Rock Creek Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Auburn, California.
- Location
- 260 Racetrack Street, Auburn, California 95603
- CMS Provider Number
- 055446
- Inspections on file
- 31
- Latest survey
- January 23, 2026
- Citations (last 12 mo.)
- 8
Citation history
Health deficiencies cited at Rock Creek Care Center during CMS and state inspections, most recent first.
Surveyors found that kitchen and storage areas contained multiple expired and unlabeled food items, including cooked tomato sauce, raw meats, vegetables, and bread. The Dietary Services Supervisor and other staff confirmed these items were not properly labeled or discarded according to facility policy, and that some foods had been stored beyond recommended timeframes.
The facility failed to follow prescribed dietary menus, affecting residents on modified texture, NCS/CCHO, and 60g Protein Renal diets. Errors included incorrect bread and dessert items, and a lack of menu-specified vegetables and garnishes. The Dietary Supervisor and Registered Dietitian acknowledged these issues, citing kitchen errors and lack of communication with residents.
The facility failed to meet food safety standards, with issues including wet and dirty sheet pans, improperly stored and labeled food, an unclean ice machine, incorrect hot food cooling practices, and dietary aides lacking knowledge of dishwashing and sanitizer procedures. Additionally, the microwave for residents' food was found dirty.
The facility failed to ensure that two dietary aides were adequately trained in food safety procedures. The aides were unable to correctly verbalize the process of manual dishwashing and the correct concentration range for sanitizer solutions, as required by facility policy. This lack of knowledge was confirmed by the Dietary Supervisor and acknowledged by the Registered Dietitian, highlighting a deficiency in staff training and competency verification.
The facility failed to ensure call lights were within reach for two residents, both with severely impaired cognition and requiring assistance with daily activities. Observations showed that call lights were not accessible, despite care plans and facility policy indicating they should be. Staff confirmed the deficiency during interviews.
A resident admitted with diagnoses of adult failure to thrive and malnutrition was inaccurately assessed in their MDS, which failed to mark them as edentulous despite having no teeth. Observations and interviews confirmed the resident's edentulous status, and the MDS LVN admitted the error. The facility could not provide policies on assessment accuracy.
A CNA transferred a resident alone using a Hoyer lift, contrary to the facility's policy requiring two staff members for such transfers. The resident, who was non-weight bearing and required assistance from two or more staff for transfers, was at risk due to this action. The Director of Staff Development confirmed that two-person transfers are standard for safety.
A CNA failed to wear the required N95 mask when entering a COVID-19 positive resident's room, despite signage indicating droplet precautions. The resident was under isolation due to COVID-19, and the facility's policy required an N95 mask, which was not followed, leading to a deficiency in infection control.
The facility failed to provide the required 80 square feet per resident in 28 multiple-resident rooms, with space ranging from 70.47 to 78.93 square feet. While some residents reported no issues, one resident experienced difficulties with space when using a Hoyer lift, affecting care provision.
The facility failed to serve food at a palatable and safe temperature, affecting three residents who reported receiving cold meals. Incomplete temperature recordings and lack of a test tray temperature log were noted. The Dietary Manager was unaware of the need for temperature checks at the point of service, and the facility's policies for meal service and food transport were not effectively implemented.
A resident with osteoarthritis and muscle weakness was unable to reach her call light, as it was wrapped around the bed's side rail. Her roommate reported having to assist with the call light, and a CNA confirmed the inaccessibility. The facility's policy requires call lights to be within easy reach, which was not followed, potentially compromising the resident's safety.
A resident's surgical staples were not removed within the physician-ordered timeframe, leading to a deficiency in maintaining professional standards of quality. The staples, located on the resident's forehead, were ordered to be removed within 10-14 days but were removed late, increasing the risk of infection. Interviews with staff confirmed the oversight and the importance of adhering to physician orders.
A resident admitted with alcohol abuse did not receive chlordiazepoxide as ordered for three days, leading to uncomfortable symptoms during detoxification. The facility's Infection Preventionist confirmed the delay was unacceptable, and records showed the medication was awaiting pharmacy delivery.
The facility failed to maintain food service safety standards when dirty and uncleanable dishware was found in use and storage. Observations revealed mugs with residue in the dining room and unclean dishware in the kitchen. Staff acknowledged the need for cleanliness checks and disposal of unsanitary items, as per facility policy, to prevent potential food-borne illnesses.
Two residents in a facility did not receive the RNA program services as ordered, which were intended to maintain or improve their range of motion and strength. Despite being referred to the RNA program after completing physical therapy, documentation showed inconsistencies in the provision of services. The Director of Rehabilitation confirmed the referrals, and the Director of Nursing and Director of Staff Development were responsible for oversight. However, the RNA program was not implemented per physician's orders, with significant gaps in documented sessions, leading to potential declines in residents' range of motion and strength.
Failure to Properly Store and Label Food Items in Kitchen and Storage Areas
Penalty
Summary
Surveyors observed that the facility failed to properly store food in accordance with professional standards and its own policies. During an inspection of the kitchen's walk-in refrigerator and freezer, multiple food items were found to be either expired, unlabeled, or both. These included cooked tomato sauce, fresh parsley, raw chicken pieces, meat packages of raw hamburger, shredded red cabbage, and fresh spinach in the refrigerator, as well as an opened, unsealed, unlabeled, and undated package of veggie burgers in the freezer. The Dietary Services Supervisor (DSS) confirmed uncertainty regarding how long some of the meat products had been thawing and acknowledged that expired and unlabeled food should not be served. In the dry goods storage area, additional items such as hamburger buns and cinnamon bread were found to be unlabeled or past their recommended storage time, with both the DSS and another staff member confirming these items should have been labeled and were inedible. Interviews with the DSS and the Administrator confirmed that kitchen staff were not following facility procedures, which require all food items to be labeled, dated, and used or discarded within specified timeframes. Facility policies reviewed by surveyors outlined clear guidelines for the storage and labeling of refrigerated, frozen, and dry goods, including maximum storage times and the requirement to discard food past expiration dates. The failure to adhere to these procedures resulted in the storage of expired and unlabeled food items, creating the potential for foodborne illness among the facility's residents.
