Ramona Rehabilitation And Post Acute Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Hemet, California.
- Location
- 485 W. Johnston Avenue, Hemet, California 92543
- CMS Provider Number
- 056214
- Inspections on file
- 27
- Latest survey
- February 13, 2026
- Citations (last 12 mo.)
- 16 (1 serious)
Citation history
Health deficiencies cited at Ramona Rehabilitation And Post Acute Care Center during CMS and state inspections, most recent first.
The facility did not ensure that an area was free from accident hazards and failed to provide adequate supervision to prevent accidents, as observed by surveyors during their review.
A resident with a history of sepsis and bacteremia did not receive IV antibiotics as ordered following hospital discharge, with multiple missed doses of ampicillin and ceftriaxone documented. Facility staff were unclear about the correct duration and continuity of the antibiotic orders, resulting in interruptions and delayed restarts of medication. This failure led to the need to extend the IV antibiotic course to address the resident's infection.
A facility failed to report an abuse allegation involving a CNA and a resident to CDPH within the required two-hour timeframe. The incident involved a resident with mild cognitive impairment, who was heard screaming about being hit and choked. Despite the lack of visible injuries, the facility's policy required immediate reporting, which was not followed, potentially delaying the investigation and exposing residents to further abuse.
Three residents were found with medications at their bedside without proper assessments or physician orders for self-administration. A resident had Nystatin powder, another had Desitin ointment, and a third had eyedrops, all without documented assessments or orders. The ADON confirmed that policies were not followed, posing potential risks to residents.
The facility failed to remove expired, discontinued, and unlabeled medications from medication carts and storage rooms, as observed during inspections. Expired medications, including ondansetron, clonidine, and dicyclomine, were found in medication carts, while an unlabeled IV bag and an expired Tubersol vial were found in storage rooms. Nurses acknowledged the oversight, and the facility's policies for removing expired medications were not followed.
The facility failed to follow safe food storage practices, as observed during a survey. A can of cranberry jelly was undated, celery was exposed to air in the refrigerator, and spinach bars in the freezer were not dated. The Dietary Manager confirmed that all food items should be dated and sealed.
The facility failed to implement proper infection control practices, including a CNA not using PPE for a resident requiring enhanced precautions, improper handling of clean linens by laundry staff, a COTA neglecting hand hygiene, failure to change nebulizer tubing as scheduled, and direct care staff wearing long artificial nails, all of which increased the risk of infection spread among residents.
A resident with obstructive uropathy and a Foley catheter was observed with an uncovered urinary bag, contrary to the facility's dignity policy. An LVN acknowledged the oversight, and the ADON confirmed the potential psychosocial impact. Facility policies emphasize maintaining resident dignity by covering urinary bags.
A resident with significant medical conditions experienced delays in receiving assistance, as call lights were not answered promptly by staff. Despite the facility's policy requiring prompt response, staff were observed ignoring the call light, leading to potential unmet needs for the resident.
A resident with severe pain did not receive the prescribed Norco 10-325 mg due to unavailability and was instead given Norco 7.5-325 mg, intended for moderate pain. Despite reporting severe pain, the facility failed to manage the resident's pain effectively, as confirmed by medication records and staff interviews.
A resident on apixaban for deep vein thrombosis was found with multiple bruises, but the facility failed to monitor for adverse effects of anticoagulant use. Staff interviews revealed a lack of awareness and action, and the facility's policy on monitoring anticoagulant therapy was not followed.
A facility failed to follow Enhanced Barrier Precautions (EBP) during wound care for a resident with multiple medical conditions, including chronic wounds. The Treatment Nurse did not wear a gown as required by the EBP protocol, despite the presence of a sign indicating EBP on the resident's room. This oversight was observed during an unannounced complaint investigation.
A resident's call light was found on the floor, out of reach, during an unannounced visit. The CNA confirmed the call light should be within reach, as per facility policy. The resident, with multiple health issues and cognitive impairments, had a care plan emphasizing the need for accessible call lights.
A Treatment Nurse in an LTC facility failed to perform hand hygiene between glove changes while providing wound care to a resident, potentially contaminating the resident's wounds. The resident had a history of cellulitis, lumbar fracture, and COPD. The facility's policy and CDC guidelines require hand hygiene before and after glove use, which was not followed in this instance.
A resident with cognitive impairment and depression alleged sexual abuse by a CNA, who was not immediately removed from duty, causing the resident distress. The incident was reported two hours later, contrary to facility policy requiring immediate action.
