Rosewood Health Facility
Inspection history, citations, penalties and survey trends for this long-term care facility in Bakersfield, California.
- Location
- 1401 New Stine Road, Bakersfield, California 93309
- CMS Provider Number
- 555116
- Inspections on file
- 36
- Latest survey
- February 12, 2026
- Citations (last 12 mo.)
- 16
Citation history
Health deficiencies cited at Rosewood Health Facility during CMS and state inspections, most recent first.
A resident with high risk for pressure injuries, total dependence on staff for mobility and hygiene, and repeated refusals to turn or reposition did not have a care plan that addressed these refusals. As a result, the resident developed an unstageable pressure injury and a deep tissue injury, both acquired in-house, due to the facility's failure to update the care plan with appropriate interventions.
A resident with a history of falls and dementia was removed from 1:1 monitoring without an IDT meeting or updated fall risk assessment, leading to an unwitnessed fall and fracture. The facility did not follow its policies for care planning and fall prevention, resulting in inadequate supervision and the resident's injury.
A resident with a history of cellulitis was observed with a significant skin condition, including raised, reddened, scaly skin on her neck and shoulder. Despite the condition and the resident's behavior of scratching, facility staff failed to notify the medical doctor promptly. The LVN, CNA, and TXN did not take appropriate action, and the condition was only identified as potentially serious by the DON. The delay in care resulted in a diagnosis of cellulitis and antibiotic treatment.
The facility failed to follow its Water Management Program when the cooling tower tested positive for Legionella, a bacteria causing lung infections. Despite treatment of the water, staff were not in-serviced on Legionella, and the facility did not fully adhere to its policy of identifying and testing residents for Legionella. This oversight potentially exposed residents, visitors, and staff to the bacteria.
A facility failed to update the care plan for a non-verbal resident with significant mobility issues, resulting in Moisture Associated Skin Damage (MASD). The care plan, last revised in September, did not reflect the need for repositioning every two hours after the resident was diagnosed with MASD in October. This oversight was confirmed by the DON, who acknowledged the necessity for more frequent repositioning to prevent skin breakdown.
A resident with a catheter due to kidney stones experienced pain and discomfort, which was not promptly assessed by the responsible LVN. Despite the resident's complaints, the LVN did not investigate the cause of the discomfort and only administered Tylenol. The Treatment Nurse later replaced the leaking catheter, alleviating the resident's pain. The facility's policy required immediate reporting and assessment of such issues, which was not followed.
The facility failed to follow its medication labeling and storage policy, as medications were found at the bedside of two residents without proper assessments or orders, and expired insulin vials were discovered on two medication carts. These deficiencies were confirmed by LVNs and the ADON.
The facility failed to obtain complete informed consent for psychotherapeutic drugs for two residents. One resident received Temazepam without the necessary signatures from a Resident Representative and a facility representative. Another resident's consent forms for Temazepam and Mirtazapine were incomplete. Staff interviews confirmed the deficiencies, and the facility's policy requires signed consent before treatment.
A resident's pain was not controlled due to the facility's failure to administer physician-ordered Glucosamine-Chondroitin tablets over several days. The medication was unavailable, and the pharmacy was not notified. The DON stated that new admission medications should be available within 4-6 hours, and OTC medications can be purchased locally. The facility lacked a policy for notifying the physician when medication was unavailable.
A resident with severe mobility issues and obesity developed Moisture Associated Skin Damage (MASD) due to the facility's failure to follow its repositioning policy. Despite the need for repositioning every two hours, the resident was only repositioned once per shift, as confirmed by the DON and AMDSC. The facility's policy emphasized the importance of regular repositioning to prevent skin breakdown, but it was not adhered to, resulting in the resident's condition.
A facility failed to monitor a resident for behavior changes and side effects after administering psychotropic medications Mirtazapine and Temazepam. Despite the facility's policy requiring monitoring for efficacy and adverse consequences, the resident received multiple doses without appropriate oversight, potentially impacting their health and safety.
The facility did not follow its policy on resident food preferences for two residents. One resident was served asparagus despite disliking it, and their meal tray lacked a green salad. Another resident's preference for a late dinner was not accommodated, requiring a family member to reheat the meal. Staff interviews confirmed these oversights, which were contrary to the facility's policy on updating and honoring resident dining preferences.