Failure to Follow Prescribed Dietary Menus
Penalty
Summary
The facility failed to adhere to the prescribed dietary menus for residents during a lunch meal service. Specifically, three residents on modified texture diets did not receive the appropriate wheat roll preparations as indicated on the menu. Additionally, two residents on a No Concentrated Sweets/Consistent Carbohydrate diet received wheat rolls contrary to their dietary restrictions. Furthermore, two residents on a 60-gram Protein Renal diet were served vanilla wafers instead of the specified cookies, and three residents received mashed potatoes and green beans instead of the planned rice and carrots. The dietary supervisor acknowledged these discrepancies, noting that some items were not prepared due to kitchen errors, such as not preparing enough rice and carrots and substituting vanilla wafers for cookies. The Registered Dietitian confirmed these issues, stating that the kitchen staff did not follow the standardized recipes, leading to insufficient preparation of certain menu items. The RD also mentioned that any substitutions should have been approved and communicated to the residents, which did not occur. Additionally, all meals were served without the parsley garnish as indicated on the menu. The facility's policy and procedure documents emphasize the importance of following prepared menus and portion control guides, as well as the necessity of adhering to standardized recipes. The failure to follow these guidelines resulted in the potential compromise of the medical and nutritional status of the residents.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as observed during a survey. Several metal sheet pans in the clean and ready-to-use storage areas were found stacked while still wet and contained food debris. This was confirmed by the Dietary Supervisor (DS) and Registered Dietician (RD), who acknowledged that dishes, pans, and pots should be completely air-dried and clean before being stored to prevent mold and bacteria growth. The facility's policy and procedure (P&P) on dishwashing indicated that dishes are to be air-dried before stacking and storing. Additionally, the facility did not properly manage opened food items in storage. Opened bags of elbow noodles and croutons were not tightly closed or labeled with open or use-by dates, and a package of hamburger meat patties was similarly unlabeled. The DS confirmed these findings and stated that opened packages should be wrapped tightly and labeled with dates. The facility's P&P on food storage and labeling required that opened food items be tightly closed, labeled, and dated. The facility also failed to maintain cleanliness and proper procedures in other areas. The ice machine had an orange slimy substance on the ice chute, which was dripping onto the ice, and the DS confirmed that the machine had not been cleaned as frequently as required. The hot food cool down process was not practiced correctly, with logs showing improper cooling times and temperatures. Dietary aides were unable to correctly verbalize the manual dishwashing process and the concentration of the sanitizer solution. Furthermore, the microwave used for residents' food was found to be dirty, with black dry food splashes inside.
Inadequate Training of Dietary Aides in Food Safety Procedures
Penalty
Summary
The facility failed to ensure that two dietary aides were adequately trained to safely and effectively carry out the functions of the food and nutrition services. Dietary Aides 1 and 2 were unable to correctly verbalize the process of manual dishwashing using three-compartment sinks. Specifically, DA 1 could not state the correct immersion time for the sanitizing step, while DA 2 incorrectly stated the immersion time as 20 seconds instead of the required 60 seconds. This discrepancy was confirmed by the Dietary Supervisor and was contrary to the facility's policy, which mandates a 60-second immersion time. Additionally, DA 1's competency audit indicated she was competent in the procedure, despite her inability to verbalize it correctly during the interview. Furthermore, DA 2 was unable to verbalize the correct concentration range for the sanitizer solution used in the sanitation bucket, which should be between 200-400 ppm. This lack of knowledge was confirmed by the Dietary Supervisor and acknowledged by the Registered Dietitian, who emphasized the importance of staff knowing the correct procedures to prevent food-borne illness. DA 2's employee file showed no completed competency audit or evidence of attending any in-service training for sanitation, which is a requirement according to the facility's job description for dietary aides.
Deficiency in Call Light Accessibility for Residents
Penalty
Summary
The facility failed to ensure that the call lights were within reach for two residents, leading to a deficiency in accommodating their needs and preferences. Resident 17, who was admitted with Parkinson's disease and muscle weakness, had severely impaired cognition and required assistance with activities of daily living. During an observation, it was noted that the call light was not within reach, and a licensed nurse confirmed that the resident would use the call light if it were available. The resident's care plan specifically indicated that the call light should be within reach and answered timely. Similarly, Resident 25, who was admitted with hemiplegia and hemiparesis following a cerebral infarction, also had severely impaired cognition and required substantial assistance with daily activities. Observations revealed that the call light was not within reach on two separate occasions, once when the resident was in bed and once when sitting in a reclining seat. Both the Director of Staff Development and a licensed nurse confirmed the call light was not accessible. The resident's fall risk care plan also indicated that the call light should be kept within reach. The facility's policy on answering call lights emphasized the importance of ensuring the call light is within easy reach of residents.
Inaccurate Dental Assessment for Resident
Penalty
Summary
The facility failed to ensure an accurate assessment for a resident, identified as Resident 22, who was admitted with multiple diagnoses including adult failure to thrive and malnutrition. The Minimum Data Set (MDS) for Resident 22, dated shortly after admission, inaccurately indicated that the resident had no memory problems and did not mark the resident as edentulous, despite the resident having all teeth missing. Observations and interviews confirmed that Resident 22 had no teeth and required dentures, information that was also communicated by the resident's responsible party during admission. The MDS Licensed Vocational Nurse acknowledged the inaccuracy in the MDS, attributing it to a mistake. The facility was unable to provide policies on the accuracy of assessments.
Inadequate Staffing for Hoyer Lift Transfer
Penalty
Summary
The facility failed to ensure that nursing staff had the necessary competencies and skill sets to meet the care and services for a resident when a Certified Nursing Assistant (CNA) transferred the resident by herself using a Hoyer lift. The resident, who was admitted with diagnoses including a fracture of the upper end of the right leg, muscle weakness, abnormalities in gait and mobility, and hemiplegia and hemiparesis following a cerebral infarction, required the assistance of two or more staff for chair/bed-to-chair transfers. The resident was also non-weight bearing on the right lower extremity, as indicated in the Minimum Data Set and Physical Therapy Evaluation. During an observation, the CNA was seen transferring the resident alone using the Hoyer lift, despite the facility's policy and procedure requiring at least two nursing assistants for such transfers. The CNA confirmed that she performed the transfer without additional staff assistance, acknowledging that Hoyer lift transfers should be done by two persons. The Director of Staff Development also stated that Hoyer lift transfers were always done by two persons for the safety of the residents, as part of training and education.
