Pleasant Hill Post Acute
Inspection history, citations, penalties and survey trends for this long-term care facility in Pleasant Hill, California.
- Location
- 1625 Oak Park Boulevard, Pleasant Hill, California 94523
- CMS Provider Number
- 055049
- Inspections on file
- 17
- Latest survey
- August 18, 2025
- Citations (last 12 mo.)
- 22
Citation history
Health deficiencies cited at Pleasant Hill Post Acute during CMS and state inspections, most recent first.
Six residents with complex medical conditions were not informed of or offered the option to formulate an Advance Directive upon admission or re-admission. Record reviews and staff interviews confirmed that these residents had no ADs on file and were not given the opportunity to establish one, despite facility policy requiring this process.
Three residents receiving enteral feeding or IV therapy did not have their feeding bags, IV lines, or tubing labeled with the required date and time, as confirmed by nursing staff and facility policy. This failure to follow professional standards was observed during care for residents with conditions such as malnutrition, dysphagia, and metabolic encephalopathy.
Two residents experienced medication administration errors when an LPN gave antihypertensive medications without checking vital signs and another LPN applied a topical pain reliever without a physician's order. Both actions were contrary to facility policy and were confirmed by the DON during interviews and record reviews.
A nurse administered Bumetanide, Carvedilol, and Losartan to a resident with hypertension and heart failure without checking vital signs as required by physician orders and facility policy. The nurse relied on earlier vitals taken by a CNA and did not verify their accuracy or obtain a current blood pressure reading, resulting in a significant medication error.
The facility did not obtain food from approved or satisfactory sources and failed to store, prepare, distribute, and serve food according to professional standards.
A resident's food items brought in by family or visitors were found in a designated refrigerator without required labeling, such as received date, open date, or use-by date, and some items were removed from original packaging. Staff interviews confirmed that facility policy requires such labeling and regular checks, but these procedures were not followed, resulting in improper storage of the resident's food.
During a COVID-19 outbreak, the facility did not keep doors closed for rooms under enhanced airborne precautions, staff failed to perform required hand hygiene before serving food to a resident, a resident with COVID-19 did not have hand hygiene supplies within reach after coughing up phlegm, and oxygen tubing for a resident was found unlabeled and on the floor, contrary to facility policy.
A resident who was cognitively intact requested copies of medical records and the contact information for a former facility physician. Despite submitting a written request and following up multiple times, the records were not provided within the required two-business-day timeframe, and the resident experienced undue concern and anxiety due to the delay. The facility delayed the request while consulting with its legal team and ultimately did not provide the physician's contact information, as the physician had retired.
A deficiency was found when a resident was prescribed or administered medications that were not clinically indicated, excessive in duration, or duplicative, without proper justification documented in the medical record.
A resident with multiple complex medical conditions was re-admitted, but the required MDS tracking entry assessment was not completed within the federally mandated seven-day timeframe. The delay was acknowledged by the MDS Coordinator and was not in accordance with facility policy, potentially impacting timely care planning and delivery.
A resident with multiple complex diagnoses did not have quarterly MDS assessments completed and transmitted within the required timeframe. The MDS Coordinator confirmed the delay, which was not in compliance with federal regulations and facility policy.
A resident in isolation did not receive a thorough activities assessment or an individualized activities program, despite being able to communicate personal interests such as music and news. The AD left key assessment sections blank, offered only limited in-room activities, and inaccurately documented participation. The resident expressed frustration and isolation, and the care team was not informed of the lack of engagement, resulting in no alternative interventions.
A resident quarantined for COVID-19 experienced repeated delays in staff response to a standalone wireless call bell that was not integrated with the facility's monitoring system. The call bell did not provide a visual signal or allow tracking of response times, leading to multiple instances where the resident waited 10 to 25 minutes or more for assistance, sometimes resorting to using a personal phone to call for help. Staff interviews confirmed inconsistent awareness and response to the call bell, in violation of facility policy requiring prompt attention to resident calls.
The facility did not provide the required minimum of 80 square feet per resident in several multiple occupancy rooms, with some rooms offering as little as 49.5 to 70 square feet per resident. Despite this, interviews and observations indicated that space was adequate for belongings and care, and no complaints were reported.
The facility failed to complete comprehensive Admission MDS assessments within 14 days for three residents, resulting in delayed care planning. The MDS Coordinator and DON acknowledged the delays, and the Administrator did not recall any issues with late entries for December 2023.
