Marlora Post Acute Rehab Hosp
Inspection history, citations, penalties and survey trends for this long-term care facility in Long Beach, California.
- Location
- 3801 E Anaheim St, Long Beach, California 90804
- CMS Provider Number
- 056234
- Inspections on file
- 38
- Latest survey
- March 12, 2026
- Citations (last 12 mo.)
- 31 (1 serious)
Citation history
Health deficiencies cited at Marlora Post Acute Rehab Hosp during CMS and state inspections, most recent first.
A resident with ESRD, DM, and significant psychiatric and behavioral issues was transferred to another SNF without the facility providing the completed Discharge Summary/Post Discharge Plan of Care to the receiving facility. Although a detailed discharge plan had been initiated, including PCP follow-up, HD schedule and transportation, monitoring of VS, one-on-one supervision, safety needs, blood sugar checks, ADL assistance, and anemia treatment information, the RN Supervisor only sent a face sheet with a transfer report/medication list, along with medications and belongings. The RN Supervisor believed the Discharge Planner had already sent the discharge summary, and no telephone report to licensed staff at the receiving facility was documented, contrary to facility policies requiring transfer/discharge documentation and communication of the discharge summary.
The facility did not notify CDPH within 24 hours after two residents and a staff member tested positive for COVID-19, despite guidance from the PHN and internal policy requiring prompt reporting of such outbreaks. The delay occurred because the IPN believed that reporting to the local public health office was sufficient, resulting in CDPH not being informed in a timely manner.
The facility did not ensure that an area was free from accident hazards and failed to provide adequate supervision to prevent accidents. Surveyors observed environmental hazards and insufficient staff monitoring, increasing the risk of resident accidents.
Two residents who required assistance with ADLs and had intact cognition were not provided with care plans addressing their assessed needs for smoking safety measures, such as smoking aprons and a cigarette extension. Both were observed smoking without the required equipment, and staff confirmed that no care plans were in place to guide interventions, contrary to facility policy.
Two residents received pain medication outside the prescribed pain level parameters, with staff administering narcotics when pain was documented as 0 or 3, contrary to physician orders specifying administration only for pain levels of 4-10. Staff interviews and record reviews confirmed that these actions did not align with facility policy or prescriber instructions.
A resident with a history of falls, cognitive impairment, and mobility issues was not provided with a comprehensive, individualized fall care plan. The care plan lacked specific interventions for the resident's non-compliance with call light use and did not address ongoing risks, resulting in an unwitnessed fall after the resident attempted to use the restroom independently.
The facility failed to ensure residents were free from significant medication errors, affecting four out of eight sampled residents. A resident did not have their heart rate checked before receiving Amiodarone, and another resident missed doses of Mexiletine, with late doses administered at incorrect intervals. The facility did not monitor for adverse effects or communicate effectively between shifts. Additionally, residents received medications without proper vital sign checks, and the facility's policies on medication administration and error documentation were not followed.
The facility's QAA and QAPI committees failed to identify significant medication errors, such as missed doses and late administration, due to a lack of focus on these issues in their current QAPI plan. The DON was unaware of these errors until surveyors identified deficiencies. The facility's policies required medication errors to be documented and reviewed by the QAPI committee, but this was not effectively implemented, placing residents at risk.
The facility failed to provide mandatory training in effective communication for two LVNs upon hire. A review of their personnel records showed no evidence of such training, and the DSD confirmed its absence from orientation. The DON acknowledged the need for mandatory training, as the facility's policy requires nursing staff to meet competency requirements, including communication skills.
The facility failed to provide mandatory QAPI training to two newly hired LVNs, as revealed during a review of their personnel records. The Director of Staff Development confirmed that QAPI training was not part of the orientation services, and the Director of Nursing acknowledged the need for such training. The facility's policy requires all nursing staff to meet competency requirements defined by state law.
The facility failed to update the Advance Directives (AD) for two residents, leading to potential conflicts with their healthcare wishes. One resident, with mental health diagnoses, signed an invalid AD form due to cognitive impairment. Another resident had an AD but the facility lacked a copy. The facility's policy requires AD information upon admission, which was not followed.
Two residents experienced significant medical events that were not promptly communicated to their physicians. A resident with diabetes had a critically high blood sugar level, and another resident missed or received late doses of a critical heart medication. The facility failed to notify the physicians as required by policy, leading to potential delays in medical intervention.
The facility failed to protect residents from abuse and neglect, resulting in significant deficiencies. A resident with end-stage renal disease was allegedly sexually assaulted by another resident, and the facility did not take adequate measures to ensure safety or monitor the situation. In another incident, an agitated resident with dementia was placed near others, leading to a physical altercation with another resident. The facility's failure to follow policies and procedures contributed to these deficiencies.
The facility failed to report a physical altercation between two residents to the CDPH within the required two-hour timeframe. One resident, with dementia and major depressive disorder, hit another resident, with major depressive disorder and PTSD, using a quad cane. Although the incident was reported to local authorities, it was not reported to CDPH as mandated by the facility's policy.
The facility failed to report allegations of physical abuse involving two residents to CDPH within the required timeframe. An altercation occurred when a resident with moderately impaired cognitive skills hit another resident with a quad cane. The incident was reported to local authorities but not to CDPH, violating the facility's policy on abuse investigation and reporting.
The facility failed to provide trauma-informed care for two residents with PTSD, as they did not assess triggers or develop care plans to prevent re-traumatization. Despite having policies in place, the facility did not implement guidelines to address the residents' trauma histories, leading to a deficiency in care.
The facility failed to ensure competent medication administration by nurses, resulting in significant errors for several residents. A resident with severe cognitive impairment received medication without proper pulse checks, while another with cardiac issues had medications administered at incorrect times and without necessary vital sign documentation. Additionally, a resident with hypotension received medication despite high blood pressure readings, and another with heart failure had medications given without proper monitoring. Interviews revealed that nurses were not adhering to facility policies, leading to these errors.