Inadequate PPE Usage for COVID-19 Positive Resident
Penalty
Summary
The facility failed to implement proper infection prevention and control practices for a resident diagnosed with COVID-19. The resident, who was admitted with diagnoses including COVID-19, moderate protein-calorie malnutrition, and muscle weakness, was placed under droplet precautions. Despite the presence of signage indicating the need for droplet precautions, a Certified Nursing Assistant (CNA) entered the resident's room wearing only a yellow surgical mask, instead of the required N95 mask, along with a gown and gloves. During an observation, the CNA acknowledged the mistake upon being reminded of the proper protocol. The facility's policy on transmission-based precautions required masks to be worn when entering rooms under droplet precautions. The Infection Preventionist confirmed that the signage indicated the need for an N95 mask, which was not adhered to by the CNA, leading to a deficiency in infection control practices.
Inadequate Room Size in Multiple-Resident Rooms
Penalty
Summary
The facility failed to ensure that 28 multiple-resident rooms met the required 80 square feet per resident. Measurements of these rooms revealed that the space per resident ranged from 70.47 to 78.93 square feet, which is below the regulatory requirement. This deficiency was identified through observations, interviews, and record reviews conducted during the survey. Despite the inadequate space, some residents reported having enough room for their belongings and did not express concerns about the room size. However, one resident reported difficulties due to the limited space, particularly when using a Hoyer lift for transfers. The resident mentioned that CNAs had to maneuver furniture, such as the bedside table, to accommodate the lift, which sometimes encroached on the roommate's space. This situation indicates that the limited room size could potentially hinder the provision of care, especially for residents requiring assistive devices. The Department recommended the continuation of a waiver for the affected rooms.
Deficiency in Serving Palatable and Properly Tempered Food
Penalty
Summary
The facility failed to provide palatable food at a safe and appetizing temperature for three of seven sampled residents, leading to dissatisfaction with meals. Residents reported that their meals were served cold, and this was confirmed through interviews and record reviews. Resident 3, who was admitted with multiple diagnoses including hemiparesis and moderate protein calorie malnutrition, reported that her breakfast was cold and could not be reheated. Resident 4, admitted with osteoarthritis and moderate protein calorie malnutrition, stated that her food was always cold, particularly the vegetables, and she was not eating well. Resident 7, with hemiparesis and diabetes, expressed that her meals were consistently cold, leading to weight loss. The facility's dietary management practices were inadequate, as evidenced by incomplete temperature recordings on the menus and the absence of a test tray temperature log. The Dietary Manager, who recently started working at the facility, acknowledged that she was not aware of the need to maintain a test tray temperature log and was only managing temperatures in the kitchen, not at the point of service to residents. The Director of Nursing and the Administrator confirmed that temperature monitoring was incomplete and that the previous cook had not documented food temperatures. The facility's policy and procedure for meal service required that food temperatures be taken prior to service and recorded on the daily therapeutic menu. However, this was not consistently done, as shown by missing temperature entries on multiple dates. Additionally, the policy for covering food during transport to maintain proper temperature was not effectively implemented, contributing to the issue of cold food being served to residents.
Resident's Call Light Inaccessibility
Penalty
Summary
The facility failed to accommodate the needs of a resident, identified as Resident 3, by not ensuring that her call light was within reach. Resident 3, who was admitted with multiple diagnoses including osteoarthritis and muscle weakness, had moderately impaired cognition as per the Minimum Data Set assessment. During an interview, Resident 2, who shared a room with Resident 3, reported that Resident 3 was unable to push the call light and often had to call out for help. Resident 2 also mentioned that she had to assist by pushing the call light for Resident 3 on multiple occasions. An observation confirmed that Resident 3 was lying in bed on her right side, facing the wall, with the call light wrapped around the left side rail, making it inaccessible. Certified Nursing Assistant 1 acknowledged that Resident 3 could not reach her call light, which could lead to potential risks such as falls if the resident attempted to move without assistance. The facility's policy on answering call lights and accommodating resident needs emphasized the importance of ensuring call lights are within easy reach and adapting the environment to meet individual needs, which was not adhered to in this case.
Failure to Follow Physician Orders for Staple Removal
Penalty
Summary
The facility failed to adhere to physician orders for a resident, resulting in a deficiency in maintaining professional standards of quality. The resident, who was admitted with multiple diagnoses including a fracture of the right lower leg and rhabdomyolysis, had surgical staples on the right side of the forehead. The physician's order specified that these staples should be removed within 10-14 days, between April 24 and April 28. However, the staples were not removed until May 3, which was beyond the ordered timeframe. Interviews with the Infection Preventionist and the Treatment Nurse confirmed the oversight. The Infection Preventionist stated that the treatment nurse is responsible for removing staples and emphasized the importance of following physician orders. The Treatment Nurse acknowledged the delay in removing the staples and recognized the associated risk of infection. The facility's policy mandates that licensed staff carry out physician orders as prescribed, which was not followed in this instance.
Delayed Medication Administration for Alcohol Withdrawal
Penalty
Summary
The facility failed to ensure timely pharmacy services for a resident who was admitted with multiple diagnoses, including alcohol abuse. Upon admission, the resident had a physician's order for chlordiazepoxide, a medication used to treat alcohol withdrawal symptoms. However, the resident did not receive the medication until three days after the order was placed. This delay was confirmed during an interview with the resident, who expressed concern about not receiving the medication needed for detoxification. The facility's Infection Preventionist acknowledged that a three-day delay in receiving medications is unacceptable and could lead to side effects. A review of the resident's records showed that the medication was not available in the emergency kit and was awaiting delivery from the pharmacy. The facility's policy requires licensed staff to carry out physician orders as prescribed, but this was not adhered to in this case, resulting in the resident experiencing uncomfortable symptoms during alcohol detoxification.