A resident with severe cognitive impairment and physical disabilities was dropped off alone at the wrong address due to a failure in communication and adherence to transportation policies. The resident required maximum assistance and supervision, but the Transportation Supervisor was not informed of these needs, resulting in the resident being left unsupervised.
A facility failed to treat a resident with dignity and respect when a CNA told the resident, 'you don't tell me what to do, I tell you what to do.' The resident, who was cognitively intact and required assistance with daily activities, did not report the incident immediately due to fear. The facility's policy requires residents to be treated with dignity and respect at all times.
A resident requiring assistance with personal care was found with uncleaned and untrimmed fingernails, despite being cognitively intact. The facility's documentation lacked records of nail care, contrary to its policy for daily cleaning and trimming to prevent infections. Interviews with staff confirmed the absence of nail care records, indicating a deficiency in supporting the resident's ADLs.
A resident's bottom dentures were reported missing, but the facility delayed the dental referral beyond the 3-day policy requirement. There was no documentation of actions taken to ensure adequate nutrition while awaiting dental services, despite the resident's inconsistent meal intake.
Failure to Develop and Implement Comprehensive Care Plan for Pressure Injury Prevention
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan that addressed all of a resident's needs, specifically regarding the prevention of pressure injuries for a resident identified as high risk. Upon admission, the resident had multiple diagnoses, including a wedge compression fracture and end-stage renal disease, and was assessed as cognitively intact but totally dependent on staff for mobility and hygiene. The resident was determined to be at high risk for pressure injuries based on a Braden Scale score of 11 and had no pressure injuries upon admission. Despite the resident's high risk status and total dependence on staff for repositioning and hygiene, documentation revealed repeated refusals by the resident to turn, reposition, and participate in hygiene care over an extended period. Staff documented these refusals and provided education on the risks and benefits of compliance, but the care plan was not updated to address the resident's ongoing refusals or to outline specific interventions for managing these refusals. The facility's policy required care plans to include measurable objectives and interventions, including those related to resident refusals, but this was not done in this case. As a result of the lack of a comprehensive care plan addressing the resident's refusals and high risk for pressure injuries, the resident developed an unstageable pressure injury to the coccyx and a deep tissue injury to the right heel, both acquired in-house. Interviews with staff and review of documentation confirmed that the care plan did not reflect the resident's pattern of refusal or provide guidance for staff on how to address these refusals, contributing to the development of the pressure injuries.
Failure to Conduct IDT Meeting and Fall Risk Assessment
Penalty
Summary
The facility failed to ensure that the Interdisciplinary Team (IDT) met to discuss the discontinuation of one-on-one (1:1) monitoring for a resident who was at high risk for falls. The resident, who had a history of falls and a diagnosis of dementia, was initially placed on 1:1 monitoring due to staff being overwhelmed with her attempts to get up without assistance. However, the monitoring was discontinued without conducting an IDT meeting to assess the resident's safety, and no fall risk assessment or updated care plan was completed following the discontinuation. The resident experienced an unwitnessed fall at the nurse's station, resulting in a fracture that required surgical intervention. Interviews with staff revealed that the resident was known to be confused and frequently attempted to get out of her wheelchair or bed without assistance. Despite this, the staff did not provide adequate supervision, and the resident was left unsupervised at the time of the fall. The facility's policies and procedures required the IDT to develop resident care plans and conduct fall risk assessments to establish a resident-centered falls prevention plan. However, these procedures were not followed, as evidenced by the lack of an IDT meeting, fall risk evaluation, and updated care plan after the discontinuation of 1:1 monitoring. This oversight contributed to the resident's fall and subsequent injury.