The facility failed to follow physician orders for a resident with multiple diagnoses, including hypertension and atrial fibrillation. Medications were not administered according to specified parameters, and staff did not document reasons for holding medications. Interviews with the LVN and DON confirmed these deficiencies.
Failure to Maintain Safe Environment and Supervision
Penalty
Summary
The facility failed to ensure that an area was free from accident hazards and did not provide adequate supervision to prevent accidents. Surveyors observed that the environment contained hazards that could lead to resident accidents, and staff did not implement sufficient measures to monitor or protect residents from these risks. This deficiency was identified based on direct observations and findings during the survey, which indicated lapses in maintaining a safe environment and in providing necessary supervision to prevent accidents.
Failure to Administer IV Antibiotics as Ordered
Penalty
Summary
A deficiency occurred when a resident with a history of sepsis, bacteremia, and a xenogenic heart valve did not receive intravenous (IV) antibiotic medications as ordered by the physician upon discharge from a general acute hospital. The resident was admitted with orders to continue prolonged IV ampicillin and ceftriaxone for a specified duration, with clear instructions documented in the admission and transfer summaries, as well as in the physician's progress notes. However, a review of the Medication Administration Record (MAR) revealed multiple missed doses of both antibiotics over several dates, including a significant gap in ampicillin administration from mid-December to late December, and several missed doses of ceftriaxone. The facility's care plans for the resident included interventions to administer IV therapy and antibiotics as ordered, and the facility's policy required licensed nurses to verify orders and document all administration details. Despite these protocols, interviews with the Assistant Director of Nursing (ADON) and Director of Nursing (DON) indicated confusion and lack of clarity regarding the duration and continuity of the antibiotic orders. The ADON noted that a registry night shift RN changed the ampicillin order from 34 days to 4 days without clear justification, and there was no explanation for the interruption and delayed restart of the medication. The DON also expressed uncertainty about why the ampicillin was stopped and restarted multiple times, stating it should have been administered consistently as originally ordered. The resident's progress notes and discharge summary confirmed that the IV ampicillin course was cut short prematurely and had to be restarted to complete the intended duration. The failure to administer the IV antibiotics as prescribed resulted in the need to extend the IV medication period to address the resident's infection. Documentation and interviews confirmed that the facility did not follow physician orders or its own policies for safe and effective administration of IV antibiotics, leading to the identified deficiency.
Delayed Reporting of Abuse Allegation
Penalty
Summary
The facility failed to report an allegation of physical abuse involving a Certified Nursing Assistant (CNA) and a resident to the California Department of Public Health (CDPH) within the required timeframe. The incident occurred on October 28, 2024, when the Assistant Director of Nursing (ADON) informed the Administrator (ADM) about the alleged abuse at 1:00 p.m. However, the ADM did not report the incident to CDPH until October 31, 2024, which was beyond the mandated two-hour window for reporting such allegations. This delay in reporting had the potential to hinder the timely investigation of the abuse claim and possibly expose other residents to further abuse. The incident involved a resident with a history of pulmonary fibrosis, chronic respiratory failure, and anxiety, who was admitted to the facility with a mild cognitive impairment. On the day of the incident, another CNA observed the accused CNA leaving the resident's room with food and fluid on her clothes, while the resident was heard screaming about being hit and choked. Despite the lack of visible injuries on the resident, the facility's policy required immediate reporting of any abuse allegations, which was not adhered to in this case.
Failure to Conduct Self-Administration Assessments for Medications
Penalty
Summary
The facility failed to conduct assessments for the safe self-administration of medications for three residents. Resident 20 was found with a 30 ml cup of Nystatin External Powder on her bedside table, which she stated was left by a nurse for her to apply later. Despite having a BIMS score indicating cognitive intactness, there was no documented assessment for her ability to self-administer the medication, nor was there a physician's order permitting her to do so. Licensed Vocational Nurse (LVN) 2 confirmed that the medication should not have been left at the bedside without an assessment. Resident 30 had an opened tube of Desitin ointment on his bedside table, which he used to relieve a rash. His medical records showed no evidence of a self-administration assessment or a physician's order for the ointment. LVN 2 acknowledged that the medication should not have been kept at the bedside and that a self-administration assessment was necessary. Similarly, Resident 33 was found with an opened bottle of eyedrops on her overbed table, which she used for eye irritation. Her records also lacked a self-administration assessment and a physician's order for the eyedrops. The Assistant Director of Nursing (ADON) stated that licensed nurses are expected to follow the facility's policy and procedure regarding self-administration assessments and medication administration. The facility's policy requires that any medications found at the bedside without authorization for self-administration be turned over to the nurse in charge. The failure to adhere to these policies resulted in the potential for residents to receive medications without proper monitoring, which could lead to harmful effects.
