Riverside Village Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Riverside, California.
- Location
- 17040 Arnold Dr., Riverside, California 92518
- CMS Provider Number
- 555404
- Inspections on file
- 48
- Latest survey
- March 10, 2026
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Riverside Village Healthcare Center during CMS and state inspections, most recent first.
A resident with schizoaffective disorder and depression, assessed as cognitively intact, began refusing multiple medications (including psychotropics), meals, blood sugar checks, and ADL care, while exhibiting delusional thoughts and escalating behavioral changes such as calling law enforcement, yelling at staff, and repeatedly refusing showers and incontinence care. Nursing notes and IDT documentation reflected ongoing refusals and impaired cognition, and CNAs reported the resident frequently declined hygiene care despite noticeable odor. Although a psychiatric consult was eventually ordered, it was delayed and not completed before the resident was transferred to the hospital for continued refusal of food, medications, and basic care, resulting in a failure to provide necessary behavioral health care and services as outlined in facility policy.
A resident with multiple chronic conditions reported feeling neglected and dismissed by hospital nursing staff prior to admission. After the resident disclosed this experience, facility staff did not implement or document the required 72-hour monitoring of the resident's psychosocial condition, as outlined in facility policy.
A resident with a history of gastroenteritis and protein-calorie malnutrition experienced multiple instances of consuming less than 50% of meals without being offered substitute options, despite facility policy requiring alternatives for low intake. Staff interviews confirmed that meal substitutes should have been provided but were not.
A resident admitted with multiple cardiac and neurological conditions was using continuous oxygen therapy, as noted in the admission assessment, but no physician order for oxygen was present in the medical record. The DON confirmed the omission and stated that the nurse should have verified and obtained the correct order, in accordance with facility policy.
A resident with multiple medical conditions did not receive timely evaluation for suture removal, blood sugar monitoring after insulin discontinuation, prompt baseline weight assessment, physician notification for low blood pressure, or oral care after meals. These lapses were confirmed through record review and staff interviews, showing failures to follow established care protocols.
A resident with end-stage renal disease missed scheduled hemodialysis treatments because transportation to the dialysis center was not arranged as required. Facility staff confirmed that transportation should have been pre-arranged and followed up according to policy, but this did not occur, resulting in the resident not receiving necessary dialysis care.
Staff did not consistently maintain resident dignity or respond promptly to call lights. A CNA failed to ensure bodily privacy for a resident with severe cognitive impairment during care. Call lights were not answered in a timely manner, with one resident and his roommate reporting significant delays in receiving assistance, and another resident feeling disrespected due to slow responses. Facility leadership and policies confirmed that these actions did not meet expectations for resident dignity and timely care.
The facility did not ensure that advance directives were readily available in the records for a resident who had executed one, and failed to provide or document written information about formulating advance directives to several other residents or their representatives. Residents affected had a range of medical conditions and varying cognitive abilities, but in each case, the required documentation and information regarding advance directives was missing, as confirmed by the Social Service Director.
Surveyors found that two residents, as well as others in additional rooms, were living in areas with peeled and damaged paint on the walls behind their headboards. Both the Maintenance Supervisor and Administrator acknowledged the issue and stated that such damage should have been repaired to maintain a clean and homelike environment, as required by facility policy.
Nursing staff failed to follow professional standards during medication administration, including leaving a resident's medication unattended and accessible to another resident, not verifying a resident's identity before giving medication, and not providing privacy during medication administration. These actions involved residents with various medical conditions and were confirmed by both the nursing staff and the DON as not meeting facility policy requirements.
Multiple residents reported long delays in receiving assistance with ADLs and call lights, with some waiting over 30 minutes or more for help, including for pain medication and toileting. Facility records showed that required CNA direct care hours were not met on numerous days, and staffing levels frequently fell below the facility's own projections, resulting in high resident-to-CNA ratios. Both the DSD and DON acknowledged that these staffing shortages led to inadequate care and delays in meeting resident needs.
A CRNA was observed placing a soup ladle directly on a tablecloth between servings instead of in a clean container, contrary to training and facility protocol. Both the CRNA and the DND acknowledged this practice could lead to cross-contamination and potential illness.
Surveyors identified several infection control deficiencies, including improper disposal of soiled diapers, a direct care staff member wearing long artificial nails, failure to use PPE and perform hand hygiene when caring for a resident with an active MRSA wound, lack of disinfection of shared equipment, and a CNA providing care while symptomatic without a mask to a resident with significant respiratory and metabolic conditions.
The facility did not ensure the lint trap of dryer 3 was maintained in safe and operable condition, as it was found damaged and filled with lint that had not been cleaned since the previous day. Laundry staff continued to use the dryer despite the damage, and records showed the issue had been previously identified as a safety concern. Maintenance and administrative staff confirmed the equipment should have been repaired or replaced according to facility policy.
A resident with a history of stroke and severe ankle contractures did not have a comprehensive care plan in place to address her contractures. Staff confirmed that only heel pads were used to prevent skin breakdown, and no specific interventions or care plan were documented or implemented, despite facility policy requiring such plans for mobility and range of motion issues.
A resident with severe ankle contractures and a history of cerebral infarction did not receive appropriate contracture management or range of motion (ROM) care. Staff interviews and record reviews confirmed that the resident was not included in the restorative nursing program, did not receive ROM exercises, and was not provided with devices to maintain joint alignment, despite facility policy and therapy recommendations.
A resident with severe cognitive impairment, dysphagia, and no natural teeth did not receive a required dental consultation despite physician orders and facility policy. Staff interviews and record review confirmed the absence of dental services for the resident, who had not been seen by a dentist since the previous year.
A nurse left a computer open and unattended during medication administration, exposing a resident's electronic health record to unauthorized view. The resident had multiple medical conditions and was cognitively intact. Facility policy and the DON both require staff to lock screens when leaving computers, but this was not followed, resulting in a breach of privacy.
A baseboard heater cover was found detached and laying on the floor in a resident's room, leaving the heating element exposed. The resident, who uses a wheelchair, reported feeling direct heat and expressed fear of being burned. The Maintenance Supervisor and Administrator acknowledged the equipment was damaged and should have been repaired to maintain safety.
Two residents with cognitive impairments were filmed by a staff member and their videos were posted on social media without obtaining consent from the residents or their representatives. The staff member acknowledged not seeking proper permission, and facility leadership confirmed that this violated resident privacy and confidentiality policies.
A resident with severe cognitive impairment and total dependence for oral hygiene did not receive required oral care after meals, resulting in food remnants being found in her mouth during a physician appointment. Staff interviews and facility policy confirmed that oral care should have been provided after every meal, but this was not done on the day in question.
A resident with left-sided weakness required two-person assistance or a mechanical lift for transfers. However, a CNA attempted to transfer the resident alone, leading to the resident experiencing pain in the right shoulder and left hip. The care plan and MDS indicated the need for two or more helpers, but the CNA did not seek assistance or use the mechanical lift, contrary to facility policy.
A resident with a history of hypertension and other medical conditions was administered Hydralazine despite having a systolic blood pressure below the physician-ordered threshold. The facility's policy requires checking vital signs and adhering to prescriber orders, which was not followed in this instance, as confirmed by interviews with LVNs and the DON.
A resident was transferred to a GACH without proper documentation justifying the transfer. The resident, admitted with fractures, expressed mental instability, prompting the transfer. However, the facility failed to document why the resident's needs couldn't be met in the facility, as required by policy.
The facility failed to maintain a comfortable environment for several residents when the air conditioning unit malfunctioned, causing room temperatures to exceed 81°F. Residents with various medical conditions expressed discomfort, and the facility lacked proper temperature monitoring. The issue was not reported to the CDPH, despite awareness from the administration.
Two residents were not properly assessed or provided with care plans for bladder and bowel incontinence. One resident experienced incontinence episodes without an assessment or care plan, while another was frequently incontinent without interventions. Facility policies on change in condition and bowel and bladder protocol were not followed.
The facility failed to accurately code MDS assessments for four residents, leading to discrepancies in their medical records. Errors included incorrect coding of hospice care, discharge status, and POLST forms. The inaccuracies were confirmed by the MDS Coordinator and the DON.
The facility failed to provide advance directive information to a resident upon admission, as required by their policy. The resident's POLST and Consents form were incomplete, and interviews with staff revealed that the process of providing this information was not followed correctly.
A facility failed to ensure privacy during resident care for a cognitively impaired, quadriplegic resident. Two CNAs transferred the resident without a privacy curtain, with the window blinds open and the roommate watching. The CNAs initiated incontinence care before realizing the need for privacy and paused to retrieve the privacy curtain. Interviews confirmed staff awareness of privacy protocols but failure to adhere due to the curtain's absence.
The facility failed to develop a care plan addressing the smoking needs of a resident and did not specify the level of assistance required for ADLs for another resident with severe cognitive impairment and quadriplegia. Staff interviews confirmed these deficiencies.
The facility failed to provide necessary assistance with ADLs for two residents, leading to deficiencies in personal hygiene and grooming. One resident was observed with disheveled hair on multiple occasions, while another had long, jagged fingernails and thick, discolored toenails. Staff acknowledged the oversights, and the care plans did not adequately address the required level of assistance.
The facility failed to supervise two residents during smoking breaks, contrary to their policy. One resident with COPD and asthma was observed smoking unsupervised and in possession of a cigarette box and lighter, while another resident with severe cognitive impairments was also smoking unsupervised. The facility's policy requires staff supervision during smoking breaks and prohibits residents from keeping smoking paraphernalia.