A facility failed to conduct an IDT meeting for a resident after multiple eye doctor appointments, resulting in a lack of awareness about the outcomes and necessary care adjustments. The resident, with conditions like ESRD and diabetes, experienced vision decline but had no IDT meeting since June, despite policy requirements for meetings upon significant changes. Staff interviews confirmed the oversight, acknowledging the need for a meeting to address the resident's care plan.
A resident with multiple health issues, including declining vision, did not have a care plan addressing his vision concerns, despite ongoing eye doctor visits and the resident's awareness of needing surgery. The facility's staff, including an LVN and the MDS Nurse, confirmed the absence of a care plan, which was against the facility's policy requiring timely and comprehensive care planning.
A resident received diclofenac sodium gel without a specified dose for over two weeks, posing a risk of incorrect dosing. The resident had serious heart conditions and impaired cognitive skills. The LVN and DON acknowledged the need for dose specification, which was not included in the medication order, contrary to the facility's policy.
A resident with a history of urinary issues and frequent UTIs did not receive consistent foley catheter care as per the facility's orders, leading to potential recurrent UTIs. The Treatment Administration Record showed missing documentation for catheter care on several dates, and interviews with staff confirmed that undocumented care was likely not provided. The facility's policy required regular catheter care and monitoring to prevent infections, but gaps in documentation indicated non-compliance.
A resident with chronic lung conditions was found to be receiving 2.5 liters per minute of oxygen instead of the prescribed 2 liters per minute. This discrepancy was confirmed by the ADON, who acknowledged the importance of following the physician's order for safe oxygen administration. The DON reiterated the need for staff to adhere to prescribed orders to ensure resident safety.
A facility failed to monitor a resident's behaviors while on psychotropic medications, risking unnecessary medication use. The resident, with dementia and other conditions, was on Escitalopram and Mirtazapine, but there was no documentation of monitoring for hopelessness, anxiety, or sleep. Staff interviews confirmed the facility did not adhere to its policy for behavioral assessment and monitoring.
A medication security lapse occurred when an LVN left a resident's Amiodarone unattended on a medication cart. The resident, with severe cognitive impairment and serious cardiac conditions, was at risk due to this oversight. The facility's policy mandates that medications be accessible only to authorized personnel.
A facility failed to sanitize a mechanical lift between uses for two residents, potentially spreading infections. CNA 1 and CNA 2 used the lift for a resident with end-stage renal disease and then for another resident with chronic kidney disease without cleaning it. CNA 1 admitted to forgetting the cleaning step, and the Director of Staff Development emphasized the importance of sanitizing equipment to prevent infection spread.
A resident at an LTC facility fell and sustained a right shoulder fracture due to a CNA's failure to follow the facility's policy requiring two-person assistance during a Mechanical Lift transfer. The resident, who was high risk for falls and dependent on staff for transfers, was injured when the CNA attempted the transfer alone. Staff interviews confirmed the policy requirement for two-person assistance, which was not followed, leading to the incident.
Two residents experienced violations of their rights and dignity in a LTC facility. One resident, with anxiety and depression, was disrespected by the ADM and BOM during a financial discussion in his room without permission. Another resident, with anxiety and schizophrenia, was moved to a new room against her wishes to accommodate new admissions. The ADM's actions did not align with facility policies on resident rights and dignity.
A resident with dysphagia experienced a choking incident, and the facility staff delayed calling 911 by 14 minutes while checking the resident's code status. The staff also failed to use a non-rebreather mask and did not retrieve the crash cart, leading to inadequate emergency care. Interviews revealed poor communication and delegation among staff during the incident.
A resident with dysphagia choked on noodles during dinner, requiring an LVN to perform the Heimlich maneuver. The LVN failed to document the incident and care provided, resulting in an incomplete medical record. This oversight hindered communication between healthcare professionals and the facility's ability to investigate the incident.
A resident's grievance about missing personal belongings, including a cellphone, was not resolved to their satisfaction. Despite the cellphone being inventoried, the facility did not replace or reimburse it, and the resident's representative was dissatisfied with the response. The facility's policy required prompt resolution of grievances, but this was not achieved.
A resident with cognitive impairment and multiple diagnoses pulled out his Foley catheter, causing moderate bleeding. The facility notified the physician promptly but delayed informing the family for five hours, leading to family dissatisfaction. The ADON acknowledged the delay and the facility's policy requires prompt notification of any change in condition.
Failure to Send Complete Discharge Summary to Receiving SNF
Penalty
Summary
The deficiency involves the facility’s failure to provide a complete Discharge Summary/Post Discharge Plan of Care to the receiving SNF when a resident was transferred. The resident had multiple significant diagnoses, including ESRD, DM, schizophrenia, depression, and anxiety disorder, and had been assessed as unable to make reasonable and consistent decisions or understand and make medical decisions. Prior documentation showed the resident had exhibited severe behavioral issues, including banging hands on the wall and attempting to grab staff members’ private parts, which led to a psychiatric hold and subsequent readmission. An IDT care conference documented that discharge options to a more appropriate SNF capable of managing the resident’s behavioral needs were discussed with the responsible party. On the day of transfer, a physician’s order directed that the resident be transferred to another SNF with all remaining medications, and that a representative from the receiving facility would pick up the resident’s medications, belongings, and discharge paperwork. Nursing progress notes documented that the RN Supervisor was unable to reach licensed staff at the receiving facility despite multiple calls, but that a representative from the receiving facility would pick up the resident’s medications, cigarettes, and belongings. The facility had initiated a Discharge Summary/Post Discharge Plan of Care the day before transfer, which included instructions to follow up with the primary care physician, details of the hemodialysis facility, treatment schedule and transportation, monitoring of vital signs and overall well-being, one-on-one supervision and safety needs, blood sugar checks, assistance with ADLs, and the latest hemoglobin result with associated anemia treatment. Despite this, the RN Supervisor provided only the face sheet with the transfer discharge report/transfer medication list, along with the resident’s belongings and medications, to the receiving facility’s representative and did not print or send the Discharge Summary Instructions. The RN Supervisor stated he believed the Discharge Planner had already sent the discharge summary to the receiving facility and that he was told only to send the transfer medication list, medications, and belongings. The responsible party later reported that the receiving SNF could not provide discharge instructions from the sending facility. Review of facility policies titled “Transfer or Discharge Documentation” and “Discharging the Resident” showed that the facility’s procedures required that a copy of the resident’s discharge summary and other appropriate documentation be communicated to the receiving facility and that a transfer summary and telephone report be completed, which did not occur in this case.
