Rio Hondo Subacute & Nursing Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Montebello, California.
- Location
- 273 E Beverly Boulevard, Montebello, California 90640
- CMS Provider Number
- 056487
- Inspections on file
- 110
- Latest survey
- February 10, 2026
- Citations (last 12 mo.)
- 74
Citation history
Health deficiencies cited at Rio Hondo Subacute & Nursing Center during CMS and state inspections, most recent first.
A resident admitted without pressure ulcers and with paraplegia and severe mobility limitations did not receive a completed Braden Scale risk assessment, and no pressure ulcer prevention care plan or specific interventions such as repositioning or a low air loss mattress were implemented. Over several days, staff documented no skin breakdown, and the IDT did not address pressure ulcer risk, while the resident remained on a regular mattress and required maximal assistance for turning and hygiene. A family member later discovered redness and open skin on the buttocks during an incontinent brief change, after an earlier refused change and unknown duration of soiling. An LVN subsequently documented a DTI on the buttock and a Stage 3 sacrococcygeal ulcer but did not measure the wound, did not timely enter or implement treatment orders, and no wound care was documented for the first two days after identification. Later assessment documented a 5 x 7 x 0.2 cm Stage 3 sacrococcygeal ulcer requiring surgical debridement, and leadership confirmed failures in admission risk assessment, care planning, wound measurement, and timely treatment, which the report states placed the resident at risk for infection, discomfort, and pain.
A cognitively intact resident with sepsis and type 2 DM, who required assistance with ADLs and had a care plan emphasizing her preference for meaningful daily routines and choice of bathing method, did not receive a shower on her regular shower day. Documentation for that day showed no bath type provided, and the resident reported that staff often failed to help her shower despite repeated requests, causing her to feel depressed and useless. The assigned CNA stated she initially offered a shower, which the resident declined at that moment due to pain, but then did not return to re-offer the shower, did not arrange for another staff member to assist, and did not notify anyone that the shower was missed, explaining she was too busy and forgot, contrary to the DON’s expectation that missed showers be reported so they can be completed.
A cognitively intact resident with a history of substance abuse and prior overdose had an active care plan requiring monitoring for signs of substance use, but staff did not document such monitoring despite repeated episodes involving contraband and substance use. Over time, staff observed the resident with vape devices, pills, and marijuana-like smoke in the room, and later saw the resident smoking an unknown substance outside with a family member, yet the care plan was not meaningfully revised and no consistent monitoring was documented. The same family member later admitted giving the resident alcohol after the resident was found vomiting with alcohol odor and was hospitalized for alcohol intoxication, but the facility still allowed this visitor and others to continue unsupervised, unrestricted visitation, and did not inform the MD of earlier incidents or instruct staff on specific behaviors to monitor, contrary to the facility’s own visitation and substance use policies.
A resident with sepsis and type 2 DM, who was cognitively intact, reported to a dialysis social worker that facility staff failed to respond to requests for assistance and behaved unprofessionally, including cursing while at work. The dialysis social worker twice contacted the facility SSD about these concerns, and the SSD initially stated she would follow up with the resident, but there was no documentation of the grievance in the grievance log or progress notes and no written resolution provided. In interviews, the resident and the dialysis social worker reported that no one from the facility had addressed the concerns, and the SSD acknowledged she does not document verbal concerns or initiate grievance forms unless specifically requested, resulting in no recorded grievance or resolution for this resident.
A cognitively intact resident with hemiplegia reported that a CNA handled him roughly during incontinence care, causing pain and prompting him to scream, which was corroborated by his roommate and reported by a family member to an LVN and an RN. The facility’s abuse policy required immediate identification of possible abuse, removal of the alleged perpetrator from duty, initiation of an investigation within two hours, protection of the resident during the investigation, and timely reporting to appropriate agencies, but staff did not recognize or process the complaint as an abuse allegation. Although the CNA was briefly reassigned that shift, the CNA was placed back on assignment with the same resident on a later shift, the Administrator/abuse coordinator was not notified, and no timely investigation or mandated protective measures were implemented, resulting in noncompliance with the facility’s abuse prohibition procedures.
A resident with hemiplegia and intact cognition and the resident’s family member reported to an LVN that a CNA was rough during incontinence care and caused pain, and the family member requested that the CNA not be assigned to the resident again. The facility’s abuse policy required reporting alleged abuse to CDPH, law enforcement, the Ombudsman, and other agencies within two hours, initiating an investigation, and protecting residents from further harm, but the LVN did not notify the ADM or DON and no required external reports were made. Staffing records later showed the same CNA was reassigned to the resident on a subsequent night shift, after which the family member found the resident in a soaking wet brief and the resident reported that no one had checked on him during the night.
A resident with a history of substance abuse and paraplegia was not adequately assessed, monitored, or supervised despite multiple documented episodes of suspected and confirmed substance use. Staff noted a frequent visitor staying overnight with suspicious behavior, observed the resident vaping what smelled like marijuana in his room, and found vape pens and non‑prescribed erectile enhancement pills in his belongings, but there was no thorough investigation, consistent monitoring, or timely physician notification. The resident, who was under the legal smoking age and assessed as unable to safely hold a cigarette, was later seen outside with a visitor placing an unknown smoking material in his mouth, and no sustained reassessment or structured supervision of visits followed. On a subsequent visit, staff found the room smelling of smoke, marijuana, and alcohol, and the resident was vomiting and foaming at the mouth; the visitor admitted providing alcohol, and the resident was diagnosed with acute alcohol intoxication. Despite these events, the same visitor continued to have unsupervised and unrestricted access, and staff reported they were not directed to monitor for substance use behaviors or to control contraband brought in by visitors.
A paraplegic resident with intact cognition and a history of substance use disorder had a physician order for an electric wheelchair to address mobility needs, but the facility did not follow through on obtaining the device. The Social Services policy required provision of medically related social services, including ambulation equipment, yet there was no documented follow-up by the case manager after the order. An IDT later decided against providing the electric wheelchair due to concerns about the resident’s prior fentanyl use and recent contraband incidents, despite the resident relying on a manual wheelchair that he could not safely self-propel, as confirmed by PT. The resident and family reported ongoing requests for the electric wheelchair, feelings of isolation, and restricted freedom of movement, while facility leadership gave conflicting accounts of Social Services’ responsibility for arranging DME for custodial residents.
A resident who was cognitively intact and fully dependent on staff due to quadriplegia was subjected to derogatory and inappropriate comments by two CNAs during a fecal disimpaction procedure. The CNAs engaged in personal conversation and made offensive remarks in the resident's presence, causing the resident to feel uncomfortable and upset. Facility policy required staff to treat residents with dignity and respect at all times, and the incident was confirmed by staff interviews.
A resident with Parkinson's Disease and a history of falls did not have required bolster pillows attached to the bed as outlined in the care plan, despite being dependent on staff for mobility and having frequent involuntary movements. Multiple staff confirmed the absence of bolsters, and observations showed the intervention was not implemented after room transfer, leading to continued risk of falls.
A resident with severe cognitive impairment and a stage 4 pressure ulcer was not adequately represented in care planning, as the responsible party was not included in interdisciplinary care conferences and was only given limited information after meetings. Staff did not provide regular or detailed updates about the wound's stage or treatment, leaving the responsible party unaware of the wound's severity and progression, in violation of facility policy.
A resident with multiple medical conditions did not receive prescribed nystatin cream, Zoryve foam, and normal saline flushes as ordered, with facility records showing missed administrations and blank documentation. Nursing staff confirmed these treatments were not given or documented, and the resident reported not receiving his medications, contrary to facility policy requiring timely administration and documentation.
A resident with severe cognitive impairment and a stage four pressure ulcer did not have consistent documentation of required turning and repositioning every two hours, as ordered by the physician. Facility staff, including CNAs and nurses, failed to record care in accordance with policy, resulting in multiple gaps in the medical record over several days.
The facility did not post accurate and current nurse staffing data as required, instead displaying outdated and projected staffing hours rather than actual hours worked for each shift. This occurred after the staff member responsible for updating the postings went on leave, and no other staff was assigned to maintain the daily updates.
Two residents experienced deficiencies in dignity and respect when one waited at least 19 minutes for staff response after activating a call light, despite staff presence at the Nurses' Station, and another was subjected to derogatory language by a CNA and subsequently felt neglected. Both incidents were confirmed through interviews, observations, and record reviews, showing a failure to follow facility policies on timely response and respectful communication.
A resident with cognitive impairment and a history of inappropriate physical contact did not have a comprehensive, person-centered care plan that clearly defined behaviors to monitor or provided specific interventions for one-to-one supervision. Facility staff failed to consistently implement the required supervision, and the care plan lacked sufficient detail to guide staff actions, resulting in lapses in monitoring after reported incidents.
A resident with a right ankle fracture experienced ongoing pain and refused to ambulate, but staff failed to consistently assess, document, and communicate the pain to the NP or physician. Despite policy requirements, pain assessments and reassessments were incomplete, and pain interventions were not always evaluated for effectiveness, leading to poor pain control and decreased mobility.
Surveyors found that the facility did not have an infection prevention and control program in place, indicating a lack of systematic measures to address infection risks for residents and staff.
A deficiency was cited when a facility area was found to contain accident hazards and lacked adequate supervision to prevent accidents, resulting in an unsafe environment for residents.
A resident's prescribed medications were left unattended at the bedside and documented as administered in the MAR, despite not being taken. The nurse placed the medications on the bedside table and left the room, contrary to facility policy requiring medications to be given in the nurse's presence. The resident, who was alert and cognitively intact, had a history of missed and incorrect medication administration, as noted in multiple care plans.
A resident's room was found cluttered and unsanitary, with trash, empty boxes, and used utensils left for about two weeks, despite facility policy and a care plan requiring a clean, clutter-free environment. The resident, who was fully alert and had chronic medical conditions, reported the ongoing issue, and the ADON confirmed that staff did not ensure regular cleaning or removal of debris.
Two residents experienced unsafe transfers when staff failed to use the correct size sling and did not follow two-person assistance protocols during mechanical lift transfers. One resident fell and sustained a head injury after being transferred with a sling that was too small, while another was transferred by a CNA working alone, contrary to policy. Staff interviews revealed a lack of training and awareness regarding sling sizing and safe transfer procedures.
A resident with chronic pain syndrome and multiple comorbidities experienced unrelieved pain after staff failed to ensure timely physician authorization and pharmacy delivery of a fentanyl patch, resulting in missed doses. Despite the resident's repeated reports of severe pain, staff did not consistently assess or document pain levels according to the care plan, and communication lapses led to delays in addressing the medication shortage.
A facility failed to ensure that CNAs were properly trained and competent in selecting the correct sling size for use with a mechanical lift, resulting in a resident with significant mobility impairments being transferred with an incorrectly sized sling. The resident slipped from the sling, sustained a head injury, and required hospital evaluation. Staff interviews and record reviews revealed widespread lack of training and awareness regarding sling sizes, and the facility's competency assessments did not address this critical aspect of safe resident transfer.
Two residents who required mechanical lift transfers did not have comprehensive care plans developed or implemented to address their assessed needs. One resident experienced a fall and head injury after being transferred with an incorrectly sized sling by two CNAs who lacked training on sling selection. Another resident, fully dependent for transfers, was observed being transferred by a single CNA despite the requirement for two-person assistance. In both cases, the absence of individualized care plans and clear instructions led to unsafe transfer practices.
A resident with a low potassium level and physician's order for daily KCL did not receive all prescribed doses, despite the MAR indicating administration. Physical counts of medication packets showed three doses were missed, and both the resident and a family member reported missed administrations. Nursing staff documented KCL as given even when it was not, leading to a discrepancy confirmed by the pharmacist and DON.
A resident with multiple serious diagnoses expired, but their medications remained in a locked box in the medication room, with staff unaware of the contents or how to access them. The facility lacked a specific policy for handling medications after a resident's death, and there was no record of the drugs stored, creating a risk for diversion or misuse.