A resident missed his scheduled medications because an LVN left the medications in his hand and exited the room without verifying ingestion. The resident, who has moderate cognitive impairment and no orders to self-administer medications, was later found with the pills scattered around him.
Failure to Provide Timely Behavioral Health Services for Resident With Schizoaffective Disorder
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident with known behavioral health needs received necessary behavioral health care and services when she began refusing medications, meals, and care. The resident was admitted with schizoaffective disorder and depression, had a documented history of schizophrenia, and was assessed as cognitively intact with decision-making capacity. Physician orders included psychotropic medications (aripiprazole and Lexapro) for schizoaffective disorder and depression. Beginning in early January, the resident progressively refused multiple medications, including psychotropic, pain, cardiovascular, gastrointestinal, and supplement medications, as well as blood sugar checks. Progress notes and interdisciplinary team documentation showed that from early January the resident exhibited behavioral changes and delusional thoughts, including repeatedly refusing medications and meals, calling law enforcement to report she had not eaten in several days, and refusing care such as changing, repositioning, and showers. Staff documented that she yelled at staff, shouted at CNAs, refused dinner and blood sugar checks, and declined to return to bed after being in her wheelchair. CNAs reported that the resident frequently refused showers and hygiene care, refused to have her incontinence brief changed, remained in her wheelchair in front of the nurse’s station, and at times had noticeable odor while continuing to refuse bathing despite repeated offers. Despite these ongoing refusals and documented behavioral changes related to her schizoaffective disorder, the resident did not receive timely psychiatric or psychological evaluation. A psychiatric consult was ordered several days after the onset of significant refusals and behavioral changes, but the evaluation was postponed and not completed before the resident was sent to the hospital for continued refusal of food, medications, and basic care. The facility’s own policies required comprehensive assessment and behavioral health services when there was a significant change in a resident’s physical, emotional, or mental condition, including refusal of treatment or medications and signs of emotional or psychosocial distress, but the necessary behavioral health services were not provided during the period of escalating refusals and behavioral symptoms.
Failure to Monitor Emotional Distress After Abuse Allegation
Penalty
Summary
The facility failed to monitor a resident's emotional distress following an allegation of abuse and neglect that occurred at a general acute hospital prior to admission. The resident, who had diagnoses including postlaminectomy syndrome, diabetes mellitus, and fibromyalgia, reported to a treatment nurse that she felt neglected and dismissed by nursing staff in the emergency room during her hospital stay. Despite this report, there was no documented follow-up or monitoring of the resident's psychosocial condition after the allegation was made. Interviews with facility staff confirmed that residents are to be monitored for 72 hours after a change of condition, which includes significant changes in emotional or mental status. The facility's policy also requires nurses to notify the attending physician and document changes in the resident's condition. However, in this case, the required 72-hour monitoring and documentation were not implemented after the resident reported the incident, resulting in a failure to provide appropriate psychosocial support.
Failure to Offer Meal Substitutes for Low Food Intake
Penalty
Summary
The facility failed to ensure that meal substitutes were offered to a resident when food intake was below 50%. Record review showed that the resident, who had diagnoses including gastroenteritis and protein-calorie malnutrition, experienced significant weight fluctuations, including a 7-pound loss in one week. Documentation indicated that on multiple occasions across August and September, the resident consumed less than half of their meals and was not offered alternative menu options as required by facility policy. Interviews with the DON and Food and Nutritional Services Director confirmed that staff should have offered meal substitutes when intake was low, but this did not occur. The facility's policy stated that a variety of foods and snacks should be available and that care plans should be adjusted if a resident is dissatisfied with their diet. Despite these guidelines, the resident was not provided with appropriate alternatives during numerous meals when intake was insufficient.
Failure to Reconcile Oxygen Therapy Orders on Admission
Penalty
Summary
The facility failed to ensure accurate reconciliation of medications on admission for a resident who was admitted with multiple complex cardiac and neurological diagnoses, including encephalopathy, chronic systolic cardiac failure, ischemic cardiomyopathy, atherosclerotic heart disease, non-rheumatic aortic valve stenosis, and difficulty walking. Upon admission, the resident was using continuous oxygen therapy at 2 liters per minute via nasal cannula, as documented in the admission assessment summary. However, a review of the physician's orders from admission through several days after did not include any order for oxygen therapy. The DON confirmed during interview and record review that the resident's record lacked a physician order for oxygen, despite the resident's continuous use of oxygen during her stay. The DON acknowledged that the licensed nurse should have verified the orders for accuracy and contacted the physician to obtain the necessary order for oxygen therapy, as required by the facility's medication reconciliation policy.
Failure to Provide Timely Wound, Blood Sugar, Weight, Blood Pressure, and Oral Care
Penalty
Summary
A resident with multiple complex medical conditions, including encephalopathy, sepsis, diabetes mellitus II, muscle wasting, and hypertension, was admitted to the facility. The facility failed to provide necessary care and treatment in several areas. The resident's left forehead laceration, which had six sutures, was not evaluated or referred to a physician for suture removal during the fourth week of stay. Documentation and interviews confirmed that no wound or suture evaluation was conducted, and the healing surgical wound with sutures was not reported to a physician as required by facility policy. Additionally, after the discontinuation of insulin medication, the resident's blood sugar levels were not monitored, despite a diagnosis of diabetes and care plan instructions to check blood glucose. The last documented blood sugar level was recorded on the day insulin was discontinued, with no further monitoring or clarification from nursing staff to the physician regarding ongoing blood sugar checks. This lapse was acknowledged by both nursing staff and the DON, who confirmed that blood sugar monitoring should have continued per facility protocol. The facility also failed to obtain the resident's baseline weight in a timely manner after admission, with a two-day delay in obtaining the initial weight. This delay was recognized by both the restorative nursing assistant and the RN, who stated that timely weight measurement is necessary for appropriate nutritional management. Furthermore, the resident experienced a change in condition with low blood pressure readings, but this was not reported to a physician as required by policy. Lastly, oral care was not provided after a meal, despite the resident's severe cognitive impairment and dependence on staff for oral hygiene, resulting in food residue being found in the resident's mouth during a subsequent physician appointment.
Failure to Arrange Timely Transportation Resulting in Missed Dialysis
Penalty
Summary
The facility failed to ensure timely and appropriate hemodialysis care for a resident with end-stage renal disease, resulting in missed dialysis treatments. The resident, who had moderate cognitive impairment and a physician's order for scheduled dialysis three times per week, did not receive dialysis on at least one occasion due to transportation not being arranged. Documentation in the nurse's notes confirmed that the missed treatment was due to the transport company not arriving, and interviews with facility staff revealed that transportation should have been pre-arranged and followed up, especially after the resident's readmission. Interviews with the Social Service Director, an LVN, and the Director of Nursing confirmed that the facility's policy required pre-arrangement and follow-up of transportation for dialysis appointments. The facility's transfer agreement also specified responsibility for arranging suitable transportation, including necessary equipment and personnel. The failure to arrange transportation as required by policy and agreement led directly to the resident missing scheduled dialysis treatments while at the facility.
Failure to Maintain Resident Dignity and Timely Response to Call Lights
Penalty
Summary
Staff failed to maintain resident dignity and respect in several instances. In one case, a CNA provided care to a resident with severe cognitive impairment without fully closing the privacy curtain, resulting in the resident's body being exposed. The CNA admitted to being in a hurry and forgetting to close the curtain, while both the RN and DON confirmed that privacy should have been maintained during care. In another instance, staff did not answer call lights in a timely manner during a shift change, with observed response times averaging 5-10 minutes. A resident with a history of stroke and hemiplegia, who was cognitively intact, reported that call lights were not answered promptly, making him feel disrespected and unimportant. The DON acknowledged that call lights should be answered as soon as possible and that delays do not promote residents' sense of well-being. Additionally, a resident reported waiting 15-20 minutes for assistance to transfer from a wheelchair to bed, with no staff responding to the call light. The resident's roommate confirmed the delay and stated he had to leave his bed to find help. The DON stated that timely response to call lights is the responsibility of all staff and that delays could result in unmet resident needs. Facility policies reviewed emphasized the importance of dignity, respect, and prompt response to resident requests.
Failure to Provide and Document Advance Directive Information and Availability
Penalty
Summary
The facility failed to ensure that advance directives (ADs) were properly documented and readily available in the records of several residents. For one resident who had executed an AD, there was no copy of the AD in either the electronic or paper chart, and the facility did not follow up with the resident's representative to obtain it. This omission was confirmed by the Social Service Director (SSD), who acknowledged that the AD should have been available and that follow-up with the family member had not occurred. Additionally, for six other residents, there was no documented evidence that written information regarding the formulation of an AD was provided to them or their representatives. These residents had various medical conditions, including acute kidney failure, cerebral vascular accident, fractures, urinary tract infection, hemiplegia, and diabetes mellitus. Some residents were cognitively intact and able to make decisions, while others had severe cognitive impairment and required information to be provided to their legal representatives. In each case, the records lacked documentation that the required information about ADs was given. During interviews, the SSD confirmed that written information about formulating an AD was not being provided to residents or their representatives, and there was no documentation to show that this requirement was being met. The facility's own policy required that residents or their legal representatives be given written information about ADs upon admission and that the existence of an AD be prominently displayed in the medical record. These requirements were not followed for the residents identified in the report.