Failure to Timely Report COVID-19 Outbreak to CDPH
Penalty
Summary
The facility failed to notify the California Department of Public Health (CDPH) within 24 hours after identifying a COVID-19 outbreak involving two residents and one staff member. Record reviews showed that one resident, admitted with Parkinson's disease and failure to thrive, exhibited symptoms such as dizziness, sore throat, and runny nose and tested positive for COVID-19. Another resident, admitted with hypothyroidism, tested positive for COVID-19 but was asymptomatic. Both cases were identified on the same day, and a staff member also tested positive the following day. Despite receiving guidance from the Public Health Nurse (PHN) to report the outbreak to CDPH, the facility's Infection Preventionist Nurse (IPN) delayed reporting, believing that notifying the local public health office would suffice. Interviews with facility leadership confirmed awareness of the reporting requirement and the PHN's guidance. The IPN and Administrator acknowledged that the outbreak met the criteria for an unusual occurrence and should have been reported to CDPH within 24 hours, as outlined in the facility's policy. The delay in reporting resulted in CDPH not being informed in a timely manner, which prevented oversight and monitoring of the facility's infection control practices during the outbreak.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
The facility failed to ensure that an area was free from accident hazards and did not provide adequate supervision to prevent accidents. Surveyors observed that the environment contained hazards that could lead to resident accidents, and staff did not implement sufficient measures to monitor or protect residents from these risks. This deficiency was identified based on direct observations and findings during the survey, which indicated lapses in maintaining a safe environment and in providing necessary supervision to prevent accidents.
Failure to Develop and Implement Smoking-Related Care Plans
Penalty
Summary
The facility failed to develop and implement care plans addressing the smoking needs of two residents who required substantial or maximal assistance with activities of daily living and had intact cognition. Both residents had documented assessments indicating the need for specific safety measures while smoking, such as the use of a smoking apron and, for one resident, a cigarette extension. Despite these documented needs, there were no care plans created to guide staff in providing the necessary interventions to ensure the residents' safety during smoking activities. Observations revealed that both residents were seen smoking without the required safety equipment, and staff confirmed that no care plans were in place for smoking-related risks. Interviews with nursing staff and the DON confirmed the absence of care plans and acknowledged that care plans are intended to guide staff in maintaining resident safety. The facility's own policy required comprehensive, person-centered care plans with measurable objectives and timetables, but this was not followed for the two residents in question.
Failure to Administer Pain Medication According to Physician Orders
Penalty
Summary
The facility failed to ensure that medications were administered as prescribed by the physician for two out of four sampled residents. For one resident with diagnoses including metabolic encephalopathy and mood disorder, the physician's order specified that Oxycodone-Acetaminophen should be given only for breakthrough pain rated 4-10 out of 10. However, the Medication Administration Record (MAR) showed that the medication was administered when the resident's pain level was documented as 0 and 3, which did not meet the criteria outlined in the physician's order. Interviews with nursing staff confirmed that the medication was given outside the prescribed parameters, and staff acknowledged that this was not in accordance with the order. Another resident, admitted with diagnoses such as encephalopathy, sciatica, and dementia, had a physician's order for Hydrocodone-Acetaminophen to be administered for moderate to severe pain (pain level 4-10). The MAR indicated that this resident also received pain medication when their pain level was documented as 0. Staff interviews confirmed that the medication should not have been administered at a pain level of 0, and that the documentation was inaccurate. The facility's policy on administering medications requires that medications be given in accordance with prescriber orders, including any specified parameters. The observed practice of administering pain medication outside the prescribed pain levels for both residents was not consistent with these requirements, as confirmed by staff interviews and record reviews.
Failure to Develop and Implement Comprehensive Fall Care Plan
Penalty
Summary
A deficiency was identified when the facility failed to develop and implement a comprehensive, resident-centered fall care plan for a resident with a history of falls, encephalopathy, sciatica, and dementia. The resident was assessed as having mildly impaired cognitive skills and required moderate assistance with several activities of daily living, including transfers and toileting. Despite being identified as a fall risk due to balance problems, history of multiple falls, and other medical conditions, the care plan only included an intervention to place the resident in a room near the nursing station for better visibility. The resident experienced an unwitnessed fall after not using the call light to request assistance with a restroom transfer. Interviews with staff revealed that the resident often attempted to go to the bathroom independently and did not consistently use the call light, despite reminders and reeducation. Staff also noted the resident's desire for independence, forgetfulness, unsteady gait, and occasional non-compliance with safety interventions. The care plan did not address the resident's non-compliance with call light use or include additional interventions tailored to the resident's specific risks and behaviors. Further review and interviews confirmed that the facility's interdisciplinary team was aware of the resident's fall risk and history but did not update the care plan to reflect the resident's ongoing needs and behaviors. The facility's policies required comprehensive, person-centered care plans based on thorough assessments and ongoing revisions as resident conditions changed. However, the care plan for this resident lacked specific, measurable interventions to address the identified risks, leading to a deficiency in care planning.