A facility failed to maintain a complete and signed inventory of a resident's personal effects, omitting the resident's car and car keys from documentation. The omission was discovered after the resident's car, which had been parked and vandalized on facility property for an extended period, was involved in a fire and subsequently towed for an arson investigation. Staff and family interviews confirmed the car's presence and lack of documentation, and facility policy requiring proper listing and signatures was not followed.
Facility staff failed to address an abandoned, vandalized vehicle belonging to a resident, which remained in the parking lot for about two years in a state of disrepair. Despite being observed by multiple staff members, the car was not reported or removed, eventually catching fire and requiring emergency response. The incident placed residents, staff, and visitors at risk, and the vehicle was later determined to be involved in an arson investigation.
The facility failed to develop, revise, and implement individualized care plans for two residents, including one with COPD and a hematoma who did not have care plans addressing oxygen therapy or new skin issues, and another with severe immobility and a Stage 3 pressure injury who did not receive timely incontinence care or repositioning as required. Staff did not update care plans to reflect changes in condition, and documentation was inconsistent with facility policy.
Two residents at risk for skin breakdown did not receive care in accordance with their care plans and facility policy. One resident with a Stage 3 pressure ulcer and MASD was not checked for incontinence or repositioned as required, remaining on his back for over six hours. Another resident with a hematoma and skin discoloration on the trunk had no care plan or interventions developed or implemented for the condition, and documentation of skin assessments was inconsistent. Staff interviews and record reviews confirmed these deficiencies in care and documentation.
A resident with ESBL resistance in the urine did not have Enhanced Barrier Precautions implemented as ordered, including the absence of required signage and PPE availability. Staff were unaware of the need for EBP, and direct care was provided without appropriate PPE during medication administration and incontinence care, contrary to facility policy and physician orders.
A resident with multiple medical conditions reported being punched on the leg by a nurse. The allegation was documented by an LVN but was not reported to CDPH, the Ombudsman, or law enforcement within the required two-hour window, as mandated by facility policy. The DON became aware of the incident two days later and then made the required reports, resulting in a delay in investigation.
A resident with a history of falls and impaired balance slipped to the floor during a transfer when wheelchair brakes were not properly locked. After the fall, CNAs moved the resident without a licensed nurse assessment, and the incident was not documented or reported according to facility policy.
A resident with COPD and heart failure did not receive appropriate respiratory care due to missing documentation, lack of clear physician orders for oxygen therapy parameters, and absence of a comprehensive, individualized care plan. Staff failed to document when oxygen was administered or discontinued, did not notify the physician about the resident's oxygen needs, and did not follow facility policies for monitoring and care planning.
A resident with chronic pain and recent leg surgery experienced severe, unrelieved pain after readmission when only acetaminophen was available, despite clear indications that stronger pain management was needed. Staff did not assess or address the resident's pain adequately, and appropriate pain medication was not provided until the following day, contrary to the facility's pain management policy.
The facility failed to provide adequate supervision and enforce safe storage of smoking materials for several residents who required supervision, resulting in a smoking-related incident where a resident set fire to bed linens and multiple residents were found with unsupervised access to cigarettes and lighters. Staff were not consistently aware of residents' possession of smoking materials, and required Interdisciplinary Team meetings and care plans addressing smoking safety were not completed for all residents who smoked.
A resident with alcoholic cirrhosis did not receive necessary behavioral health services, including psychiatric referral and person-centered care planning, despite documented agreements and observed behaviors indicating ongoing risk. Facility staff did not implement or document interventions for substance abuse, and required behavioral health services were not provided.
A resident with diabetes and a history of hypoglycemia was readmitted from the hospital without proper review or implementation of discharge orders for blood sugar monitoring and insulin administration. Nursing staff failed to clarify missing orders, did not monitor for hypoglycemia or hyperglycemia, and administered insulin without checking blood sugar. When the resident developed severe hypoglycemia and altered consciousness, staff delayed emergency response and failed to notify the physician promptly, resulting in the resident's transfer to the ICU and subsequent death.
Two residents were not protected from physical abuse by another resident with a history of aggression. After one resident was struck with a metal bar, the aggressor was moved to share a room with a legally blind resident, who was later hit in the face with a radio. Staff failed to assess roommate compatibility, did not act on reports of aggressive behavior, and did not follow abuse prevention policies, resulting in harm and emotional distress to both victims.
A physical altercation occurred between two residents, where one was reportedly struck by another using a wheelchair armrest. Staff failed to obtain separate, accurate statements from both residents and did not conduct a comprehensive investigation as required by facility policy. Documentation was incomplete, and the administrator could not provide evidence of a thorough investigation into the incident.
A resident with a history of acute respiratory failure and diabetes was transitioned to an oral diet, and GT feedings were stopped. After a failed attempt by a PA to remove the GT, staff did not promptly refer the resident to a GI specialist as recommended, resulting in the tube remaining in place and not being flushed for several weeks. Facility staff did not follow up on the recommendation or notify the attending physician, contrary to facility policy.
A resident requiring hemodialysis did not receive timely assistance to be ready for scheduled treatments, resulting in frequent delays in transportation and late dialysis sessions. Facility staff also failed to document post-dialysis assessments, vital signs, and return times as required by policy, leading to incomplete records and delayed care.
A resident with renal failure and diabetes had significant discrepancies in weight documentation, with staff copying weights from hemodialysis records without reweighing the resident. The RD and nursing staff did not verify or address the incorrect weight entries, resulting in inaccurate records despite facility policy requiring accurate and timely weight documentation.
The facility failed to implement an effective infection prevention and control program, leading to the spread of scabies among residents. A resident diagnosed with scabies did not receive timely treatment, and their roommate was not placed under contact isolation as required. The infection preventionist did not adequately manage the situation, resulting in potential transmission of the infection.
Three residents at high risk for falls experienced repeated incidents due to the facility's failure to update care plans, analyze root causes, and implement effective interventions. One resident suffered a fractured ankle after multiple falls without timely care plan updates, another fractured a shoulder after slipping on medication powder left on the floor, and a third was repeatedly found on the floor due to inadequate supervision and staff communication. Staff interviews confirmed lapses in monitoring, environmental safety, and individualized care planning.
Multiple residents with catheters or incontinence experienced delayed physician notification of critical lab results, inconsistent monitoring and documentation of catheter care, and inadequate incontinence care, leading to recurrent UTIs and hospital transfers. Staff did not consistently follow protocols for assessment, documentation, or timely reporting of significant changes in condition.
Four residents did not receive proper pressure ulcer care, including one who developed and experienced worsening of pressure ulcers due to inconsistent repositioning and incontinence care. Two residents with healed ulcers did not have their low air loss mattresses set or checked as ordered, and another resident with a Stage 4 ulcer lacked weekly wound assessments and communication with the wound specialist. Documentation and monitoring practices did not meet facility policy requirements.
Three residents with varying cognitive and physical impairments were unable to access their call light devices due to improper placement by staff, leaving them unable to request assistance for basic needs. Staff interviews confirmed the call lights were not within reach, contrary to facility policy.
A facility did not consistently inform residents of their rights and responsibilities, as shown by a lack of documentation in Resident Council Minutes and confirmed by interviews with alert and oriented residents. The Activity Director acknowledged that information about residents' rights was not regularly communicated or posted, and a resident stated that knowing their rights would help them feel more empowered.
Failure to Assess, Care Plan, and Treat Leading to Development of Stage 3 Pressure Ulcer
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate pressure ulcer prevention and treatment for a newly admitted resident who was admitted without pressure ulcers and had paraplegia, muscle weakness, and lack of coordination. The admission record and history and physical documented no pressure ulcers on admission, and therapy evaluations showed the resident required maximal assistance for bed mobility, activities, and personal hygiene. Despite this high-risk profile, the Braden Scale for Predicting Pressure Ulcer Risk completed on the admission date was left incomplete, with no scoring or staff signature, and the resident’s risk level for pressure ulcer development was not determined as required by the facility’s Skin Integrity Management policy. From admission through several days, weekly body checks documented no skin breakdown, and the interdisciplinary care conference did not identify or address any pressure ulcer risk or presence. From admission through more than a week, the facility did not develop a comprehensive care plan with specific interventions to prevent pressure ulcers for this resident. No care plan was in place to address pressure ulcer prevention or to incorporate interventions such as repositioning, use of a low air loss mattress, or incontinence management, despite the resident’s dependence on staff for turning and repositioning. During this period, the resident remained on a regular mattress rather than a low air loss mattress. On one day, the resident’s family member assisted a CNA with an incontinent brief change and observed new redness and open skin on the buttocks/sacrococcyx area that had not been present previously. The CNA reported that the resident had refused an earlier brief change, did not know how long the brief had been soiled, and did not directly observe the buttock area during the change because she was holding the resident while the family member performed the cleaning. Later that same day, an LVN was informed by the family member about the skin issue and initially had not yet assessed the resident’s skin or notified the physician. After assessing the resident, the LVN documented a change in condition note indicating a deep tissue injury on the left buttock and a Stage 3 pressure ulcer with surrounding deep tissue injury on the sacrococcyx and reported notifying the physician with a recommendation for wound consultation and treatment orders. However, there was no documentation of physician wound treatment orders on that date, and the wound was not measured for length, width, depth, or other characteristics at the time of initial identification. Physician orders for wound treatment were documented the following day, directing cleansing with normal saline, application of Medi-Honey and barrier cream to the sacrococcyx Stage 3 ulcer, and zinc oxide to the left buttock DTI. The MAR/TAR showed no evidence that any initial wound or skin treatments were provided on the day the Stage 3 ulcer was identified, and no evidence that the ordered treatments were performed the following day. The LVN later stated she had received a telephone order for treatment but did not enter it into the electronic MAR/TAR because she did not know how, and she did not perform the initial wound treatments, assuming treatment nurses would do so. Subsequent wound assessment by a physician assistant documented a Stage 3 pressure ulcer on the sacrococcyx with purple discoloration, measuring 5 cm by 7 cm by 0.2 cm, with light serosanguineous drainage, and noted that surgical debridement was performed. Later observations confirmed the resident continued to lie in bed without a low air loss mattress, even after the pressure ulcer was identified. A Braden Scale completed several days after ulcer identification showed the resident at moderate risk for pressure ulcer development. Nursing leadership and staff interviews confirmed that the Braden Scale had not been properly completed on admission, that no pressure ulcer prevention care plan had been developed from admission through the period when the ulcer developed, that the wound was not initially measured, and that ordered wound treatments were not provided on the first two days after identification. Staff also acknowledged that the resident required assistance of two people for turning and repositioning and that interventions such as repositioning, maintaining clean and dry skin, frequent incontinence care, and use of a low air loss mattress were standard preventive measures that were not implemented in a timely manner for this resident. The report states that as a result of these deficient practices, the resident developed a deep tissue injury and a Stage 3 pressure ulcer on the sacrococcyx that required surgical debridement. The report further states that these deficient practices placed the resident at risk for infection, discomfort, and pain at the pressure ulcer site.
Failure to Honor Resident Choice and Provide Scheduled Shower
Penalty
Summary
The deficiency involves the facility’s failure to honor a cognitively intact resident’s right to exercise choice and autonomy regarding bathing on a regularly scheduled shower day. The resident, admitted with diagnoses including sepsis and type 2 diabetes mellitus, required substantial/maximal assistance with several ADLs, including shower/bath, and had a care plan indicating she needed partial/moderate assistance for bathing as necessary. Her care plan also documented that it was important for her to have daily routines and preferences accommodated, including choosing between a tub bath, shower, bed bath, or sponge bath. On the date in question, facility documentation for the resident’s bathing task listed all bathing-related items as “not applicable,” indicating no bath type was provided or recorded. On that same day, the resident reported she did not receive a shower despite it being her regular shower day and stated that staff often did not help her shower even when she asked multiple times, which made her feel depressed and useless. She stated she had her own personal hygiene products and did not understand why staff would not assist her. The assigned CNA confirmed that the resident’s regular shower days were Tuesdays and Thursdays and acknowledged that the resident did not receive a shower because the CNA was busy. The CNA reported that when she first approached the resident in the morning, the resident declined a shower at that time due to pain, and the CNA did not return later to offer the shower, nor did she notify anyone else that the shower had not been provided, stating she was busy and forgot. The DON stated that residents should receive showers on scheduled days and that CNAs who cannot provide a scheduled shower are expected to notify the charge nurse so another staff member can assist.