Failure to Maintain Homelike Environment Due to Damaged Walls
Penalty
Summary
Surveyors observed that the facility failed to maintain a comfortable and homelike environment for its residents, as evidenced by multiple instances of peeled and damaged paint on the walls behind residents' headboards in several rooms. Specifically, the damaged walls were noted in the rooms of two residents, as well as in additional rooms, during multiple observations. The Maintenance Supervisor acknowledged awareness of the damaged painted walls and stated that they should have been fixed and repainted. The Administrator also confirmed that maintenance was expected to check and repair any damaged walls or surfaces in resident rooms, and that the facility should provide a homelike environment for all residents. A review of the facility's policy and procedure titled "Homelike Environment" indicated that residents are to be provided with a safe, clean, comfortable, and homelike environment, including clean, sanitary, and orderly surroundings. The observed failure to repair and maintain the painted walls did not align with the facility's stated policy and had the potential to negatively impact the residents' experience of comfort and pleasantness during their stay.
Failure to Follow Professional Standards During Medication Administration
Penalty
Summary
The facility failed to ensure professional standards of practice were followed during medication administration for three residents. In one instance, a nurse left an open packet of Lidocaine Patch 5% labeled for one resident on a shelf next to another resident, making it readily accessible and not secured in the medication cart or discarded. The nurse confirmed the medication was not handled according to policy, and the Director of Nursing (DON) stated that medications should not be left unattended in the presence of another resident. The facility's policy requires that medications ordered for a particular resident may not be administered to another resident and must be administered safely and as prescribed. In another case, a nurse administered medication to a resident without verifying the resident's identity. The resident was cognitively intact and had a history of a right wrist and hand fracture, bradycardia, and difficulty walking. The nurse acknowledged not following the facility's process of confirming the resident's name and date of birth or checking the identification wristband before administering medication. The DON and another nurse both confirmed that the expectation is to verify resident identity before medication administration, as outlined in the facility's policy. Additionally, a nurse did not provide privacy to a resident during medication administration. The resident, who was cognitively intact and had a history of a left femur fracture, diabetes, and hypertension, was not afforded privacy such as pulling a curtain or closing the door during the process. The nurse admitted to not providing privacy and stated that it is the resident's right. The DON reiterated that staff should promote, maintain, and protect resident privacy during treatment procedures, as required by the facility's dignity policy.
Failure to Provide Sufficient Nursing Staff and Timely Resident Assistance
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of residents, as evidenced by multiple resident complaints and documented staffing shortages. Several residents reported significant delays in receiving assistance with activities of daily living (ADLs) and in response to call lights, particularly during evening and night shifts. For example, one resident described waiting 15 to 20 minutes for help after sliding off his bed, with no staff responding even after his roommate also activated the call light. Other residents confirmed similar experiences, with some waiting over 30 minutes or even up to an hour for assistance, including for pain medication and toileting needs. These residents were cognitively intact and had medical conditions such as spinal fusion, cauda equina syndrome, kidney disorders, pulmonary issues, fractures, and mobility difficulties, all of which increased their need for timely care. A review of facility records revealed that the required minimum of 2.4 Certified Nursing Assistant (CNA) Direct Care Service Hours Per Patient Day (DHPPD) was not met on 16 days in March and 11 days in April. Staffing assignment sheets showed that the number of CNAs on duty frequently fell below the facility's own assessment projections, resulting in higher resident-to-CNA ratios than planned. On several occasions, three CNAs were responsible for up to 18 residents during night shifts, and day and evening shifts were also understaffed. The Director of Staff Development (DSD) and Director of Nursing (DON) both acknowledged that these staffing levels were insufficient to provide safe, efficient, and adequate care, and that the required DHPPD was not consistently achieved. Facility policies required timely responses to call lights and sufficient staffing to meet resident needs as outlined in care plans and the facility assessment. Despite these policies, the documented staffing shortages and resident reports of delayed care demonstrate that the facility did not adhere to its own standards or regulatory requirements. The DSD and DON confirmed that the lack of adequate staffing led to delays in care, increased risk for falls, and residents being left soiled or without timely assistance.
Improper Storage of Serving Utensil During Meal Service
Penalty
Summary
During a dining room observation, a Certified Restorative Nurse Assistant (CRNA) was seen using a four-ounce ladle to serve soup and then placing the ladle directly on the tablecloth instead of in a clean container between servings. The CRNA acknowledged in an interview that she had been trained to place the ladle on a clean tray and recognized that placing it on the tablecloth could cause cross-contamination and illness. The Director of Food and Dietary (DND) confirmed that the CRNA had received proper training and that the ladle should not have been placed on the table between servings, noting the potential for resident illness due to cross-contamination.
Multiple Lapses in Infection Control Practices
Penalty
Summary
Surveyors observed multiple failures in infection prevention and control practices within the facility. Two used diapers were found placed on top of a resident's cabinet drawer instead of being disposed of in a trash bin, as confirmed by both the LVN and the Infection Preventionist. This action was contrary to facility policy and was acknowledged by staff as a source of potential contamination. Additionally, a direct care staff member was observed wearing long artificial fingernails while providing resident care. The staff member admitted to having acrylic nails that extended significantly beyond the fingertip, and both the Infection Preventionist and facility policy indicated that such nails are prohibited for direct care staff due to the risk of harboring pathogens and causing skin injury to residents. Further deficiencies were identified in the use of personal protective equipment (PPE) and hand hygiene. A Certified Restorative Nursing Assistant (CRNA) was observed providing care to a resident with an active MRSA wound infection without donning the required gown and gloves, despite clear signage and physician orders for contact precautions and enhanced barrier precautions. The CRNA also failed to clean and disinfect the Hoyer lift after use with the same resident and did not perform hand hygiene after providing care. These lapses were acknowledged by the CRNA and confirmed by the Infection Preventionist as violations of facility policy and CDC recommendations for infection control. Another incident involved a Certified Nursing Assistant (CNA) who was observed providing care to a resident while exhibiting symptoms of a respiratory infection, including sniffling and a runny nose, without wearing a mask. The CNA admitted to feeling ill and not reporting her symptoms to a supervisor, as required by facility policy. The resident receiving care had chronic obstructive pulmonary disease, diabetes, and was dependent on supplemental oxygen, making her particularly vulnerable. Facility leadership confirmed that staff are required to report illness and wear masks if symptomatic, but these procedures were not followed in this instance.
Failure to Maintain Safe and Functional Laundry Equipment
Penalty
Summary
The facility failed to maintain a safe, functional, and comfortable environment when the lint trap of dryer 3 in the laundry area was found to be damaged and not cleaned. During an observation and interview with laundry staff, the lint trap was seen with an opening at the corner and filled with thick, soft lint that had not been removed since the previous day. The laundry staff confirmed that the damaged lint trap was still being used and had not been cleaned as required. Review of the DRYER'S LINT TRAP CLEANING LOG showed that the lint trap was not cleaned from noon on one day until 8 a.m. the following day. Additionally, a daily meeting record indicated that dryer 3 had previously been identified as having safety concerns. Further interviews with the Maintenance Supervisor and Administrator confirmed that the lint trap was torn and should have been repaired or replaced to prevent hazards. The facility's maintenance policy requires that all equipment be maintained in a safe and operable manner, and that hazards be addressed promptly. Despite these requirements, the damaged lint trap remained in use and uncleaned, creating a potential safety risk.
Failure to Develop Care Plan for Foot Contractures
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan to address the contractures of the feet for a resident with a history of cerebral infarction and severe joint immobility in both ankles. Observations showed the resident lying in bed with both ankles extended downward and no adaptive devices in use. Interviews with staff confirmed that the resident had longstanding foot drop and only heel pads were used to prevent skin breakdown, with no specific interventions or care plan in place for the contractures. Record reviews further indicated that the resident had significant lower extremity impairment and severe joint immobility, but there was no documented evidence of a care plan addressing these issues. Staff interviews, including with a CNA, LVN, and the DON, confirmed the absence of a care plan for the resident's contractures, despite facility policies requiring comprehensive, person-centered care plans to address such needs. The lack of a care plan meant that the resident did not receive tailored interventions to manage or prevent worsening of the contractures, as required by the facility's own policies and procedures regarding care planning and mobility management.
Failure to Provide Contracture Management and ROM Care
Penalty
Summary
The facility failed to provide appropriate care and treatment to manage contractures for a resident with severe joint immobility in both ankles. Observations showed the resident lying in bed with both feet extended downward, wearing only soft foam heel pads to protect against skin breakdown. Interviews with staff revealed that no range of motion (ROM) exercises or contracture management devices were provided, as there was no physician order for such interventions. The restorative nursing assistant confirmed that the resident, who had a history of cerebral infarction and severe joint immobility, was not included in the restorative nursing program for ROM exercises, despite previous physical therapy discharge instructions recommending continued ROM care. Record reviews indicated that the resident had documented contractures and impairment in both lower extremities, with multiple assessments and physician notes confirming the condition. The licensed nurse and physical therapist both acknowledged that the resident should have been referred for therapy and provided with appropriate devices to prevent further contracture and foot drop. Facility policies required treatment and services for residents with limited ROM, including proper positioning, body alignment, and passive ROM exercises, but these were not implemented for this resident.