Significant Medication Errors in LTC Facility
Penalty
Summary
The facility failed to ensure that four out of eight sampled residents were free from significant medication errors. Specifically, the licensed nurses did not check Resident 6's heart rate prior to administering Amiodarone as ordered, resulting in 26 instances of non-compliance over two months. Additionally, Resident 26 did not receive Mexiletine as prescribed, with missed and late doses documented, and the facility failed to ensure the medication was available for administration. The Quality Assurance Performance Improvement (QAPI) team did not identify or act to correct these errors, and the facility's policy on adverse consequences and medication errors was not followed. Resident 26 experienced significant issues with the administration of Mexiletine, a medication critical for treating life-threatening ventricular arrhythmias. The resident missed a dose on one occasion and received doses at intervals shorter than the prescribed eight hours on multiple occasions. The facility also failed to monitor Resident 26 for adverse effects when doses were missed or administered late. Furthermore, the communication between shifts regarding late administration was inadequate, leading to potential risks for the resident. The facility also failed to adhere to physician's orders for other residents. Resident 29 received Midodrine despite having a systolic blood pressure greater than the prescribed threshold, and Resident 30's blood pressure and pulse rate were not checked before administering Amiodarone. These deficiencies were compounded by the facility's failure to document vital signs accurately, with 'Not Applicable' being recorded instead of actual readings. The facility's policies on medication administration and error documentation were not followed, contributing to the risk of adverse consequences for the residents involved.
Removal Plan
- Resident 26 was seen by MD 2. The DON spoke to MD 2 and informed him Resident 26 missed a dose of Mexiletine and was given a late dose.
- The DON provided one on one training to the Licensed Vocational Nurses (LVNs) who documented Mexiletine's late and missed administration. The DON discussed the importance of making sure medications are available, the process of when to reorder medications, and process if dose was late or missed, physician notification, monitoring of residents for adverse effect for missing medications and development of change of condition Situation, Background, Assessment, Recommendation (SBAR) and care plan.
- The DON provided one on one counseling and in-service with LVN 2 in failing to administer the Mexiletine dose as scheduled and as ordered by the physician, the possible adverse effects of late administration and notification to the physician and monitoring of resident and/or responsible party if the schedule of the medication dose needs to be altered or changed.
- The DON provided a phone one on one counseling and in-service with involved LVN 3 in failing to administer the Mexiletine dose as scheduled and as ordered by the physician, and about the adverse effects of late administration including the process if the medication dose schedule needs to be altered or change such as notification to the physician. The DON will provide in-person counseling and in-service upon return to work of LVN 3 who failed to administer Mexiletine dose.
- The facility's contracted Pharmacy Consultant initiated an in-service with thirteen LVNs regarding administration of medications, the adverse effects of missing the dose and/or late medication administration. In-services will continue until all twenty-five LVNs have participated.
- The facility contracted Pharmacy Consultant is scheduled to do a Medication Regimen Review (MRR) for Residents receiving antiarrhythmic medications including Residents 6, 11, 20, 26, 30, 43, 51 and 70.
- The facility's Medical Director will initiate an in-service training with the seven LVNs on the importance of administering antiarrhythmic medications as ordered and at the specified time; the adverse effects of not administering medications or late administration, and adverse effects of overdosing on medications when administered medication too close between doses. The Medical Director will continue to conduct the in-service until the remaining eighteen LVNs have participated.
Failure to Address Medication Errors in QAPI Program
Penalty
Summary
The facility's Quality Assessment and Assurance (QAA) and Quality Assurance Performance Improvement (QAPI) committees failed to identify and address significant medication errors within the facility. During an interview, the Director of Nursing (DON) revealed that the current QAPI plan was focused on falls and discharges against medical advice, and medication administration errors were not included in their program. The DON admitted that they were unaware of the medication errors, which included missed doses, late administration, and not following physician's orders, until deficiencies were identified by surveyors. A review of the facility's policies and procedures indicated that medication errors were supposed to be documented, reported, and reviewed by the QAPI committee to inform necessary process changes or additional staff training. However, the QAPI program, as revised in February 2020, was not effectively implemented to monitor and evaluate these errors. This oversight placed all residents at risk for adverse effects due to the mismanagement of their medication regimen.
Failure to Provide Mandatory Communication Training for LVNs
Penalty
Summary
The facility failed to ensure that two Licensed Vocational Nurses (LVN 2 and 3) received mandatory training in effective communication upon hire. During an interview and record review with the Director of Staff Development (DSD), it was found that the personnel records of LVN 2 and 3 lacked documented evidence of training in effective communication. The DSD confirmed that effective communication was not included in the orientation services for newly hired staff. In a subsequent interview with the Director of Nursing (DON), it was acknowledged that mandatory training needed to be implemented in the facility. The facility's policy and procedure, titled 'Competency of Nursing Staff' from May 2019, indicated that all nursing staff must meet specific competency requirements, including communication skills, as defined by state law. This oversight had the potential to result in staff with poor communication skills, which could negatively affect the residents' quality of care.
Failure to Provide QAPI Training to New LVNs
Penalty
Summary
The facility failed to ensure that two Licensed Vocational Nurses (LVN 2 and 3) received mandatory training on the Quality Assurance and Performance Improvement (QAPI) program upon hire. This deficiency was identified during an interview and record review with the Director of Staff Development (DSD), where it was found that the personnel records of LVN 2 and 3 lacked documented evidence of QAPI training. The DSD confirmed that QAPI training was not included in the orientation services for new staff. Additionally, the Director of Nursing (DON) acknowledged the need for mandatory training to be implemented in the facility. The facility's policy and procedure on the competency of nursing staff, dated May 2019, indicated that all nursing staff must meet specific competency requirements as defined by state law.
