on their tables and did not always return to ensure the medications were taken. One nurse confirmed dropping off medications for a resident without staying to observe ingestion, and there was no order for self-administration for that resident. Facility policy required staff to remain with residents until all medications were taken. The residents involved had varying degrees of cognitive impairment and complex medical histories, including conditions such as ALS, diabetes, neuropathy, cerebral ischemia, chronic hepatitis, heart failure, chronic kidney disease, acute respiratory failure, dementia, and hyperlipidemia. Interviews with facility leadership confirmed that leaving medications at the bedside was not permitted and contradicted both facility policy and staff training.
Failure to Protect Resident from Physical Abuse by Another Resident
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment and a history of delirium was physically struck in the face by another resident who had no cognitive impairment. The incident took place in the hallway near the nurse's station, where the resident with cognitive impairment was in her wheelchair and was cut off by the other resident, also in a wheelchair, who then hit her. The event was witnessed by the Human Resource Director (HRD), who immediately separated the two residents and notified the appropriate staff. The altercation was also captured on facility video surveillance, confirming the physical abuse. The facility's policy on abuse prevention requires protection of residents from abuse by anyone, including other residents. Despite this policy, the physical altercation occurred, resulting in a failure to protect the resident from abuse. Interviews with both residents and the HRD confirmed the incident, and the video evidence corroborated the sequence of events. The resident who was struck did not recall the incident, while the resident who struck her stated it was in self-defense, though he could not recall the exact date.
Failure to Timely Report and Document Resident-to-Resident Altercation
Penalty
Summary
The facility failed to report an allegation of abuse and did not submit the results of their investigation to the California Department of Public Health within the required timeframe. This deficiency was identified through observation, interviews, and record review, which revealed that an incident occurred where one resident struck another in the face while both were in their wheelchairs in a hallway. The incident was witnessed by the Human Resource Director (HRD), who immediately separated the residents and notified the floor nurse, DON, and Administrator. However, there was no documentation of the incident in the progress notes or care plans for either resident, and the event was not reported to the Department as required. The residents involved had significant medical histories: one had severe cognitive impairment and was unable to recall the incident, while the other admitted to hitting in self-defense but could not remember the date. The HRD confirmed the incident was captured on video and occurred on Halloween, but neither the DON nor the Director of Staff Development (DSD) were aware of the event until interviewed by surveyors. The DON stated that staff were expected to separate residents, report the incident, and follow up with assessments and monitoring, but these steps were not documented or completed. A review of facility records and Department logs confirmed that no abuse allegations were reported during the relevant period, and the facility's policy required timely identification, investigation, and reporting of abuse allegations. The management team, including the Administrator, DON, and others, were present in the facility on the day of the incident, yet the required reporting and documentation did not occur, impeding the Department's ability to conduct a timely investigation.
Failure to Protect Resident from Physical Abuse by Another Resident
Penalty
Summary
A resident with severe obesity, bed confinement, and severe cognitive impairment was physically abused by another resident who entered his room and struck him in the face with a hanger. The incident was confirmed through interviews and record reviews, including a nursing note documenting two new superficial scratches on the resident's left cheek. The resident who committed the abuse had moderate cognitive impairment and Parkinson's disease, and admitted to entering the other resident's room and hitting him with a hanger due to being upset by his yelling. Staff interviews confirmed awareness of the incident, with the Social Services Director and Director of Nursing both acknowledging the facility's responsibility to protect residents from abuse. The facility's policy on abuse prevention was reviewed and stipulated that residents have the right to be free from abuse, including physical abuse. The failure to prevent this incident resulted in physical harm to the resident and demonstrated a lapse in protecting residents from abuse by others within the facility.