Failure to Provide Required Dental Consultation
Penalty
Summary
The facility failed to provide a dental consultation for a resident who was observed to be missing upper and lower teeth and reported not having dentures or having seen a dentist. The resident, who had a diagnosis of dysphagia and was on a mechanical soft diet, had a physician's order for dental health services as needed and was documented as edentulous in the dental hygiene progress notes. Despite these documented needs and orders, there was no evidence in the resident's record that a dental consultation had been provided since the previous year. Interviews with the Social Service Director and the Director of Nursing confirmed that there was no documentation of a dental visit for the resident and acknowledged that the resident should have been seen by the dentist according to facility policy. The facility's policy indicated that routine and emergency dental services should be available in accordance with the resident's assessment and plan of care, and that social services should assist with appointments and transportation. The lack of dental services was identified through observation, record review, and staff interviews.
Resident Health Information Left Unsecured During Medication Pass
Penalty
Summary
A licensed vocational nurse (LVN) failed to safeguard resident-identifiable information by leaving a computer open and unattended during medication administration, with a resident's electronic health record visible to unauthorized individuals. This incident was directly observed by surveyors, and the LVN acknowledged that this action was a violation of the facility's policy, which requires staff to close or lock computer monitors when leaving the medication cart. The Director of Nursing (DON) confirmed that staff are expected to lock their screens before leaving the area to prevent unauthorized access to resident information. The resident involved had been admitted with multiple diagnoses, including a left femur fracture, difficulty walking, diabetes, and hypertension, and was assessed as cognitively intact. The facility's policies on HIPAA compliance and resident dignity require the protection of confidential clinical information and the maintenance of resident privacy. The failure to secure the electronic health record resulted in the potential for the resident's information to be disclosed to individuals not involved in their care.
Baseboard Heater Cover Detached and Unrepaired in Resident Room
Penalty
Summary
A baseboard heater cover in a resident's room was found open, detached, and laying on the floor during an observation. The resident, who was in a wheelchair, reported feeling a warm breeze directly from the exposed heater and expressed fear of passing by it due to the risk of being burned. The heater cover's condition created a direct exposure to the heating element for the resident. The Maintenance Supervisor confirmed that the heater cover was damaged and detached, acknowledging that it should have been repaired promptly to prevent further damage and potential harm. The Administrator stated that maintenance staff are expected to repair damaged equipment to ensure a safe environment. Facility policy requires maintenance of equipment in a safe and operable manner, but in this instance, the heater was not maintained according to these standards.
Failure to Protect Resident Privacy and Confidentiality in Social Media Posting
Penalty
Summary
Facility staff failed to safeguard the privacy and confidentiality of two residents when a staff member filmed them and posted the videos on social media without obtaining consent from the residents or their representatives. Both residents had cognitive impairments, with one having severe impairment and the other moderate, as documented in their records. There was no evidence in the residents' records that consent was obtained for filming or posting the videos. During interviews, both residents did not recall giving permission for the videos to be made or shared online. The Social Services Director acknowledged making and posting the videos, stating that verbal agreement was obtained from the residents, but also recognized their short-term memory loss and did not seek consent from their representatives. The Director of Nursing confirmed that representatives were not notified or asked for permission prior to the videos being made and posted, and stated that this was a violation of the residents' privacy and rights. Facility policy requires respect for resident privacy and confidentiality, which was not followed in this instance.
Failure to Provide Oral Care After Meals for Dependent Resident
Penalty
Summary
A deficiency was identified when a resident with severe cognitive impairment and total dependence for oral hygiene did not receive appropriate oral care after meals. The resident, who had diagnoses including major depressive disorder, dementia, encephalopathy, sepsis, and muscle wasting, was known to have difficulty swallowing and would hold food in her cheeks after eating. According to the care plan and staff interviews, oral care was required after every meal and before bed, especially for residents with feeding issues. However, on the day of a scheduled physician appointment, the resident was fed breakfast and prepared for transport, but food remnants were later found in her mouth at the physician's office. Staff interviews confirmed that oral care should have been provided after meals, and the facility's policy required assistance with oral hygiene for residents unable to perform this activity independently. Documentation and staff statements indicated that the resident was dependent on staff for oral care, and the failure to provide this care after meals resulted in food being left in the resident's mouth, as discovered during the external appointment.
Failure to Provide Adequate Assistance During Resident Transfer
Penalty
Summary
The facility failed to provide appropriate staff assistance during a transfer for Resident A, who required moderate to maximum assistance due to weakness and flaccidity on the left side following a stroke. The Rehabilitation Program Manager (RPM) recommended a two-person assist or a mechanical lift for all transfers. However, during an incident, CNA 1 attempted to transfer Resident A alone, which was against the care plan that required two-person assistance or the use of a mechanical lift. During the transfer, CNA 1 grabbed Resident A's right arm and left leg, dragging her to the edge of the bed, which caused Resident A to nearly fall. Resident A experienced pain in her right shoulder and left hip following the incident. The care plan and Minimal Data Set (MDS) indicated that Resident A was dependent on helpers for transfers, requiring two or more helpers to complete the activity safely. Interviews with staff, including the Director of Nursing (DON) and other CNAs, confirmed that CNA 1 did not seek assistance or use the mechanical lift as required. The facility's policy on Activities of Daily Living (ADLs) emphasized the need for appropriate support and assistance based on the resident's assessed needs. The failure to adhere to these guidelines resulted in Resident A experiencing physical pain and had the potential to cause injury.
Failure to Adhere to Physician's Order for Blood Pressure Medication
Penalty
Summary
The facility failed to administer medication according to the physician's order for one resident, identified as Resident 1. The resident was prescribed Hydralazine to manage hypertension, with specific instructions to hold the medication if the systolic blood pressure (SBP) was below 110 or the heart rate was below 60. However, on October 15, 2024, the medication was administered despite the resident having an SBP of 101, which was below the threshold set by the physician's order. Resident 1 had a medical history that included conditions such as fusion of the spine in the lumbar region, spinal stenosis, end-stage renal disease, dependence on renal dialysis, and hypertensive heart disease. Interviews with the facility's Licensed Vocational Nurses (LVNs) and the Director of Nursing (DON) confirmed the importance of adhering to physician orders to prevent potential harm to residents. The facility's policy on administering medications emphasized the need to verify vital signs and follow prescriber orders to ensure resident safety.
Inadequate Documentation for Resident Transfer
Penalty
Summary
The facility failed to ensure an appropriate and necessary transfer for a resident who was moved to a general acute care hospital (GACH) without documented justification. The resident, who had been admitted with a fracture of the lumbosacral spine and pelvis, was transferred without evidence in the progress notes from the physician explaining why the resident's needs could not be met at the facility. The Notice of Transfer/Discharge Form and the Interact Transfer Form indicated the transfer was necessary for the resident's welfare, but lacked specific documentation of the resident's needs and the facility's attempts to meet those needs. Interviews with the Director of Nursing (DON) and the Administrator revealed that the resident had expressed feelings of mental instability and a need for help, which led to the physician's order for transfer. However, the facility's policy requires detailed documentation of the basis for transfer, including the specific needs that cannot be met and the receiving facility's ability to meet those needs. This documentation was not present, indicating a failure to comply with the facility's transfer or discharge policy.
Failure to Maintain Comfortable Environment Due to AC Malfunction
Penalty
Summary
The facility failed to provide a comfortable environment for five of the 13 sampled residents when the air conditioning unit was not functioning, resulting in room temperatures exceeding 81 degrees Fahrenheit. This issue was observed during an initial tour where fans were placed in hallways and resident rooms to mitigate the heat. Interviews with the Director of Nursing (DON), Licensed Vocational Nurse (LVN 1), and the Maintenance Director (MD) revealed that some rooms were more affected than others, and the facility was waiting for fuses to be fixed on some air conditioning units. The MD admitted to not tracking room temperatures during this period. Residents 6, 7, and 8 expressed discomfort due to the heat, with some choosing to stay in common areas like the TV room or dining room to avoid their hot rooms. Resident 7, who has peripheral vascular disease, cellulitis, and ovarian cancer, mentioned that the fan in her room was insufficient, especially with the presence of oxygen concentrators. Resident 6, diagnosed with COPD, lung cancer, and respiratory failure, also avoided her room due to the heat. Resident 8, with rib fractures, heart failure, and kidney failure, noted that her room received direct sunlight, making it particularly warm despite the fan. The facility's policy on maintaining a homelike environment specifies safe temperatures between 71 and 81 degrees Fahrenheit. However, observations showed room temperatures ranging from 77 to 85.5 degrees Fahrenheit. The DON was unable to confirm how temperatures were being monitored, as the facility's temperature gun was missing, and wall thermostats were not functioning. The Administrator acknowledged awareness of the issue but had not reported it to the California Department of Public Health (CDPH).
Failure to Assess and Address Incontinence in Residents
Penalty
Summary
The facility failed to properly assess and provide appropriate care for two residents, Resident A and Resident B, regarding their bladder and bowel continence. Resident A was admitted with diagnoses including intracerebral hemorrhage and epileptic syndrome and was initially documented as continent. However, from June 2 to June 7, 2024, Resident A experienced episodes of bladder incontinence and was placed on an adult brief. Despite this change, there was no documented evidence of an assessment or a care plan to address the incontinence. Interviews with CNAs confirmed Resident A's incontinence, and the MDS Coordinator acknowledged that a change of condition should have been initiated and a bladder program developed. Resident B, admitted with cystitis and sepsis, reported being incontinent of bladder and bowel and wearing a brief at all times. The medical record indicated frequent incontinence, but there was no documented care plan to address this issue. The MDS Coordinator stated that Resident B should have been placed on a bowel and bladder program after the fourth day of incontinence, but no interventions were implemented to help regain control. The facility's policies on change in condition and bowel and bladder protocol were not followed. The policies required a comprehensive assessment and care plan development upon significant changes in a resident's condition. The facility's in-service training records indicated that staff were trained on documenting changes in condition, but this was not reflected in the care provided to Residents A and B.