The facility failed to complete the MDS discharge assessments for three residents within the required 14 days from their discharge date. The MDS Coordinator acknowledged the late entries and the lack of a facility protocol on MDSC policies. This delay resulted in an inaccurate reflection of the resident census, potentially affecting census tracking and staffing ratios.
The facility failed to maintain safe and sanitary food storage conditions, including moldy bread, a dented can of applesauce, and unsealed food items. The RD acknowledged these issues, which were against the facility's policies.
The facility had a 13.79% medication error rate when four medication errors out of 29 opportunities were observed. A resident did not receive the correct eye drop and Vitamin C dosage, while another resident's Vitamin D3 dosage was not verified with the physician. These errors were acknowledged by the LVN and the DON.
The facility failed to provide at least 80 square feet of living space per resident for 24 residents in multiple rooms. Despite observations indicating sufficient space for care and no resident complaints, a record review confirmed that the rooms did not meet the required space per resident.
Failure to Inform and Offer Advance Directives to Residents Upon Admission
Penalty
Summary
Six residents were identified as not having been informed of, or provided with, the option to formulate an Advance Directive (AD) upon admission or re-admission to the facility. Record reviews for these residents revealed that their medical charts did not contain any documentation of an AD, nor evidence that they had been offered the opportunity to create one. Interviews with the Medical Records Director and Operations Manager confirmed that these residents had no ADs on file and had not been given the option to establish one during the admission process, contrary to facility policy. The residents affected had significant medical conditions, including hemiplegia, atrial fibrillation, diabetes mellitus, right lower leg fracture, COPD, chronic kidney disease, congestive heart failure, degenerative nervous system disease, acute and chronic respiratory failure, chronic lymphocytic leukemia, anoxic brain damage, breast cancer history, and traumatic subdural hemorrhage. The facility's policy required that the existence of an AD be determined prior to or upon admission by inquiring with the resident or their representative, but this process was not followed for the six residents in question.
Failure to Label Enteral Feeding and IV Lines According to Professional Standards
Penalty
Summary
The facility failed to ensure that services provided met professional standards of quality for three residents who required specialized nutritional and intravenous care. For one resident receiving enteral feeding due to malnutrition and dysphagia, the fiber source nutrition bag and tubing were not labeled with the date and time as required. The nursing supervisor confirmed that labeling was necessary for safety and infection control, and that the omission placed the resident at risk for complications. Facility policy required that enteral feeding bags and tubing be labeled with the date and time when prepared and administered. Two other residents receiving intravenous therapy also had deficiencies in labeling. One resident with dysphagia had an IV line secured with Tegaderm, but neither the dressing nor the IV tubing was labeled, making it unclear when the IV line was placed or changed. The Director of Nursing acknowledged that this failure could lead to infection and complications. Another resident with metabolic encephalopathy had a peripheral IV line and tubing that were also not labeled. The nursing supervisor stated that labeling with date and time was required to prevent infection. Facility policy specified that all IV tubing must be labeled with date, time, and initials.
Medication Administration Errors Due to Failure to Verify Orders and Vital Signs
Penalty
Summary
A deficiency occurred when a nurse administered three antihypertensive medications—Bumetanide, Carvedilol, and Losartan—to a resident with a history of hypertension, congestive heart failure, and a cardiac pacemaker without checking the resident's vital signs prior to administration. The nurse stated she relied on CNAs to check vital signs and did not verify them herself before giving the medications. The facility's policy required verification of vital signs before administering such medications, especially for residents with complex cardiac histories. In a separate incident, another nurse applied a topical pain reliever (Biofreeze gel) to a resident's knees without a physician's order. Upon review, the nurse confirmed there was no order for the medication and acknowledged the error. The resident had a history of immune system disorders, and the facility's policy specified that medications must be administered only as prescribed and after confirming there are no known allergies or contraindications. Both incidents were confirmed by the Director of Nursing during interviews and record reviews.
Failure to Check Vital Signs Before Administering Antihypertensive Medications
Penalty
Summary
A Licensed Vocational Nurse (LVN) administered Bumetanide, Carvedilol, and Losartan to a resident without checking the resident's vital signs prior to medication administration. The resident had a history of essential primary hypertension, congestive heart failure, and a cardiac pacemaker. The nurse relied on vital signs taken earlier in the morning by a Certified Nursing Assistant and did not verify their accuracy or obtain a recent blood pressure reading, despite physician orders specifying parameters for holding antihypertensive medications based on current systolic blood pressure and heart rate. The Director of Nursing confirmed that the medications were not administered in a safe manner, as the LVN did not follow the required parameters or check the resident's vital signs before giving the medications. The resident's care plan and the facility's medication administration policy both required adherence to these parameters and verification of vital signs prior to administration. The failure to check vital signs before administering these medications constituted a significant medication error.