Failure to Update Advance Directives for Two Residents
Penalty
Summary
The facility failed to ensure that the medical records of two residents were up to date concerning their Advance Directives (AD), as per the facility's policy. Resident 38 was admitted with several mental health diagnoses and was moderately impaired in cognitive skills. Upon admission, the AD Acknowledgement form was not discussed with Resident 38 due to their lack of alertness. The form was eventually signed on 12/5/2024, but it was deemed invalid as the resident was not capable of making medical decisions at that time. The Social Service Director and Director of Nursing acknowledged that the form should have been completed within 72 hours of admission during a care conference meeting. Resident 86 was admitted with conditions including atrial fibrillation and anxiety disorder, and was also moderately impaired in cognitive skills. The AD Acknowledgement form indicated that Resident 86 had an Advance Healthcare Directive (AHCD), but the facility did not have a copy of it. The resident did not recall discussing the AD Acknowledgement form, although they had spoken with their doctor about their wishes. The Director of Nursing noted that the form should have been completed during the admission process to ensure the facility had a copy of the AD. The facility's policy, revised in December 2016, requires that residents be provided with information about their right to formulate an AD upon admission. If a resident is incapacitated, the information should be given to their legal representative, and the resident should receive the information later if they become able to understand it. The policy also mandates that information about the existence of any AD be prominently displayed in the medical record. The failure to adhere to this policy resulted in the facility not being fully informed of the residents' wishes regarding their healthcare decisions.
Failure to Notify Physicians of Critical Medical Events
Penalty
Summary
The facility failed to notify the primary care physician of two residents regarding significant medical events. Resident 6, diagnosed with Diabetes Mellitus, had a critically high blood sugar level of 508 mg/dL, which was not communicated to the physician as required by the facility's policy. This oversight was confirmed through interviews and record reviews, where it was noted that the physician was not informed of the elevated blood sugar level, which was considered a change in condition necessitating immediate notification. Resident 26, who was on a strict medication regimen for ventricular tachycardia, experienced multiple instances of missed or late doses of mexiletine, a critical heart medication. The facility's records showed that doses were either missed or administered late on several occasions, yet there was no documentation that the physician was notified of these medication errors. Interviews with staff confirmed that these were considered medication errors and should have been reported to the physician for further instructions and monitoring. The facility's policies clearly outlined the need for prompt physician notification in cases of significant changes in a resident's condition or medication errors. However, in both cases, the facility did not adhere to these protocols, resulting in a lack of timely communication with the residents' physicians, which could have led to delays in necessary medical interventions.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
The facility failed to protect three residents from abuse and neglect, leading to significant deficiencies in care. Resident 69, who was diagnosed with end-stage renal disease, generalized muscle weakness, and hypertension, was allegedly sexually assaulted by another resident, Resident 1, in March 2023. Despite the incident being reported to the charge nurse and the Social Service Director (SSD), appropriate measures were not taken to ensure Resident 69's safety. Resident 1 was initially moved to another room but was later placed back near Resident 69, causing distress and fear for Resident 69. The facility did not adequately monitor or document the situation, failing to separate the residents effectively and ensure Resident 69's emotional well-being. In another incident, Resident 146, who had a history of dementia and aggressive behavior, was placed in front of the nursing station despite being agitated and combative. This placement led to a physical altercation with Resident 62, who was struck with a quad cane and punched by Resident 146. The facility did not take appropriate measures to separate Resident 146 from other residents, resulting in preventable abuse. The Director of Staff Development acknowledged that the situation was mishandled and should have been reported as abuse to the California Department of Public Health. The facility's policies and procedures regarding resident rights and abuse prevention were not followed, contributing to the deficiencies. The Social Service Director and other staff members failed to document and monitor the incidents properly, and the facility did not ensure the safety and well-being of the residents involved. These actions and inactions placed the residents at risk for further abuse and neglect, violating their rights to be free from harm.
Failure to Timely Report Abuse Allegations
Penalty
Summary
The facility failed to report allegations of physical abuse involving two residents to the California Department of Public Health (CDPH) within the required two-hour timeframe. Resident 146, who has diagnoses including dementia and major depressive disorder, was involved in a physical altercation with Resident 62, who has diagnoses including major depressive disorder and PTSD. The incident occurred when Resident 146 grabbed Resident 62's quad cane and hit Resident 62 in the chest and arms. Despite the altercation being reported to the local police department and the ombudsman, it was not reported to CDPH as required by the facility's policy. The facility's policy on abuse investigation and reporting mandates that all reports of resident abuse and neglect be promptly reported to local, state, and federal agencies. The policy specifies that alleged violations involving abuse must be reported within two hours. The failure to report this incident to CDPH within the regulated timeframe resulted in CDPH's inability to investigate the allegation of abuse timely and had the potential for other allegations of abuse to go unreported.
Failure to Report Abuse Allegations to CDPH
Penalty
Summary
The facility failed to report allegations of physical abuse involving two residents to the California Department of Public Health (CDPH) within the required five-day period. Resident 62, who had intact cognitive skills and required assistance with daily activities, was involved in an altercation with Resident 146, who had moderately impaired cognitive skills and required substantial assistance with daily activities. The incident occurred when Resident 146 grabbed Resident 62's quad cane and hit Resident 62 in the chest and arms. The Director of Nursing (DON) confirmed that the altercation was reported to the local police department and the ombudsman but not to CDPH, and no investigative report was sent to CDPH. The facility's policy and procedure on abuse investigation and reporting, revised in April 2017, required the Administrator or designee to provide a written report of the findings to the appropriate agencies within five working days of the incident. This failure to report resulted in CDPH's inability to investigate the allegation of abuse timely and had the potential for other allegations of abuse to go unreported.