Failure to Address Resident's Skin Condition
Penalty
Summary
The facility failed to adhere to its policy and procedure regarding changes in a resident's condition, specifically for one resident who exhibited a significant skin condition. The resident was observed with a large area of raised, reddened, scaly skin on the left side of her neck extending toward her shoulder. Despite the visible condition and the resident's behavior of scratching and picking at the affected area, the facility staff did not promptly notify the resident's medical doctor or take appropriate action to address the condition. Interviews with the facility staff, including an LVN, CNA, and TXN, revealed a lack of awareness and appropriate response to the resident's condition. The LVN assigned to the resident was unaware of the cause of the skin condition and only applied barrier cream as treatment. The CNA noted the resident's constant scratching and itchiness but could not recall how long the condition had persisted. The TXN attributed the condition to the resident's behavior and did not seek further medical evaluation, such as a dermatologist consultation. The Director of Nursing later identified the condition as potentially being psoriasis or eczema, which required medical attention. However, the facility's delay in notifying the resident's medical doctor and obtaining appropriate treatment resulted in a failure to follow their policy on change of condition. This oversight had the potential for negative medical outcomes, as the resident was eventually diagnosed with cellulitis and prescribed antibiotics after the medical doctor was informed.
Legionella Contamination in Cooling Tower
Penalty
Summary
The facility failed to adhere to its Water Management Program policy and procedure when the cooling tower tested positive for Legionella bacteria, which can cause lung infections. The Safety Officer (SO) reported that the cooler connected to the water tower tested positive for Legionella, and the water treatment company treated the water. However, the Director of Nursing (DON) confirmed that staff had not been in-serviced on Legionella or legionella pneumonia. The Infection Preventionist (IP) reviewed the Legionnaire Testing report, which indicated a small amount of Legionella in the cooling tower, but not in the kitchen or health center. Despite this, an internal email suggested the building was not affected. The facility's policy, dated July 2017, required reviewing medical and microbiology records, identifying new and recent residents with healthcare-associated pneumonia, and testing them for Legionella. The Centers for Disease Control and Prevention guidelines emphasize the importance of identifying and investigating Legionnaires' disease cases, especially when positive environmental tests for Legionella occur. The facility's failure to follow these guidelines and its own policy potentially exposed residents, visitors, and staff to the bacteria, as the cooling tower's Legionella levels were above normal, although the sink levels were within an acceptable range.
Failure to Update Care Plan Leads to Skin Damage
Penalty
Summary
The facility failed to update the care plan for Resident 20, who was non-verbal and had diagnoses including weakness or inability to move on the left side of her body, severe loss of strength on the left side, inability to talk, and obesity. The care plan, last revised on 9/27/24, indicated that two staff members were to reposition the resident at least once a shift and as necessary. However, after Resident 20 was diagnosed with Moisture Associated Skin Damage (MASD) on 10/24/24, the care plan was not updated to reflect the need for repositioning every two hours, as stated by the Director of Nursing (DON). This oversight resulted in the development of MASD due to prolonged exposure to moisture, as observed during a staff repositioning on 11/4/24.
Failure to Provide Timely Catheter Care Assessment
Penalty
Summary
The facility failed to adhere to its policy and procedure for catheter care, resulting in a deficiency related to Resident 49. The resident, who had a catheter due to kidney stones and sediment in his urine, reported experiencing pain from the catheter. Despite informing his nurse about the discomfort, no timely nursing assessment or intervention was provided. The Licensed Vocational Nurse (LVN) responsible for Resident 49 acknowledged the complaint but did not assess the cause of the discomfort, instead opting to medicate the resident with Tylenol. The LVN intended to inform the Treatment Nurse (TN) but did not perform the necessary assessment herself. The Treatment Nurse later assessed the situation and found the catheter leaking, subsequently replacing it and relieving the resident's discomfort. The Director of Nursing confirmed that the LVN should have conducted a focused assessment to determine the cause of the catheter discomfort. A review of the facility's policy indicated that any unusual findings, such as pain or signs of complications, should be reported immediately to a physician or supervisor. The failure to follow these procedures led to Resident 49 experiencing unnecessary discomfort.
Medication Labeling and Storage Deficiencies
Penalty
Summary
The facility failed to adhere to its policy and procedure regarding medication labeling and storage, as observed in two instances involving residents and medication carts. Medications were found at the bedside of two residents without a self-medication assessment or physician order, which is against the facility's policy. Specifically, Resident 219 had Calazinc on the bedside table, and Resident 58 had Vitamin A&D ointment at the bedside. Both residents lacked the necessary physician orders and self-medication assessments to keep medications at their bedside, as confirmed by the Assisted Director of Nursing (ADON). Additionally, the facility failed to properly manage the expiration of insulin vials on two medication carts. Four insulin vials were found to be expired, which contradicts the facility's policy that requires multi-dose vials to be dated and discarded within 28 days unless otherwise specified by the manufacturer. The expired insulins included Insulin Lispro and Insulin Humalog on the South-wing cart, and Insulin Lantus and Insulin Lispro on the West-wing cart. Licensed Vocational Nurses (LVNs) confirmed the expiration of these medications during observations and interviews.
