Moraga Post Acute
Inspection history, citations, penalties and survey trends for this long-term care facility in Moraga, California.
- Location
- 348 Rheem Boulevard, Moraga, California 94556
- CMS Provider Number
- 055085
- Inspections on file
- 20
- Latest survey
- March 12, 2026
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Moraga Post Acute during CMS and state inspections, most recent first.
A resident with vascular dementia, impaired gait, lower extremity limitations, and a documented history of falls was repeatedly assessed as high risk for falls, yet fall care plans were not updated with new interventions after multiple unwitnessed falls and ongoing attempts to get out of bed unassisted. Staff relied on general measures such as low bed position, call light within reach, and periodic safety checks, and the facility did not provide one-on-one sitters, instead discussing such arrangements with families. While the primary CNA was on break and coverage was assigned to another CNA who was occupied in another room, the resident attempted to ambulate from bed to the doorway without assistance, was observed by another resident’s family member to lose balance and fall forward, and was later found by staff with a bleeding head laceration and subsequently diagnosed with a subarachnoid hemorrhage.
A resident with dementia and anxiety, who had no documented psychosis or behavioral symptoms on admission assessment, was started on and later had the dose increased of Seroquel for "vascular dementia manifested by manic behaviors," and was also given PRN Ativan for anxiety. The IDT did not document assessment of angry outbursts or hallucinations or implement person-centered non-pharmacological interventions before initiating or escalating the antipsychotic, and the use of Seroquel and Ativan was not addressed in the resident’s care plan with appropriate interventions. Informed consent forms for both medications lacked documentation that the resident’s representative had been informed and consented, and the MD confirmed she did not directly obtain consent, contrary to facility policy requiring a specifically diagnosed condition, behavioral interventions, and prescriber-obtained informed consent for psychotropic use.
A resident with neutropenia, hemiplegia, hemiparesis, functional diarrhea, and heart failure was admitted directly into a conference room and remained there for six weeks, even though this area was not approved for patient housing and lacked a sink and bathroom. The care plan documented that the resident was housed in the conference room and required staff to bring water and soap for handwashing, and observations showed the resident using a bedside commode behind an improvised curtain with the door sometimes left open during care. Staff reported that the family requested a private room and chose the conference room after being told it had been used previously for residents, and leadership cited past COVID-19-related flexibility but could not provide current authorization, while state regulations and CDPH guidance reviewed by surveyors did not support using the conference room as a resident room.
The facility failed to properly label and date eye drop medications for two residents, leading to the potential use of less effective medication. Observations revealed that Latanoprost Ophthalmic solutions for both residents lacked an open date, despite instructions to discard 42 days after opening. Interviews with the ADON and Pharmacy Consultant confirmed the necessity of open dates to ensure medication effectiveness.
A facility failed to properly store and dispose of medications, as expired lorazepam was found in a refrigerator for ready-to-use medications, and a medication disposal bin was left unsecured. An LVN confirmed the expired status of the lorazepam, and the DON acknowledged the need for securing the disposal bin. Facility policies required proper disposal and secure storage of medications.
The facility did not employ a full-time registered dietitian and the Dietary Supervisor lacked the necessary qualifications for the dietary manager position, posing risks of foodborne illness and malnutrition to residents. The DS had only a Food Manager certification, while the RD worked part-time.
The facility failed to maintain kitchen equipment and environment in a sanitary and operational condition, with two ovens not functioning properly and unsanitary conditions observed. Despite awareness of these issues by the Dietary Supervisor, Maintenance Supervisor, and Administrator, no corrective actions were taken, leading to potential food safety risks.
The facility failed to maintain a record system for controlled drugs, as the DON and pharmacist did not dispose of medications quarterly as required. Logs were disorganized, and records for 2021 were missing. The pharmacist confirmed the process should occur quarterly, but the facility's policy only required records to be kept for two years, conflicting with state law.
The facility failed to maintain accurate medical records and care plans for three residents. An LPN did not document the administration of a controlled medication for a resident. Two residents had multiple undocumented medication administrations, confirmed by the DON. Another resident's care plan inaccurately restricted her movement due to infection control, despite observations of her moving freely in common areas.