Failure to Maintain Food Service Safety Standards
Penalty
Summary
The facility failed to maintain professional standards for food service safety, as observed during a survey. During an observation in the main dining room, it was noted that three mugs available for resident use had brown and white residue stuck inside. The Activities Assistant confirmed the mugs were not clean and should not be used for residents, indicating a lapse in cleanliness standards. Additionally, in the kitchen, the Certified Dietary Manager identified a plastic cup with yellow residue and a bowl with white residue on the rack of ready-to-use dishware, confirming they were not clean and needed to be rewashed. Furthermore, a plastic cup with brown residue and two bowls with rough surfaces were deemed uncleanable and required disposal. The Dietary Aide, responsible for putting away dishware, acknowledged the expectation to check for cleanliness and stated that uncleanable dishware should be discarded, while dirty but cleanable items should be sent back for washing. The facility's policy on sanitation, dated 2023, mandates that unsightly, unsanitary, or hazardous dishware should be discarded. These observations and interviews highlight the facility's failure to adhere to its own sanitation policies, potentially exposing residents to food-borne illnesses due to the use of dirty dishware.
Failure to Implement RNA Program as Ordered
Penalty
Summary
The facility failed to provide appropriate treatment and services to two residents as part of the Restorative Nursing Assistant (RNA) program, which was intended to help maintain or improve their range of motion and strength. Resident 1, who was admitted with muscular dystrophy and multiple sclerosis, reported inconsistencies in receiving RNA program assistance, which was supposed to occur three times a week. Similarly, Resident 2, admitted with generalized muscle weakness and gait abnormalities, expressed uncertainty about the frequency of RNA sessions and noted infrequent assistance. Interviews and record reviews revealed that both residents were referred to the RNA program after completing physical therapy, as indicated in their PT discharge summaries. The Director of Rehabilitation confirmed the referrals, and the Director of Nursing (DON) and Director of Staff Development (DSD) were responsible for overseeing the RNA program. However, documentation showed that neither resident received RNA assistance as ordered, with significant gaps between documented sessions. The DSD confirmed the lack of documentation for refusals and acknowledged that undocumented sessions were not conducted. The facility's policy required certified and trained RNA staff to provide treatments per physician's orders, but this was not adhered to. The RNA 1 confirmed that if RNA assistance was not documented, it was not performed. The failure to implement the RNA program as ordered had the potential to result in declines in range of motion and strength for the affected residents.
Latest citations in California
Two residents with dementia, schizoaffective disorder, and major depressive disorder, both with moderately impaired cognition and needing moderate ADL assistance, were found unclothed together in one resident's bed. One resident later stated she did not want sexual activity and did not consent, while the other resident could not recall the encounter. An LVN reported that both residents verbally consented at the time but acknowledged no assessment had been done to determine their capacity to consent to sexual activity. The DON identified the incident as sexual abuse and confirmed that allowing sexual activity without prior capacity assessment was inconsistent with facility policy and that the resident was not protected from sexual abuse.
Two residents with dementia, schizoaffective disorder, major depressive disorder, and moderately impaired cognition, both needing moderate assistance with ADLs, were found unclothed together in one resident’s bed. The resident later stated she did not consent to sexual contact, while the other resident did not recall any sexual activity. An LVN documented the incident and acknowledged it constituted sexual abuse that should have been reported immediately to the abuse coordinator and appropriate agencies, but did not report it. The administrator, who serves as the abuse coordinator, stated she relies on staff to notify her immediately of such allegations so they can be reported to CDPH, law enforcement, and the Ombudsman, but this did not occur, resulting in the allegation not being reported as required.
A resident with Parkinson’s disease, osteoporosis, and osteoarthritis reported being punched in the face by another resident, resulting in facial bruising. The resident’s MDS showed intact cognition, and a change in condition evaluation documented the assault; however, the MD was not notified until more than a day later. The care plan directed licensed nurses to assess the resident’s body, and staff observed a purplish bruise on the right lower eyelid/orbital area, but this was not documented in the progress notes. Required every-shift monitoring for 72 hours after the change in condition was not documented on multiple day shifts. The DON confirmed lack of awareness of the bruise and acknowledged missing documentation and monitoring, despite facility policies requiring immediate provider notification and complete, accurate charting of changes in condition.
A nurse left a medication cart unlocked and unattended in the hallway while administering insulin to a resident with diabetes, cardiac, and post-surgical conditions. The cart was out of the nurse's direct line of sight, contrary to facility policy requiring medication carts to be locked when not in use. The DON confirmed that medications should be secured to prevent unauthorized access.
A resident’s legal representative requested copies of the resident’s medical records through a faxed request from a law office’s third-party service, but the records were not provided within the required timeframe. The MRD confirmed receiving the request and stated he had forwarded the documents to the DON for review over a month earlier and had not received them back to release. Upon review of federal requirements for record access, the ADON acknowledged that the facility did not comply with the regulation requiring provision of copies within two working days of request.
Two CNAs violated privacy and confidentiality requirements when one CNA used a personal cell phone to record and photograph two residents during a perceived altercation and then sent the video to another CNA. The residents, who had significant medical conditions including paraplegia, seizures, dysphagia, and severe cognitive impairment, were dependent on staff for ADLs. The second CNA reported that a family member later took her phone without permission, accessed the contents, and transmitted the videos and photos to facility leadership. Facility staff, including an LVN, the DSD, and the administrator, stated that HIPAA rules and facility policies prohibit staff from recording residents on personal devices and allow resident photographs only with consent and for medical purposes as part of the chart, and that the facility’s "Stop and Watch" process requires observation and reporting, not filming.
A resident with a stage 4 sacrococcygeal PI, Parkinson’s disease, hypertension, moderate cognitive impairment, and high assistance needs was not provided care consistent with the facility’s pressure injury prevention policy. Although the care plan included daily wound treatment and use of a LAL mattress, it lacked an individualized repositioning schedule and did not document education or reminders about repositioning. Facility documentation showed only that the resident was assisted to roll each shift, with no evidence of q2h turning in bed or of how often incontinence briefs were checked and changed. After the resident refused Foley catheter reinsertion, the IDT did not identify incontinence as a risk factor or add new wound-protective or moisture-preventive interventions, and the subsequent care plan for non-compliance omitted such measures. The TXN and DON confirmed that repositioning and protection of the wound from incontinence were not clearly implemented or reflected in the care plan, despite policy requirements.
A resident with Parkinson’s disease, cognitive impairment, and significant assistance needs for mobility and toileting experienced two early-morning falls resulting in head injuries. After the first fall, the IDT documented potential interventions such as a bed alarm and floor mat but did not identify the cause of the fall, did not obtain a physician order for the floor mat, and did not ensure the care plan addressed supervision or bed alarm function. Before and after the falls, the care plan lacked interventions for supervision despite poor safety awareness and failure to use the call light, and the second fall occurred when the resident slid from bed while reaching for a snack bag placed on the bedside table. IDT follow-up documentation for the second fall was incomplete, and staff acknowledged that fall causes were not identified and resident-centered interventions were not fully implemented.