Failure to Follow Food Procurement and Handling Standards
Penalty
Summary
The facility failed to procure food from sources that are approved or considered satisfactory and did not store, prepare, distribute, and serve food in accordance with professional standards. This deficiency was identified during the survey process, indicating that the facility did not meet regulatory requirements for food safety and handling. No additional details about specific residents, staff, or events are provided in the report.
Failure to Properly Label and Store Resident Food Brought from Outside
Penalty
Summary
The facility failed to ensure that food items brought in by family or visitors for a resident were properly labeled and stored according to facility policy. During an observation and review in the conference room refrigerator designated for residents' outside food, it was found that a resident's liquid food items, including a partially used carton of lactose-free milk and several plastic bags of single-packed creamers, were not labeled with required information such as received date, open date, use-by date, or expiration date. The milk carton only had an expiration date, and the creamers were removed from their original packaging and lacked any dating or labeling. Interviews with the Infection Preventionist (IP) and Dietary Manager (DM) confirmed that the facility's policy requires all food items brought in for residents to be labeled with the resident's name, the item, and a use-by date, and that perishable items should be discarded on or before the use-by date. The IP stated that she checks the refrigerator daily on weekdays and another staff member checks on weekends, but acknowledged missing the missing dates and labeling on the items in question. The facility's written policies also require opened beverages to be dated and discarded after 24 hours, and all food items to be sealed or covered during storage, which was not followed in this instance.
Failure to Follow Infection Control Practices During COVID-19 Outbreak
Penalty
Summary
The facility failed to follow infection prevention and control practices in several key areas during a COVID-19 outbreak. Four out of five rooms designated for residents with COVID-19 had their doors left open, despite signage indicating enhanced airborne precautions requiring doors to remain closed. Staff interviews confirmed awareness of the requirement to keep doors closed, and the Infection Preventionist acknowledged that open doors could contribute to the spread of infection. Facility policy and CDC guidance both require doors to be closed for residents on airborne precautions. A Certified Nursing Assistant (CNA) did not perform hand hygiene after touching resident care areas and before serving food to a resident in a COVID-19 isolation room. The CNA donned gloves without prior hand hygiene and handled food and room surfaces with the same gloved hands. There were no hand hygiene supplies available outside the room. Facility policy requires hand hygiene before and after donning or doffing gloves, and staff interviews confirmed this expectation. Additionally, a resident who was positive for COVID-19 and coughing up phlegm did not have hand hygiene supplies within reach, making it difficult to clean his hands after coughing. The only available hand sanitizer was mounted on the wall approximately 12 feet away, and staff acknowledged that the resident was not expected to get out of bed to use it. In another instance, a resident receiving oxygen therapy had oxygen tubing that was not labeled and was found on the floor, kinked and stuck under a garbage can. Staff confirmed that tubing should not touch the floor and should be secured or wrapped if too long, as per facility policy.
Failure to Timely Provide Resident Access to Medical Records
Penalty
Summary
The facility failed to provide a resident with access to his requested medical records within the required two-business-day timeframe. The resident, who was cognitively intact with a BIMS score of 15, requested copies of his medical records and the contact information for his former facility physician. Despite submitting a written request and following up multiple times in person and by phone, the resident did not receive the records until three weeks later. The facility's Medical Records Director confirmed that the request was delayed due to consultation with the facility's legal team, as the resident had an active legal case against a sister company. The resident was also denied the contact information for his former physician, as the physician had retired and was no longer affiliated with the facility. Facility policy states that residents are entitled to access or obtain copies of their personal or medical records within two business days of an oral or written request. However, the resident's request was not fulfilled within this timeframe, resulting in undue concern and anxiety for the resident. The delay was attributed to internal communication with the legal team and clarification of the specific records requested, rather than prompt fulfillment of the resident's rights as outlined in facility policy.
Unnecessary Drugs in Resident Drug Regimens
Penalty
Summary
A deficiency was identified regarding the management of residents’ drug regimens. The facility failed to ensure that each resident’s drug regimen was free from unnecessary drugs, as required by regulations. This indicates that at least one resident was prescribed or administered medications that were not clinically indicated, excessive in duration, or duplicative, without adequate justification documented in the medical record.