Incomplete Informed Consent for Psychotherapeutic Drugs
Penalty
Summary
The facility failed to adhere to its policy and procedure regarding obtaining informed consent for the use of psychotherapeutic drugs for two residents, Resident 48 and Resident 217. For Resident 48, the Physician Orders indicated the administration of Temazepam through a feeding tube, but the informed consent documentation was incomplete. Specifically, the consent form lacked the signature of the Resident Representative and a facility representative, which is required before initiating treatment with psychotherapeutic drugs. Similarly, for Resident 217, the Order Review History Report showed the administration of Temazepam and Mirtazapine, but the informed consent forms were incomplete. During interviews, both LVN 3 and RN 1 acknowledged the deficiencies in the informed consent process, with LVN 3 indicating that the doctor was responsible for obtaining consent and the nurse for witnessing the signature. The facility's policy clearly states that consent must be signed and documented in the individual's medical record before treatment, which was not followed in these cases.
Failure to Administer Physician-Ordered Medication
Penalty
Summary
The facility failed to ensure that physician-ordered medication was available for a resident, resulting in the resident's pain not being adequately controlled. The resident, identified as Resident 217, had a physician order for Glucosamine-Chondroitin tablets to be administered twice daily to manage joint pain. However, the medication was not administered on multiple occasions from November 2nd to November 6th, as documented in the Medication Administration Record (MAR). Licensed Vocational Nurse (LVN) 1 confirmed that the medication was unavailable and stated that the pharmacy should have been notified when medication was not available. The Director of Nursing (DON) indicated that the expectation for new admission medication availability is within 4-6 hours, and over-the-counter medications can be purchased from a local pharmacy if necessary. Despite this, the facility did not have a policy for notifying the physician when medication was unavailable, and no such policy was provided upon request. The resident reported experiencing pain levels of 6 to 7 out of 10 in the left knee, indicating moderate to severe pain due to the lack of medication administration.
Failure to Reposition Resident Leads to Skin Damage
Penalty
Summary
The facility failed to adhere to its policy and procedure regarding repositioning for a resident, resulting in the development of Moisture Associated Skin Damage (MASD). Resident 20, who was non-verbal and had diagnoses including weakness and severe loss of strength on the left side of her body, inability to talk, and obesity, was not repositioned according to the facility's guidelines. The care plan for Resident 20, which should have been updated to reflect a repositioning schedule of every two hours following a diagnosis of MASD, was not revised appropriately. Observations and documentation revealed that Resident 20 was repositioned only once per shift, contrary to the facility's policy. The Director of Nursing (DON) and Assistant Minimum Data Set Coordinator (AMDSC) confirmed the lack of documentation for repositioning during the night shift, indicating a failure to follow the established repositioning schedule. The facility's policy, dated 2001, emphasized the importance of repositioning to prevent skin breakdown and promote circulation, particularly for residents who are immobile or dependent on staff for repositioning. Despite these guidelines, the facility did not ensure that Resident 20 was repositioned every two hours, leading to the development of MASD.
Failure to Monitor Psychotropic Medication Effects
Penalty
Summary
The facility failed to adhere to its policy and procedure regarding psychotropic medication use for a resident, identified as Resident 217. The facility did not monitor changes in behavior or side effects for the medications Mirtazapine, prescribed for depression, and Temazepam, prescribed for sleep issues. This oversight was identified during an interview and record review with the Assistant Director of Nursing (ADON), where it was revealed that the facility had not been monitoring the resident for behavior changes or side effects after administering these medications. The facility's policy, dated 2001, requires that psychotropic medications, including anti-depressants and hypnotics, be subject to specific prescribing, monitoring, and review requirements. This includes adequate monitoring for efficacy and adverse consequences. Despite this policy, the facility administered four doses of Mirtazapine and four doses of Temazepam to Resident 217 without the necessary monitoring, potentially affecting the resident's health and safety.
