Mountain View Post Acute
Inspection history, citations, penalties and survey trends for this long-term care facility in Barstow, California.
- Location
- 27555 Rimrock Rd, Barstow, California 92311
- CMS Provider Number
- 555162
- Inspections on file
- 30
- Latest survey
- June 17, 2025
- Citations (last 12 mo.)
- 19
Citation history
Health deficiencies cited at Mountain View Post Acute during CMS and state inspections, most recent first.
A resident with acute pulmonary edema and muscle weakness received PT and OT services for 25 days without a physician's order. Therapy assistants conducted sessions, but clinical records lacked documentation of physician authorization or notification. The DON was unaware of the requirement for a physician's order, and the facility had no formal policy to ensure compliance.
A nurse left a computer screen displaying a resident's sensitive medical information unattended and visible in a hallway while administering medication. The resident's record included diagnoses such as fibromyalgia, cardiomegaly, and acute respiratory failure. The nurse admitted to not following proper procedures, and facility leadership confirmed that this action was not in line with policy requiring protection of resident-identifiable information.
A deficiency was identified when an LVN failed to perform hand hygiene after removing gloves following contact with a resident's Foley catheter while the resident was on Enhanced Barrier Precautions. The LVN then shook hands with the resident and left the room without sanitizing hands, contrary to facility policy and infection control expectations as confirmed by the IP and DON.
A resident with a history of muscle weakness and repeated falls experienced an unwitnessed fall, resulting in head stitches. The facility's interdisciplinary team did not review the fall incident as required by the Fall Prevention Program policy, which mandates risk assessment and care plan interventions.
A resident's debit card was misused by the facility's Business Office Manager to pay for the resident's outstanding balance instead of personal necessities like clothing and shoes, as agreed with the bank. The resident had authorized the card for personal expenses, but the funds were used against the bank's terms, potentially neglecting the resident's needs. The facility's policy requires written authorization for fund management, which was not followed, leading to the misappropriation.
A resident with Type 2 DM did not receive Metformin from admission until a month later due to a failure in the facility's assessment and communication processes. The LVN assumed blood sugar checks were for an infection, and the admitting RN did not verify medication needs with the physician, despite the resident's high blood sugar levels.
A facility failed to promptly notify a resident about the Skilled Facility Advanced Beneficiary Notice of Non-coverage (SNF ABN) and the Notice of Medicare Non-Coverage (NOMC), leading to a delay in informing the resident's representative about the end of Medicare coverage and appeal rights. The responsible party signed the NOMC form 18 days after coverage ended, contrary to the facility's policy requiring timely notification.
The facility failed to respond to call lights promptly, as reported by two residents with mobility and muscle weakness issues. They experienced significant delays in receiving assistance, contrary to the facility's policy requiring timely responses. Interviews with staff did not yield specific solutions to the residents' concerns.
The facility failed to follow infection control practices, with staff wearing acrylic nails longer than allowed and improper management of urinary catheters for two residents. Acrylic nails were worn by a CNA, the AD, and the IP, contrary to the facility's policy. Additionally, a resident's catheter bag was on the floor, and another's tubing was dragging, both posing infection risks. The DON and IP acknowledged these practices were against the facility's infection control policies.
The facility failed to maintain their walk-in refrigerator and freezer in safe operating condition, leading to potential food spoilage and increased risk for foodborne illness for 42 residents. The equipment was found malfunctioning, with temperatures recorded above acceptable limits, and the facility's policy on maintaining equipment was not followed.
The facility failed to maintain the dignity of two residents by not covering their urinary catheter drainage bags with dignity bags, as required by the facility's policy. One resident with acute kidney failure and another with fournier gangrene were observed with uncovered catheter bags, making the urine visible. The Director of Nursing confirmed the policy requirement for dignity bags to maintain privacy and dignity, which was not followed.
A resident's RAI-MDS was inaccurately coded, failing to indicate a fall since admission, despite evidence from clinical records and resident reports. The MDS nurse responsible acknowledged the error, which stemmed from an incomplete review of available documentation. This oversight had the potential to result in unmet care needs, jeopardizing the resident's health and safety.
A resident with a history of falls and conditions like hemiparesis was found to have only one fall mat instead of the two specified in his care plan. Despite facility policies emphasizing fall prevention, staff acknowledged the oversight, and the Director of Nursing confirmed that care plan interventions were not followed, increasing the risk of injury.