Failure to Provide Trauma-Informed Care for Residents with PTSD
Penalty
Summary
The facility failed to provide trauma-informed care for two residents diagnosed with PTSD, potentially leading to re-traumatization and negative impacts on their psychosocial status. Resident 62, who was admitted with major depressive disorder and PTSD, had intact cognitive skills and required assistance with daily activities. The resident's trauma history included exposure to war-related casualties, natural disasters, and life-threatening situations. Similarly, Resident 146, admitted with dementia, major depressive disorder, and PTSD, had moderately impaired cognitive skills and required varying levels of assistance with daily activities. This resident's trauma history also included exposure to war-related casualties, natural disasters, and life-threatening illnesses. Interviews with the Director of Staff Development and the Director of Nursing revealed that the facility did not assess the residents' triggers or develop trauma-informed care plans to address these triggers and prevent re-traumatization. The facility's policy on trauma-informed care emphasized the importance of minimizing triggers and re-traumatization for trauma survivors, particularly during the transition to an institutional setting. However, the facility did not implement these guidelines, resulting in a deficiency in providing appropriate care for residents with PTSD.
Medication Administration Errors Due to Incompetent Nursing Staff
Penalty
Summary
The facility failed to ensure that licensed nurses were competent during medication administration for four out of eight sampled residents, leading to significant medication errors. Resident 6, who had severe cognitive impairment and a history of heart disease, was supposed to receive amiodarone hydrochloride with specific instructions to hold the medication if the pulse was less than 60 BPM. However, the Medication Administration Record (MAR) showed that the pulse reading was marked as 'not applicable' multiple times, and the medication was still administered. Resident 26, with a history of ventricular tachycardia and cardiac arrhythmia, was prescribed amiodarone and mexiletine with specific administration times and conditions. The MAR indicated that doses were missed, administered late, or given without the required pulse readings. Additionally, the administration audit report showed that mexiletine was given at incorrect intervals, potentially leading to adverse effects. Resident 29, diagnosed with hypotension and atrial fibrillation, was to receive midodrine with instructions to hold the medication if the systolic blood pressure exceeded 130 BPM. Despite this, the MAR documented that the medication was administered even when the blood pressure was above the specified limit. Similarly, Resident 30, with atrial fibrillation and congestive heart failure, had medications administered without proper documentation of vital signs. Interviews with the Director of Nursing and Director of Staff Development revealed that the nurses were not following the facility's policy, leading to these medication errors.
Failure to Conduct IDT Meeting for Resident's Vision Decline
Penalty
Summary
The facility failed to ensure that an Interdisciplinary Team (IDT) Care Conference meeting was initiated for a resident, identified as Resident 86, after multiple eye doctor appointments. This oversight resulted in neither the staff nor the resident being aware of the outcomes from these appointments. The deficiency violated the resident's right to actively participate in the IDT meeting to discuss his plan of care and services, potentially delaying necessary discussions about needed care and services. Resident 86 was admitted to the facility with diagnoses including end-stage renal disease, type 2 diabetes, anemia, and hypertension. The resident had intact cognitive status and required assistance with various self-care and functional activities. Despite these needs, the last recorded IDT Care Conference Meeting for Resident 86 was on 6/27/2024, with no mention of vision decline. The resident reported seeing an eye doctor two months prior, who recommended surgery, but he was unaware of any arrangements for the procedure, and his vision was deteriorating. Interviews with facility staff, including a Licensed Vocational Nurse, Social Service Director, Assistant Director of Nursing, and MDS Nurse, revealed that there was no IDT meeting held in September 2024, despite the resident's reported vision decline and visits to an outside eye doctor. The facility's policy required IDT meetings for significant changes in a resident's condition, but this was not adhered to in Resident 86's case. The staff acknowledged that an IDT meeting should have been conducted to address the resident's vision issues and update the care plan accordingly.
Failure to Implement Vision Care Plan for Resident
Penalty
Summary
The facility failed to implement a care plan for a resident, identified as Resident 86, who experienced a decline in vision. This deficiency was identified during a survey that included observation, interviews, and record reviews. Resident 86 was admitted with multiple diagnoses, including end-stage renal disease, type 2 diabetes, anemia, and hypertension. Despite having intact cognitive status and the ability to make decisions about his care, there was no care plan addressing his vision decline, which was a concern he had verbalized since September. During the survey, it was observed that Resident 86 was aware of his need for eye surgery due to worsening vision, but there were no updates on the surgery's schedule. Interviews with the Licensed Vocational Nurse (LVN) and the MDS Nurse confirmed that there was no comprehensive care plan for the resident's vision issues, despite his ongoing visits to an eye doctor. The LVN acknowledged that a care plan should have been in place to ensure the healthcare team was aware of the interventions and to assess their effectiveness. The Director of Nursing (DON) also confirmed the absence of a care plan for the resident's vision decline. The facility's policy requires a comprehensive, person-centered care plan to be developed within seven days of the comprehensive assessment and to be revised as the resident's condition changes. However, this was not done for Resident 86, indicating a failure to adhere to the facility's care planning procedures.
Medication Order Lacks Specified Dose
Penalty
Summary
The facility failed to ensure that the medication order for a resident's diclofenac sodium external gel included a specified dose. This oversight resulted in the medication being administered without a documented dose from November 17, 2024, to December 3, 2024. The resident, who was readmitted to the facility with serious heart conditions and had severely impaired cognitive skills, received the medication for pain management without clarity on the amount to be applied. The lack of a specified dose in the medication order posed a risk of overdosing or underdosing the resident. Interviews and record reviews revealed that the Licensed Vocational Nurse (LVN) acknowledged the absence of a specified dose in the Medication Administration Record (MAR) and recognized the need for clarification on the order. The Director of Nursing (DON) confirmed that medication orders must indicate the dose to ensure correct administration. The facility's policy and procedure for administering medication emphasized the importance of verifying the right dosage, among other factors, before administering medication. However, this policy was not adhered to in this instance, leading to the deficiency.