Late Completion of Re-Entry MDS Assessment
Penalty
Summary
The facility failed to complete the federally mandated Minimum Data Set (MDS) tracking entry assessment within the required seven-day timeframe following a resident's re-entry. Specifically, the MDS for a resident who was re-admitted with multiple complex diagnoses, including anoxic brain damage, acute respiratory failure with hypoxia, malnutrition, contractures of both knees, and a history of breast cancer, was not completed on time. The assessment was due on 4/15/25 but was not completed until 4/18/25, as confirmed by the MDS Coordinator during an interview and record review. The facility's policy requires that resident assessments be conducted and submitted in accordance with federal and state timeframes, and the MDS Coordinator acknowledged responsibility for ensuring timely completion. The delay in completing the re-entry MDS assessment could have resulted in a delay in identifying the resident's care needs and in the delivery of appropriate treatment, as the assessment is used to inform care planning and interventions.
Failure to Complete and Transmit Quarterly MDS Assessments Timely
Penalty
Summary
The facility failed to complete and transmit quarterly Minimum Data Set (MDS) assessments for one of 47 sampled residents, as required by federal regulations. Specifically, the MDS Coordinator acknowledged that the assessments for a resident were not completed and transmitted within the mandated 14-day timeframe following the Assessment Reference Date (ARD). Review of the resident's records showed gaps in timely completion and submission of both annual and quarterly MDS assessments. The facility's policy requires that the assessment coordinator or designee ensures resident assessments are submitted to CMS' Internet Quality Improvement Evaluation System (iQIES) in accordance with federal and state guidelines. The resident involved had a complex medical history, including anoxic brain damage, acute respiratory failure with hypoxia, malnutrition, contractures of both knees, and a personal history of breast cancer. The failure to complete and transmit the required MDS assessments as scheduled could have resulted in delayed assessment of the resident's needs and monitoring of their progress over time. The MDS Coordinator confirmed during interview and record review that the assessments were late, which was not in compliance with the facility's policy and federal requirements.
Failure to Provide Individualized Activities Assessment and Program
Penalty
Summary
The facility failed to provide a thorough assessment and individualized activities program for one resident who was admitted and subsequently placed in isolation due to a respiratory infection. Despite the resident's ability to communicate his interests, including a preference for music, animals, and keeping up with the news, the activity assessment was incomplete, with key sections left blank. The resident reported not being offered any activities or television channels that matched his interests and expressed frustration and feelings of isolation as a result. The Activity Director acknowledged that the assessment was not fully conducted and that only limited in-room activities, such as television and newsletters, were offered, which the resident often declined. Participation records were inaccurately documented, reflecting participation when the resident had actually refused. Additionally, the Activity Director did not communicate the resident's lack of engagement to the rest of the care team, resulting in no alternative interventions being provided. The Director of Nursing confirmed that the initial assessment was insufficient and that accurate documentation and individualized activities are essential for resident well-being.
Delayed Response to Resident Call Bell Due to Inadequate Call System
Penalty
Summary
The facility failed to ensure that a resident's call bell system was answered in a timely manner. The resident, who was quarantined for COVID-19, had a standalone wireless call bell that was not connected to the facility's call light monitoring panel at the nursing station. This call bell did not activate a visual signal outside the room and did not allow for tracking of response times. Multiple observations and interviews revealed that staff responses to the resident's call bell were often delayed, with response times ranging from 10 to 25 minutes or more. On several occasions, the resident had to use a personal cell phone to call the front desk for assistance after waiting for extended periods. The resident reported feeling frustrated due to these delays and had been using the same call bell system for over a week. Staff interviews confirmed that the call bell emitted an audible sound in the hallway, but there was no system in place to monitor or track when the bell was activated. Staff members, including the charge nurse, receptionist, activity director, and nursing supervisor, indicated that they could not always hear the bell, especially if they were not nearby. The facility's policy required immediate response to call lights and completion of tasks within five minutes if possible, but this was not consistently followed for the resident in question. The lack of a properly functioning and monitored call system resulted in delayed responses to the resident's needs.
