Sharon Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Los Angeles, California.
- Location
- 8167 West Third St., Los Angeles, California 90048
- CMS Provider Number
- 055755
- Inspections on file
- 91
- Latest survey
- March 19, 2026
- Citations (last 12 mo.)
- 14
Citation history
Health deficiencies cited at Sharon Care Center during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and documented lack of decision-making capacity was admitted with multiple diagnoses, including benign neoplasm of the meninges, altered mental status, and adult failure to thrive. The facility’s IPN stated that policy requires a signed consent from the resident or representative before administering vaccines such as influenza, pneumonia, and COVID, to confirm education on risks and benefits. However, there was no documented evidence that the resident’s representative was provided or signed any immunization consent, despite facility IPCP policies specifying procedures for obtaining direct and proxy consent for vaccinations.
A resident with muscle wasting, lack of coordination, and ESRD had multiple assessments showing bilateral leg weakness, dependence for sit-to-stand and bed-to-chair transfers, and a need for a total (Hoyer) lift with two-person assist. Despite this, staff routinely transferred the resident with one-person assist using a gait belt, and the resident was not on fall precautions. The care plan was not updated after a prior fall or after readmission assessments to reflect the need for a Hoyer lift and two-person assistance, and on one occasion the resident sustained an assisted fall during a wheelchair-to-bed transfer performed by a CNA using a gait belt alone.
A resident with Parkinson’s disease and other conditions was receiving Mirtazapine 15 mg for depression, and their MDS documented frequent depressive symptoms, yet depression was not coded as an active diagnosis and no depression-related care plan was in place. During interviews, an LVN, the DON, and the MDS nurse confirmed that the depression diagnosis from the hospital and continued psychotropic order were not reflected in the MDS or care plan, and the IDT conference notes did not document a medication review, contrary to the facility’s psychotropic medication policy requiring documented indication and evaluation on admission or readmission.
A resident admitted with type 2 DM and a history of MI had an active DM diagnosis documented on the MDS, but no corresponding diabetes care plan was developed when the diagnosis triggered in the assessment system, contrary to facility policy requiring individualized care plans with measurable objectives and timetables. During surveyor review with the DON and MDS nurse, no care plan appeared when searching under "Diabetes Mellitus," and a diabetes care plan dated the day before the interview was found only when searching under "diabetes." The DON admitted she created this plan after overhearing the surveyor request it and that it was incomplete, and the MDS nurse confirmed there was no explanation for the earlier omission and that, without a diabetes care plan, the resident’s care would be incomplete.
A resident with dementia, rheumatoid arthritis, anemia, and HTN, who required partial to moderate assistance with ADLs and had a family member as DPOA, did not receive timely access to requested medical records through the resident representative. The facility’s policy required access to personal and medical records within 24 hours and copies within two business days of a request, but the Medical Records Director delayed processing a mailed request until returning from vacation, and records were not provided until many days later. The Facility Administrator confirmed that the delay occurred because the facility waited for corporate office clearance, and although a medical records consultant was available when the MRD was off, that consultant was responsible for many other facilities, resulting in the resident representative being denied timely access to the records as required by policy.
A resident with epilepsy, a femur fracture, ESRD, and a three-year history of left ear hearing loss did not have a comprehensive care plan addressing the hearing deficit. An MDS documented adequate hearing, while an ENT consult noted chronic hearing loss, wax removal, and recommended follow-up. The resident later voiced concern about persistent hearing loss and lack of further interventions. Review by the MDS nurse and DON confirmed there were no care plan problems, goals, monitoring parameters, or orders related to hearing loss, despite facility policy requiring individualized care plans for all identified problems.
A resident with multiple medical conditions and at risk for malnutrition experienced significant unplanned weight loss after the facility failed to follow physician orders for a Restorative Nursing Aide (RNA) feeding program at both breakfast and lunch. Instead, only breakfast was covered by RNAs, while lunch was handled by CNAs, contrary to the care plan and physician orders. Staff interviews and documentation confirmed the deviation from prescribed care, resulting in continued poor oral intake and weight loss.
A resident with a fractured arm and other medical conditions experienced ongoing pain despite receiving Oxycodone-Acetaminophen every six hours. The resident repeatedly requested more frequent pain medication, but staff did not notify the physician or adjust the medication schedule as required by the care plan and facility policy, resulting in unmanaged pain and discomfort.
A resident with non-Hodgkin lymphoma and requiring assistance with ADLs did not have transportation arranged in advance for a scheduled chemotherapy appointment. Staff only became aware of the oversight on the morning of the appointment after the resident reminded them, leading to a last-minute call for backup transportation. Facility policy requires transportation to be scheduled promptly after appointments are set, but this was not followed.