Deficient Foley Catheter Care Leads to Potential UTI Risk
Penalty
Summary
The facility failed to provide appropriate foley catheter care for a resident, identified as Resident 25, which led to the potential for recurrent urinary tract infections (UTIs). Resident 25 was admitted with several diagnoses, including obstructive and reflux uropathy, hypertension, benign prostatic hyperplasia, and mechanical complications of an indwelling urethral catheter. The resident required maximal assistance for various self-care activities and had intact cognitive status, allowing him to understand and make decisions about his care. The deficiency was identified through a review of Resident 25's Treatment Administration Record (TAR) for November 2024, which showed missing documentation for foley catheter care on multiple dates. The facility's policy required catheter care every shift, three times a day, and monitoring for signs of infection such as foul odor, hematuria, and sediments in urine. However, there were gaps in documentation, indicating that the care may not have been provided as ordered. During interviews, both a Licensed Vocational Nurse (LVN) and the Director of Nursing (DON) confirmed that if care was not documented, it was likely not provided. Observations and interviews with Resident 25 revealed that he had experienced frequent UTIs in the past, although he did not have one at the time of the interview. The facility's policy emphasized the importance of maintaining clean technique and regular monitoring to prevent catheter-associated UTIs. The lack of consistent documentation and adherence to the care plan increased the risk of Resident 25 developing recurrent UTIs, as confirmed by the DON during the interview.
Incorrect Oxygen Administration for Resident
Penalty
Summary
The facility failed to ensure that a resident was receiving the correct concentration of oxygen, which was a deviation from the physician's order. The resident, who was readmitted with diagnoses including interstitial pulmonary disease, pulmonary fibrosis, acute respiratory failure, and dependence on supplemental oxygen, was observed to have their oxygen set at 2.5 liters per minute instead of the prescribed 2 liters per minute. This discrepancy was confirmed by the Assistant Director of Nursing (ADON) during an observation and interview. The ADON acknowledged the importance of adhering to the prescribed oxygen level to maintain proper lung function. The Director of Nursing (DON) also emphasized the necessity for staff to follow physician orders to ensure resident safety. The facility's policy on oxygen administration, revised in 2010, requires verification of the physician's order for safe oxygen administration, which was not followed in this instance.
Failure to Monitor Resident on Psychotropic Medications
Penalty
Summary
The facility failed to adequately monitor the behaviors of a resident who was prescribed psychotropic medications, which could lead to unnecessary medication use. The resident, who was admitted with diagnoses including dementia, major depressive disorder, PTSD, and limb amputations, was receiving Escitalopram for depression and anxiety, and Mirtazapine for sleep issues. However, there was no documented evidence that the resident's feelings of hopelessness, anxiety, or sleep patterns were monitored to assess the effectiveness of these medications. Interviews with the Director of Staff Development and the Director of Nursing revealed that the facility did not follow its policy and procedure for behavioral assessment, intervention, and monitoring. The policy required the interdisciplinary team to document any changes in behavior, mood, and function, and to monitor progress until stable. The lack of monitoring was acknowledged by the staff, indicating a failure to ensure the resident's behaviors were assessed to determine the necessity and effectiveness of the psychotropic medications.
Medication Security Lapse
Penalty
Summary
The facility failed to ensure the secure storage of medications, as evidenced by an incident involving Resident 70's medication. During a medication pass, an LVN placed Resident 70's Amiodarone on top of the medication cart and left it unattended. This action was observed on December 4, 2024, at 9:30 a.m. The unattended medication was later noticed by the Director of Staff Development, who confirmed that medications should not be left unattended to prevent unauthorized access by other residents. Resident 70 had been readmitted to the facility with serious cardiac conditions, including ventricular fibrillation and hypertensive heart disease with heart failure. The resident's cognitive skills for daily decision-making were severely impaired, as indicated by the Minimum Data Set dated November 23, 2024. The facility's policy on medication storage specifies that medication supply should only be accessible to authorized personnel, highlighting the importance of secure medication handling to ensure resident safety.
Failure to Sanitize Mechanical Lift Between Residents
Penalty
Summary
The facility failed to observe proper infection control measures when using a mechanical lift for two residents. Certified Nursing Assistant (CNA 1) and CNA 2 used the mechanical lift to transfer Resident 69, who required substantial assistance due to conditions such as end-stage renal disease and generalized muscle weakness, to a wheelchair. After completing the transfer, CNA 1 did not sanitize the mechanical lift before placing it in the hallway. Subsequently, CNA 1 used the same unsanitized lift to assist Resident 14, who was dependent on assistance for personal hygiene and dressing due to chronic kidney disease and anxiety disorder, into a Geri chair. During an interview, CNA 1 acknowledged forgetting to clean the mechanical lift between uses, recognizing the importance of this practice to prevent infection spread. The Director of Staff Development confirmed that equipment like mechanical lifts must be cleaned before and after use to prevent cross-contamination. The facility's policy on infection prevention and control, dated October 10, 2018, mandates maintaining a sanitary environment to prevent communicable diseases, which was not adhered to in this instance.
Failure to Provide Adequate Assistance During Mechanical Lift Transfer
Penalty
Summary
The facility failed to provide adequate care and services to prevent a fall for a resident by not ensuring that a Certified Nursing Assistant (CNA) provided a two-person physical assist when using a Mechanical Lift. The facility's policy requires at least two people to be present during transfers with a Mechanical Lift to ensure safety. However, CNA 1 attempted to transfer the resident alone, resulting in the resident falling from the lift and sustaining a right shoulder nondisplaced fracture. The resident, who was initially admitted to the facility with diagnoses including end-stage renal disease, generalized muscle weakness, and hypertension, was assessed as high risk for falls. The resident required substantial assistance for transfers and was dependent on staff for moving from one surface to another. On the day of the incident, the resident returned from dialysis and requested help to go to bed. CNA 1 attempted the transfer alone, leading to the resident falling and injuring their shoulder. Interviews with staff, including the Licensed Vocational Nurse (LVN), Director of Staff Development (DSD), and Director of Nursing (DON), confirmed that the facility's policy mandates two-person assistance for transfers using a Mechanical Lift. The Occupational Therapist (OT) noted that the resident's right arm and shoulder range of motion were impaired following the fall, requiring therapy to regain function. The facility's policy, revised in October 2019, clearly states the requirement for two-person assistance during such transfers, which was not adhered to in this case.