Failure to Restrict and Monitor Visitor Access for Resident With Ongoing Substance Use Incidents
Penalty
Summary
The deficiency involves the facility’s failure to implement and monitor its visitation and substance use disorder policies for a resident with a known history of psychoactive substance abuse and prior fentanyl overdose. The resident, who was cognitively intact but dependent on staff for transfers and with impaired mobility, had an active care plan for substance use that called for monitoring for signs and symptoms of substance use and abuse, such as confusion, drowsiness, outbursts of anger, and mood changes. Despite this, there was no documented evidence over multiple months that staff monitored the resident for these signs as outlined in the care plan. The facility’s visitation policy allowed for limiting or supervising visitors who abused, coerced, or exploited residents or who had a history of bringing illegal substances into the facility, but the facility did not operationalize these restrictions for this resident. Multiple documented incidents showed that the resident possessed or used substances and smoking materials, often in the presence of a specific family member visitor. On one occasion, staff observed the family member staying almost every night in the resident’s room and notified the DON and police due to suspicious behavior, but there was no documented investigation to determine the source of contraband. On another date, staff found the resident with vape devices and Blue Chew pills; these items were removed and given to a family member, and a late entry note by the DON recommended ongoing monitoring due to the resident’s substance-related history. However, there was no subsequent documentation that the resident was supervised or monitored for suspicious behaviors or signs of substance use as recommended. Later, staff documented that the resident’s room smelled like marijuana while the resident was with a visitor, and both were educated on facility policy, but the care plan was not revised to add new interventions related to this event. Further incidents continued without changes to visitation practices or documented monitoring. A restorative nursing assistant reported seeing the resident outside the facility with the same family member, who appeared to place an unknown smoking material to the resident’s mouth; this was reported to nursing and the administrator, and an order was obtained to closely monitor the resident for changes in level of consciousness, but there was no documentation that such monitoring occurred. Subsequently, the resident was found in his room vomiting, with foaming at the mouth and a smell of alcohol present; the family member at the bedside admitted giving the resident alcohol, and the resident was sent to the hospital and diagnosed with alcohol intoxication and alcohol abuse. When the resident returned from the hospital, there was no documentation that supervision or monitoring of the resident or the family member’s visits was implemented. Visitor sign-in records showed that the same family member and other friends continued to visit without restrictions or supervision. Interviews with the administrator, DON, nursing staff, and receptionist confirmed that no visitation restrictions or supervision were put in place for this family member, that there was no investigation into earlier contraband incidents, that the physician was not informed of key events, and that staff were not instructed on specific behaviors to monitor, despite the resident’s history and repeated episodes involving visitor-introduced substances.
Failure to Document and Resolve Resident Grievance Regarding Staff Responsiveness and Professionalism
Penalty
Summary
The deficiency involves the facility’s failure to follow its grievance policy and to promptly address and resolve a resident’s grievance. The facility’s policy titled “Grievances/Concerns,” dated 8/25/2021, states that upon receipt of a grievance or concern, staff will initiate a grievance/concern form and document it on the Grievance/Concern Log, and that the department manager will notify the person filing the grievance of the resolution and/or status within 72 hours. Despite this policy, there was no grievance form or log entry for the concerns raised about staff responsiveness and professionalism, and no written resolution was provided within the required timeframe. The resident involved was originally admitted and later readmitted with diagnoses including sepsis and type 2 diabetes mellitus. A History and Physical dated 12/30/2025 documented that the resident had capacity to understand and make decisions, and a Minimum Data Set dated 1/02/2026 indicated the resident was cognitively intact. On 12/22/2025, during dialysis, the resident reported to the dialysis social worker that staff at the facility did not respond when assistance was requested and that staff behaved unprofessionally, including cursing while at work. The dialysis social worker documented contacting the facility’s Social Services Director (SSD) by phone that same day, with the resident present, and the SSD stated she would follow up with the resident upon her return to the facility. Subsequent documentation from the dialysis center dated 1/12/2026 showed that the dialysis social worker attempted to contact the SSD again, left a voicemail, and did not receive a response. The facility’s grievance/complaint log for December 2025 contained no entries for this resident, and the resident’s progress notes from 12/22/2025 to 1/13/2026 contained no documentation of the concerns or any follow-up. In interviews, the dialysis social worker reported that the resident stated no one from the facility had addressed her concerns, and the resident confirmed that no one had followed up as of 1/13/2026. The SSD stated she had no documented grievances for this resident, did not document verbal concerns because there were too many residents, did not initiate grievance forms unless specifically requested, and could not recall the issues brought to her attention, resulting in no grievance resolution being provided to the resident.
Failure to Identify, Investigate, Report, and Protect After Allegation of Rough Handling During Care
Penalty
Summary
The deficiency involves the facility’s failure to identify, investigate, report, and implement protective measures in response to an allegation of abuse, as required by its Abuse Prohibition Policy and Procedures. The policy stated that staff must identify events that may constitute abuse, immediately remove the alleged perpetrator from duty pending investigation, initiate an investigation within two hours, protect patients during the investigation, and report allegations of abuse to appropriate agencies within specified time frames. Despite these requirements, when a family member reported that a CNA had handled a resident roughly during incontinence care and requested that the CNA not be reassigned, the facility did not treat this as a potential abuse allegation and did not follow the policy’s mandated steps. The resident involved had hemiplegia and hemiparesis following a cerebral infarction affecting the left dominant side, as well as essential hypertension, and was documented as cognitively intact with capacity to understand and make decisions. Staffing records showed that the CNA in question was assigned to the resident on consecutive shifts. A change in condition evaluation documented that the resident claimed the CNA was rough while turning him, and that the supervisor was made aware and the CNA was reassigned for the remainder of that shift. However, there was no indication that the incident was reported to the Administrator or DON as the abuse coordinator, and no immediate investigation or protective measures consistent with the abuse policy were initiated at that time. Interviews further substantiated the allegation and the facility’s failure to act in accordance with its policy. The family member reported that the resident said the CNA hurt his left arm and that a roommate, who was alert, confirmed hearing the resident scream during care. The resident later stated that the CNA pulled him by his left arm, causing pain, and that he screamed but the CNA did not stop or respond. The roommate reported hearing the resident say “you hurt me” while the CNA continued care and appeared to be in a hurry. Despite the family member’s request that the CNA not be reassigned, staffing records and interviews confirmed that the CNA was again assigned to the resident on a subsequent night shift, and the Administrator stated she was not informed of the complaint and that the CNA should not have been reassigned pending investigation. The CNA reported that no one interviewed her or explained why she had been reassigned on the day of the complaint, further demonstrating that no timely investigation or protective process was initiated as required by the facility’s abuse policy.
Failure to Timely Report Alleged Abuse and Prevent Reassignment of Accused CNA
Penalty
Summary
The deficiency involves the facility’s failure to timely report an allegation of abuse and to protect a resident from further contact with the alleged perpetrator, as required by its Abuse Prohibition Policy and Procedures. The policy, dated 2/23/2021, required that upon receiving information about suspected or alleged abuse, the designee report the allegation to CDPH, local law enforcement, the Ombudsman, and other required agencies within two hours, initiate an investigation within two hours, document witness interviews, and protect patients from further harm during the investigation. On 1/11/2026 at 10:00 AM, a cognitively intact resident with hemiplegia and hemiparesis following a cerebral infarction, and the resident’s family member, reported to an LVN that a CNA had been rough while turning the resident and had hurt the resident. The LVN documented the complaint in a Change in Condition Evaluation and reassigned the CNA for the remainder of that shift but did not report the allegation to the DON or Administrator, assuming the RN on duty would do so. As a result, the Administrator, who is the facility’s abuse coordinator, was not informed and no required external reports were made within the mandated two-hour timeframe. The resident’s admission and assessment records showed that the resident had the capacity to understand and make decisions and was cognitively intact. The family member stated that the resident’s roommate, who was alert, confirmed hearing the resident scream while the CNA was changing the resident’s briefs. The family member reported the incident to the LVN and RN and specifically requested that the CNA not be assigned to the resident again. Despite this, staffing assignment sheets showed that the same CNA was again assigned to the resident on the night shift of 1/12/2026. The family member later reported that when she arrived the next morning, the resident stated no one had checked on or changed him during the night, and the family member found the resident’s diaper soaking wet; the resident identified the assigned CNA as the same CNA previously reported for rough handling. The Administrator confirmed she was unaware of the initial complaint and stated that, had she been informed, she would have initiated the abuse investigation and reporting process as outlined in the facility’s policy.
Failure to Control Visitor-Introduced Substances and Supervise High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to maintain an environment free of accident hazards and to provide adequate supervision and assistance to a resident with a known history of substance abuse and prior fentanyl overdose. The resident was admitted with psychoactive substance abuse and paraplegia, required assistance with ADLs and transfers, and had care plans and policies in place related to substance use disorder, smoking, visitation, and comprehensive care planning. Despite these, the facility did not consistently assess, monitor, or document signs and symptoms of substance use or abuse as required by the resident’s care plans and the facility’s policies. Staff documented that a family member frequently stayed overnight in the resident’s room and engaged in unspecified suspicious behavior that led to police notification, but there was no documented investigation, IDT follow‑up, or reassessment of the resident for substance use or abuse after this event. The facility also failed to adequately address multiple specific incidents involving contraband substances and unsafe smoking. On one occasion, an LVN observed the resident vaping a substance that smelled like marijuana in his room, with his roommate coughing from the smoke. The resident was later found in possession of vape pens, a marijuana “live resin” vape, and non‑prescribed Blue Chew erectile enhancement pills, which were confiscated. Progress notes and interviews show that although these items were removed and a care plan was created to monitor for changes related to non‑prescribed medications, there was no documented ongoing monitoring for substance use, suspicious behaviors, or adverse effects, and the physician was not informed of these incidents. Staff also documented complaints of the resident’s room smelling like marijuana when the resident was with a visitor, but there is no evidence that the substance abuse care plans were revised with new interventions in response. The facility further failed to enforce its smoking and visitation policies and to implement increased supervision despite repeated incidents involving the same visitor. A smoking evaluation documented that the resident was not allowed to smoke due to being under the legal smoking age and unable to safely hold a cigarette, yet a restorative nursing attendant later observed the same family member placing an unknown smoking material in the resident’s mouth outside the front of the facility. Staff and the administrator approached and educated the resident, and an NP ordered close monitoring for changes in level of consciousness, but there is no documentation of reassessment for substance use or abuse or of specific supervision of visits. Subsequently, the same family member visited again; staff entered the resident’s room, noted smells of smoke, marijuana, and alcohol, and found the resident vomiting, foaming at the mouth, and unable to hold his head up. The visitor admitted providing alcohol, and hospital records confirmed acute alcohol intoxication. After the resident’s return, visitor logs show that the same family member continued to visit without documented restrictions or supervised access, and interviews confirm that staff were not instructed to monitor or supervise visits or to watch for specific substance‑related behaviors, despite the resident’s history and prior documented incidents.