A resident with a history of falls experienced another fall, but the LTC facility failed to conduct a post-fall risk assessment or update the care plan as required by their policies. The DON confirmed that these steps were not taken, despite the facility's protocols mandating such actions after a fall.
A resident with type 2 diabetes was administered insulin Lispro 2 hours before mealtime, contrary to physician's orders, due to an LVN not reading the full order. This error was confirmed by the DON, who noted that facility policies on medication administration were not followed, placing the resident at risk for hypoglycemia.
An IV medication cart was left unlocked and unattended at a nurses' station, containing supplies like syringes and antibiotics. A registered nurse admitted to forgetting to lock the cart, which was against the facility's policy requiring carts to be locked unless in use. The Director of Nurses confirmed the policy was not followed.
Rehabilitative Services Provided Without Physician Order
Penalty
Summary
The facility failed to ensure that specialized rehabilitative services were provided in accordance with federal regulations for one of two sampled residents. A resident who was readmitted with acute pulmonary edema and muscle weakness received both physical therapy (PT) and occupational therapy (OT) services for 25 days without a physician's order. Observations confirmed that the resident participated in PT and OT sessions, including sitting to standing transfers and arm exercises, under the guidance of therapy assistants. A review of the resident's clinical records revealed no documented physician's order for PT or OT treatment, nor any evidence that a physician had been notified about these services. During interviews, the Director of Rehab confirmed the ongoing therapy services, and the Director of Nurses stated unawareness of the regulatory requirement for a physician's order for such services. The facility did not have a formal policy or procedure to ensure physician oversight for rehabilitative treatments.
Failure to Safeguard Resident Confidential Information
Penalty
Summary
A Licensed Vocational Nurse (LVN) failed to safeguard a resident's confidential medical information by leaving a computer screen displaying the resident's clinical records unattended and visible in a hallway. The incident occurred when the LVN entered a resident's room to administer medication, leaving the computer with the resident's information accessible to others. The resident's medical record included sensitive information such as diagnoses of fibromyalgia, cardiomegaly, and acute respiratory failure with hypoxia. During interviews, the LVN acknowledged the lapse, attributing it to habit, and the Registered Nurse Supervisor confirmed that staff are expected to close or change the computer screen when stepping away. The Director of Nursing reviewed the facility's policy, which requires that computer screens showing clinical information not be left unattended or visible to unauthorized individuals, and acknowledged that the policy was not followed in this instance.
Failure to Perform Hand Hygiene After Foley Catheter Care for Resident on Enhanced Barrier Precautions
Penalty
Summary
A deficiency occurred when a Licensed Vocational Nurse (LVN) failed to perform hand hygiene after contact with a resident's Foley catheter while the resident was on Enhanced Barrier Precautions (EBP) due to multiple medical conditions, including hypertension, type 2 diabetes mellitus, COPD, protein-calorie malnutrition, and dysphagia. During an observation, the LVN was seen wearing gloves while touching the resident's Foley catheter and bag, then removed the gloves, shook hands with the resident, and exited the room without performing hand hygiene. Interviews with the LVN, Infection Preventionist (IP), and Director of Nursing (DON) confirmed that facility policy requires hand hygiene after glove removal and after contact with devices such as urinary catheters, especially for residents on EBP. The LVN acknowledged the oversight, and both the IP and DON stated that the expectation is for staff to wear appropriate PPE and perform hand hygiene as outlined in facility policies.
Failure to Implement Post-Fall Protocol
Penalty
Summary
The facility failed to implement its post-fall protocol for a resident who experienced a fall on October 23, 2024. The interdisciplinary team did not conduct a review of the fall incident, which was unwitnessed, as required by the facility's Fall Prevention Program policy. This policy mandates that each resident be assessed for fall risk and receive care and services tailored to their individualized level of risk to minimize the likelihood of falls. The policy also requires the nurse and/or interdisciplinary team to initiate interventions on the resident's care plan according to their level of risk. The resident involved in the incident was admitted with diagnoses including muscle weakness, abnormalities of gait and mobility, and repeated falls. During an observation and interview on October 28, 2024, the resident mentioned having fallen recently and receiving stitches on her head as a result. The Director of Nursing confirmed that the interdisciplinary team failed to assess the resident after the fall, which was a deviation from the facility's established procedures.