A resident with severe cognitive impairment and multiple neurological diagnoses was dependent on staff for hygiene and mobility. During an IDT meeting, the resident’s family member communicated specific care preferences, but facility staff did not develop or update a comprehensive person-centered care plan to include these preferences. Review of care plans over several months showed no documentation of the communicated preferences, despite facility policy requiring the IDT to create a measurable, time-framed care plan based on assessed needs and expressed preferences.
A resident with COPD and severely impaired cognition, dependent on staff for all ADLs and mobility, had a physician order for continuous supplemental O2 at a fixed rate of 2 L/min. During observations, the resident was found receiving O2 at 3 L/min. An LVN recognized the discrepancy and reported it to an RN supervisor, but there was no documentation of any clinical rationale for the increased flow, no physician notification, and no order change. The care plan directed staff to administer O2 as ordered, and facility policy required verification of the order, documentation of flow rate and rationale, and appropriate reporting, which were not followed.
Failure to Protect Cognitively Impaired Resident From Sexual Abuse
Penalty
Summary
The facility failed to ensure a resident was free from sexual abuse when two cognitively impaired residents were found unclothed together in one resident's bed without prior assessment of their capacity to consent to sexual activity. One resident had dementia, schizoaffective disorder, and major depressive disorder, with documentation of fluctuating capacity to understand and make decisions and a Minimum Data Set (MDS) indicating moderately impaired cognition and a need for moderate assistance with ADLs. During an interview at her bedside, this resident stated she did not want to engage in sexual activity and did not consent to sexual contact with the other resident. The second resident involved also had dementia, schizoaffective disorder, and major depressive disorder, with an MDS showing moderately impaired cognition and a need for moderate assistance with ADLs. In an interview, he stated he liked women and liked to socialize with women but could not recall whether he engaged in sexual activity with the first resident. An LVN reported observing both residents unclothed in the first resident's bed and stated that, at the time of the incident, both residents verbally consented to sexual activity, but she was not aware of any assessment having been performed to determine either resident's capacity to consent. The DON stated the incident was considered sexual abuse, that it was not the facility's practice to allow sexual activity without appropriate assessment, and that the facility failed to ensure the resident was protected from sexual abuse, contrary to the facility's abuse prevention policy.
Failure to Report Alleged Sexual Abuse Between Cognitively Impaired Residents
Penalty
Summary
The deficiency involves the facility’s failure to report an allegation of sexual abuse between two residents to the State Survey Agency, Ombudsman, and local law enforcement as required by federal regulations and the facility’s own abuse reporting policy. A nurse documented that one resident (Resident 2) and another resident (Resident 4) were found unclothed together in Resident 2’s bed, and the nurse acknowledged that this situation constituted sexual abuse and should have been reported immediately to the abuse coordinator and appropriate agencies, but she did not report the incident. The facility’s policy stated that all staff are mandated reporters and must notify appropriate authorities within two hours of becoming aware of abuse and immediately notify the Abuse Prevention Coordinator and their supervisor. Resident 2 had dementia, schizoaffective disorder, major depressive disorder, fluctuating capacity to understand and make decisions, and moderately impaired cognition, and required moderate assistance with ADLs. During an interview at her bedside, Resident 2 stated she did not consent to sexual contact with Resident 4. Resident 4 also had dementia, schizoaffective disorder, major depressive disorder, moderately impaired cognition, and required moderate assistance with ADLs, and stated he did not recall engaging in sexual activity with any residents. The Administrator, who served as the abuse coordinator, stated she was responsible for reporting all abuse allegations to CDPH, law enforcement, and the Ombudsman, and that staff were responsible for notifying her immediately of sexual abuse allegations so they could be reported and investigated. The failure of staff to notify the Administrator and report the incident resulted in the sexual abuse allegation not being reported as required, causing a delay in an onsite investigation by CDPH.
Failure to Assess, Notify, and Monitor Resident After Facial Trauma
Penalty
Summary
The deficiency involves the facility’s failure to follow professional standards of nursing practice in assessing and monitoring a resident after a reported change of condition related to facial trauma. The resident was admitted with Parkinson’s disease, age-related osteoporosis, and osteoarthritis, and had intact cognitive skills for daily decision-making per a recent MDS. On the evening of 3/26/2026, a Change in Condition Evaluation documented that another resident hit this resident on the nose and both cheeks. The evaluation showed that the attending physician was not notified until 10 p.m. on 3/27/2026, approximately 26.5 hours after the reported incident, and the physician’s recommendation was to monitor the resident’s nose and cheeks for any changes and pain. The resident’s care plan, initiated on 3/26/2026, documented the report that another resident hit him on the nose and both cheeks and included an intervention for licensed nurses to check and assess the resident’s body. In an interview, the resident described that the other resident came into the room, stood on the left side of the bed, and punched him in the face. A photograph taken two days after the alleged incident showed a purplish-blue bruise on the right lower orbital area, although the resident declined to provide a copy of the picture. A CNA later reported observing a purple bruise on the resident’s right lower eyelid on 3/27/2026, described as extending from the inner to the middle lower eyelid and about the size of the tip of her fifth digit. During record review and interviews, an LVN stated that on 3/27/2026 the resident’s right lower eyelid had a dime-sized purplish bruise, but there was no documentation of this bruise in the progress notes. The LVN also stated that the resident should have been monitored every shift for 72 hours after the change of condition, yet there was no documented evidence of monitoring on the 7 a.m. to 3 p.m. shifts on 3/27/2026, 3/28/2026, and 3/29/2026. The DON reported not being made aware of the right eyelid bruise, confirmed that the resident should have been monitored every shift for at least 72 hours following the change of condition, and acknowledged there was no confirmed documentation of monitoring on the identified shifts. Facility policies required immediate physician consultation for significant changes in condition and complete, accurate documentation of changes and services provided, but the facility failed to identify, document, and monitor the resident’s change of condition in accordance with these policies.