Failure to Provide Ordered Electric Wheelchair and Medically Related Social Services
Penalty
Summary
The deficiency involves the facility’s failure to provide medically related social services, specifically an ordered electric wheelchair, to a paraplegic resident. The facility’s policy on Social Services, dated September 2021, stated that medically related social services are provided to maintain or improve each resident’s ability to meet everyday physical needs, including equipment for ambulation. Resident 1, originally admitted in November 2023 and later readmitted, had diagnoses including paraplegia and psychoactive substance abuse. A Minimum Data Set dated October 10, 2025, documented intact cognition and memory, with the resident requiring partial to total assistance for activities of daily living and being dependent for transfers and toileting. On July 14, 2025, the physician ordered an electric wheelchair for the resident and directed the facility’s case manager to request authorization. However, there was no documentation or endorsement of follow-up on this order. During an interdisciplinary care conference on September 26, 2025, attended by the resident’s family member, Social Services staff, the Director of Rehabilitation, and the Director of Staffing and Development, the team determined that providing an electric wheelchair was not appropriate at that time. Their rationale was the resident’s history of substance use disorder, prior fentanyl use, and recent contraband incidents involving marijuana vape products and non-prescribed supplements, and they believed access to an electric wheelchair could increase the potential for self-harm related to drug-seeking behavior. The record also noted that the resident was using a manual wheelchair with staff and family assistance and could navigate the facility and go on outings with support. Interviews and observations showed that the resident could not independently and safely propel the manual wheelchair. The resident’s family member reported that the resident had requested an electric wheelchair since July 2025 and had not received it, and that the resident was experiencing isolation and loneliness. During observation in the resident’s room, the resident stated he could not safely wheel himself alone and felt his mobility and right to move freely were restricted; when attempting to propel the manual wheelchair in a straight line, he veered to the right and struck the bedside table and wall. A physical therapist confirmed the resident could not propel a manual wheelchair due to poor coordination. The current case manager stated she was unaware of the electric wheelchair order and that there was no documentation regarding the request. The Social Services Director stated she believed Social Services only arranged DME for residents being discharged and did not know what happened to the July 2025 order, while the DON stated Social Services was responsible for arranging DME for custodial residents. The Administrator acknowledged that there was no documented follow-up on the July 14, 2025 electric wheelchair order until the September 26, 2025 meeting and that the decision not to provide the electric wheelchair was based on concerns about the resident’s safety related to illegal substance use behaviors.
Failure to Maintain Resident Dignity During Care Procedure
Penalty
Summary
Certified Nursing Assistants (CNAs) 2 and 3 failed to treat a resident with respect and dignity during a fecal disimpaction procedure. The resident, who was cognitively intact but fully dependent on staff due to quadriplegia and had a history of anxiety and depression, was present in the room when CNAs 2 and 3 engaged in a personal conversation that included derogatory and inappropriate comments. Specifically, while Registered Nurse (RN) 1 left the room to retrieve lubricant, CNA 2 made a comment, "What if you spit on it?" in response to CNA 3's remark, "You can either hit it or quit it," both of which were made in the presence of the resident. The resident reported feeling uncomfortable and upset by these comments and responded by yelling at the staff. Facility policy and procedures reviewed indicated that residents are to be treated with dignity and respect at all times, and demeaning practices are prohibited. The resident's care plan specifically noted the need for staff to maintain the resident's dignity and comfort during incontinence care. Interviews with the CNAs confirmed the inappropriate conversation took place in the resident's presence, and the Director of Nursing acknowledged that such comments could be perceived as hurtful and offensive, potentially resulting in psychosocial harm.
Failure to Implement Fall Prevention Interventions for High-Risk Resident
Penalty
Summary
The facility failed to implement the care plan for a resident with a history of falls, specifically neglecting to ensure the placement of bolster pillows on the mattress while the resident was in bed. The resident, who had diagnoses including Parkinson's Disease with significant tremors and contractures, was dependent on staff for all activities of daily living and functional mobility. Despite being identified as at risk for falls and having experienced unwitnessed falls resulting in pain and hospital transfer, the care plan interventions such as attaching bolster pillows to the mattress and positioning the resident in the center of the bed were not carried out. Observations and interviews revealed that, following the resident's falls, the care plan was revised to include specific interventions like keeping a floor mat on the left side of the bed, moving the right side of the bed against the wall, and ensuring the bed was in the lowest position. However, during multiple observations, the resident was found in bed without the required bolster pillows, and staff confirmed that the bolsters were not present. Staff interviews indicated awareness of the resident's frequent involuntary movements and the need for bolsters to prevent sliding or falling, yet the intervention was not implemented. Further review and interviews with facility staff, including the Assistant Director of Nursing, revealed that the care plan was not updated promptly after the initial fall and that the recommended interventions were not consistently applied, particularly after the resident was transferred to a different room. The lack of communication and follow-through resulted in the omission of the bolster pillows, despite clear documentation and interdisciplinary team recommendations to use them as a preventive measure for recurrent falls.
Failure to Inform and Involve Responsible Party in Pressure Ulcer Care Planning
Penalty
Summary
The facility failed to ensure that the responsible party (RP) for a resident with a stage 4 pressure ulcer was properly informed and included in care planning meetings, as required by facility policy. The resident, who had severe cognitive impairment and lacked decision-making capacity, was admitted with significant medical conditions including a stage 4 sacral pressure ulcer, Type 2 Diabetes Mellitus, and a tracheostomy. Facility policies mandated that the RP be notified of the care plan and participate in the development and revision of the comprehensive care plan, especially for significant conditions such as pressure ulcers. Record reviews and interviews revealed that although the RP was listed as an attendee in care conference documentation, she was not actually present during the meetings. Instead, she was informed separately by phone after the meetings concluded, and the information provided was limited. The RP reported that she was only told that the wound had re-opened, without being informed of the wound's stage, measurements, or specific details. Facility staff confirmed that updates to the RP were not provided regularly or in sufficient detail, and that the RP was not given the opportunity to ask questions or participate meaningfully in the care planning process. Staff interviews further indicated that the RP was not informed about the staging or measurements of the wound, with some staff expressing that such details were withheld because they believed the RP would not understand or would ask more questions. The responsible party was not included in the interdisciplinary care conferences, contrary to facility policy and regulatory requirements, and was not kept fully informed about the resident's wound status or treatment plan. This resulted in the RP being unaware of the severity and progression of the resident's pressure ulcer.
Failure to Administer and Document Physician-Ordered Medications and Treatments
Penalty
Summary
The facility failed to administer prescribed medications and treatments as ordered by the physician for a resident with multiple medical conditions, including epileptic seizures, a pressure ulcer, and chronic kidney disease. Specifically, the resident did not receive scheduled doses of nystatin cream for wound care, Zoryve foam for seborrheic dermatitis, and normal saline flushes for PICC line maintenance on several documented occasions. Review of the Treatment Administration Record (TAR) and IV Administration Record revealed multiple blank entries, indicating missed administrations of these medications and treatments. Interviews with nursing staff confirmed that the absence of documentation on the TAR and IV Administration Record meant the medications and treatments were not given. Both the Licensed Vocational Nurse and the Registered Nurse Supervisor acknowledged that the resident should have received these medications daily as ordered, and that the records should not have contained blank spaces. The staff also confirmed that the missed administrations were not documented as given or offered. The resident reported not receiving his prescribed creams and described feeling unwell as a result. The facility's policy required medications to be administered within one hour of the prescribed time unless otherwise specified, and for all administrations to be documented. The failure to follow physician orders and document medication and treatment administration resulted in the resident not receiving necessary care for his wounds and PICC line maintenance.
Failure to Maintain Consistent Documentation for Pressure Ulcer Prevention
Penalty
Summary
The facility failed to maintain current, detailed, and consistent medical records for one resident who required turning and repositioning every two hours to prevent the worsening of a stage four pressure ulcer, as ordered by the physician. The facility's policy required documentation of the date and time care was given, the names and titles of staff involved, the position in which the resident was placed, reasons for changing position, resident participation, any problems or complaints, refusals and interventions, and the signature and title of the person recording the data. However, a review of the resident's records revealed multiple gaps in documentation by both CNAs and nurses over several days, with missing entries for required time slots and shifts. The resident involved had severe cognitive impairment, a history of a stage four pressure ulcer, Type 2 Diabetes Mellitus, and tracheostomy status, and was unable to make decisions or understand care instructions. Despite physician orders and facility policy, staff failed to consistently document turning and repositioning in both the bedside folder and the computer system. During an interview, the RNS confirmed that if documentation was missing, it indicated the resident was not turned or repositioned as required. These documentation lapses were observed over a period of several days, affecting the resident's prescribed wound care regimen.
Failure to Post Accurate and Current Nurse Staffing Data
Penalty
Summary
The facility failed to ensure that accurate and current nurse staffing data, including the total number and actual hours worked by licensed (RNs, LVNs) and unlicensed (CNAs) nursing staff, were posted daily at the beginning of each shift as required. Observations revealed that the posted staffing document in the facility's front lobby was outdated by five days and only displayed projected staffing hours rather than the actual hours worked for each shift. The document did not meet the facility's policy, which requires posting the actual time worked for each category and type of nursing staff within two hours of the beginning of each shift. Interviews with the Administrator confirmed that the Director of Staff Development, who was responsible for updating and posting the staffing data, had been on leave, and no other staff member was assigned to this responsibility. The Administrator acknowledged not noticing the outdated posting and had created a document showing only projected staffing hours, not actual hours worked. This resulted in the facility not maintaining compliance with its own policy and regulatory requirements for daily nurse staffing postings.
Failure to Ensure Timely Response and Respectful Communication for Residents
Penalty
Summary
The facility failed to honor residents' rights to dignity and respect in two separate instances involving two residents. In the first case, a cognitively intact resident who was physically dependent on staff for all activities of daily living (ADLs) was observed waiting at least 19 minutes for assistance after activating the call light. During this period, staff were seen at the Nurses' Station while the call light remained illuminated and audible. The resident reported frequent delays in staff response, sometimes waiting up to an hour, and often had to rely on his roommate to seek help. Interviews with staff revealed confusion and lack of accountability regarding who was responsible for responding to the call light, with some staff assuming others would respond. The facility's policy required timely response to call lights, but this was not followed, resulting in unmet needs and compromised the resident's dignity and safety. In the second instance, another resident reported that a CNA used derogatory language, calling him a "stupid old man" after he requested hot water. The resident stated that when he confronted the CNA, the CNA responded, "I don't care." The resident felt disrespected and neglected, and subsequently noticed that the CNA no longer acknowledged or assisted him during assigned shifts. The incident was reported to a nurse, and the resident provided a description of the CNA involved. Documentation and interviews confirmed that the resident felt a change in the CNA's behavior towards him after the incident, leading to further feelings of neglect. Both cases were substantiated through interviews, observations, and record reviews. The facility's policies on answering call lights and treating residents with dignity and respect were not adhered to, resulting in residents experiencing delays in care and disrespectful communication. The deficiencies were directly observed and corroborated by resident statements, staff interviews, and review of facility records.
Failure to Develop and Implement Comprehensive Care Plan for Resident with Inappropriate Behaviors
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident who exhibited inappropriate physical contact with other residents. The care plan did not specify the exact behaviors to be monitored during one-to-one supervision, nor did it provide clear, resident-centered interventions or define the duration and criteria for discontinuing the supervision. The lack of specificity in the care plan was confirmed during interviews with nursing staff and the Assistant Director of Nursing, who acknowledged that the care plan's directive to monitor for episodes of inappropriate touching was vague and not tailored to the resident's actual behaviors. Observations and interviews revealed that the one-to-one supervision outlined in the care plan was not consistently implemented. On multiple occasions, the resident was observed without a staff member providing the required one-to-one supervision. Staff interviews indicated that the assigned sitter was sometimes absent, and coverage was not always provided as required by the care plan. One staff member admitted to monitoring the resident from the hallway while performing other duties, rather than providing continuous, direct supervision as specified. The resident involved had a history of cognitive impairment and required moderate assistance with activities of daily living. The care plan was initiated after incidents of inappropriate touching were reported by another resident, who described multiple episodes of unwanted physical contact. Despite the care plan and orders for one-to-one monitoring, facility staff failed to ensure that supervision was maintained at all times, and the care plan lacked the necessary detail to guide staff in effectively monitoring and addressing the resident's behaviors.