Inaccurate MDS Coding for Multiple Residents
Penalty
Summary
The facility failed to accurately code Minimum Data Set (MDS) assessments for four residents, leading to discrepancies in their medical records. Resident #34, who had severe cognitive impairment and was receiving hospice care, had an MDS that did not reflect the hospice services. Both the MDS Coordinator and the Director of Nursing (DON) acknowledged the inaccuracy during interviews. Similarly, Resident #61 was discharged to an assisted living facility, but the MDS incorrectly indicated a discharge to a hospital. This error was also confirmed by the MDS Coordinator and the DON during interviews. Resident #16's MDS inaccurately reflected that their Physician Orders for Life-Sustaining Treatment (POLST) form was signed by a physician, nurse practitioner, or physician assistant, despite the form lacking such a signature. Additionally, the MDS incorrectly indicated the status of the resident's advance directives. The MDS Coordinator and the DON both confirmed these inaccuracies. Resident #30's MDS had similar issues, with the POLST form not being signed and the MDS inaccurately reflecting the resident's advance directives. These errors were also acknowledged by the MDS Coordinator and the DON. The facility's policy on certifying the accuracy of resident assessments was not followed, as evidenced by the multiple inaccuracies in the MDS coding for these residents. The Administrator, DON, and MDS Coordinator all confirmed that the MDS should accurately reflect the residents' medical status and care plans, but this was not the case for the four residents reviewed. These discrepancies highlight a failure in the facility's processes for ensuring accurate and complete resident assessments.
Failure to Provide Advance Directive Information
Penalty
Summary
The facility failed to provide advance directive information to Resident #57 upon admission, as required by their policy. The resident was admitted on 04/20/2024, but the Physician Orders for Life-Sustaining Treatment (POLST) and the Consents form were incomplete regarding advance directives. The Director of Nursing (DON) confirmed that there was no documentation of discussions about advance directives with Resident #57. The Social Services Director (SSD) and the Social Services Assistant (SSA) also failed to document any discussion about advance directives during the care conference, which is a part of their standard procedure. Interviews with the DON, SSD, SSA, and the Administrator revealed that the process of providing advance directive information was not followed correctly. The SSD was on vacation during Resident #57's admission, and the SSA, who participated in the care conference, did not document any discussion about advance directives. The SSA admitted that recently they had not been documenting these discussions, but she did not know why. This lapse in procedure led to the failure to provide Resident #57 with the necessary information about advance directives, as required by the facility's policy and state law.
Failure to Ensure Privacy During Resident Care
Penalty
Summary
The facility failed to ensure privacy during resident care for one resident. The incident involved a resident with severe cognitive impairment, quadriplegia, and muscle wasting, who was dependent on staff for toileting hygiene and was always incontinent of urine and bowel. During an observation, two CNAs transferred the resident from a geriatric chair to their bed using a mechanical lift without a privacy curtain in place, with the window blinds open, and the resident's roommate watching. The CNAs proceeded with incontinence care without ensuring privacy, as the privacy curtain was removed for cleaning. The resident's gown was pulled up, and their brief was unfastened in full view of the roommate before the CNAs realized the need for privacy and paused the care to retrieve the privacy curtain. Interviews with the CNAs and the Director of Nursing revealed that the staff were aware of the requirement to provide privacy during resident care but failed to adhere to this protocol due to the absence of the privacy curtain. The Director of Nursing and the Administrator both confirmed that the expectation was for staff to ensure privacy during any resident care tasks. The CNAs acknowledged that they should not have proceeded with the transfer and care without the privacy curtain in place.
Failure to Address Smoking and ADL Assistance in Care Plans
Penalty
Summary
The facility failed to develop a care plan to address the smoking needs of Resident #32, who was admitted on 04/22/2024 and was identified as a smoker using tobacco products two to five times per day. Despite the resident being cognitively intact and requiring specific safety measures such as a smoking apron, cigarette holder, supervision, and one-on-one assistance, the comprehensive care plan did not reflect these needs. Observations and interviews with staff, including the MDS Coordinator, LVN, DON, and Administrator, confirmed that the resident's smoking status and required safety interventions were not included in the care plan. Additionally, the facility did not ensure that the care plan for Resident #46, who was admitted on 02/29/2024 with severe cognitive impairment and quadriplegia, specified the level of assistance required for activities of daily living (ADLs). The resident's care plan indicated impaired ADL function and the need for assistance but did not detail the specific level of assistance needed. Interviews with the MDS Coordinator, DON, and Administrator confirmed that the care plan lacked necessary details on the level of assistance required for ADLs, which is crucial for staff to provide appropriate care.
Failure to Provide Assistance with ADLs
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADLs) for two residents, leading to deficiencies in personal hygiene and grooming. Resident #44, who had severe cognitive impairment and was totally dependent on staff for personal hygiene, was observed on multiple occasions with disheveled hair. Despite the facility's policy requiring staff to assist residents with ADLs, including grooming, the resident's hair was not groomed as expected. The Director of Nursing (DON) and a Certified Nurse Assistant (CNA) acknowledged the oversight, with the CNA admitting to forgetting to brush the resident's hair after dressing them. Resident #46, who had severe cognitive impairment and was dependent on staff for personal hygiene, was found with long, jagged fingernails and thick, discolored toenails. The resident's comprehensive care plan did not adequately address the level of assistance required for grooming and personal hygiene, including routine nail care. Staff interviews revealed that the resident's nails had not been trimmed since admission, and the responsibility for nail care was not clearly defined among the staff. The DON and the Administrator confirmed that the resident was dependent on staff for nail care and that the issue should have been addressed prior to the surveyor's observation.
Failure to Supervise Resident Smoking
Penalty
Summary
The facility failed to establish and maintain safe resident smoking practices as per their Policy & Procedure (P&P) Smoking Policy-Resident. Two residents were observed smoking on the patio without staff supervision, which is against the facility's policy that requires staff to monitor residents during smoking breaks and to collect smoking paraphernalia afterward. The Director of Nursing (DON) confirmed that residents should not be smoking unsupervised and should not have cigarettes and lighters in their possession without staff oversight. The Activity Assistant (AA), who was responsible for monitoring the smoke breaks, was unaware of how one resident obtained his cigarettes and lighter before the designated smoke break time. Resident 1, who has a diagnosis of Chronic Obstructive Pulmonary Disease (COPD) and asthma, was observed smoking unsupervised and in possession of a cigarette box and lighter. His medical records indicated that he should smoke with supervision and use a smoking apron, which he often refused to wear. Despite his refusal, there was no reassessment for his smoking safety without the apron, and no care plan was developed for his smoking needs. Resident 2, who has a traumatic brain injury and severe cognitive impairments, also requires supervision while smoking. However, he was observed smoking unsupervised as well. The Activity Director (AD) confirmed that activity staff are responsible for monitoring residents during smoke breaks and that new residents are assessed for smoking safety during the admission process. However, the AD did not have copies of the smoking safety documents for Residents 1 and 2, as they were discarded after the residents were discharged. The DON verified that a smoking care plan for Resident 1 was missing and should have been developed within 14 days of his admission. The facility's policy mandates that residents with restricted smoking privileges must be directly supervised while smoking and are not allowed to keep smoking articles in their possession.
Failure to Ensure Resident Took Medications
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors when a Licensed Vocational Nurse (LVN) did not follow the facility's medication administration policy. The LVN left the resident's medications in his hand and exited the room without witnessing the resident take his medications. This resulted in the resident missing his 8:00 a.m. dose of medications, including muscle relaxers Metocarbonal and Cyclobenzaprine. During an observation, the resident was found lying in bed with several pills on his mattress, bedside table, and shoulder, indicating that he had not taken his medications as required. The LVN admitted to not ensuring that the resident swallowed his medications before leaving the room and acknowledged that the resident did not have a doctor's order to self-administer his medications. The Director of Nursing (DON) confirmed that the facility's procedure requires nurses to verify that medications are taken before leaving the room and that the resident had not been assessed for the cognitive ability to self-administer medications. The resident's medical records indicated a diagnosis of lower leg muscle contracture and a moderate cognitive impairment, with no orders to self-administer medications.
Latest citations in California
Two residents with dementia, schizoaffective disorder, and major depressive disorder, both with moderately impaired cognition and needing moderate ADL assistance, were found unclothed together in one resident's bed. One resident later stated she did not want sexual activity and did not consent, while the other resident could not recall the encounter. An LVN reported that both residents verbally consented at the time but acknowledged no assessment had been done to determine their capacity to consent to sexual activity. The DON identified the incident as sexual abuse and confirmed that allowing sexual activity without prior capacity assessment was inconsistent with facility policy and that the resident was not protected from sexual abuse.
Two residents with dementia, schizoaffective disorder, major depressive disorder, and moderately impaired cognition, both needing moderate assistance with ADLs, were found unclothed together in one resident’s bed. The resident later stated she did not consent to sexual contact, while the other resident did not recall any sexual activity. An LVN documented the incident and acknowledged it constituted sexual abuse that should have been reported immediately to the abuse coordinator and appropriate agencies, but did not report it. The administrator, who serves as the abuse coordinator, stated she relies on staff to notify her immediately of such allegations so they can be reported to CDPH, law enforcement, and the Ombudsman, but this did not occur, resulting in the allegation not being reported as required.