Expired and Unlabeled Medications Found in Facility
Penalty
Summary
The facility failed to ensure that expired, discontinued, and unlabeled medications and intravenous (IV) fluids were not readily available for use, as observed during inspections of medication carts and storage rooms. On October 23, 2024, an inspection of the Station 4 Medication Cart revealed several expired medications, including ondansetron, clonidine, hyoscyamine, and chest congestion tablets, which were still stored in the cart. Licensed Vocational Nurse (LVN) 9 acknowledged that these medications were expired and should have been removed to prevent potential harm to residents. Similarly, an inspection of the Station 3 Medication Cart found expired dicyclomine and ondansetron tablets, which LVN 10 confirmed were discontinued and should have been removed. Further inspections on October 24, 2024, revealed additional deficiencies in medication storage practices. In the Station 1 Medication Storage Room, a bag of Dextrose 10% IV was found unlabeled and readily available for use, which Registered Nurse (RN) 1 confirmed should have been labeled. In the Station 2 Medication Storage Room, a multi-dose vial of Tubersol injection was found stored beyond its expiration date, which RN 1 acknowledged should have been disposed of after 30 days of opening. The facility's policies and procedures, including those for auditing and removing expired medications, were not adhered to, as evidenced by the presence of expired and unlabeled medications in the medication carts and storage rooms. The Assistant Director of Nursing (ADON) stated that it was the nurses' responsibility to ensure expired medications were removed from the carts, and the facility's policy indicated that expired medications should be removed regularly and when encountered. However, these protocols were not followed, leading to the deficiencies observed during the survey.
Improper Food Storage Practices
Penalty
Summary
The facility failed to adhere to safe food storage practices in the kitchen, as observed during a survey. A seven-pound can of cranberry jelly was found in the dry storage area without a date, indicating a lack of proper labeling. Additionally, two stalks of celery were discovered in the walk-in refrigerator with the plastic bag open, exposing the celery to air, which is against the facility's policy of keeping food items sealed. Furthermore, five three-pound bars of chopped spinach were found in the freezer without any dates, violating the facility's policy that requires all food items to be dated when received. These lapses in food storage practices were identified during an initial kitchen tour with the Dietary Manager, who acknowledged that all food items should be dated and properly sealed to prevent exposure to air.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to implement proper infection control practices in several instances, leading to potential risks of infection spread among residents. A Certified Nursing Assistant (CNA) did not use personal protective equipment (PPE) when providing care to a resident who required enhanced barrier precautions due to an indwelling catheter and other medical conditions. Despite clear signage and instructions, the CNA admitted to forgetting to wear the necessary gown and gloves, which was confirmed by interviews with other staff members, including the Infection Prevention (IP) nurse and the Assistant Director of Nursing (ADON). In another instance, the Laundry Staff (LS) did not follow proper procedures for handling and storing clean linens. The LS was observed stacking linens in a cart without a protective gown and allowing them to come into contact with a wall, which was considered a contaminated surface. This improper handling was acknowledged by the LS and confirmed by the Housekeeping/Laundry Supervisor and the IP, who emphasized the risk of cross-contamination and infection spread due to such practices. Additionally, a Certified Occupational Therapy Assistant (COTA) failed to perform hand hygiene before and after providing therapy to residents, which was observed and admitted by the COTA. The Director of Rehab and the IP highlighted the importance of handwashing to prevent infection spread. Furthermore, the facility staff did not adhere to the schedule for changing nebulizer tubing, as observed with Resident 50, whose tubing showed signs of buildup and was not changed as per the physician's order. Lastly, two direct care staff members were found wearing long artificial nails, contrary to the facility's policy, which could harbor pathogens and pose a risk of infection to residents.