A Licensed Vocational Nurse failed to perform proper hand hygiene during medication administration for three residents, including handling medications and medical instruments without changing gloves or sanitizing hands. The Director of Nursing acknowledged the importance of hand hygiene but had not conducted medication pass observations since starting in February 2023, relying instead on a nurse consultant who had previously reported handwashing as a common concern.
A facility failed to accurately complete the MDS assessment for a resident's mobility, incorrectly indicating the resident was unable to walk due to health reasons. Interviews and records showed the resident could walk with assistance, receiving help from an RNA multiple times a week. The MDS Coordinator admitted a coding error, highlighting the importance of accurate assessments to ensure proper care planning.
A facility failed to accurately complete and update the PASARR assessment for a resident over four years. The initial PASARR was completed late and inaccurately indicated no psychotropic medication use, despite the resident receiving quetiapine. A subsequent PASARR incorrectly suggested a short-term stay, although the resident remained long-term. The MDSC overlooked the need for a Level II PASARR despite the resident's mental health diagnoses.
A resident with a history of stroke and diabetes, requiring extensive assistance for personal hygiene, was found with long fingernails and blackish material under the nail tips. Despite the facility's policy on regular nail care, the assigned nurse was unaware of the need for trimming, leading to a deficiency in care.
Failure to Adequately Supervise High-Risk Resident Resulting in Fall With Head Injury
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision and implement effective fall-prevention interventions for a resident with a known high risk for falls and cognitive impairment. The resident was admitted with diagnoses including abnormalities of gait and mobility, age-related physical debility, osteoarthritis, a lumbar compression fracture, and vascular dementia. The admission MDS documented that walking at least 10 feet in a room was not attempted due to medical or safety concerns, that the resident used a walker and wheelchair, had lower extremity range-of-motion limitations, and had a prior fall before admission. The resident’s BIMS score was 8, indicating moderately impaired mental status with inability to recall the correct year, month, and day of the week. The facility’s own assessments repeatedly identified the resident as being at high risk for falls, with fall risk assessment scores of 28, 28, and 36 on three separate dates. Interdisciplinary team notes documented multiple falls: staff heard screaming and found the resident on the floor on one occasion; on another, a staff member heard the resident calling for help and found the resident on the floor after an unwitnessed fall in which the resident reported striking her head. Despite these repeated unwitnessed falls and the resident’s ongoing behaviors of trying to get out of bed to ambulate with agitation, aggression, and hallucinations, the fall care plans dated after these events were not updated with new or enhanced interventions beyond general measures such as keeping the bed low and call light within reach. On the date of the cited incident, a family member of another resident observed the high-risk resident ambulating from her bed toward the room doorway, losing balance, and falling forward to the ground. Staff were not present at the time of the fall and were summoned by the family member. The resident was found on the floor with a laceration on the left frontal forehead and uncontrolled bleeding and was subsequently transferred to the hospital, where a subarachnoid hemorrhage was diagnosed. Interviews with staff indicated that the resident frequently attempted to get out of bed without assistance, that hourly safety checks and reminders to call for help were relied upon, and that the facility did not provide one-on-one sitters for fall-risk residents, instead discussing such arrangements with families. The facility’s fall policy required staff to identify interventions related to specific risks and causes based on evaluations and data, but the care plans were not revised with additional interventions after the repeated unwitnessed falls and escalating fall risk behaviors.
Failure to Ensure Appropriate Use and Consent for Psychotropic Medications
Penalty
Summary
The deficiency involves the facility’s failure to prevent the use of unnecessary psychotropic medications and to ensure a resident was free from unnecessary drugs. One resident with non-Alzheimer’s dementia and an anxiety disorder had an admission MDS showing a BIMS score of 8, indicating moderately impaired cognition, but no documented hallucinations, delusions, or behavioral symptoms such as aggression, wandering, or rejection of care. Despite this, the physician ordered Seroquel 25 mg twice daily for “vascular dementia manifested by manic behaviors,” and later increased the dose after reports of aggressive outbursts and confusion. The diagnosis of vascular dementia was used as the indication for the antipsychotic, and there was no documentation that the IDT evaluated the resident’s angry outbursts or hallucinations or identified and implemented person-centered non-pharmacological interventions before starting or increasing the Seroquel. The resident was also prescribed Ativan 0.5 mg by mouth at night as needed for anxiety and received multiple PRN doses over several days. Review of the medical record, including the Order Summary Reports, MARs, and care plans, showed that the facility did not incorporate the use of Seroquel and Ativan into the resident’s care plan with appropriate interventions. The DON was unable to provide IDT documentation or a care plan addressing the resident’s angry outbursts with person-centered non-pharmacological approaches prior to the administration of Seroquel, despite facility policies requiring thorough evaluation of behavioral symptoms and use of behavioral interventions unless contraindicated. Informed consent procedures for psychotropic medications were not followed as required. The Psychotherapeutic Drug Informed Consent forms for both Seroquel and Ativan did not contain documentation that informed consent was obtained from the resident’s representative prior to their use. The physician acknowledged not speaking directly with the resident’s representative regarding informed consent for these medications and stated that nurses were expected to obtain consent. The facility’s stated process was for licensed nurses to call the resident’s representative, explain the medication, its use, and side effects, and document consent, but this was not documented in the record for this resident. These omissions occurred despite facility policies stating that psychotropic medications may only be administered when necessary to treat a specifically diagnosed condition, with appropriate documentation, behavioral interventions, and informed consent obtained by the prescribing clinician.