A resident with Parkinson’s disease, osteoporosis, and osteoarthritis reported being punched in the face by another resident, resulting in facial bruising. The resident’s MDS showed intact cognition, and a change in condition evaluation documented the assault; however, the MD was not notified until more than a day later. The care plan directed licensed nurses to assess the resident’s body, and staff observed a purplish bruise on the right lower eyelid/orbital area, but this was not documented in the progress notes. Required every-shift monitoring for 72 hours after the change in condition was not documented on multiple day shifts. The DON confirmed lack of awareness of the bruise and acknowledged missing documentation and monitoring, despite facility policies requiring immediate provider notification and complete, accurate charting of changes in condition.
A nurse left a medication cart unlocked and unattended in the hallway while administering insulin to a resident with diabetes, cardiac, and post-surgical conditions. The cart was out of the nurse's direct line of sight, contrary to facility policy requiring medication carts to be locked when not in use. The DON confirmed that medications should be secured to prevent unauthorized access.
A resident’s legal representative requested copies of the resident’s medical records through a faxed request from a law office’s third-party service, but the records were not provided within the required timeframe. The MRD confirmed receiving the request and stated he had forwarded the documents to the DON for review over a month earlier and had not received them back to release. Upon review of federal requirements for record access, the ADON acknowledged that the facility did not comply with the regulation requiring provision of copies within two working days of request.
Two CNAs violated privacy and confidentiality requirements when one CNA used a personal cell phone to record and photograph two residents during a perceived altercation and then sent the video to another CNA. The residents, who had significant medical conditions including paraplegia, seizures, dysphagia, and severe cognitive impairment, were dependent on staff for ADLs. The second CNA reported that a family member later took her phone without permission, accessed the contents, and transmitted the videos and photos to facility leadership. Facility staff, including an LVN, the DSD, and the administrator, stated that HIPAA rules and facility policies prohibit staff from recording residents on personal devices and allow resident photographs only with consent and for medical purposes as part of the chart, and that the facility’s "Stop and Watch" process requires observation and reporting, not filming.
A resident with a stage 4 sacrococcygeal PI, Parkinson’s disease, hypertension, moderate cognitive impairment, and high assistance needs was not provided care consistent with the facility’s pressure injury prevention policy. Although the care plan included daily wound treatment and use of a LAL mattress, it lacked an individualized repositioning schedule and did not document education or reminders about repositioning. Facility documentation showed only that the resident was assisted to roll each shift, with no evidence of q2h turning in bed or of how often incontinence briefs were checked and changed. After the resident refused Foley catheter reinsertion, the IDT did not identify incontinence as a risk factor or add new wound-protective or moisture-preventive interventions, and the subsequent care plan for non-compliance omitted such measures. The TXN and DON confirmed that repositioning and protection of the wound from incontinence were not clearly implemented or reflected in the care plan, despite policy requirements.
A resident with Parkinson’s disease, cognitive impairment, and significant assistance needs for mobility and toileting experienced two early-morning falls resulting in head injuries. After the first fall, the IDT documented potential interventions such as a bed alarm and floor mat but did not identify the cause of the fall, did not obtain a physician order for the floor mat, and did not ensure the care plan addressed supervision or bed alarm function. Before and after the falls, the care plan lacked interventions for supervision despite poor safety awareness and failure to use the call light, and the second fall occurred when the resident slid from bed while reaching for a snack bag placed on the bedside table. IDT follow-up documentation for the second fall was incomplete, and staff acknowledged that fall causes were not identified and resident-centered interventions were not fully implemented.
A resident with severe cognitive impairment and multiple neurological diagnoses was dependent on staff for hygiene and mobility. During an IDT meeting, the resident’s family member communicated specific care preferences, but facility staff did not develop or update a comprehensive person-centered care plan to include these preferences. Review of care plans over several months showed no documentation of the communicated preferences, despite facility policy requiring the IDT to create a measurable, time-framed care plan based on assessed needs and expressed preferences.
A resident with COPD and severely impaired cognition, dependent on staff for all ADLs and mobility, had a physician order for continuous supplemental O2 at a fixed rate of 2 L/min. During observations, the resident was found receiving O2 at 3 L/min. An LVN recognized the discrepancy and reported it to an RN supervisor, but there was no documentation of any clinical rationale for the increased flow, no physician notification, and no order change. The care plan directed staff to administer O2 as ordered, and facility policy required verification of the order, documentation of flow rate and rationale, and appropriate reporting, which were not followed.
Failure to Protect Cognitively Impaired Resident From Sexual Abuse
Penalty
Summary
The facility failed to ensure a resident was free from sexual abuse when two cognitively impaired residents were found unclothed together in one resident's bed without prior assessment of their capacity to consent to sexual activity. One resident had dementia, schizoaffective disorder, and major depressive disorder, with documentation of fluctuating capacity to understand and make decisions and a Minimum Data Set (MDS) indicating moderately impaired cognition and a need for moderate assistance with ADLs. During an interview at her bedside, this resident stated she did not want to engage in sexual activity and did not consent to sexual contact with the other resident. The second resident involved also had dementia, schizoaffective disorder, and major depressive disorder, with an MDS showing moderately impaired cognition and a need for moderate assistance with ADLs. In an interview, he stated he liked women and liked to socialize with women but could not recall whether he engaged in sexual activity with the first resident. An LVN reported observing both residents unclothed in the first resident's bed and stated that, at the time of the incident, both residents verbally consented to sexual activity, but she was not aware of any assessment having been performed to determine either resident's capacity to consent. The DON stated the incident was considered sexual abuse, that it was not the facility's practice to allow sexual activity without appropriate assessment, and that the facility failed to ensure the resident was protected from sexual abuse, contrary to the facility's abuse prevention policy.
Failure to Report Alleged Sexual Abuse Between Cognitively Impaired Residents
Penalty
Summary
The deficiency involves the facility’s failure to report an allegation of sexual abuse between two residents to the State Survey Agency, Ombudsman, and local law enforcement as required by federal regulations and the facility’s own abuse reporting policy. A nurse documented that one resident (Resident 2) and another resident (Resident 4) were found unclothed together in Resident 2’s bed, and the nurse acknowledged that this situation constituted sexual abuse and should have been reported immediately to the abuse coordinator and appropriate agencies, but she did not report the incident. The facility’s policy stated that all staff are mandated reporters and must notify appropriate authorities within two hours of becoming aware of abuse and immediately notify the Abuse Prevention Coordinator and their supervisor. Resident 2 had dementia, schizoaffective disorder, major depressive disorder, fluctuating capacity to understand and make decisions, and moderately impaired cognition, and required moderate assistance with ADLs. During an interview at her bedside, Resident 2 stated she did not consent to sexual contact with Resident 4. Resident 4 also had dementia, schizoaffective disorder, major depressive disorder, moderately impaired cognition, and required moderate assistance with ADLs, and stated he did not recall engaging in sexual activity with any residents. The Administrator, who served as the abuse coordinator, stated she was responsible for reporting all abuse allegations to CDPH, law enforcement, and the Ombudsman, and that staff were responsible for notifying her immediately of sexual abuse allegations so they could be reported and investigated. The failure of staff to notify the Administrator and report the incident resulted in the sexual abuse allegation not being reported as required, causing a delay in an onsite investigation by CDPH.
Failure to Assess, Notify, and Monitor Resident After Facial Trauma
Penalty
Summary
The deficiency involves the facility’s failure to follow professional standards of nursing practice in assessing and monitoring a resident after a reported change of condition related to facial trauma. The resident was admitted with Parkinson’s disease, age-related osteoporosis, and osteoarthritis, and had intact cognitive skills for daily decision-making per a recent MDS. On the evening of 3/26/2026, a Change in Condition Evaluation documented that another resident hit this resident on the nose and both cheeks. The evaluation showed that the attending physician was not notified until 10 p.m. on 3/27/2026, approximately 26.5 hours after the reported incident, and the physician’s recommendation was to monitor the resident’s nose and cheeks for any changes and pain. The resident’s care plan, initiated on 3/26/2026, documented the report that another resident hit him on the nose and both cheeks and included an intervention for licensed nurses to check and assess the resident’s body. In an interview, the resident described that the other resident came into the room, stood on the left side of the bed, and punched him in the face. A photograph taken two days after the alleged incident showed a purplish-blue bruise on the right lower orbital area, although the resident declined to provide a copy of the picture. A CNA later reported observing a purple bruise on the resident’s right lower eyelid on 3/27/2026, described as extending from the inner to the middle lower eyelid and about the size of the tip of her fifth digit. During record review and interviews, an LVN stated that on 3/27/2026 the resident’s right lower eyelid had a dime-sized purplish bruise, but there was no documentation of this bruise in the progress notes. The LVN also stated that the resident should have been monitored every shift for 72 hours after the change of condition, yet there was no documented evidence of monitoring on the 7 a.m. to 3 p.m. shifts on 3/27/2026, 3/28/2026, and 3/29/2026. The DON reported not being made aware of the right eyelid bruise, confirmed that the resident should have been monitored every shift for at least 72 hours following the change of condition, and acknowledged there was no confirmed documentation of monitoring on the identified shifts. Facility policies required immediate physician consultation for significant changes in condition and complete, accurate documentation of changes and services provided, but the facility failed to identify, document, and monitor the resident’s change of condition in accordance with these policies.