Misappropriation of Resident's Personal Funds
Penalty
Summary
The facility failed to protect a resident from the misappropriation of their personal funds. The Business Office Manager used the resident's debit card to pay for the resident's outstanding balance at the facility, rather than for personal necessities like clothing and shoes, as was agreed upon with the bank. The resident had given permission for the card to be used for personal expenses, but the Business Office Manager acknowledged using it to cover the resident's past due balance, which was against the terms of the bank agreement. This action was taken despite the resident having the capacity to understand and make decisions, as indicated in their medical records. The facility's policy on managing personal funds requires a written authorization and completion of a Resident Fund Management Service form before the facility can manage a resident's funds. However, the Business Office Manager admitted to using the funds inappropriately, and the Administrator believed the card could be used for the resident's personal costs, including paying off the outstanding balance. This misappropriation of funds had the potential to neglect the resident's personal needs, as the funds were not used for the intended purpose of purchasing personal items like clothing and shoes.
Failure to Administer Diabetes Medication
Penalty
Summary
The facility failed to accurately assess and manage the medication needs of a resident diagnosed with Type 2 Diabetes Mellitus. The resident was admitted with a diagnosis that included Type 2 DM, but from August 11, 2024, until September 12, 2024, the resident did not receive Metformin, a medication necessary for managing their condition. This oversight was discovered during an interview with a Licensed Vocational Nurse (LVN), who stated that the Medication Administration Record (MAR) only indicated a need for blood sugar checks before meals, without specifying the need for Metformin. The LVN assumed the blood sugar checks were related to an infection rather than diabetes management. Further investigation revealed that the registered nurse responsible for the resident's admission was unaware of the need for Metformin until informed by the resident's family. Despite the resident's admission record indicating a diagnosis of Type 2 DM, the nurse did not verify with the physician whether the resident required medication for this condition. A review of the resident's blood sugar summary showed a dangerously high level of 462 mg/dL on August 24, 2024, indicating a lack of proper diabetes management. Metformin was eventually ordered on September 12, 2024, highlighting a significant delay in addressing the resident's medical needs.
Failure to Notify Resident of Medicare Non-Coverage
Penalty
Summary
The facility failed to adhere to its Medicare denial process policy by not promptly notifying a resident about the Skilled Facility Advanced Beneficiary Notice of Non-coverage (SNF ABN) and the Notice of Medicare Non-Coverage (NOMC). These documents are crucial for informing the resident about potential non-coverage of services and their appeal rights. The deficiency involved a resident whose responsible party was not informed in a timely manner about the end of Medicare coverage and the appeal process, as required by the facility's policy. The responsible party signed the NOMC form 18 days after the Medicare coverage had ended, indicating a significant delay in communication. The facility's policy, dated October 8, 2018, mandates that Medicare beneficiaries be properly notified when they do not meet the requirements for covered services. However, the review of the facility's documents showed no evidence that the responsible party was informed about the SNF ABN or the appeal process before the termination of Medicare coverage. During an interview, the Business Office Director confirmed that the responsible party was offered the opportunity to sign the forms but only signed the NOMC form well after the coverage had ended. This failure resulted in the resident's representative not being promptly informed of their appeal rights and financial liability for services no longer covered by Medicare.
Failure to Respond to Call Lights Promptly
Penalty
Summary
The facility failed to adhere to its policy and procedure regarding the timely response to call lights, which is crucial for providing care and services to residents. This deficiency was observed in two residents who reported significant delays in staff response to their call lights. Resident 1, who was admitted with abnormalities of gait and mobility and shortness of breath, stated that staff often took up to half an hour to respond to call lights. Similarly, Resident 2, admitted with generalized muscle weakness and a history of repeated falls, reported that staff frequently did not respond when assistance was requested, and it took an excessive amount of time for them to respond to call lights. Interviews with facility staff, including a registered nurse supervisor and the facility administrator, revealed a lack of specific response to the concerns raised by the residents. The facility's policy, revised in December 2022, mandates that staff members who see or hear an activated call light are responsible for responding promptly, and if unable to fulfill the resident's request, they should notify the appropriate personnel. The failure to follow this policy potentially jeopardized the health and safety of the residents involved.