Plan Of Correction
Facility Response Submission of the Plan of Correction does not constitute admission or agreement by the Provider of the truth of the facts alleged or conclusion set forth in this statement of deficiencies. The Plan of Correction is prepared and/or executed solely because it is required by the provision of Federal and State laws. This Plan of Correction constitutes the facility's credible allegation of compliance Corrective Action On 4/7/2026 Resident 1 was reassessed by LVN 3 and no skin issue was identified. On 4/7/2026 LVN 3 received one-on-one in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. Identification of other residents and corrective action On 4/8/2026 DON and/or designee reviewed audits provided by medical records for all change of condition in month of April to ensure proper documentation and monitoring are in place. No other deficient practice noted. Measures to prevent recurrence On 4/7/2026 LVN 3 received one-on-one in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. On 4/8/2026 Licensed nurses received in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. Monitoring and incorporation into the QA system HID will audit change of conditions using Change of Condition Audit form daily Monday-Friday and will report any finding during daily stand-up meeting Monday-Friday on-going. DON or designee will review change of conditions from prior day during daily clinical meetings (Monday -Friday) on going to ensure the nurse notified the attending physician regarding resident's significant change of condition and documented. Any deficient finding will be reported to DON and/or administrator for further corrective action/recommendation. Any trend of deficient finding(s) will be documented on Change of Condition Audit Form and will be reviewed during the monthly QA meeting for further review and/or recommendation(s). Administrator who will then report to the Quality Assurance (QA) team during monthly Quality Assurance (QA)/Quality Assurance and Performance Improvement (QAPI) for further evaluation/recommendation and to provide feedback and program modification if needed x3 months or until compliant. Date Corrective action to be completed: 4/8/2026
Medication Cart Left Unlocked During Medication Pass
Penalty
Summary
During a medication pass for a resident with a history of surgical aftercare, cardiac arrest, heart failure, and type 2 diabetes mellitus, a licensed nurse prepared and administered Novolog insulin using a pen-injector. The nurse left the medication cart unlocked and unattended in the hallway, approximately two feet outside the resident's bedroom doorway, while administering the injection inside the room. The cart was out of the nurse's direct line of sight during this time. The nurse acknowledged that the cart was left unlocked and should have been secured when not in direct view. Facility policy and procedure documents reviewed indicated that medication carts must be kept closed and locked when out of sight of the medication nurse or aide, and that compartments containing drugs and biologicals are to be locked when not in use. The Director of Nursing confirmed that medications should be locked and secured to prevent unauthorized access by unlicensed staff and residents. The failure to lock the medication cart during the medication pass was observed and confirmed through interviews and record review.
Plan Of Correction
From 4/4/2025 through 4/7/2025, the DON, DSD, and ADSD completed 1:1 inservices with licensed staff regarding the facility policy and procedure titled Storage of Medications. Medication carts must be kept locked when unattended. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 3 times a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 2 times a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 1 time a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will random monitor medication carts being locked when unattended for 1 month. System effectiveness will be evaluated during the facility's monthly Quality Assurance Performance Improvement Committee meetings for three (3) months.
Failure to Timely Provide Resident Medical Records Upon Request
Penalty
Summary
The facility failed to provide timely access to medical records as required under 42 CFR 483.10(g)(2) for one resident. The resident’s face sheet showed an admission date of November 18, 2025, with multiple diagnoses, but no additional clinical details were provided. A legal representative’s office faxed an initial request for the resident’s medical records on February 26, 2026. As of March 26, 2026, the legal representative’s staff reported that the office had not yet received the requested records from the facility. On April 2, 2026, the Medical Record Director (MRD) confirmed documentation that a third-party service for the law office had requested the resident’s medical records on February 26, 2026. The MRD stated he had submitted the requested documents to the Director of Nursing (DON) for review over a month prior but had not received them back to proceed with releasing the records. During a concurrent interview and record review, the Assistant Director of Nursing (ADON) reviewed the State Operations Manual Appendix PP guidance on residents’ rights to access personal and medical records, which requires that copies be provided within two working days of request. The ADON acknowledged that this regulatory requirement was not followed by the facility.
Plan Of Correction
F0573 Right to Access/Purchase Copies of Records What corrective action(s) will be accomplished for those Residents found to have been affected by the deficient practice? Medical Records Director (MRD) released medical records for Resident 1 as requested by the legal representative (Legal Staff) on April 21, 2026. How will other individuals with the potential to be affected by this deficient practice be identified and protected? No other Resident was identified to have been effected by the deficient practice. What systemic changes will be implemented to ensure that the deficient practice does not recur? The Quality Assurance Committee met on April 14, 2026 to review the Policy and Procedure which was then forwarded to the Knolls West Post Acute legal team for further evaluation. Revision of the policy will be discussed and approved by the Quality Assurance Committee to ensure the facility meets all Federal and State Regulations. F0573 Right to Access/Purchase Copies of Records (CONT.)The Administrator and the Medical Records Director (MRD) are responsible for informing the requesting party for the demand for payment for the requested medical documentation being provided and until payment is received the facility will hold the chart copies.How corrective action(s) will be monitored to ensure solutions are being achieved and sustainedThe Resident's Responsible Party will be notified upon receipt of the Medical Records Request and review in the presence of the facility representative. Records will be provided if it does not pertain to any legal matters after payment is received. The Administrator and/or Designee is responsible for reporting to the Quality Assurance Committee on a monthly basis and monitoring to ensure that corrective action is implemented and evaluated for its effectiveness. The same will be reviewed on a quarterly basis to the Quality Assurance Committee meeting x 3 quarters or until 100% compliance is achieved and sustained.Date of CompletionApril 23, 2026
Unauthorized Resident Recording and Disclosure Violating Privacy and Confidentiality
Penalty
Summary
The deficiency involves a failure to protect residents’ privacy and confidentiality when a CNA used a personal cell phone to record and photograph two residents without their knowledge or consent, and then shared that content with another CNA. One resident had paraplegia, depression, muscle weakness, dorsalgia, and polyneuropathy, was cognitively intact, and dependent on staff for ADLs. The other resident had diagnoses including seizures, dysphagia, acute kidney dysfunction, and muscle weakness, was able to make needs known but could not make medical decisions, had severely impaired decision-making, and was also dependent on staff for ADLs. Both residents were therefore in a position of dependence on staff for care at the time of the incident. According to CNA 2, on a specific date she recorded a video of the two residents because one resident started an altercation with the other. She stated she recorded the incident for “evidence” and to show CNA 1, acknowledging that recording residents was not part of facility policy and that she should not have recorded or taken photographs of them. CNA 1 confirmed that she received the video on her personal cell phone from CNA 2 and stated that the recording was made for “safety purposes” due to a situation that was perceived as potentially escalating to physical aggression. CNA 1 reported that she did not share or post the video on social media or distribute it to others, but that a family member took her phone without permission and accessed its contents. CNA 1 further stated that this family member sent the video and pictures of the two residents to the facility, and that she notified the facility that her phone had been taken but did not disclose that it contained videos or photographs of the residents because she was unaware that the family member had accessed or distributed them. The DSD reported receiving a text message from an unknown number containing approximately two videos and an undetermined number of photographs of the two residents, along with the names of CNA 1 and CNA 2. The DSD, LVN 2, and the Administrator each stated that staff were required to follow HIPAA regulations, that staff were not permitted to record or possess videos or photographs of residents on personal devices, and that any photographs of residents required consent and had to be for medical purposes as part of the medical record. Facility policies on confidentiality, residents’ rights, and dignity stated that unauthorized release, access, or disclosure of resident information, including video or audio, was prohibited and that staff must protect resident privacy and treat residents with dignity and respect. The videos received by the DSD did not show an altercation between the residents, and staff interviews confirmed that filming residents was not part of the facility’s “Stop and Watch” process, which instead required observation, intervention, and reporting of changes in condition or behaviors to nursing staff.