Failure to Meet Minimum Square Footage Requirements in Resident Rooms
Penalty
Summary
The facility failed to provide the required minimum of 80 square feet per resident in multiple resident bedrooms, as observed and confirmed through interviews and record review. Specifically, rooms 14, 15, 12, 16, 17, 18, 19, 20, 21, and 22 were identified as not meeting this standard, with some rooms having as little as 49.5 to 70 square feet per resident, and one room with 4 beds providing only 68.5 square feet per resident. Despite these deficiencies, observations and interviews conducted during the survey period indicated that there was adequate space for residents' belongings and for caregivers to provide care, and no complaints were reported by residents or staff regarding room space.
Failure to Complete Timely Admission MDS Assessments
Penalty
Summary
The facility failed to ensure a comprehensive Admission Minimum Data Set (MDS) assessment was completed within 14 calendar days of admission for three sampled residents. Resident 45 was admitted on [DATE], but the MDS assessment was completed late on 12/29/23, missing the required completion date of 12/23/23. Similarly, Residents 313 and 317 had their MDS assessments completed late, as indicated in the MDS 3.0 Final Validation Report dated 12/30/23. The Minimum Data Set Coordinator (MDSC 1) acknowledged the delay and stated that the timely completion of admission assessments is crucial for planning resident care. The Director of Nursing (DON) confirmed that admission MDS assessments should be completed within 14 days from the assessment reference date (ARD). During interviews, the Administrator (ADM) stated he did not recall any issues with late MDS entries for December 2023. The Centers for Medicare and Medicaid Services (CMS) guidelines require that the Admission Assessment be completed no later than 14 days after admission to a facility. The failure to complete these assessments on time resulted in delayed care planning for Residents 45, 313, and 317, potentially impacting the care and services they received based on their health status.
Failure to Complete MDS Discharge Assessments Timely
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) discharge assessments for three sampled residents were completed within the required 14 days from their discharge date. During an interview, the MDS Coordinator acknowledged awareness of the late MDS discharge entries and admitted that there was no facility protocol on MDSC policies. Specifically, Resident 45 was discharged on January 9, 2024, but their MDS discharge assessment was not completed until February 14, 2024. Similarly, Resident 315 was discharged on January 10, 2024, with the assessment completed on February 7, 2024, and Resident 316 was discharged on January 24, 2024, with the assessment completed on February 9, 2024. This delay in completing discharge assessments resulted in an inaccurate reflection of the resident census, potentially interfering with census tracking and staffing ratios.
Food Storage and Safety Deficiencies
Penalty
Summary
The facility failed to prepare and serve food under safe and sanitary conditions. During an initial observation of the kitchen, moldy and unusable French bread, a dented can of unsweetened applesauce, and unsealed food items such as hashbrowns and brown rice were found in the dry storage room. The Registered Dietician (RD) acknowledged the presence of moldy bread that should have been discarded and stated that dented cans should have been separated from the stock. The facility's Policy and Procedure (P&P) indicated that dented and rusty cans should be separated and returned for a refund. Additionally, the facility's dry storage chart specified that opened bread should be stored for one day and that rice and hashbrowns should be stored in airtight containers once opened.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility had a 13.79% medication error rate when four medication errors out of 29 opportunities were observed during medication administration for two residents. Resident 165 did not receive an eye drop and an oral medication according to the physician's order. Specifically, the resident was supposed to receive Restasis eye drops but was given Refresh eye drops instead, and was also given an incorrect dosage of Vitamin C. LVN 1 admitted that Refresh eye drops were the only ones available in the medication cart for Resident 165 and acknowledged the error in the Vitamin C dosage. Resident 264's medication administration also contained errors. The LVN administered Vitamin D3 without verifying the correct dosage with the physician, as the physician's order did not specify the dosage. The Director of Nursing confirmed that the dosage should have been verified with the doctor. These failures resulted in medication not being given in accordance with the prescriber's orders, which may negatively affect the residents' health.
Failure to Provide Adequate Living Space per Resident
Penalty
Summary
The facility failed to provide at least 80 square feet of living space per resident for 24 residents occupying multiple resident bedrooms. Specifically, rooms 12, 14, 15, 16, 17, 18, 19, 20, 21, and 22 were identified as having less than the required space per resident. During random interviews and observations of care and services, it was noted that there was sufficient space for the provision of care, no heavy equipment obstructing care, and adequate personal space and privacy for residents. There were no complaints from residents regarding insufficient space for their belongings, and no negative consequences or safety concerns were observed. However, a record review of the Client Accommodations Analysis confirmed that the rooms did not meet the 80 square feet requirement per resident, with specific measurements provided for each room.
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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