Failure to Provide Adequate Pain Management and Assessment
Penalty
Summary
The facility failed to provide adequate pain management for a resident following a fall that resulted in a right ankle fracture. Despite the resident's ongoing complaints of pain, especially during physical therapy and ambulation, there was a lack of consistent and thorough pain assessment, documentation, and follow-up. The facility's policy required assessment of pain type, frequency, intensity, and duration, as well as re-evaluation of interventions, but these steps were not consistently performed. Documentation often showed zero pain levels and no administration of pain medication, even when physical therapy notes and staff interviews indicated the resident was experiencing pain and refusing to ambulate due to discomfort. There were multiple instances where the resident's pain was not communicated to the nurse practitioner or physician, despite persistent complaints and refusal to participate in therapy. Physical therapy and CNA staff noted the resident's pain and functional decline, but this information was not always relayed to licensed nursing staff or documented in the medical record. Additionally, when pain medication was administered, there was insufficient documentation of pain reassessment to determine the effectiveness of the intervention, as required by facility policy. The lack of communication and documentation led to poor pain control and a decline in the resident's mobility. Interviews with staff confirmed that pain complaints were sometimes forgotten or not reported due to workload, and that there was a lack of awareness regarding the resident's physical restrictions and pain status. The resident's medical history included a right ankle fracture and fluctuating cognitive capacity, which further complicated assessment and management. The failure to accurately assess, document, and communicate the resident's pain, as well as to notify the appropriate medical providers, resulted in inadequate pain management and contributed to the resident's refusal to ambulate and functional decline.
Failure to Implement Infection Prevention and Control Program
Penalty
Summary
The facility failed to provide and implement an infection prevention and control program. This deficiency was identified during the survey process, as the facility did not have an established or operational program to prevent and control infections among residents and staff. The absence of such a program was observed and documented by surveyors, indicating a lack of systematic measures to address infection risks within the facility. No specific residents, staff members, or incidents were detailed in the report, and there were no direct observations of infection events or outcomes related to this deficiency. The deficiency is based solely on the facility's failure to have the required infection prevention and control program in place.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
A deficiency was identified due to the failure to ensure that a specific area within the facility was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment did not meet safety standards, which resulted in the presence of accident hazards and insufficient oversight to protect residents from potential harm. No additional details regarding the specific hazards, the number of residents affected, or their medical conditions at the time of the deficiency are provided in the report.
Failure to Ensure Proper Medication Administration and Monitoring
Penalty
Summary
A deficiency was identified when a resident's prescribed medications were found unadministered in a medication cup on the bedside table, despite being documented as given in the Medication Administration Record (MAR). Observation revealed that the medications, which included Vitamin C, Aspirin, Iron, Gabapentin, a multivitamin with minerals, and Zinc, remained untouched over 90 minutes after the time they were recorded as administered. The resident, who was cognitively intact and alert, stated she had not taken the medications because she was sleeping. The nurse responsible acknowledged placing the medications at the bedside and leaving the room, and confirmed that medications should be administered in the nurse's presence to ensure proper administration and prevent errors. The resident had a history of missed and incorrect medication administration, as documented in multiple care plans addressing missed doses and wrong medications given, with interventions to monitor for adverse effects and notify the medical doctor. Facility policy requires that medications be administered safely and timely, with the MAR only to be initialed after the medication is given. The observed practice of leaving medications unattended and documenting them as administered did not align with facility policy and created a risk for medication errors.
Failure to Maintain Clean and Clutter-Free Resident Room
Penalty
Summary
Facility staff failed to maintain a clean and sanitary environment in one resident's room, resulting in the accumulation of trash, debris, and clutter. During an observation, the resident's room was found to have a used meal tray cover, empty boxes, used plastic bottles, empty drink cartons, and used eating utensils scattered across the floor and bedside table. The resident reported that the clutter and trash had been present for approximately two weeks and that the room was consistently cluttered. The facility's policy requires a clean, sanitary, and orderly environment, and the resident's care plan specifically included maintaining a clutter-free environment to reduce fall risk. The resident involved had diagnoses of urinary tract infection and chronic obstructive pulmonary disease and was fully alert with no cognitive impairment, as indicated by recent assessments. The Assistant Director of Nursing confirmed that housekeeping is responsible for cleaning resident rooms twice daily and that nursing staff are expected to contact housekeeping as needed. The ADON also noted that the resident frequently orders and stores items in the room, contributing to the clutter. The failure to maintain cleanliness and orderliness in the resident's room was not in accordance with facility policy and the resident's care plan.
Failure to Ensure Proper Sling Use and Supervision During Mechanical Lift Transfers
Penalty
Summary
The facility failed to ensure that residents who required mechanical lift transfers were provided with the correct size sling and adequate supervision, resulting in accidents and potential hazards. In one incident, two CNAs used a small sling instead of the required extra-large full body sling to transfer a resident with hemiplegia and other mobility impairments. Despite the resident expressing concern that the sling was too tight, the CNAs proceeded with the transfer, during which the resident slipped out of the sling, fell, and sustained a large hematoma on the back of the head, as well as nausea and vomiting. The resident was transferred to the hospital for evaluation and treatment following the fall. The investigation revealed that the CNAs involved were not aware of the different sling sizes and had not received specific training or competency evaluation regarding the selection and use of the correct sling size for mechanical lift transfers. Interviews with staff, including laundry and housekeeping personnel, indicated a general lack of knowledge about sling sizing, with slings being distributed without regard to size or resident-specific needs. The facility's competency checklist for mechanical lift use did not include assessment of sling size or review of resident assessments for recommended sling size based on weight. In a separate incident, a CNA transferred another resident, who was dependent for all transfers and required a mechanical lift with a medium-sized sling, without the required assistance of a second staff member. The CNA acknowledged being aware of the two-person policy but proceeded alone because other staff were busy. This action was observed by the ADON, who confirmed it was against facility policy and placed the resident at risk for falls and injury. The facility's policy and the manufacturer's instructions both required proper sling sizing and two-person assistance for safe mechanical lift transfers, but these protocols were not consistently followed.
Failure to Ensure Timely Pain Medication Refill and Assessment
Penalty
Summary
A deficiency occurred when the facility failed to provide safe and appropriate pain management for a resident with chronic pain syndrome, quadriplegia, depression, anxiety, left hip osteoarthritis, and opioid dependence. The resident was prescribed a fentanyl transdermal patch to be applied every 72 hours for chronic pain, as well as oxycodone as needed for moderate to severe pain. The facility did not ensure that the required medication order refill form for the fentanyl patch was signed by the physician in a timely manner, resulting in the resident missing two scheduled doses of the fentanyl patch. Documentation shows that the facility ran out of the fentanyl patch, and there was a delay in following up with the physician and pharmacy to secure the necessary authorization and delivery of the medication. During the period when the fentanyl patch was unavailable, the resident reported experiencing severe pain and repeatedly requested the medication from nursing staff. Despite the resident's complaints, documentation in the SBAR Summary for Providers indicated that the resident was not experiencing pain, which contradicted the resident's own statements and the observations of a CNA who noted the resident was always in pain. The resident's care plan required staff to monitor for pain, assess pain characteristics, utilize a pain scale, and medicate as ordered, but these interventions were not consistently implemented during the period when the fentanyl patch was missed. Interviews with facility staff revealed a lack of communication and follow-up regarding the missing medication. Nurses did not endorse the need to follow up on the fentanyl patch order to subsequent shifts, and there was no documented evidence of timely follow-up with the physician or pharmacy after the initial missed dose. The facility's policies required medications to be ordered in advance and pain management to be consistent with professional standards and the resident's care plan, but these procedures were not followed, resulting in unrelieved pain for the resident until the fentanyl patch was reapplied several days later.
Failure to Ensure CNA Competency in Mechanical Lift Sling Selection Leads to Resident Injury
Penalty
Summary
The facility failed to ensure that five certified nurse assistants (CNAs) were trained and competent in the use of the mechanical lift device, specifically in selecting and using the correct sling size for residents, as required by facility policy and the manufacturer's instructions. This deficiency was identified through observation, interviews, and record review, which revealed that CNAs were not provided with adequate in-service training or competency assessments regarding the different sling sizes and their appropriate use based on resident assessments and weight. Instead, CNAs learned to use the mechanical lift and slings informally from coworkers, and there was a widespread lack of awareness among staff, including laundry and maintenance personnel, about the existence of different sling sizes and their significance. As a result of this lack of training and competency, two CNAs used a small sling instead of the required full body, extra-large sling to transfer a resident with significant mobility impairments, including hemiplegia, hemiparesis, muscle weakness, and contractures. During the transfer, the resident slipped out of the incorrectly sized sling and fell, sustaining a large hematoma on the back of the head, pain, and nausea/vomiting, which necessitated transfer to an acute care hospital for evaluation and treatment. The incident was documented in the resident's progress notes, care conference records, and hospital emergency department records, all of which confirmed the use of the wrong sling size and the resulting injury. Further investigation revealed that the facility's competency checklists for mechanical lift use did not include assessment or demonstration of selecting the correct sling size and capacity for residents. Interviews with CNAs, laundry staff, and the maintenance director confirmed that staff were unaware of the different sling sizes and had not received training on this aspect of resident care. The Director of Staff Development also acknowledged that no training or skills competencies had been conducted on sling size selection for the mechanical lift, and the Director of Nursing confirmed that the competency checklist was incomplete in this regard.
Failure to Develop and Implement Comprehensive Care Plans for Mechanical Lift Transfers
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for two residents who required the use of a mechanical lift for transfers. For the first resident, who had a history of hemiplegia, hemiparesis, muscle weakness, contractures, and osteoarthritis, the assessment indicated a need for a total lift with a full body, extra-large sling. However, there was no documented care plan addressing the use of the mechanical lift or specifying the appropriate sling size. This omission led to an incident where two CNAs used an incorrect, smaller sling, resulting in the resident slipping out of the sling and falling, causing a head injury. Interviews with the CNAs revealed they were not trained on sling sizes or proper use, and the care plan did not provide guidance on these critical details. For the second resident, who was dependent for all transfers due to quadriplegia and multiple contractures, the assessment indicated the need for a total lift with a full body, medium-size sling and two-person assistance. Despite this, there was no care plan developed or implemented to address the use of the mechanical lift for this resident. During an observation, a CNA was seen transferring the resident alone with the mechanical lift, contrary to facility policy and the resident's needs. The CNA acknowledged awareness of the two-person requirement but proceeded alone due to other staff being busy, placing the resident at risk. Both cases demonstrated a lack of individualized, comprehensive care planning in accordance with resident assessments, facility policy, and manufacturer instructions. The absence of clear, documented care plans specifying the correct equipment and procedures for mechanical lift transfers contributed to unsafe practices, including the use of incorrect sling sizes and insufficient staff assistance during transfers. These deficiencies were confirmed through record reviews, staff interviews, and direct observation.
Failure to Administer and Accurately Document Potassium Chloride as Ordered
Penalty
Summary
The facility failed to ensure that Potassium Chloride (KCL) was administered to a resident as ordered by the physician and in accordance with facility policy. The resident, who had a history of seizure and paraplegia, was readmitted with a low potassium level and had a physician's order for daily KCL administration. The Medication Administration Record (MAR) indicated that KCL was given daily over a five-day period, but a physical count of the medication packets revealed that three doses were not administered as documented. Interviews with nursing staff and review of the medication cart confirmed that there were more KCL packets remaining than should have been if the medication had been administered as recorded. The resident and a family member both reported that the resident did not receive KCL on certain days, with the family member observing and questioning the lack of administration. The charge nurse initially stated that KCL was not available, but later administered a dose after repeated inquiries from the family. Further review by the pharmacist and the Director of Nursing corroborated the discrepancy between the number of KCL packets delivered, the number remaining, and the MAR documentation. The facility's policy required accurate documentation and timely administration of medications, but the nurses documented administration of KCL even when it was not given, resulting in a failure to meet the resident's pharmaceutical needs as ordered.