Resident Housed in Unapproved Conference Room Without Sink or Bathroom
Penalty
Summary
The deficiency involves the facility’s failure to comply with state regulations requiring that residents be housed only in areas approved for patient housing. One resident was admitted directly into a conference room and remained there from admission through discharge, a total of six weeks. The conference room was located behind the reception desk at the facility entrance, had advertising brochures on the walls, and was separated primarily by a curtain, with the door left open during care at times. The resident’s care plan specifically documented housing in the conference room and noted that staff needed to bring in water and soap for handwashing because there was no sink in the room. The resident had multiple medical diagnoses, including neutropenia, hemiplegia, hemiparesis, functional diarrhea, and heart failure, and had an intact cognitive status based on a BIMS score of 13. Observations showed the resident in a patient bed in the conference room with a bedside commode and bedside table, and the resident reported using a bell to call for help. A CNA confirmed there was no bathroom or sink in the room, that the resident used the commode for bowel movements, and that privacy was difficult to maintain because the room was primarily separated by a curtain and the door was not fully closed during care. Interviews with staff revealed that the resident’s family requested a private room and selected the conference room after being informed it had been used in the past for resident housing. The Admissions Coordinator stated the census listed the resident in a standard room number, but the resident was always physically located in the conference room. The DON acknowledged the conference room was not ideal for patient care due to the lack of a toilet and sink. The current Administrator and former administrator referenced prior CDPH authorization during the COVID-19 pandemic to use the conference room for residents, but neither could provide dates or documentation, and a review of CDPH waivers and AFLs showed no current authorization and confirmed that temporary COVID-19 waivers had been discontinued, while state regulations prohibit housing patients in non-approved areas without temporary permission in an emergency.
Improper Labeling and Dating of Eye Drop Medications
Penalty
Summary
The facility failed to ensure the proper labeling and dating of eye drop medications for two residents, Resident 98 and Resident 100. During an observation of Medication Cart A, it was noted that Resident 98's Latanoprost Ophthalmic solution did not have an open date on the label, despite instructions to discard the medication 42 days after opening. Similarly, an observation of Medication Cart B revealed that Resident 100's Latanoprost Ophthalmic solution also lacked an open date. Both medications had an expiration date of June 2026 and required refrigeration until opening. Interviews with the Assistant Director of Nursing (ADON) confirmed that the eye drops should have had an open date to ensure they were discarded as per the instructions, preventing the use of potentially less effective medication. Resident 100 had a diagnosis of primary open-angle glaucoma, bilateral indeterminant stage, and Resident 98 had physician orders for Latanoprost to treat glaucoma. The Pharmacy Consultant Supervisor also stated that the eye drops should have an open and use-by date to maintain their effectiveness.
Improper Storage and Disposal of Medications
Penalty
Summary
The facility failed to ensure proper storage and disposal of medications, as observed during a survey. Two bottles of expired lorazepam, a medication used to treat anxiety, were found in a refrigerator designated for ready-to-use medications. This was noted during an observation in the medication room with an LVN, who acknowledged that the medications were expired and should not have been stored there. The facility's pharmacist confirmed that expired or discontinued medications should be placed in a designated disposal area for destruction. A review of Resident 10's physician orders indicated that the resident had an order for lorazepam, and the last dose was administered prior to the survey. The facility's policy stated that discontinued or outdated drugs should be returned to the pharmacy or destroyed. Additionally, the survey revealed that the lid of a black medication disposal bin in the medication storage room was loosely open, allowing easy access to its contents, which included pills, capsules, and other medication forms. The DON acknowledged that the lid should be secured, as indicated by the label on the bin, which stated that it should remain closed and items should not be removed. The facility's policy required that all drugs and biologicals be stored in a safe, secure, and orderly manner, which was not adhered to in this instance.