Plan Of Correction
This Plan of Correction is the facility's credible allegation of compliance. Preparation and/or execution of this plan of correction does not constitute admission or agreement by the provider of the truth or facts alleged, or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of federal and state law. F0583 Personal Privacy/Confidentiality of Records How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: Corrective actions were immediately implemented for Resident 1 and Resident 2 upon identification of the deficient practice. The facility initiated an investigation on 03/23/2026 and conducted immediate interviews with staff and residents utilizing structured interview tools to assess scope, impact, and additional potential concerns. Interviews confirmed the incident was isolated and no additional residents reported privacy violations or concerns. The staff members involved were removed from duty immediately. Following completion of the investigation, both employees were terminated in accordance with facility policy due to violation of resident rights, HIPAA, and facility confidentiality policies. Both employees completed formal Declarations and Attestations of Deletion of Unauthorized Recordings, confirming removal of all recordings and non-distribution of content. Documentation includes: Ashley Zelaya, CNA – Declaration executed 03/30/2026 at 9:21 AM, attesting deletion of all recordings and acknowledgment of policy violation Leslie Bram Reyes, CNA – Declaration executed 03/26/2026 at 10:42 AM, attesting deletion of all recordings and acknowledgment of policy violation Residents and/or responsible parties were notified. Social Services completed assessments with no identified psychosocial harm. All corrective actions were completed by 03/26/2026. How the facility identifies other residents having the potential to be affected by the same deficient practice and what corrective action will be taken. A facility-wide audit was initiated on 03/25/2026 using the Briarcrest Comprehensive Privacy, Recording, and Resident Rights Audit Tool. The audit included direct observation, staff interviews, and resident interviews to evaluate compliance with privacy practices, personal device use, and HIPAA requirements. Interviews were conducted using standardized staff and resident interview tools to ensure consistency and thoroughness in data collection. Findings from the audit confirmed that no additional residents were affected by the deficient practice and no additional incidents of unauthorized recording or disclosure were identified. Staff were immediately re-educated by Director and staff development on HIPAA Privacy Rule requirements, the facility's prohibition on personal device recordings, and the appropriate use of the Stop and Watch process for reporting changes in resident conditions. This corrective action was completed by 03/27/2026. What measures will be put into place or what systemic changes will the facility make to ensure that the deficient practice does not recur. The facility implemented systemic changes to prevent recurrence of the deficient practice by reinforcing a zero-tolerance policy for unauthorized recordings and strengthening staff accountability related to resident privacy and confidentiality. Staff completed mandatory re-training by the Director of Staff Development on Resident Rights, HIPAA, and Privacy/Confidentiality requirements. Staff were required to re-acknowledge facility policies related to confidentiality and personal device use. The facility implemented routine supervisory rounding to monitor compliance with personal device restrictions. In addition, the facility installed visible signage at the receptionist area clearly articulates that video recording is strictly prohibited inside resident rooms and in any facility areas where residents are present. The facility also posted signage throughout the entire facility, in both English and Spanish, indicating that video recording is not allowed to ensure clear communication to staff, visitors, and all individuals entering the facility. Privacy and HIPAA compliance were further integrated into new employee orientation, annual competencies, and ongoing in-service education. The Director of Staff Development completed initial re-education by 03/27/2026, and staff completed required training by 04/05/2026. How the facility plans to monitor its performance to make sure that solutions are sustained. To ensure sustained compliance, the facility incorporated privacy and confidentiality monitoring into its Quality Assurance and Performance Improvement (QAPI) program. The facility implemented an ongoing monitoring system beginning on 03/25/2026 utilizing the established audit tool, which confirmed that no additional residents were affected, and no further incidents occurred during the initial audit period. The facility will continue monitoring through weekly audits for four consecutive weeks, followed by monthly audits for three months. These audits will include direct observation of staff practices, verification of compliance with personal device policies, and evaluation of adherence to HIPAA and privacy requirements. Audit findings will be documented using standardized tools and reviewed by the Director of Nursing, with results reported to the Quality Assurance and Performance Improvement (QAPI) Committee for analysis and trending. If any issues are identified, immediate corrective action will be implemented, including re-education and progressive discipline as appropriate. If no trends or repeat deficiencies are identified after the monitoring period, the facility will discontinue routine auditing and remove the issue from active QAPI monitoring. Dates when corrective action will be completed. 4/17/2026
Failure to Implement Repositioning and Moisture Management for Stage 4 Pressure Injury
Penalty
Summary
The deficiency involves the facility’s failure to provide care and services to prevent deterioration of a stage 4 sacrococcygeal pressure injury in accordance with its own pressure injury prevention policy. The resident had a documented stage 4 PI of the sacral region, Parkinson’s disease, hypertension, moderate cognitive impairment, and required substantial/maximal assistance with toileting hygiene, rolling, and transfers. A Braden Scale score of 16 identified the resident as at risk for pressure injury. The Skilled Evaluation Nurse note indicated a pressure-reducing device for the bed but did not indicate that the resident was to be turned and repositioned every two hours. The resident’s care plan for the stage 4 sacrococcyx PI included cleansing with normal saline, applying Santyl ointment, and covering with dry and foam dressings daily, as well as providing pressure relief and a low air loss mattress to support body alignment and position. However, the care plan did not include an individualized repositioning schedule or education and reminders about the importance of repositioning. Documentation from the facility’s records showed that the resident was assisted to roll left and right every shift, but there was no documentation that the resident was turned and repositioned every two hours while in bed, nor was there documentation of the frequency of incontinence brief checks and changes after each episode. After the resident refused reinsertion of a Foley catheter, nursing progress notes documented the refusal but the IDT wound management conference record did not identify incontinence as a risk factor affecting healing of the stage 4 PI and did not document any new recommendations following the catheter refusal. A subsequent care plan addressing the resident’s potential for worsening condition related to non-compliance with Foley catheter reinsertion did not include wound protective measures or moisture-preventive interventions. During interviews, the treatment nurse acknowledged uncertainty about how often the resident was turned/repositioned or how frequently incontinence briefs were checked and changed, and confirmed that the care plan did not include measures to ensure turning at least every two hours or effective measures to protect the sacrococcyx PI. The DON stated that staff were supposed to ensure turning at least every two hours and protection of the wound dressing from incontinence, and that the IDT did not address this risk, so the care plan was not revised, despite facility policy requiring prompt cleaning after incontinence, use of barrier products, individualized repositioning schedules, and ongoing review of interventions for effectiveness.