Failure to Discard and Account for Medications After Resident Expiration
Penalty
Summary
The facility failed to properly store and discard medications belonging to a resident who had expired. During an observation in the medication room, a locked black box labeled with the resident's name was found on the top shelf of a storage cabinet. The registered nurse present was unaware of the box's existence, did not know the code to open it, and could not identify the medications inside. There was no record of the drug contents in the box, and it was unclear whether any controlled substances were present. The director of nursing confirmed that the facility did not have a specific policy for handling medications of residents who had expired and acknowledged that the medications should have been discarded to prevent diversion or misuse. The facility's policy stated that discontinued, outdated, or deteriorated medications should be returned or destroyed per pharmacy instructions, but this was not followed in this case. The resident involved had a history of sepsis, type 2 diabetes mellitus, end stage renal disease, and anemia, and had expired prior to the discovery of the medications.
Failure to Maintain Accurate Inventory of Resident's Personal Effects
Penalty
Summary
The facility failed to maintain a complete and accurate Inventory of Personal Effects for a resident, as required by its own policy and accepted professional standards. Upon admission, the resident's inventory form did not include all personal belongings, specifically omitting the resident's car and car keys, and the form was not signed by the resident. The omission was confirmed during a review of the resident's records, which showed that the inventory was signed only by a registered nurse, who could not recall why the resident had not signed the form or why the car and keys were not listed. The facility's policy requires that all items brought into the facility be listed and that the inventory form be signed by both the resident (or representative) and an employee. The deficiency came to light following an incident in which smoke was observed coming from a car parked in the facility's lot, later identified as belonging to the resident in question. The car had been parked at the facility for an extended period, had previously been vandalized, and was ultimately towed by police for an arson investigation. Interviews with facility staff and the resident's family member revealed that the car had been present for years, had been moved within the parking lot, and had suffered damage, but was never reported or properly documented as the resident's property in facility records. Further review of the resident's transfer documentation to a hospital showed that personal belongings were not listed at the time of transfer. The facility's interim administrator acknowledged that the lack of a complete and signed inventory made it difficult to monitor or verify the resident's belongings. The facility's policy and procedure on personal property explicitly require listing all items and obtaining the necessary signatures, which was not followed in this case.
Abandoned Resident Vehicle Left in Disrepair Leads to Fire Hazard
Penalty
Summary
Facility staff failed to maintain a safe and comfortable environment for residents, staff, and visitors by allowing an abandoned car, belonging to a resident, to remain unattended in the facility's parking lot for approximately two years. The car was in a state of disrepair, with flat tires, a broken window, and filled with trash and debris. Multiple staff members, including the Maintenance Manager, Housekeeping Manager, Dietary Supervisor, and Social Worker, observed the car in this condition but did not report it to facility management or take action to have it removed. The Maintenance Manager did not consider the abandoned car as trash or debris, despite facility policy requiring the grounds to be kept free from hazards. On 5/13/2025, the abandoned car caught fire, producing significant smoke and requiring intervention from facility staff, police, and the fire department. The fire was extinguished without reported injuries, but the incident placed 159 residents, staff, and visitors at risk of injury from burns due to the fire hazard. The police determined the fire was an act of arson and towed the vehicle for investigation. Interviews revealed that staff and a family member had been aware of the car's deteriorated and vandalized condition for an extended period but did not escalate the issue. The resident who owned the car had a history of cerebral vascular accident with right-sided hemiplegia and was noted to have moderately impaired cognition on the most recent assessment. At the time of the incident, the resident was not present in the facility, having been transferred to an acute hospital. The car and its keys were not listed in the resident's inventory of personal effects, and there was no documentation of the car being reported as abandoned. Facility policy required maintenance of the grounds in a safe and operable manner, but this was not followed in the case of the abandoned vehicle.
Failure to Develop and Implement Individualized Comprehensive Care Plans
Penalty
Summary
The facility failed to develop, revise, and implement individualized comprehensive care plans for multiple residents, as required by policy and regulation. For one resident with chronic obstructive pulmonary disease (COPD) and a history of heart failure, morbid obesity, and diabetes, the care plan did not include specific goals or interventions for the management of respiratory care and oxygen therapy, despite a physician's order for oxygen and the resident being observed receiving oxygen. Documentation was inconsistent, with no evidence in the Medication Administration Record or progress notes that oxygen was administered as ordered, and the care plan lacked measurable objectives or timetables for monitoring the resident's respiratory status. Staff interviews confirmed that the care plan was not updated to reflect the resident's current needs, and the facility's own policies regarding care plan development and revision were not followed. Additionally, the same resident was readmitted with a reddish/purplish discoloration and hematoma to the right trunk area, but the care plan did not address this new skin issue. There was conflicting documentation between the body check and the readmission skin assessment regarding the presence of skin issues, and no care plan or interventions were developed for the hematoma. Staff acknowledged that the lack of a care plan for this condition meant there was no ongoing assessment or monitoring, which could lead to further complications. The facility's policy required care plans to be updated with new or changed conditions, but this was not done in this case. Another resident with a history of hemiplegia, functional quadriplegia, and high risk for skin breakdown was found to have a reopened Stage 3 pressure injury and moisture-associated skin damage (MASD). The care plan did not include individualized interventions for the new MASD, and staff failed to provide timely incontinence care and repositioning as required. Observations showed the resident remained in the same position for extended periods, and staff interviews confirmed that care was not provided every two hours as indicated in the care plan and facility policy. The lack of updated care plans and failure to implement required interventions contributed to the risk of worsening skin conditions for this resident.
Failure to Provide Pressure Ulcer Prevention and Skin Integrity Management
Penalty
Summary
The facility failed to provide appropriate care and services for the prevention and management of skin breakdown for two residents at risk for skin integrity issues. For one resident with a history of hemiplegia, hemiparesis, functional quadriplegia, and diabetes, the care plan required frequent incontinence checks and changes, as well as turning and repositioning every two hours due to severe risk for pressure injuries and the presence of a Stage 3 pressure ulcer and moisture-associated skin damage (MASD). Observations and staff interviews revealed that this resident was left lying on his back for over six hours without being repositioned or having incontinence care provided as required. Staff confirmed that the resident was not checked or changed according to the care plan and facility policy, and the necessary interventions were not implemented consistently throughout the observed period. Another resident, who was readmitted with morbid obesity, diabetes, and a history of falls, was found to have a palm-sized reddish/purplish discoloration/hematoma on the right trunk area upon readmission. Documentation and interviews indicated that the initial body check did not identify any skin issues, while a subsequent skin assessment noted multiple skin concerns, revealing inconsistencies in documentation. The care plan for this resident did not include any goals or interventions for the management or monitoring of the hematoma and skin discoloration. Staff interviews confirmed that no care plan or interventions were developed or implemented for this issue, and there was no ongoing assessment or reassessment of the affected area. Facility policies required individualized care plans, regular skin assessments, and timely interventions for residents at risk of skin breakdown. However, the facility did not follow these policies for either resident, as evidenced by the lack of timely incontinence care, repositioning, and the absence of care planning and monitoring for new or existing skin conditions. These failures were confirmed through direct observation, record review, and staff interviews.
Failure to Implement Enhanced Barrier Precautions for Resident with ESBL
Penalty
Summary
The facility failed to implement its infection prevention and control program (IPCP) for a resident diagnosed with Extended Spectrum Beta Lactamase (ESBL) resistance in the urine. Despite a physician's order for Enhanced Barrier Precautions (EBP) and a care plan specifying the need for meticulous handwashing and proper use of personal protective equipment (PPE), staff were not informed or reminded of the required precautions. There was no EBP signage or PPE cart placed at or inside the resident's room, and staff were unaware of the need for EBP for this resident. Direct observations revealed that a Licensed Vocational Nurse (LVN) administered medication to the resident without wearing gloves or a gown, and a Certified Nurse Assistant (CNA) provided incontinence care without an isolation gown. Both staff members stated they were not aware that the resident required EBP, and noted the absence of signage and PPE carts that would typically indicate such precautions. Review of facility policies confirmed that EBP should be communicated to staff and PPE made available near or outside the resident's room for high-contact care activities. Interviews with staff, including the Assistant Director of Nursing (ADON), confirmed that the required EBP was not in place for the resident. The facility's own policies and procedures, as well as the resident's care plan and physician's orders, were not followed, resulting in a failure to implement necessary infection control measures for a resident with a multidrug-resistant organism. This lapse was identified through observation, interview, and record review.
Failure to Timely Report Alleged Physical Abuse
Penalty
Summary
The facility failed to report an allegation of physical abuse involving a resident who reported being punched on the leg by an unnamed nurse. The resident, who had a history of infection of amputation stumps, anxiety disorder, and transient cerebral ischemic attack, was cognitively intact and dependent on staff for several activities of daily living. On the date of the incident, the resident informed a Licensed Vocational Nurse (LVN) that a nurse had punched him. The LVN documented the allegation in a Change of Condition (COC) form but did not notify the California Department of Public Health (CDPH), the Ombudsman, or local law enforcement within the required two-hour timeframe as outlined in the facility's policy and procedure. The Interim Director of Nursing (IDON) later discovered the abuse allegation during a review of nursing notes two days after the incident and subsequently reported it to the appropriate authorities. The facility's policy clearly states that any suspicion or allegation of abuse must be reported immediately to the administrator and to state agencies, the Ombudsman, and law enforcement within two hours. However, this protocol was not followed, resulting in a delay in reporting and investigation of the abuse allegation.
Failure to Prevent Accident and Assess Resident After Fall
Penalty
Summary
The facility failed to prevent an accident hazard and provide adequate supervision as required by policy and the resident's care plan. A resident with a history of falls, morbid obesity, and type 2 diabetes was being transferred from bed to wheelchair when the wheelchair brakes were not properly locked, causing the wheelchair to move and the resident to slip onto the floor. The resident required substantial assistance for transfers and had impaired balance, as documented in the care plan and assessments. The incident was not documented in the medical record, and there was no evidence of a fall being recorded for the resident on the date in question. Following the fall, certified nursing assistants (CNAs) moved the resident back to bed without a licensed nurse assessment, contrary to facility protocol. One CNA reported the fall to an LVN, who did not assess the resident or initiate a change of condition report, and instead directed the CNAs to return the resident to bed. The interim director of nursing and administrator were unaware of the incident until days later, and no investigation or required notifications were initiated at the time of the fall. The facility's policy required evaluation and documentation of all falls, which was not followed in this case.
Failure to Provide and Document Appropriate Respiratory Care for a Resident with COPD
Penalty
Summary
The facility failed to provide necessary respiratory care and services in accordance with its own policies, procedures, and standards of practice for a resident diagnosed with COPD and congestive heart failure. The resident was admitted and readmitted with these diagnoses, and the Minimum Data Set indicated intact cognition and no documented shortness of breath or respiratory treatments, including oxygen therapy. However, the Medication Administration Record did not show evidence that the resident received oxygen as needed over several days, despite a physician's order for oxygen therapy at 2L/min via nasal cannula as needed for COPD. This order lacked specific parameters for when to initiate, adjust, or discontinue oxygen therapy. Documentation was inconsistent and incomplete regarding the administration of oxygen. The Weights and Vitals Summary showed multiple instances where the resident was on oxygen, but the amount delivered was not specified. Nursing staff interviews confirmed that there was no documentation in the MAR or progress notes about when oxygen was started, the reason for its use, the resident's response, or when it was discontinued. There was also no evidence that the physician was notified about the resident's need for oxygen or that assessments were performed to determine the effectiveness or necessity of the therapy. The resident's care plan did not include specific goals or interventions related to respiratory care or oxygen therapy, despite the resident receiving oxygen. Facility policies required ongoing evaluation, documentation, and individualized care planning for residents with COPD, but these were not followed. Both the Registered Nurse Supervisor and the Interim Director of Nursing acknowledged the lack of adherence to facility policies and the absence of a resident-centered care plan for oxygen therapy, as well as insufficient documentation and communication with the physician.