Violation of Resident Rights and Dignity
Penalty
Summary
The facility failed to uphold and protect the rights of two residents, resulting in a deficiency related to resident dignity and respect. Resident 2, who has diagnoses including generalized anxiety disorder, major depressive disorder, and hemiplegia, experienced a violation of privacy and dignity when the Administrator (ADM) and Business Office Manager (BOM) entered his room without permission to discuss his outstanding balance. The ADM spoke to Resident 2 in a demeaning manner, questioning his financial decisions in a way that made him feel anxious and disrespected. This interaction was witnessed by Resident 2's roommate, who confirmed the disrespectful tone used by the ADM. Resident 3, diagnosed with anxiety disorder, major depressive disorder, and schizophrenia, was moved to another room against her wishes. Despite expressing her disagreement with the room change due to anxiety concerns, the ADM proceeded with the move to accommodate newly admitted residents near the nurse's station. The Ombudsman was contacted by Resident 3, who felt her rights were violated, and the ADM acknowledged the resident's refusal but decided to move her regardless. The facility's policy on room changes states that resident preferences should be considered, and residents have the right to refuse a move if it is for staff convenience. The facility's policies on resident rights and quality of life emphasize treating residents with dignity, respect, and privacy. However, the actions of the ADM in both cases did not align with these policies, leading to feelings of anxiety, humiliation, and a lack of trust among the affected residents. The ADM admitted to not having permission to discuss financial matters in Resident 2's room and acknowledged leaving the door open during the conversation, further compromising privacy. These actions contributed to the deficiency in maintaining resident dignity and respect.
Delayed Emergency Response for Choking Resident
Penalty
Summary
The facility failed to promptly activate Emergency Medical Services (EMS) and provide appropriate emergency care when a resident was observed choking while eating. The incident involved a resident with a history of dysphagia and severely impaired cognitive skills, who was dependent on staff for eating. During the choking episode, the resident's oxygen saturation fluctuated between 52% and 82%, and the staff administered oxygen at an insufficient rate via a nasal cannula instead of using a non-rebreather mask, which would have been more effective. The delay in calling 911 was due to the actions of RN 1 and LVN 1, who prioritized checking the resident's code status and consulting with the Director of Staff Development (DSD) over immediately contacting emergency services. This resulted in a 14-minute delay before EMS was called. Additionally, the staff failed to retrieve the crash cart and a non-rebreather mask, which were necessary for providing adequate emergency care to the resident. Interviews with staff members revealed a lack of clear communication and delegation during the emergency. CNA 1 and CNA 2 were not instructed to call 911 or retrieve the crash cart, and LVN 1 did not inform RN 1 about performing the Heimlich maneuver. The Director of Nursing (DON) and DSD acknowledged that the facility's response was inadequate, emphasizing that 911 should have been called immediately and the crash cart should have been brought to the resident's room to prevent a delay in care.
Failure to Document Choking Incident and Care
Penalty
Summary
The facility failed to document the care provided to a resident who experienced a choking incident during dinner. The resident, who had a history of dysphagia and severely impaired cognitive skills, was being fed noodles by a CNA when they began to choke. The CNA called for assistance, and an LVN performed the Heimlich maneuver, successfully expelling food particles from the resident's mouth. However, the LVN did not document the incident or the care provided in the resident's medical record, citing being busy as the reason for the oversight. This lack of documentation resulted in an incomplete medical record for the resident, which did not reflect the choking incident or the subsequent care provided. The facility's policy required detailed documentation of such incidents, including the time, assessment data, and the resident's response. The failure to document prevented accurate communication between healthcare professionals and hindered the facility's ability to review and investigate the incident thoroughly.
Failure to Resolve Resident's Grievance Regarding Missing Belongings
Penalty
Summary
The facility failed to resolve a grievance to the satisfaction of a resident and their representative regarding missing personal belongings, specifically a cellphone. The resident, who was admitted with diagnoses including sepsis, depression, and hemiparesis, had intact cognition and required supervision for activities of daily living. The resident's inventory list included a black cellphone, which was reported missing along with other items such as a backpack, checkbook, and social security card. Despite the grievance being filed, the resolution did not address the cellphone, which was inventoried, and the resident's representative expressed dissatisfaction with the lack of replacement or reimbursement. The facility's policy required prompt resolution of grievances to the satisfaction of the resident or their representative, but this was not achieved. The Social Services Director acknowledged that the cellphone should have been replaced or reimbursed, as it was listed in the inventory. The Administrator, however, stated that the resident had the ability to safeguard their belongings and was not satisfied with the resolution. The facility's grievance policy indicated that all grievances should be responded to in writing with a rationale, but this was not adequately fulfilled in this case.
Delayed Family Notification of Change in Resident's Condition
Penalty
Summary
The facility failed to notify a family member in a timely manner when there was a change of condition for a resident. The resident, who was admitted with diagnoses including congestive heart failure, obstructive and reflux uropathy, and unspecified dementia, had mildly impaired cognitive skills and required moderate assistance for various activities of daily living. On a specific date, the resident pulled out his Foley catheter, resulting in moderate bleeding at the penile tip. The physician was notified at 3:22 a.m., but the family was not informed until 8:00 a.m., leading to dissatisfaction and concern from the family. The Assistant Director of Nursing (ADON) acknowledged the delay in notifying the family and stated that the facility's protocol requires prompt notification of any change in a resident's condition. The facility's policy and procedure documents also emphasize the importance of promptly informing the resident, their physician, and their representative of any changes in medical or mental condition. The ADON admitted that a five-hour delay in notifying the family was not acceptable, although the facility did attempt to inform them. The family expressed upset over the lack of immediate notification and the decision not to send the resident to the hospital immediately after the incident.
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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