Failure to Provide Ordered Restorative Nursing Services Due to Staffing Reassignments
Penalty
Summary
The facility failed to provide restorative nursing services as ordered by the physician for one resident with hemiplegia and hemiparesis following a cerebrovascular event. The resident was supposed to receive restorative nursing services three times per week, as indicated by an active physician's order, but records showed that she only received these services two times per week during several weeks. The resident herself reported not receiving her regular therapy services, which she needed to prevent stiffness in her affected hand. Interviews with staff revealed that the Restorative Nurse Assistant (RNA) responsible for providing these services was frequently reassigned to work as a Certified Nursing Assistant (CNA) due to staffing shortages, and no replacement RNA was provided on those days. The Director of Rehabilitation confirmed the missed services and stated that he had no control over staffing assignments. The facility's assignment sheets did not clearly document when the RNA was working as a CNA versus providing restorative services, and the RNA estimated that on more than half of his shifts in the relevant month, he was reassigned, resulting in 20 to 22 residents per day not receiving restorative nursing services.
Unattended Medication Left at Bedside Without Physician Order
Penalty
Summary
A licensed nurse left a cup containing nine pills on a resident's bedside table, unattended, without a physician's order for self-administration. The resident, who had hemiplegia and hemiparesis following cerebrovascular disease but no memory impairment, reported that the nurse left the medications for her to take but noted that one of her prescribed medications was missing. Observation confirmed the unattended medications, and the nurse acknowledged leaving them at the bedside. The Director of Staff Development confirmed that facility policy prohibits leaving medications unattended at a resident's bedside without a physician's order, and that no residents, including the one involved, had such an order. Facility policy and the job description for licensed nurses both require that medications be administered according to established standards and only with proper authorization for self-administration.
Delayed Call Light Response and Missed Medication
Penalty
Summary
The facility failed to ensure that call lights for two residents were answered promptly, as observed and confirmed through interviews and record reviews. One resident, admitted with metabolic encephalopathy and no memory impairment, reported that call lights often took between 30 minutes to an hour-and-a-half to be answered, including instances when she pressed the call light for her roommate who was unable to get out of bed. Another resident, with hemiplegia and hemiparesis following cerebrovascular disease and no memory impairment, was observed to have her call light ringing for 25 minutes without response. This resident had a care plan instructing her to use the call light for assistance with activities of daily living. During the observation, the second resident was found with a cup of medications left unattended on her bedside table, and she reported that a prescribed medication was missing. She had pressed her call light to notify staff of the missing medication and had been waiting for about 25 minutes. The resident stated that staff frequently took up to an hour to respond to call lights and that she had been left wet and soiled for extended periods due to these delays, leading her to feel neglected. The LPN confirmed the missed medication and that the call light could not be seen from the nurses' station. Facility policy required call lights to be answered as soon as possible, and the DON stated the expectation was within 10 minutes.
Significant Medication Errors Due to Late and Improper Administration
Penalty
Summary
A licensed nurse failed to ensure that a resident was free from significant medication errors by administering morning medications more than one hour late, leaving the medications unattended at the resident's bedside, and omitting an important medication that was required to be given with breakfast. The resident, who had a history of hemiplegia and hemiparesis following cerebrovascular disease, was observed with a cup containing nine medications left on her bedside table after 10 a.m., and she reported that one medication was missing. The nurse confirmed both the late administration and the omission of metformin, which was supposed to be given with breakfast. A review of the resident's Medication Administration Record showed that all scheduled morning medications were to be administered at 8 a.m. or 9 a.m., with none scheduled for 10 a.m. or later. The nurse acknowledged that breakfast was served between 8 a.m. and 8:30 a.m., and that the medications, including those requiring administration with food, were given outside the prescribed time window. Facility policy required medications to be administered within one hour before or after the scheduled time, and the Director of Staff Development confirmed that deviations from this protocol constituted medication errors.
Unqualified Social Service Directors Employed
Penalty
Summary
The facility, licensed for 168 beds, failed to ensure that its Social Service Directors (SSDs) met the minimum federal qualifications for their positions. One SSD, assigned to Unit One, held a Bachelor's Degree in communications, which does not meet the requirement for a degree in Social Work or a Human Services field. The other SSD, assigned to Unit Two, did not possess a college degree at all. Personnel files for both SSDs lacked documentation of the required educational qualifications, such as resumes or proof of degrees. The facility's own job description for the Social Services Director position specified a Bachelor's Degree in Social Work or Human Services and two years of supervised social work experience in a healthcare setting, but these requirements were not met by the current SSDs.
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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