Failure to Provide Timely and Appropriate Pain Management
Penalty
Summary
A resident with a complex medical history, including chronic pain syndrome, osteoarthritis, sciatica, recent fractures, and a recent surgery to the left leg, was readmitted to the facility following a hospital stay. Upon readmission, the resident's pain management orders from the hospital, which included acetaminophen-hydrocodone for moderate and severe pain, were not continued. Instead, the only pain medication available was acetaminophen, which was insufficient for the resident's reported pain levels. The resident repeatedly verbalized severe pain and expressed that the acetaminophen was not effective, but no stronger pain medication was provided until the following day. Facility staff failed to adequately assess, treat, and document the resident's pain in accordance with the facility's pain management policy. Multiple staff members, including a treatment nurse and an LVN, did not assess the resident's pain level during care interactions, despite clear verbal and non-verbal indications of severe pain. The resident reported a pain level of 10 out of 10 and described significant distress, including sleeplessness and feelings of hopelessness, yet staff did not promptly notify the physician or obtain appropriate pain management orders in a timely manner. Documentation showed that the resident's care plan included interventions to anticipate and respond to pain, but these were not effectively implemented. The medication administration record did not reflect appropriate pain medications for moderate or severe pain until after a significant delay. The deficiency resulted from the facility's failure to identify, assess, and manage the resident's pain as required by policy, leading to prolonged and unrelieved pain for the resident.
Failure to Supervise Smoking and Prevent Smoking-Related Hazards
Penalty
Summary
The facility failed to ensure adequate supervision and a hazard-free environment for residents who smoke, resulting in multiple deficiencies related to smoking safety. Several residents who required supervision with smoking, as indicated by their care plans and smoking assessments, were found to have unsupervised access to cigarettes and lighters. In one incident, a resident with a history of noncompliance with the smoking policy was able to smoke in bed, resulting in burned linens while three roommates were present in the room. The facility was unaware that this resident had retained smoking materials in his possession, and the incident required intervention by staff and notification of police. Other residents with documented needs for supervision were observed with cigarettes and lighters in their possession, both in their rooms and in the designated smoking patio. Despite care plans specifying that smoking materials should be kept at the nurses' station and that residents should be supervised while smoking, staff interviews revealed a lack of awareness regarding residents' possession of these items. Some staff members stated that residents are not allowed to have lighters due to fire and safety concerns, especially with the presence of oxygen in the facility, but acknowledged that some residents still retained these items. Additionally, the facility did not consistently conduct Interdisciplinary Team (IDT) meetings to assess the risks and benefits of smoking for all residents who smoke, as required by facility policy. Only a minority of residents who smoked had attended such meetings, and some residents did not have care plans addressing smoking safety. These failures resulted in unsafe conditions for residents, staff, and visitors, as evidenced by the smoking-related incident and the observed lapses in supervision and policy adherence.
Failure to Provide Behavioral Health Services for Resident with Alcohol Abuse
Penalty
Summary
The facility failed to ensure that a resident with a primary diagnosis of alcoholic cirrhosis received necessary behavioral health care and services as required. The Social Services Director (SSD) did not refer the resident to a psychiatrist or psychologist for appropriate counseling and behavioral services for alcoholism, despite the resident's agreement to such services as documented in a behavioral contract. The behavioral contract, signed by the resident, specified that the resident would be referred to psychiatric services and would participate in periodic checks of personal belongings, but there was no evidence that these interventions were implemented. Additionally, the facility's licensed nurses and SSD did not develop or implement person-centered care plans addressing the resident's behavioral health needs related to substance abuse. The care plans in the resident's record focused on other diagnoses and general behaviors but did not include interventions or goals specific to managing alcohol abuse, psychiatric referrals, or participation in support programs such as Alcoholics Anonymous. Observations of the resident's behavior, including going outside near a liquor store, were documented, but no corresponding behavioral health interventions or referrals were made. Interviews with facility staff confirmed that no care plan or behavioral health services were provided to address the resident's substance abuse issues, despite multiple opportunities and documented agreements to do so. The facility's policies required individualized care plans and behavioral management, but these were not followed in this case, resulting in a lack of appropriate treatment and services for the resident's psychosocial adjustment difficulties.
Failure to Ensure Continuity of Diabetic Care and Emergency Response
Penalty
Summary
A facility failed to provide appropriate treatment and care for a resident with a diagnosis of Diabetes Mellitus (DM) and a history of hypoglycemia, resulting in a series of critical lapses in care. Upon the resident's readmission from an acute hospital, the admitting RN did not review or verify all discharge orders, including those for blood sugar (BS) monitoring and insulin administration, with the attending physician or nurse practitioner. The licensed staff did not review the resident's medical history of DM and prior hypoglycemic episodes, nor did they ensure continuity of diabetic care by implementing necessary BS monitoring as previously ordered. As a result, the resident's care plan for DM was not implemented, and there was no monitoring for hypoglycemia or hyperglycemia for several days after readmission. Further, the facility failed to clarify or obtain necessary physician orders for BS monitoring and insulin administration upon readmission, despite the resident's recent hospitalization for hypoglycemia. An LVN entered an order for routine insulin injection without prior physician authorization, and another LVN administered insulin without checking the resident's BS beforehand, contrary to the care plan and facility policy. When the resident experienced a significant change in condition, including an altered level of consciousness and a critically low BS of 27, the nursing staff did not perform adequate assessment or promptly notify the physician or nurse practitioner. There was also a delay in calling 911 emergency services, despite clear indications of a medical emergency. These failures led to the resident experiencing severe hypoglycemia, altered mental status, and hypotension, necessitating emergency transfer to an acute hospital, where the resident was admitted to the ICU and subsequently died. The deficiency was identified as Immediate Jeopardy by the California Department of Public Health due to the facility's failure to ensure appropriate admission orders and continuity of care for diabetes management, resulting in actual harm to the resident.
Removal Plan
- The admitting licensed nurse was provided a one-to-one re-education and training by the vice president of education on receiving diabetic treatment and services, in accordance with professional standards of practice, have care plan, and physician orders for the management of hypoglycemia.
- Admitting licensed nurse will be provided re-education and training by the vice president of education on received diabetic treatment and services, in accordance with professional standards of practice, have care plan, and physician orders for the management of DM and hypoglycemia prior to her next scheduled work.
- The interim director of nursing was provided by the vice president of education with training on care plan for DM and review the resident's records to ensure the care plan is being followed, in accordance with the Director of Nursing's job description.
- The Interdisciplinary Team was also provided education and training by the vice president of education regarding reviewing the residents plan of care upon admission/readmission, change of condition and as needed.
- The Medical Director was informed by the administrator regarding the IJ findings for further corrective actions and recommendations.
- Diabetic residents had their care plan reviewed. Eighteen residents care plans were revised and 20 new care plans were initiated by the interim Director of Nursing or designees, to reflect blood glucose monitoring check order and current diabetic management protocol of hypoglycemia and hyperglycemia.
- The interim Director of Nursing initiated education to licensed nursing staff on all shift on diabetic management with emphasis on the following: Ensure diabetic residents upon admission/re-admission have blood sugar monitoring as ordered.
- Ensure diabetic residents have parameters for low and high BS and has order to give when below/high BS parameters.
- Ensure physicians are notified when resident's blood sugar falls below the parameters as specified by Physician.
- Licensed Nurses that are newly hired, on vacation, on leave, part time, or on call and registry staff will be given inservice by the Interim DON or designee prior to the start of their shift or hired.
- The facility's policies and procedures regarding Diabetic Management of residents was reviewed.
- The Interim Director of Nursing or designee audited new admission and current residents with diagnosis of Diabetes for diabetic management and ensure appropriate interventions are in place and care planned. Facility created an audit tool for residents with diagnosis of Diabetes for diabetic management.
- New hires will receive education on Diabetic Management, and resident safety by the Interim Director of Nursing or designee.
- Registry staff will be provided with accelerated orientation that includes checking of blood glucose levels and care plan initiation on residents upon admission/re-admission and as needed.
- A Quality Assurance Performance Improvement Performance Improvement Project will be implemented to review and interpret all audit findings pertaining to the new admission and current residents with diabetes by the IDT during clinical meetings and RN Supervisor on weekends.
- The Interim DON and or designee will continue to review QAPI plan to address, monitor progress and address missed opportunities by conducting root cause analysis and continuous quality improvement with collaboration with attending physician's medical director, pharmacy consultant and company management clinical resource.
- New admissions/re-admissions will be reviewed during clinical meeting by the IDT headed by the Interim DON and RN Supervisor on weekends to ensure that all admitted resident with Diabetes diagnosis, treatment and services with accordance with professional standard of practice which include diabetic management protocol for hypoglycemia and hyperglycemia, monitoring of blood glucose as ordered and care plan.
- The RN Supervisor on weekends will review all admissions/re-admissions to ensure compliance with Diabetes treatment and services with accordance with professional standard of practice which include diabetic management protocol for hypoglycemia and hyperglycemia, monitoring of blood glucose as ordered and care plan.
- The RN Supervisor during the shift will be notified by the Charge Nurse for any change of condition for coordination of care.
Failure to Protect Residents from Physical Abuse by Another Resident
Penalty
Summary
The facility failed to protect two residents from physical abuse by another resident, resulting in two separate incidents of harm. One resident, who required moderate assistance with activities of daily living and had diagnoses including heart failure and mobility issues, was struck on the left elbow with a metal bar removed from another resident's wheelchair after a verbal altercation. This resident experienced bruising, redness, and emotional distress following the incident. Despite the resident reporting a prior incident where water was thrown at them by the same aggressor, no effective intervention was implemented to prevent further abuse, and the two residents continued to share a room until the physical assault occurred. Following the first incident, the aggressive resident was moved to share a room with another resident who was legally blind and had multiple impairments, including dementia and muscle weakness. Five days after this room change, the aggressive resident struck the blind resident on the face with a radio, causing a laceration and redness. Staff interviews revealed that concerns about the aggressor's behavior were reported, but there was no evidence of a thorough assessment of roommate compatibility or adequate supervision to prevent further incidents. Staff also failed to recognize or act upon warning signs, such as verbal aggression and agitation, prior to the physical assault. The facility's policies required immediate reporting and intervention in cases of suspected abuse, including separating residents involved in altercations and providing adequate supervision when risk was identified. However, the report documents that staff did not consistently follow these procedures. There was a lack of proper investigation into the initial incident, and staff did not escalate or act upon reports of aggressive behavior. The failure to assess roommate compatibility and to intervene after reports of verbal aggression directly contributed to the subsequent physical abuse and injury of a vulnerable, blind resident.
Failure to Conduct Thorough Investigation of Resident Altercation
Penalty
Summary
The facility failed to thoroughly investigate an alleged physical altercation between two residents, as required by its Abuse Prohibition Policy and Procedure. After one resident reported being struck on the left elbow by another resident using a wheelchair armrest, staff did not obtain separate, accurate statements from both residents involved. Instead, a nurse copied and pasted the same statement for both residents, despite one resident denying the incident. There was no evidence that staff interviewed witnesses or conducted a comprehensive investigation into the circumstances of the altercation. The records show that the resident who reported being hit had a history of heart failure, gait abnormalities, and required assistance with daily activities, while the other resident had paraplegia and was independent in wheelchair mobility. The incident was reported to staff, and the residents were separated, but documentation of the investigation was incomplete. The facility did not document any further assessment or investigation into why the altercation occurred or whether there were underlying behavioral issues that could lead to further incidents. Interviews with staff and the administrator confirmed that the required investigative steps, such as obtaining individual statements and thoroughly documenting the investigation, were not followed. The administrator was unable to provide additional documentation to demonstrate a thorough investigation. The facility's policy required causative factors to be investigated within two hours and for the investigation to be thoroughly documented, but these steps were not completed, resulting in an incomplete investigation of the alleged abuse.