Deficiency in Dietary Management Qualifications
Penalty
Summary
The facility failed to employ a full-time registered dietitian and did not ensure that the person designated as the director of food and nutrition services met the necessary federal and state educational qualifications for a dietary manager position. The Dietary Supervisor (DS) was working full-time in this role but only had a Food Manager certification obtained through an online training course, which was deemed insufficient for the dietary manager position. The DS had been in this role for one year, while the Registered Dietitian (RD) worked part-time, being present at the facility only two days a week. The lack of a full-time, qualified individual overseeing the food and nutrition services posed a risk to residents who consumed food from the kitchen. This deficiency increased the potential for foodborne illnesses and decreased nutrient intake, which could lead to malnutrition or even death. The Administrator acknowledged that the DS's ServSafe certification did not meet the required qualifications for the dietary manager position, highlighting a significant oversight in staffing and compliance with regulatory standards.
Deficiencies in Kitchen Equipment and Sanitation
Penalty
Summary
The facility failed to maintain its kitchen equipment and environment in a sanitary and operational condition, leading to potential food safety issues. Two ovens were not functioning properly; one oven was unable to cook chicken to the required food safety temperature, and the other was inoperable. The Dietary Supervisor and Cook were aware of these issues, and the Cook had to manually adjust cooking methods to ensure food safety. Despite being informed of the faulty ovens three to six months prior, the Maintenance Supervisor and Administrator had not addressed the necessary repairs or replacements. Additionally, the facility's kitchen environment was not maintained in a clean and sanitary condition. Observations revealed brownish black debris on a countertop toaster oven, cracked and discolored kitchen floor tiles, a dusty ceiling vent, a malodorous and insecure grease trap, and a cabinet drawer that did not fully close. The Dietary Supervisor, Maintenance Supervisor, and Administrator were aware of these issues, but no corrective actions had been taken. The facility's sanitation policy requires all kitchen areas to be clean and equipment to be in good repair, which was not adhered to in this case.
Failure to Maintain Controlled Drug Records
Penalty
Summary
The facility failed to ensure that the pharmacist provided consultation services to maintain a record system for the receipt, disposition, and reconciliation of all controlled drugs for three years. During an interview and record review with the Director of Nursing (DON), it was revealed that the controlled medication disposition binder was disorganized, with logs and medication packages unaccounted for since 10/5/2022. The DON admitted that she and the facility's pharmacist were responsible for disposing of controlled medications into the final incinerator container together, but she had not had the time to do so. Additionally, the DON was unable to locate the controlled drug disposition records for the year 2021. In a phone interview, the pharmacist confirmed that the controlled drugs in need of disposal were to be reconciled and documented for any discrepancies before being placed in sealable plastic bags with a liquid and then into an incinerator container for destruction by a contractor. The pharmacist stated that this process should occur quarterly, and the disposition documentation should be retained for three years. However, the facility's policy indicated that completed medication disposition records should be kept for at least two years, or as mandated by state law. The California Codes for Pharmacy require that such logs be retained for at least three years, highlighting a discrepancy in the facility's policy and practice.
Inaccurate Medical Records and Care Plan Documentation
Penalty
Summary
The facility failed to maintain complete and accurate medical records for three residents, leading to potential risks in medication administration and care provision. For Resident 9, a Licensed Vocational Nurse (LVN) did not document the administration of a controlled medication, oxycodone, immediately after it was given. This discrepancy was noted during an observation where the nurse acknowledged administering the medication but failing to record it in the Medication Administration Record (MAR) and Controlled Drug Record (CDR). For Resident 30, there were multiple instances where medications were not documented as administered on specific dates. The Director of Nursing (DON) confirmed the absence of documentation for several medications, including those for blood pressure, insulin, and other critical treatments. LVNs responsible for these omissions cited being sidetracked or could not provide explanations for the lack of documentation, which was against the facility's policy requiring immediate documentation post-administration. Resident 15's care plan inaccurately reflected her movement restrictions due to infection control measures. Despite being on strict contact isolation, observations and interviews revealed that the resident was seen outside her room, engaging in activities like ambulation therapy and moving around in common areas. This inconsistency between the care plan and actual practice was confirmed through surveillance footage and staff interviews, indicating a failure to update and adhere to the care plan accurately.