Infection Control Deficiencies in Staff Practices and Catheter Management
Penalty
Summary
The facility failed to adhere to infection control practices as evidenced by staff members wearing acrylic nails longer than the tip of their fingers. Three staff members, including a Certified Nursing Assistant (CNA), the Activities Director (AD), and the Infection Preventionist (IP), were observed with acrylic nails exceeding the permissible length. The facility's Employee Handbook explicitly prohibits artificial nails for staff involved in direct patient care, food services, or medical supply handling, yet this policy was not followed. The Director of Nursing (DON) acknowledged the oversight, confirming that the handbook's guidelines were not enforced. Additionally, the facility did not maintain proper infection control regarding urinary catheter management for two residents. One resident's urinary catheter bag was observed on the floor, and another resident's catheter tubing was seen dragging on the floor. These practices pose a risk of cross-contamination and infection. The Infection Preventionist and the DON both recognized that catheter bags and tubing should not be in contact with the floor, as per the facility's infection prevention policies. The facility's policies, including the Infection Surveillance and Catheter Care procedures, were not adhered to, as evidenced by the observations of catheter management. The DON and IP both confirmed that these practices were not in line with the facility's infection control standards, which are designed to prevent the spread of infections and ensure a safe environment for residents.
Refrigeration Equipment Malfunction
Penalty
Summary
The facility failed to maintain their walk-in refrigerator and freezer in safe operating condition, as both were found to be malfunctioning and unable to maintain acceptable temperatures. On June 10, 2024, during an observation and interview with the Dietary Services Supervisor (DSS), it was noted that the refrigerator and freezer felt like they were at room temperature, and the thermometers had been removed. The DSS confirmed that the equipment had been identified as not working at 4:00 AM that day, having broken sometime overnight. The temperature log for June 10, 2024, recorded the refrigerator at 55 degrees Fahrenheit and the freezer as off, which is above the acceptable temperature limits of not greater than 41 degrees Fahrenheit for refrigeration and not greater than 0 degrees Fahrenheit for the freezer. Further observations on June 11, 2024, with the Registered Dietician (RD) showed the refrigerator at 36.3 degrees Fahrenheit and the freezer at 38.3 degrees Fahrenheit, with the freezer temperatures ranging between 10 degrees Fahrenheit and 35 degrees Fahrenheit throughout the day. A review of the facility's policy on maintaining mechanical and electrical equipment in safe operating condition revealed that the policy was not followed, as stated by the DSS. This failure had the potential to cause food spoilage and increased risk for foodborne illness for all 42 residents receiving food from the facility's kitchen.
Failure to Maintain Resident Dignity with Uncovered Catheter Bags
Penalty
Summary
The facility failed to maintain the dignity of two residents by not covering their urinary catheter drainage bags with dignity bags, as required by the facility's policy. Resident 35, who was admitted with acute kidney failure, metabolic encephalopathy, and obstructive and reflux uropathy, was observed on multiple occasions with an uncovered catheter bag, making the urine visible. This was noted during observations on June 10 and June 13, 2024, with the Infection Preventionist confirming the requirement for dignity bags. Similarly, Resident 500, admitted with fournier gangrene, abnormalities of gait and mobility, and muscle weakness, was found with an uncovered catheter bag during an observation on June 11, 2024. The resident confirmed that the facility did not provide a dignity bag. The Director of Nursing acknowledged that the facility's policy mandates the use of dignity bags to maintain resident privacy and dignity, which was not adhered to in these cases. The facility's policies on promoting resident dignity and catheter care were reviewed, highlighting the requirement for privacy bags to cover catheter drainage bags at all times.