Failure to Honor Resident Food Preferences
Penalty
Summary
The facility failed to adhere to its policy and procedure regarding resident food and dining preferences for two residents. For one resident, the facility did not offer an alternative food item despite the resident's documented dislike for asparagus. Additionally, the resident's meal tray was missing a green salad, which was part of the standing orders. This oversight was confirmed during interviews and record reviews with facility staff, including a CNA and an LVN, who acknowledged the discrepancies in the meal provided to the resident. Another resident's preference for a late dinner was not honored, as reported by a family member who stated that they had to keep the meal tray warm or reheat it later in the evening. Interviews with facility staff, including a CNA and the Certified Dietary Manager, indicated that accommodations for late dining preferences were possible, yet not implemented in this case. The facility's policy on resident food and dining preferences, which emphasizes updating preferences regularly and accommodating individual choices, was not followed, leading to these deficiencies.
Failure to Provide Safe Transportation for Cognitively Impaired Resident
Penalty
Summary
The facility failed to provide safe transportation for a resident with severe cognitive impairment and physical disabilities, resulting in the resident being dropped off alone at the wrong address. The resident, who had a BIMS score indicating severe cognitive impairment, required maximum assistance for mobility and had significant medical conditions, including hemiplegia, memory deficit, and dysphagia. Despite these needs, the Transportation Supervisor dropped the resident off at an incorrect location without ensuring a family member was present to meet him. The Transportation Supervisor admitted to the mistake and stated that she was not informed by the facility about the resident's need for supervision during transportation. The Social Services Director and Administrator both acknowledged that the resident should not have been left alone due to his cognitive and physical limitations. The facility's policy on transportation required that any special considerations be documented in the resident's clinical record, but this was not effectively communicated or adhered to, leading to the incident.
Failure to Treat Resident with Dignity and Respect
Penalty
Summary
The facility failed to ensure that a resident was treated with dignity and respect, as evidenced by an incident involving a Certified Nursing Assistant (CNA). During an interview, the facility's Administrator reported that the resident had informed them that the CNA had stated, 'you don't tell me what to do, I tell you what to do.' The resident, who was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15, did not report the incident immediately due to fear of physical and mental repercussions. The resident required maximum assistance for bathing and lower body dressing and moderate assistance for upper body dressing. The Social Services Director confirmed that the resident was alert, oriented, and capable of making her own decisions. The facility's policy on dignity, dated February 2021, mandates that residents are treated with dignity and respect at all times.
Deficiency in Resident Nail Care
Penalty
Summary
The facility failed to provide adequate assistance with Activities of Daily Living (ADL) care for a resident, specifically in maintaining personal hygiene through nail care. The resident, who was cognitively intact and required assistance with personal care, was observed with long fingernails containing dark gray debris. The resident reported that her fingernails had not been cleaned or trimmed for several days, indicating a lack of necessary support from the facility staff. The facility's documentation, including the CNA Weekly Skin Report and the ADL flowsheet, showed inconsistencies and omissions in recording nail care for the resident. Despite the facility's policy requiring daily cleaning and regular trimming of nails to prevent infections, there was no documentation of such care being provided. Interviews with staff, including a CNA and the Director of Nursing, confirmed the absence of nail care records, highlighting a deficiency in adhering to the facility's established procedures for supporting residents' ADLs.
Failure to Provide Timely Dental Services and Nutritional Support
Penalty
Summary
The facility failed to adhere to its policy and procedure regarding dental services for a resident who lost their bottom dentures. The resident's family reported the missing dentures on May 23, 2024, but the facility did not coordinate a dental evaluation for replacement until June 6, 2024. This delay in referral was contrary to the facility's policy, which required a referral within three days of the dentures being lost. Furthermore, there was no documentation of any measures taken to ensure the resident could eat and drink adequately while awaiting dental services. The resident's meal intake logs from May 2024 showed inconsistent and often inadequate food consumption, with instances of 0% intake during meals. Despite these observations, the facility did not document any interventions to address the resident's nutritional needs during the period they were without dentures. The lack of timely referral and absence of documented nutritional support measures contributed to the deficiency identified by the surveyors.
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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