Failure to Identify Fall Causes and Implement Supervision and Safety Interventions
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to keep the environment free from accident hazards and to provide adequate supervision and assistance devices to prevent accidents for a resident with significant fall risk. The resident had diagnoses including stage 4 sacral pressure ulcer, Parkinson’s disease, and hypertension, and was assessed as moderately cognitively impaired, with poor decision-making and a need for assistance with toileting, transfers, and ambulation. On one occasion, the resident was found on the floor at approximately 4:05 AM with a right forehead laceration requiring transfer to an acute care hospital for suturing. Following this first fall, the IDT Fall Management Follow-Up record listed interventions such as a medication regimen review, bed in lowest position, landing floor mat, and bed alarm, but there was no documented evidence identifying the cause of the fall. The resident’s care plan addressing strength and safety awareness deficits did not include supervision for safety despite poor safety awareness and not remembering to use the call light. The care plan for the actual fall with minor injury did not include ensuring that the bed alarm was functioning. Additionally, physician orders from 9/10/2025 to 1/29/2026 did not contain an order for a floor mat, despite this intervention being recommended in the IDT record. A second fall occurred at around 4:10 AM when the resident was again found on the floor next to the bed, holding a snack bag. The resident, described as alert but forgetful, stated that she had been trying to reach a snack bag on the bedside table and slid down from the bed, and redness was observed on the left side of the forehead after reportedly hitting the bedside table. The IDT Fall Management Follow-Up record for this second fall was incomplete, with no checked interventions. Interviews with the MDS nurse and DON confirmed that the IDT records should have identified the causes of the falls, that frequent monitoring and supervision were not care planned despite the resident’s cognitive impairment and poor safety awareness, and that the recommended floor mat was never ordered or applied, contrary to the facility’s own policies on assessing falls and developing comprehensive person-centered care plans.
Failure to Incorporate Resident Care Preferences Into Person-Centered Care Plan
Penalty
Summary
Surveyors identified a failure to develop a comprehensive person-centered care plan that incorporated a resident’s specific care preferences. The resident was readmitted on 8/31/2025 with multiple diagnoses, including metabolic encephalopathy, Alzheimer’s disease, blindness in the right eye, a history of TIA, and cerebral infarction without residual deficits. An MDS dated 10/30/2025 documented that the resident’s cognition was severely impaired and that the resident was dependent on staff for oral hygiene, toileting hygiene, personal hygiene, and movement. On 3/17/2026, the IDT met with a family member, who communicated specific care preferences for the resident. During interviews, the SSD and DSD confirmed that the family member had provided detailed care preferences at the 3/17/2026 IDT meeting, but a review of the resident’s care plans from 8/31/2025 to 3/31/2026 showed no documented care plan addressing those preferences. The DSD stated that a care plan should have been developed to reflect the resident’s care preferences, that it is the MDS nurse’s responsibility to develop the care plan, and that the absence of such a care plan could result in the preferences not being honored. The Administrator stated that the care plan is essential as it is used by staff as a guide to understand and implement the resident’s plan of care. The facility’s policy on Comprehensive Person-Centered Care Plans required the IDT to develop a comprehensive person-centered care plan with measurable objectives and time frames to meet identified needs, which was not done in this case.
Failure to Administer Oxygen Therapy as Ordered
Penalty
Summary
The deficiency involves the facility’s failure to administer oxygen therapy as ordered by the physician for a resident with COPD. The resident was admitted with chronic obstructive pulmonary disease and had severely impaired cognition, requiring total staff assistance for all ADLs and mobility. A physician’s order dated 3/27/2026 directed that the resident receive continuous supplemental oxygen at a fixed rate of 2 L/min, with no indication that staff could adjust the flow rate. The resident’s care plan for altered respiratory status related to COPD instructed staff to administer oxygen as ordered. On 3/31/2026, during observations at the bedside at 8:45 a.m. and 9:40 a.m., the resident was noted to be receiving oxygen at 3 L/min, which did not match the physician’s order. An LVN reported that the resident was on 3 L/min when he checked vital signs that morning and stated this was not the ordered rate; he said he reported this to the previous shift’s RN supervisor but was unsure what action was taken. Another RN supervisor confirmed there was no documentation in the record to support an increased flow rate or any notification to the physician about the change from 2 L/min to 3 L/min, and reiterated that the order was for a fixed rate of 2 L/min. During a concurrent observation and interview, the prior RN supervisor acknowledged the resident was on 3 L/min and that the flow rate needed to be corrected to match the order. The facility’s oxygen administration policy required staff to verify a physician order, document the flow rate and rationale, and report information per professional standards, which was not followed in this instance.
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