Plan Of Correction
Facility Response Submission of the Plan of Correction does not constitute admission or agreement by the Provider of the truth of the facts alleged or conclusion set forth in this statement of deficiencies. The Plan of Correction is prepared and/or executed solely because it is required by the provision of Federal and State laws. This Plan of Correction constitutes the facility's credible allegation of compliance Corrective Action On 4/7/2026 Resident 1 was reassessed by LVN 3 and no skin issue was identified. On 4/7/2026 LVN 3 received one-on-one in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. Identification of other residents and corrective action On 4/8/2026 DON and/or designee reviewed audits provided by medical records for all change of condition in month of April to ensure proper documentation and monitoring are in place. No other deficient practice noted. Measures to prevent recurrence On 4/7/2026 LVN 3 received one-on-one in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. On 4/8/2026 Licensed nurses received in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. Monitoring and incorporation into the QA system HID will audit change of conditions using Change of Condition Audit form daily Monday-Friday and will report any finding during daily stand-up meeting Monday-Friday on-going. DON or designee will review change of conditions from prior day during daily clinical meetings (Monday -Friday) on going to ensure the nurse notified the attending physician regarding resident's significant change of condition and documented. Any deficient finding will be reported to DON and/or administrator for further corrective action/recommendation. Any trend of deficient finding(s) will be documented on Change of Condition Audit Form and will be reviewed during the monthly QA meeting for further review and/or recommendation(s). Administrator who will then report to the Quality Assurance (QA) team during monthly Quality Assurance (QA)/Quality Assurance and Performance Improvement (QAPI) for further evaluation/recommendation and to provide feedback and program modification if needed x3 months or until compliant. Date Corrective action to be completed: 4/8/2026
Medication Cart Left Unlocked During Medication Pass
Penalty
Summary
During a medication pass for a resident with a history of surgical aftercare, cardiac arrest, heart failure, and type 2 diabetes mellitus, a licensed nurse prepared and administered Novolog insulin using a pen-injector. The nurse left the medication cart unlocked and unattended in the hallway, approximately two feet outside the resident's bedroom doorway, while administering the injection inside the room. The cart was out of the nurse's direct line of sight during this time. The nurse acknowledged that the cart was left unlocked and should have been secured when not in direct view. Facility policy and procedure documents reviewed indicated that medication carts must be kept closed and locked when out of sight of the medication nurse or aide, and that compartments containing drugs and biologicals are to be locked when not in use. The Director of Nursing confirmed that medications should be locked and secured to prevent unauthorized access by unlicensed staff and residents. The failure to lock the medication cart during the medication pass was observed and confirmed through interviews and record review.
Plan Of Correction
From 4/4/2025 through 4/7/2025, the DON, DSD, and ADSD completed 1:1 inservices with licensed staff regarding the facility policy and procedure titled Storage of Medications. Medication carts must be kept locked when unattended. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 3 times a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 2 times a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 1 time a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will random monitor medication carts being locked when unattended for 1 month. System effectiveness will be evaluated during the facility's monthly Quality Assurance Performance Improvement Committee meetings for three (3) months.
Failure to Timely Provide Resident Medical Records Upon Request
Penalty
Summary
The facility failed to provide timely access to medical records as required under 42 CFR 483.10(g)(2) for one resident. The resident’s face sheet showed an admission date of November 18, 2025, with multiple diagnoses, but no additional clinical details were provided. A legal representative’s office faxed an initial request for the resident’s medical records on February 26, 2026. As of March 26, 2026, the legal representative’s staff reported that the office had not yet received the requested records from the facility. On April 2, 2026, the Medical Record Director (MRD) confirmed documentation that a third-party service for the law office had requested the resident’s medical records on February 26, 2026. The MRD stated he had submitted the requested documents to the Director of Nursing (DON) for review over a month prior but had not received them back to proceed with releasing the records. During a concurrent interview and record review, the Assistant Director of Nursing (ADON) reviewed the State Operations Manual Appendix PP guidance on residents’ rights to access personal and medical records, which requires that copies be provided within two working days of request. The ADON acknowledged that this regulatory requirement was not followed by the facility.
Plan Of Correction
F0573 Right to Access/Purchase Copies of Records What corrective action(s) will be accomplished for those Residents found to have been affected by the deficient practice? Medical Records Director (MRD) released medical records for Resident 1 as requested by the legal representative (Legal Staff) on April 21, 2026. How will other individuals with the potential to be affected by this deficient practice be identified and protected? No other Resident was identified to have been effected by the deficient practice. What systemic changes will be implemented to ensure that the deficient practice does not recur? The Quality Assurance Committee met on April 14, 2026 to review the Policy and Procedure which was then forwarded to the Knolls West Post Acute legal team for further evaluation. Revision of the policy will be discussed and approved by the Quality Assurance Committee to ensure the facility meets all Federal and State Regulations. F0573 Right to Access/Purchase Copies of Records (CONT.)The Administrator and the Medical Records Director (MRD) are responsible for informing the requesting party for the demand for payment for the requested medical documentation being provided and until payment is received the facility will hold the chart copies.How corrective action(s) will be monitored to ensure solutions are being achieved and sustainedThe Resident's Responsible Party will be notified upon receipt of the Medical Records Request and review in the presence of the facility representative. Records will be provided if it does not pertain to any legal matters after payment is received. The Administrator and/or Designee is responsible for reporting to the Quality Assurance Committee on a monthly basis and monitoring to ensure that corrective action is implemented and evaluated for its effectiveness. The same will be reviewed on a quarterly basis to the Quality Assurance Committee meeting x 3 quarters or until 100% compliance is achieved and sustained.Date of CompletionApril 23, 2026
Unauthorized Resident Recording and Disclosure Violating Privacy and Confidentiality
Penalty
Summary
The deficiency involves a failure to protect residents’ privacy and confidentiality when a CNA used a personal cell phone to record and photograph two residents without their knowledge or consent, and then shared that content with another CNA. One resident had paraplegia, depression, muscle weakness, dorsalgia, and polyneuropathy, was cognitively intact, and dependent on staff for ADLs. The other resident had diagnoses including seizures, dysphagia, acute kidney dysfunction, and muscle weakness, was able to make needs known but could not make medical decisions, had severely impaired decision-making, and was also dependent on staff for ADLs. Both residents were therefore in a position of dependence on staff for care at the time of the incident. According to CNA 2, on a specific date she recorded a video of the two residents because one resident started an altercation with the other. She stated she recorded the incident for “evidence” and to show CNA 1, acknowledging that recording residents was not part of facility policy and that she should not have recorded or taken photographs of them. CNA 1 confirmed that she received the video on her personal cell phone from CNA 2 and stated that the recording was made for “safety purposes” due to a situation that was perceived as potentially escalating to physical aggression. CNA 1 reported that she did not share or post the video on social media or distribute it to others, but that a family member took her phone without permission and accessed its contents. CNA 1 further stated that this family member sent the video and pictures of the two residents to the facility, and that she notified the facility that her phone had been taken but did not disclose that it contained videos or photographs of the residents because she was unaware that the family member had accessed or distributed them. The DSD reported receiving a text message from an unknown number containing approximately two videos and an undetermined number of photographs of the two residents, along with the names of CNA 1 and CNA 2. The DSD, LVN 2, and the Administrator each stated that staff were required to follow HIPAA regulations, that staff were not permitted to record or possess videos or photographs of residents on personal devices, and that any photographs of residents required consent and had to be for medical purposes as part of the medical record. Facility policies on confidentiality, residents’ rights, and dignity stated that unauthorized release, access, or disclosure of resident information, including video or audio, was prohibited and that staff must protect resident privacy and treat residents with dignity and respect. The videos received by the DSD did not show an altercation between the residents, and staff interviews confirmed that filming residents was not part of the facility’s “Stop and Watch” process, which instead required observation, intervention, and reporting of changes in condition or behaviors to nursing staff.