Failure to Cover Urinary Bag Compromises Resident Dignity
Penalty
Summary
The facility failed to uphold the dignity and respect of a resident by not covering their urinary bag, which was observed hanging below the level of the resident's bed and filled with 300 ml of yellow liquid. This incident was noted during an observation with an LVN, who acknowledged that the urinary bag should have been covered with a dignity bag to prevent embarrassment. The resident, who was admitted with obstructive uropathy and had a Foley catheter in place, lacked the capacity to understand and make decisions, as indicated in their medical records. The facility's policy on dignity, dated February 2021, mandates that residents are treated with dignity and respect at all times, including keeping urinary catheter bags covered. The Assistant Director of Nursing confirmed that leaving the urinary bag uncovered could have a psychosocial effect on the resident and that it should have been covered. The facility's policy on Resident Rights also emphasizes the importance of maintaining or enhancing each resident's dignity and respect.
Failure to Respond to Call Light Promptly
Penalty
Summary
The facility failed to answer the call light within a reasonable time for one resident, which had the potential to not meet the resident's needs. An interview with the resident revealed that he could not get help for up to an hour, usually during the morning shift. The resident was admitted with a fusion of the spine, wedge compression fracture of T7-T8 vertebrae, and ankylosing spondylitis of the thoracic region, and was mentally capable of understanding. The family representative confirmed that the resident complained about the lack of response from the nursing staff, stating that assistance was only provided when she called the nurse's station from home. Observations on a specific date showed the call light in the resident's room was on while several staff members were talking at the nurse station, and a CNA was seen walking from room to room without answering the call light. The CNA acknowledged that call lights should be answered promptly and admitted to hearing the call light but not responding. The facility's policy, dated December 2016, mandates that all call bells be answered promptly, which was not adhered to in this instance.
Failure to Administer Prescribed Pain Medication
Penalty
Summary
The facility failed to manage the pain of Resident 137, who was admitted with a displaced fracture of the second cervical vertebra, contusion of the left hand, fibromyalgia, and pain in the left shoulder and upper arm. Upon arrival at the facility, Resident 137 did not receive the prescribed pain medication until the following day, despite requesting it during the night. The nurse informed the resident that the doctor's orders were not available, and the medication was not accessible. Throughout the resident's stay, there were multiple instances where the prescribed Norco 10-325 mg for severe pain was not administered, and instead, Norco 7.5-325 mg was given, which was intended for moderate pain. This occurred despite the resident reporting severe pain levels ranging from 7 to 10. The facility's medication administration records confirmed these discrepancies, and the pharmacy records showed that the Norco 10-325 mg was not pulled from the Cubix reserve when needed. Interviews with the nursing staff revealed a lack of effective pain management for Resident 137. LVN 2 acknowledged the resident's complaints of unmanaged pain and the unavailability of the prescribed medication. LVN 3 confirmed that the Norco 10-325 mg was not consistently available and that the resident's pain was not being managed appropriately. RN 1 also recognized the failure to administer the correct medication for severe pain and noted that the facility's process for obtaining and administering narcotic medications was not followed as expected.
Failure to Monitor Anticoagulant Use in Resident
Penalty
Summary
The facility failed to adequately monitor a resident's use of anticoagulants, leading to a deficiency in care. Resident 138, who was on apixaban for a history of deep vein thrombosis, was observed with multiple bruises on both arms. Despite the presence of these bruises, there was no documented monitoring for potential adverse effects of the anticoagulant, such as bleeding or bruising. The resident reported not receiving any instructions on monitoring for signs and symptoms of bleeding, and there was no order for baseline labs or monitoring for bleeding symptoms. Interviews with facility staff, including LVN 8, RN 1, and the ADON, revealed a lack of awareness and action regarding the resident's condition. LVN 8 admitted to not noticing the bruising, and RN 1 confirmed there was no order to monitor for bleeding signs. The ADON acknowledged that the facility's process should include monitoring for adverse effects of anticoagulants, but no such monitoring was documented for Resident 138. The facility's policy on anticoagulation therapy, which requires monitoring for signs of excessive bruising and other bleeding symptoms, was not followed in this case.
Failure to Follow Enhanced Barrier Precautions During Wound Care
Penalty
Summary
The facility failed to adhere to the Enhanced Barrier Precautions (EBP) protocol during wound care for a resident, which was observed during an unannounced complaint investigation. The Treatment Nurse (TN) was seen preparing for a dressing change and wound observation for a resident who had a sign indicating EBP on the outside of their room. Although the TN donned gloves, she did not wear a gown as required by the EBP protocol during the wound care procedure. The resident involved had multiple medical conditions, including orthostatic hypotension, chronic kidney disease, Parkinson's disease, malignant neoplasm of the colon, and type 2 diabetes mellitus. The resident was also receiving palliative care and was capable of making decisions. The facility's policy required staff to use gloves and gowns for high-contact resident care activities, such as wound care, for residents with open wounds. The failure to follow these precautions had the potential to spread multi-drug resistant organisms.