Inaccurate Coding of RAI-MDS for Resident's Fall
Penalty
Summary
The facility failed to accurately code the Resident Assessment Instrument-Minimum Data Set (RAI-MDS) for a resident, identified as Resident 33, who was sampled for accidents. The RAI-MDS assessment, dated on an unspecified date, incorrectly indicated that Resident 33 had not sustained any falls since admission, despite evidence to the contrary. Resident 33, who was admitted with diagnoses including hemiparesis and hemiplegia following a cerebral infarction, muscle weakness, and repeated falls, reported having fallen a few weeks prior while in the facility. This was corroborated by a Resident Care Conference Review document dated May 10, 2024, and a physician's progress note dated May 23, 2024, both of which documented a recent fall. The Minimum Data Set Nurse (MDS 1) responsible for completing the RAI-MDS assessment admitted that the section regarding falls was coded incorrectly due to an error. MDS 1 stated that she reviewed the facility's risk management report and progress notes in the resident's clinical record when completing the assessment. However, the risk management report did not indicate any falls, leading to the incorrect coding. The CMS Long Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's manual specifies that all available sources, including medical records and incident reports, should be reviewed for any falls since the last assessment. The failure to accurately code the RAI-MDS had the potential to result in unmet care needs for Resident 33, potentially jeopardizing the resident's health and safety.
Failure to Implement Fall Prevention Measures for Resident
Penalty
Summary
The facility failed to ensure that a resident, identified as Resident 33, had fall mats on both sides of his bed as specified in his care plan. This deficiency was observed during a survey when it was noted that Resident 33, who had a history of repeated falls and was at risk due to conditions such as hemiparesis and hemiplegia, only had one fall mat on the left side of his bed. The care plan, which was intended to prevent falls and minimize injury, clearly indicated that fall mats should be placed on both sides of the bed. However, during interviews, staff, including a registered nurse, acknowledged the absence of the second fall mat and were unable to explain why the care plan was not fully implemented. The deficiency was further highlighted by a review of the facility's policies and procedures, which emphasized the importance of comprehensive care plans and fall prevention measures tailored to each resident's needs. Despite these guidelines, the facility did not adhere to the specified interventions for Resident 33, potentially increasing the risk of injury from falls. The Director of Nursing confirmed that the care plan interventions were supposed to be followed, yet the oversight persisted, indicating a lapse in the execution of the resident's individualized care plan.
Failure to Implement Fall Prevention Program
Penalty
Summary
The facility failed to implement its fall prevention program for a resident who was reviewed for accidents. The resident, who had a history of hemiparesis, hemiplegia, muscle weakness, and repeated falls, experienced a fall on May 24, 2024. Despite the fall, the facility did not complete a post-fall risk assessment or update the resident's care plan, which was last revised on May 8, 2024. The resident's care plan, which was supposed to be updated after any fall, remained unchanged, indicating a lack of adherence to the facility's policies and procedures. Interviews with the Director of Nursing (DON) revealed that the facility's protocol required a fall risk assessment and an interdisciplinary team meeting after any fall to discuss the incident and implement necessary interventions. However, there was no evidence that these steps were taken for the resident. The facility's policies, dated December 19, 2022, and revised December 28, 2023, clearly outlined the need for a post-fall assessment and care plan updates, which were not followed in this case.
Medication Administration Error in LTC Facility
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors when insulin Lispro was not administered according to the physician's orders. The resident, who was admitted with conditions including type 2 diabetes mellitus with hyperglycemia, was given 2 units of insulin Lispro by an LVN. The LVN administered the insulin 2 hours before mealtime, contrary to the physician's order which specified that the insulin should be given subcutaneously before meals and not sooner than 15 minutes prior. The LVN admitted to not reading the full order, leading to the premature administration of the medication. The Director of Nursing confirmed that the facility's policies and procedures regarding medication administration were not followed. The facility's policy required medications to be administered in accordance with the written orders of the attending physician and within a specific timeframe relative to mealtimes. The failure to adhere to these policies placed the resident at risk for hypoglycemia and potentially jeopardized their health and safety.
Unattended and Unlocked IV Medication Cart
Penalty
Summary
The facility failed to ensure the secure storage of intravenous (IV) medications, as observed when an IV medication cart was left unlocked and unattended at the nurses' station. This cart, used by licensed nurses to transport medications to resident rooms, contained IV supplies, including syringes, needles, and antibiotics. During an observation and interview, a registered nurse (RN) acknowledged that the cart should not have been left open, as it contained residents' information on medication labels and posed a safety risk to ambulatory residents. Further interviews revealed that the RN was the only person with access to the IV medication cart and admitted to forgetting to lock it. A review of the facility's policy and procedure, titled Specific Medication Administration Procedures, indicated that medication carts should be locked at all times unless in use and under direct observation. The Director of Nurses confirmed that the policy was not followed and expressed the expectation that nurses should lock the IV medication cart when not in use.
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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