Plan Of Correction
This Plan of Correction is the facility's credible allegation of compliance. Preparation and/or execution of this plan of correction does not constitute admission or agreement by the provider of the truth or facts alleged, or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of federal and state law. F0583 Personal Privacy/Confidentiality of Records How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: Corrective actions were immediately implemented for Resident 1 and Resident 2 upon identification of the deficient practice. The facility initiated an investigation on 03/23/2026 and conducted immediate interviews with staff and residents utilizing structured interview tools to assess scope, impact, and additional potential concerns. Interviews confirmed the incident was isolated and no additional residents reported privacy violations or concerns. The staff members involved were removed from duty immediately. Following completion of the investigation, both employees were terminated in accordance with facility policy due to violation of resident rights, HIPAA, and facility confidentiality policies. Both employees completed formal Declarations and Attestations of Deletion of Unauthorized Recordings, confirming removal of all recordings and non-distribution of content. Documentation includes: Ashley Zelaya, CNA – Declaration executed 03/30/2026 at 9:21 AM, attesting deletion of all recordings and acknowledgment of policy violation Leslie Bram Reyes, CNA – Declaration executed 03/26/2026 at 10:42 AM, attesting deletion of all recordings and acknowledgment of policy violation Residents and/or responsible parties were notified. Social Services completed assessments with no identified psychosocial harm. All corrective actions were completed by 03/26/2026. How the facility identifies other residents having the potential to be affected by the same deficient practice and what corrective action will be taken. A facility-wide audit was initiated on 03/25/2026 using the Briarcrest Comprehensive Privacy, Recording, and Resident Rights Audit Tool. The audit included direct observation, staff interviews, and resident interviews to evaluate compliance with privacy practices, personal device use, and HIPAA requirements. Interviews were conducted using standardized staff and resident interview tools to ensure consistency and thoroughness in data collection. Findings from the audit confirmed that no additional residents were affected by the deficient practice and no additional incidents of unauthorized recording or disclosure were identified. Staff were immediately re-educated by Director and staff development on HIPAA Privacy Rule requirements, the facility's prohibition on personal device recordings, and the appropriate use of the Stop and Watch process for reporting changes in resident conditions. This corrective action was completed by 03/27/2026. What measures will be put into place or what systemic changes will the facility make to ensure that the deficient practice does not recur. The facility implemented systemic changes to prevent recurrence of the deficient practice by reinforcing a zero-tolerance policy for unauthorized recordings and strengthening staff accountability related to resident privacy and confidentiality. Staff completed mandatory re-training by the Director of Staff Development on Resident Rights, HIPAA, and Privacy/Confidentiality requirements. Staff were required to re-acknowledge facility policies related to confidentiality and personal device use. The facility implemented routine supervisory rounding to monitor compliance with personal device restrictions. In addition, the facility installed visible signage at the receptionist area clearly articulates that video recording is strictly prohibited inside resident rooms and in any facility areas where residents are present. The facility also posted signage throughout the entire facility, in both English and Spanish, indicating that video recording is not allowed to ensure clear communication to staff, visitors, and all individuals entering the facility. Privacy and HIPAA compliance were further integrated into new employee orientation, annual competencies, and ongoing in-service education. The Director of Staff Development completed initial re-education by 03/27/2026, and staff completed required training by 04/05/2026. How the facility plans to monitor its performance to make sure that solutions are sustained. To ensure sustained compliance, the facility incorporated privacy and confidentiality monitoring into its Quality Assurance and Performance Improvement (QAPI) program. The facility implemented an ongoing monitoring system beginning on 03/25/2026 utilizing the established audit tool, which confirmed that no additional residents were affected, and no further incidents occurred during the initial audit period. The facility will continue monitoring through weekly audits for four consecutive weeks, followed by monthly audits for three months. These audits will include direct observation of staff practices, verification of compliance with personal device policies, and evaluation of adherence to HIPAA and privacy requirements. Audit findings will be documented using standardized tools and reviewed by the Director of Nursing, with results reported to the Quality Assurance and Performance Improvement (QAPI) Committee for analysis and trending. If any issues are identified, immediate corrective action will be implemented, including re-education and progressive discipline as appropriate. If no trends or repeat deficiencies are identified after the monitoring period, the facility will discontinue routine auditing and remove the issue from active QAPI monitoring. Dates when corrective action will be completed. 4/17/2026
Failure to Implement Repositioning and Moisture Management for Stage 4 Pressure Injury
Penalty
Summary
The deficiency involves the facility’s failure to provide care and services to prevent deterioration of a stage 4 sacrococcygeal pressure injury in accordance with its own pressure injury prevention policy. The resident had a documented stage 4 PI of the sacral region, Parkinson’s disease, hypertension, moderate cognitive impairment, and required substantial/maximal assistance with toileting hygiene, rolling, and transfers. A Braden Scale score of 16 identified the resident as at risk for pressure injury. The Skilled Evaluation Nurse note indicated a pressure-reducing device for the bed but did not indicate that the resident was to be turned and repositioned every two hours. The resident’s care plan for the stage 4 sacrococcyx PI included cleansing with normal saline, applying Santyl ointment, and covering with dry and foam dressings daily, as well as providing pressure relief and a low air loss mattress to support body alignment and position. However, the care plan did not include an individualized repositioning schedule or education and reminders about the importance of repositioning. Documentation from the facility’s records showed that the resident was assisted to roll left and right every shift, but there was no documentation that the resident was turned and repositioned every two hours while in bed, nor was there documentation of the frequency of incontinence brief checks and changes after each episode. After the resident refused reinsertion of a Foley catheter, nursing progress notes documented the refusal but the IDT wound management conference record did not identify incontinence as a risk factor affecting healing of the stage 4 PI and did not document any new recommendations following the catheter refusal. A subsequent care plan addressing the resident’s potential for worsening condition related to non-compliance with Foley catheter reinsertion did not include wound protective measures or moisture-preventive interventions. During interviews, the treatment nurse acknowledged uncertainty about how often the resident was turned/repositioned or how frequently incontinence briefs were checked and changed, and confirmed that the care plan did not include measures to ensure turning at least every two hours or effective measures to protect the sacrococcyx PI. The DON stated that staff were supposed to ensure turning at least every two hours and protection of the wound dressing from incontinence, and that the IDT did not address this risk, so the care plan was not revised, despite facility policy requiring prompt cleaning after incontinence, use of barrier products, individualized repositioning schedules, and ongoing review of interventions for effectiveness.
Failure to Identify Fall Causes and Implement Supervision and Safety Interventions
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to keep the environment free from accident hazards and to provide adequate supervision and assistance devices to prevent accidents for a resident with significant fall risk. The resident had diagnoses including stage 4 sacral pressure ulcer, Parkinson’s disease, and hypertension, and was assessed as moderately cognitively impaired, with poor decision-making and a need for assistance with toileting, transfers, and ambulation. On one occasion, the resident was found on the floor at approximately 4:05 AM with a right forehead laceration requiring transfer to an acute care hospital for suturing. Following this first fall, the IDT Fall Management Follow-Up record listed interventions such as a medication regimen review, bed in lowest position, landing floor mat, and bed alarm, but there was no documented evidence identifying the cause of the fall. The resident’s care plan addressing strength and safety awareness deficits did not include supervision for safety despite poor safety awareness and not remembering to use the call light. The care plan for the actual fall with minor injury did not include ensuring that the bed alarm was functioning. Additionally, physician orders from 9/10/2025 to 1/29/2026 did not contain an order for a floor mat, despite this intervention being recommended in the IDT record. A second fall occurred at around 4:10 AM when the resident was again found on the floor next to the bed, holding a snack bag. The resident, described as alert but forgetful, stated that she had been trying to reach a snack bag on the bedside table and slid down from the bed, and redness was observed on the left side of the forehead after reportedly hitting the bedside table. The IDT Fall Management Follow-Up record for this second fall was incomplete, with no checked interventions. Interviews with the MDS nurse and DON confirmed that the IDT records should have identified the causes of the falls, that frequent monitoring and supervision were not care planned despite the resident’s cognitive impairment and poor safety awareness, and that the recommended floor mat was never ordered or applied, contrary to the facility’s own policies on assessing falls and developing comprehensive person-centered care plans.
Failure to Incorporate Resident Care Preferences Into Person-Centered Care Plan
Penalty
Summary
Surveyors identified a failure to develop a comprehensive person-centered care plan that incorporated a resident’s specific care preferences. The resident was readmitted on 8/31/2025 with multiple diagnoses, including metabolic encephalopathy, Alzheimer’s disease, blindness in the right eye, a history of TIA, and cerebral infarction without residual deficits. An MDS dated 10/30/2025 documented that the resident’s cognition was severely impaired and that the resident was dependent on staff for oral hygiene, toileting hygiene, personal hygiene, and movement. On 3/17/2026, the IDT met with a family member, who communicated specific care preferences for the resident. During interviews, the SSD and DSD confirmed that the family member had provided detailed care preferences at the 3/17/2026 IDT meeting, but a review of the resident’s care plans from 8/31/2025 to 3/31/2026 showed no documented care plan addressing those preferences. The DSD stated that a care plan should have been developed to reflect the resident’s care preferences, that it is the MDS nurse’s responsibility to develop the care plan, and that the absence of such a care plan could result in the preferences not being honored. The Administrator stated that the care plan is essential as it is used by staff as a guide to understand and implement the resident’s plan of care. The facility’s policy on Comprehensive Person-Centered Care Plans required the IDT to develop a comprehensive person-centered care plan with measurable objectives and time frames to meet identified needs, which was not done in this case.
Failure to Administer Oxygen Therapy as Ordered
Penalty
Summary
The deficiency involves the facility’s failure to administer oxygen therapy as ordered by the physician for a resident with COPD. The resident was admitted with chronic obstructive pulmonary disease and had severely impaired cognition, requiring total staff assistance for all ADLs and mobility. A physician’s order dated 3/27/2026 directed that the resident receive continuous supplemental oxygen at a fixed rate of 2 L/min, with no indication that staff could adjust the flow rate. The resident’s care plan for altered respiratory status related to COPD instructed staff to administer oxygen as ordered. On 3/31/2026, during observations at the bedside at 8:45 a.m. and 9:40 a.m., the resident was noted to be receiving oxygen at 3 L/min, which did not match the physician’s order. An LVN reported that the resident was on 3 L/min when he checked vital signs that morning and stated this was not the ordered rate; he said he reported this to the previous shift’s RN supervisor but was unsure what action was taken. Another RN supervisor confirmed there was no documentation in the record to support an increased flow rate or any notification to the physician about the change from 2 L/min to 3 L/min, and reiterated that the order was for a fixed rate of 2 L/min. During a concurrent observation and interview, the prior RN supervisor acknowledged the resident was on 3 L/min and that the flow rate needed to be corrected to match the order. The facility’s oxygen administration policy required staff to verify a physician order, document the flow rate and rationale, and report information per professional standards, which was not followed in this instance.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