Call Light Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that the call light was within reach for one of the sampled residents, identified as Resident 2. During an unannounced visit to investigate a complaint regarding quality of care, it was observed that Resident 2's call light was on the floor, out of reach. A Certified Nursing Assistant (CNA) confirmed this observation and acknowledged that call lights should be within reach, indicating a lapse in adherence to the facility's policy. Resident 2 was admitted with multiple diagnoses, including chronic kidney disease, atrial fibrillation, pressure ulcer, osteoarthritis, Alzheimer's disease, and vascular dementia. The resident's care plan specifically noted the need for the call light to be within reach due to his musculoskeletal issues. Additionally, Resident 2's medical records indicated he lacked the capacity to understand and make decisions, further emphasizing the importance of having the call light accessible to ensure his needs could be met promptly.
Infection Control Breach During Wound Care
Penalty
Summary
The facility failed to ensure proper infection control practices were followed by a Treatment Nurse (TN) during wound care for a resident. On June 25, 2024, the TN was observed providing skin care to a resident without performing hand hygiene after removing contaminated gloves and before donning clean gloves. This lapse in protocol occurred while the TN was applying Triamcinolone Acetonide External Cream to various areas of the resident's body, including under the breasts, groin, abdominal fold, buttocks, and sacral area. The TN acknowledged the oversight during an interview, admitting that hand hygiene should have been performed between glove changes. The resident involved had a medical history that included cellulitis of the lower limbs, a lumbar fracture, and chronic obstructive pulmonary disease (COPD). The facility's policy and procedure, as well as the Centers for Disease Control and Prevention's guidelines, clearly state the necessity of hand hygiene before and after glove use, especially when moving between different body sites. The failure to adhere to these guidelines had the potential to contaminate both the TN's hands and the resident's wounds, posing a risk of infection.
Failure to Remove CNA After Abuse Allegation
Penalty
Summary
The facility failed to ensure the immediate removal of a Certified Nursing Assistant (CNA 2) after a resident, identified as Resident A, made an allegation of sexual abuse against him. On May 5, 2024, Resident A accused CNA 2 of inappropriate behavior, including licking and looking down at her private area. Despite the allegation, CNA 2 continued to work in the presence of Resident A, causing her distress and refusal to eat. The incident was reported by CNA 1 to the Registered Nurse Supervisor (RNS) approximately two hours after it occurred, which was not in accordance with the facility's policy. Resident A, who was admitted with a diagnosis of depression and had a cognitive impairment score of 3, was visibly upset and angry upon seeing CNA 2 after the alleged incident. The facility's policy, dated October 2022, mandates the immediate removal of an employee suspected of abuse from resident care and suspension during the investigation. However, this protocol was not followed, as CNA 2 remained on duty to cover for another staff member, and the incident was not reported to the administrator immediately as required.
Failure to Follow Physician Orders for Medication Administration
Penalty
Summary
The facility failed to ensure physician orders were followed for one of three sampled residents, Resident A. Resident A was admitted with diagnoses including COPD, hypertension, diabetes mellitus, and atrial fibrillation. The physician orders for Resident A included Clonidine, Metoprolol, and Diltiazem, each with specific administration parameters based on blood pressure and pulse rates. However, the facility did not adhere to these orders, as evidenced by the Medication Administration Record (MAR) and interviews with staff members. On multiple occasions, Clonidine was not administered when Resident A's systolic blood pressure exceeded 160, as required by the physician's order. Additionally, Metoprolol and Diltiazem were administered even when Resident A's pulse rate was below the specified threshold of 70 beats per minute. This was confirmed through a review of the MAR, which showed instances where these medications were given despite the pulse rate being below the ordered parameters. Interviews with the Licensed Vocational Nurse (LVN) and the Director of Nursing (DON) revealed that the staff did not follow the physician's orders correctly. The LVN acknowledged the importance of adhering to medication orders and documenting reasons for holding medications. The DON confirmed that the medications were administered incorrectly and attributed the errors to staff misreading the physician's orders. The facility's policies on medication administration and monitoring vital signs prior to administration were not followed, leading to these deficiencies.
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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