Delayed Referral and Removal of Gastrostomy Tube
Penalty
Summary
Facility staff failed to ensure timely removal of a resident's gastrostomy tube (GT) as ordered by the physician. The resident, who had a history of acute respiratory failure and type 2 diabetes, was transitioned to an oral diet, and GT feedings were discontinued. Despite a physician's order for GT removal and an attempt by a physician assistant (PA) to remove the tube, the removal was unsuccessful due to severe resistance. The PA documented the failed attempt and recommended referral to a gastrointestinal (GI) specialist, notifying the charge nurse and registered nurse supervisor. Following the PA's recommendation, facility staff did not promptly initiate a referral to a GI specialist. There was no evidence in the resident's chart that the referral was made until over a month later, despite a second recommendation from a nurse practitioner. The resident's appointment with a GI specialist was not scheduled until more than two months after the initial recommendation. During this period, the GT was not being flushed, and the resident reported that the tube had been inactive for several weeks. Interviews with facility staff, including the interim director of nursing, confirmed that licensed nurses did not follow up on the PA's recommendation or notify the attending physician about the failed removal. Facility policy required prompt reporting of complications and adherence to best practices in enteral feeding, but these procedures were not followed. This resulted in the resident's unused GT remaining in place for an extended period, with the potential for complications.
Failure to Provide Timely and Documented Dialysis Care
Penalty
Summary
Facility staff failed to provide safe and appropriate dialysis care for a resident with a history of renal failure and type 2 diabetes mellitus, who required hemodialysis three times a week. The facility did not ensure that staff completed post-hemodialysis treatment status documentation in accordance with its own policy and procedure on dialysis care. Specifically, the resident's Hemodialysis Communication Records for multiple dates lacked documentation of vital signs, dialysis site status, monitoring for post-dialysis complications, and the licensed nurse's signature. Nursing Progress Notes also failed to record the times the resident left for and returned from dialysis appointments, as well as the resident's status upon return. The facility did not assist the resident to be ready for scheduled hemodialysis treatments at the designated pick-up time of 12:30 PM on Mondays, Wednesdays, and Fridays. Interviews with the dialysis center secretary and the resident revealed that the resident was frequently not prepared on time, causing delays in transportation and late arrivals at the dialysis center. As a result, the resident's dialysis sessions often started later than scheduled, sometimes as late as 3 PM to 4 PM, and finished in the evening. On one occasion, the resident was not picked up from the dialysis center until after 10:30 PM due to these delays. The facility's own staff, including the interim director of nursing and social worker, acknowledged that the resident was not consistently ready for transportation at the scheduled time, contributing to the delays. The facility's policy required nursing staff to communicate vital information to the dialysis provider and maintain thorough documentation, but these requirements were not met. The lack of timely preparation and incomplete documentation resulted in frequent delays in the resident's dialysis treatment sessions.
Failure to Accurately Document Resident Weight
Penalty
Summary
The facility failed to maintain accurate documentation of a resident's weight in accordance with accepted professional standards and practices. Specifically, there were significant discrepancies in the recorded weights for a resident with diagnoses of renal failure and diabetes mellitus. On one occasion, the resident's weight was documented as 169.4 lbs. post-dialysis, while a subsequent record indicated a weight of 116.4 lbs., representing a 53 lb. difference. These weights were copied from the Hemodialysis Communication Record without reweighing the resident, as confirmed by staff interviews and record reviews. The resident's weight was not accurately recorded on multiple occasions, and staff responsible for weighing residents, including the Rehab Nursing Assistant and Certified Nurse Assistants, did not reweigh the resident to verify the accuracy of the recorded weights. The Registered Dietitian also relied on the incorrect weight from the Hemodialysis Communication Record without requesting a reweigh or reporting the discrepancy to nursing staff. During an in-person evaluation, the RD did not recommend a reweigh despite the significant weight loss noted in the records. The Interim Director of Nursing acknowledged that the weights were not recorded accurately and that staff should not have copied weights from other records. Facility policy required accurate and timely documentation of weights, including obtaining a baseline weight upon admission and weekly weights thereafter. The failure to follow these procedures resulted in inaccurate documentation of the resident's weight, which was not identified or corrected by nursing or dietary staff.
Failure to Implement Infection Control Program for Scabies
Penalty
Summary
The facility failed to implement an ongoing infection prevention and control program to prevent and control the spread of scabies among residents. Resident 1 was diagnosed with scabies on 3/6/25, but the facility did not implement the dermatology orders to apply Permethrin 5% topical cream promptly. The medication was not available, and there was a lack of follow-up to ensure the order was relayed and executed. Additionally, Resident 1 was not placed on contact isolation until 3/10/25, four days after the diagnosis, increasing the risk of transmission. Resident 2, who was Resident 1's roommate, was not placed under contact isolation as per physician orders and was transferred to another room with three new roommates on 3/10/25. This transfer occurred without proper monitoring and tracking for scabies exposure, and there was no surveillance tracking for Residents 3, 4, and 5 or other potentially exposed residents and staff. The facility's infection preventionist did not adequately assess, implement, monitor, and manage the infection prevention and control program when Resident 1 was diagnosed with scabies. The facility's infection prevention and control program was not effectively managed, as evidenced by incomplete documentation and lack of follow-up on infectious cases. The infection preventionist was not familiar with specific tasks and did not spend sufficient time on infection prevention duties. The facility's policy and procedure for infection prevention and control were not followed, leading to potential transmission of communicable diseases and infections among residents, staff, and visitors.
Failure to Maintain Hazard-Free Environment and Adequate Supervision for High-Risk Residents
Penalty
Summary
The facility failed to provide a hazard-free environment and adequate supervision for three residents at high risk for falls, resulting in multiple incidents and injuries. For one resident with a history of falls, muscle weakness, and dementia, the care plan was not updated after repeated falls, and interventions were not adjusted in a timely manner. Despite several falls, including one that resulted in a non-displaced acute fracture of the left ankle, the interdisciplinary team did not consistently conduct post-fall meetings or root cause analyses, and staff did not closely monitor the resident after each incident. Family members and staff interviews confirmed that safety measures such as floor mats were often not in place, and the care plan was not individualized or updated to reflect new interventions. Another resident, who was independent with transfers and ambulation but had a history of falls and muscle weakness, slipped on Nystatin powder left on the floor after staff applied it for a skin condition. The resident sustained a left proximal humerus fracture. The care plan for this resident was left blank after the fall, and the root cause analysis conducted by the interdisciplinary team did not accurately identify the environmental hazard. The resident reported that the call light was not answered promptly after the fall, and staff interviews confirmed that the care plan did not address the risk of slipping on powder, nor was the resident included in the post-fall conference. A third resident, with severe cognitive impairment and a risk of falls due to confusion and abnormal gait, was found crawling on the floor on multiple occasions. The care plan interventions were limited to verbal reminders and ensuring the call light was within reach, but staff were not adequately informed of the resident's fall risk. On one occasion, a CNA left the resident unattended after refusing care, unaware of the resident's need for frequent supervision. Staff interviews revealed a lack of communication regarding the resident's fall risk and the need for increased monitoring, despite repeated incidents of the resident being found on the floor.
Failure to Prevent and Manage UTIs and Catheter-Related Complications
Penalty
Summary
The facility failed to provide appropriate care and services to prevent new and recurrent urinary tract infections (UTIs), infection, blockage, or bleeding for five sampled residents. For one resident with an indwelling catheter, there was a significant delay in notifying the primary physician of critical laboratory values, including a high white blood cell count and low blood glucose, with follow-up occurring approximately 14.5 hours after the lab reported the results. Licensed nurses did not consistently assess or document daily nursing assessments related to the resident's indwelling catheter and urine output characteristics over a ten-day period. Additionally, when the resident became increasingly lethargic and unresponsive, staff failed to monitor and document vital signs, changes in mental status, and food intake, and did not immediately notify the physician of the resident's worsening condition. Other residents with suprapubic or indwelling catheters and a history of recurrent UTIs were not consistently kept clean and dry when incontinent of urine and stool. Documentation and interviews revealed that incontinence care was sometimes delayed due to staffing shortages, and records of care were incomplete, making it unclear whether timely care was provided. For these residents, there was also a lack of care plans to monitor or prevent the recurrence of UTIs, and no additional infection prevention measures were implemented beyond routine care, even after multiple UTIs and hospitalizations. The facility also failed to assess and monitor for signs and symptoms of UTI, such as sediment, blood in the urine, back or flank pain, and fever, as ordered by physicians for residents with catheters. Observations and interviews indicated that staff did not consistently follow protocols for monitoring, documentation, and physician notification in the event of significant changes in condition. Facility policies required prompt reporting of critical lab results and significant changes in resident status, as well as thorough documentation, but these were not followed, resulting in delayed care and hospital transfers for affected residents.
Failure to Provide Adequate Pressure Ulcer Care and Monitoring
Penalty
Summary
The facility failed to provide appropriate pressure ulcer care and prevent new ulcers from developing for four residents. One resident, who was admitted without any skin breakdown, developed a Stage 2 coccyx pressure ulcer that progressed to Stage 3, and also developed a left heel vascular ulcer during their stay. Documentation revealed that the resident was dependent for activities of daily living, always incontinent, and at risk for pressure ulcers, but there was no consistent documentation of skin assessments or evidence that turning, repositioning, and incontinence care were performed as required. Interviews with nursing staff indicated that the resident was likely not repositioned every two hours and briefs were not changed frequently, resulting in prolonged exposure to moisture and soiling, which contributed to the worsening of the pressure ulcer. Two other residents with a history of healed pressure ulcers were not provided with proper maintenance and monitoring of their low air loss (LAL) mattresses. The LAL mattresses were not set according to the residents' weights and were not checked every shift for proper setting, connection, and functioning as ordered by the physician. Documentation was missing for multiple shifts, and observations confirmed that the mattress settings did not match the residents' weights. Staff interviews confirmed the importance of these interventions to prevent recurrence or worsening of pressure ulcers, but the required checks and documentation were not consistently performed. Another resident with a Stage 4 pressure ulcer did not have weekly wound assessments documented in the nursing progress notes or interdisciplinary team reports after a certain date. Additionally, the facility failed to obtain records from the wound specialist regarding the resident's wound condition and treatment recommendations. Staff interviews confirmed that weekly wound assessments and communication with the wound specialist were not maintained, resulting in a lack of information about the wound's condition and the effectiveness of the treatment plan. The facility's own policy required regular skin inspections, documentation, and ongoing monitoring, which were not followed in these cases.
Failure to Ensure Call Light Accessibility for Multiple Residents
Penalty
Summary
The facility failed to ensure that call light devices were accessible to residents at all times, as required by their own policy and resident assessments. For three sampled residents, the call light was not within reach, preventing them from signaling for assistance with activities of daily living (ADLs). The facility's policy specifically states that call lights must be accessible from the bed, toilet, shower, and floor, but this was not followed in these cases. One resident with diabetes and a below-knee amputation was observed searching for his call light, which was clipped behind the head of the bed and out of sight. He was unable to request help for a bothersome toenail. Another resident with dementia and muscle weakness was found lying in bed with her call light placed on top of the nightstand, out of her reach and sight, making her unable to request assistance to change her incontinence brief. A third resident with schizophrenia and hypertension was left in his wheelchair at the bedside with the call light stuck on the bed frame, far from his reach, and he was observed attempting to bend over to access it to request help returning to bed. Staff interviews confirmed that in each instance, the call light was not accessible to the resident, and staff acknowledged the importance of keeping call lights within reach. The Acting Director of Nursing also stated that call lights should always be within residents' reach to ensure assistance can be provided when needed, especially in emergencies.
Failure to Inform Residents of Their Rights and Responsibilities
Penalty
Summary
The facility failed to inform residents of their rights and responsibilities, as required by federal and state regulations. Review of Resident Council Minutes over several months showed that while topics such as the smoking policy and grievance process were discussed, there was no documentation that residents were informed about their broader rights. During a group interview, the majority of alert and oriented residents reported that they had not received information about their rights from the facility. One resident noted that awareness of rights only improved when the ombudsman began attending meetings, though the specific date of this change was not provided. Further review with the Activity Director (AD) confirmed that neither the Activity Calendar nor the Resident Council Minutes reflected any communication of residents' rights beyond smoking and grievance policies. The AD also acknowledged that there was no posted information about residents' rights in the Activity Room. A resident expressed that knowing their rights would make them feel more empowered. The facility's own policy, revised in 12/2021, states that residents are to be informed of their rights and responsibilities, but this was not being consistently implemented.
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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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