Inadequate Hand Hygiene During Medication Administration
Penalty
Summary
The facility failed to ensure proper infection prevention and control practices during medication administration by a Licensed Vocational Nurse (LVN). The LVN did not perform hand hygiene while administering medications to three residents, which included handling medications, using medical instruments, and administering injections and eye drops. Specifically, the LVN did not change gloves or sanitize hands between different tasks and residents, increasing the risk of cross-contamination and infection transmission. The Director of Nursing (DON) acknowledged the importance of hand hygiene in preventing infections and stated that staff were expected to perform hand hygiene before and after medication administration and when touching items in residents' rooms. However, the DON admitted that no medication pass observations had been conducted for licensed nurses since she started in February 2023. The facility relied on a nurse consultant from a contracted pharmacy company for quarterly medication administration observations, which had previously reported handwashing as a common concern.
Inaccurate MDS Assessment on Resident Mobility
Penalty
Summary
The facility failed to accurately complete the Minimum Data Set (MDS) assessment for a resident, specifically regarding the resident's functional status on mobility. The MDS assessment inaccurately indicated that the resident was unable to walk due to health and safety reasons. However, interviews and record reviews revealed that the resident was able to walk with assistance in the hallways and outside on the patio, receiving assistance from a Restorative Nursing Assistant (RNA) at least three times per week. This discrepancy resulted in an inaccurate reflection of the resident's medical condition. During the review, it was found that the MDS assessment under Functional Abilities incorrectly showed that walking was not attempted due to a medical condition, while the Restorative Nursing Programs section indicated that the resident walked three days in the last seven calendar days. The MDS Coordinator acknowledged that this was an item coding error and should have been coded as moderate assistance for walking. The MDS Coordinator emphasized the importance of accurate MDS assessments, as inaccuracies could affect the resident's plan of care. The Long-Term Care Facility Resident Assessment Instrument (RAI) manual requires that assessments accurately reflect the resident's status, as per federal regulations.
Failure to Accurately Complete PASARR Assessment
Penalty
Summary
The facility failed to accurately complete and update the Level I Preadmission Screening and Resident Review (PASARR) assessment for a resident over a period of more than four years. The resident was admitted in December 2018, and the initial PASARR screening was completed a week after admission, inaccurately indicating that the resident was not prescribed psychotropic medications, despite records showing she was receiving quetiapine for hospital delirium. Additionally, a PASARR completed in June 2019 for the resident's readmission inaccurately suggested that the resident's stay would require less than 30 days of nursing facility services, although she remained a long-term resident. The Minimum Data Set Coordinator (MDSC) also failed to recognize the need for a Level II PASARR screening, despite the resident having diagnoses of schizophrenia and psychosis, which could have warranted further evaluation. The facility's policy required all new admissions and readmissions to be screened for mental disorders, intellectual disabilities, or related disorders, and to refer individuals meeting certain criteria for a Level II screening. However, this process was not followed, resulting in an inaccurate reflection of the resident's medical status and potentially impacting the care and services provided.
Failure to Provide Necessary Fingernail Care
Penalty
Summary
The facility failed to provide necessary assistance for fingernail care to a resident, identified as Resident 30, who had long fingernails with blackish material under the nail tips. This deficiency was observed during an interview and observation session with the resident, who expressed a desire to have her fingernails trimmed. The resident's medical history included a stroke and diabetes mellitus, and she required extensive physical assistance for personal hygiene tasks, as documented in her Minimum Data Set and Activities of Daily Living care plan. Despite the resident's need for assistance, the assigned nurse, LVN 2, was unaware of why the resident's fingernails had not been trimmed. The facility's policy on fingernail care, revised in February 2022, emphasized the importance of cleaning the nail bed, keeping nails trimmed, and preventing infections. However, this policy was not adhered to in the case of Resident 30, leading to the potential risk of injury and infection due to the untrimmed fingernails.
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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