A resident with diabetes and hyperglycemia was found with prescription triamcinolone ointment at bedside, which was applied by CNAs at the resident's request without a formal assessment or physician order for self-administration. Interviews revealed that staff did not confirm the appropriateness of this practice with licensed nurses, and facility policy requires only licensed personnel to administer medications.
A resident with muscle weakness and chronic kidney disease, who required substantial assistance and was able to communicate her needs, was not provided with warm water to make tea during meals as documented in her food preferences. Staff were aware of her preference, but the omission of a tea bag on the tray led to the CNA not providing hot water, resulting in the resident's preference not being honored and causing frustration.
A resident's room was found to have scattered chipped paint on the wall, which made the resident feel upset and did not meet the facility's standards for a homelike environment. Staff, including an LVN and the Maintenance Director, acknowledged the issue and stated it should have been addressed, as facility policy requires maintaining a clean and comfortable setting.
A resident with multiple medical and mental health diagnoses, who was identified as having difficulty hearing, did not have a comprehensive care plan developed to address their communication needs. Staff and social services confirmed the resident's hearing challenges, but no interventions or individualized strategies were documented or implemented, contrary to facility policy.
Three residents did not receive proper pressure ulcer prevention due to staff failing to ensure low air loss mattresses were functioning and set according to physician orders. One resident's mattress was leaking air and taped, while two others had mattresses set at incorrect weight levels, contrary to their care plans and orders. Nursing staff confirmed these issues could compromise skin integrity and wound healing.
Two residents were placed at risk of falls and injury when an extension cord was taped from a bathroom outlet, running under a door and across the floor to a bed, in violation of the facility's electrical safety policy. Both the Maintenance Director and DON acknowledged the setup was unsafe and could cause tripping.
A resident with an indwelling catheter and multiple medical conditions was observed to have a large amount of sediment in the catheter tubing on multiple occasions. Despite a physician order to change the catheter for excessive sedimentation and staff awareness of the need to notify the physician, no notification was made and the catheter was not changed as ordered.
A resident with a gastrostomy tube had a feeding tube syringe that was not labeled or dated, as required by facility policy. Nursing staff confirmed that syringes should be dated and changed daily, but this was not done, making it unclear when the syringe was last replaced.
A resident with end stage renal disease and an AV shunt did not have the required emergency kit at the bedside to manage potential bleeding, despite physician orders and facility policy. Nursing staff and the DON confirmed the absence of the kit and its importance for immediate response to dialysis-related emergencies.
CNAs applied a prescription ointment to a resident without a physician's order or proper authorization, contrary to facility policy. The resident, who required assistance with personal care, directed the CNAs to apply the medication, and staff did so without consulting a licensed nurse or confirming an order. Facility policy restricts medication administration to licensed personnel, and this protocol was not followed.
Two residents were found to have medications left unsecured at their bedside, including a topical cream and oral tablets. Nursing staff acknowledged that medications should not be left with residents and confirmed this was not in line with facility policy, which requires all drugs and biologicals to be stored securely in locked compartments.
Surveyors found that food items, including sandwiches and butter cups, were not labeled or dated as required, and expired items were not discarded. Additionally, the dishwashing machine did not have the correct sanitizer concentration, as confirmed by staff and test strips. These deficiencies were observed during interviews and record reviews, and were not in accordance with facility policies.
A urinal containing urine was found on a bedside table next to a resident's food and drinks. The resident had impaired cognition and required assistance with daily activities, including eating. An LVN and the DON confirmed that this practice was not safe and did not comply with the facility's infection prevention and control policy, which requires maintaining a sanitary environment.
A resident with significant physical limitations was unable to signal for assistance because the call light in their room was not working. Staff confirmed the malfunction, and there was uncertainty about how often maintenance checks were performed. Facility policy required the call system to be functional and regularly maintained, but the issue was not identified or corrected before it was observed.
Fourteen resident rooms were found to be below the required 80 square feet per resident for multiple occupancy, with measurements confirming insufficient space. Staff and residents did not report issues with care or mobility in these rooms, and a waiver had been requested for the affected rooms, but the deficiency was cited due to noncompliance with federal space requirements.
A facility failed to ensure a resident's PRN psychotropic medication, Seroquel, had a 14-day administration limit, as required by policy. The resident, with schizophrenia and major depressive disorder, was prescribed Seroquel without the necessary stop date, increasing the risk to their mental well-being. The facility's Psychiatrist did not order the medication, and the Director of Nursing and Pharmacy Consultant acknowledged the oversight.
A facility failed to complete a PASRR Level II assessment for a resident with schizophrenia, major depressive disorder, and metabolic encephalopathy. The PASARR Level I was incomplete, missing a critical question about suspected mental illness, which should have triggered further evaluation. The resident exhibited cognitive impairment and behavioral issues, yet the necessary assessment and support from the Department of Mental Health were not provided. Staff interviews confirmed the oversight.
A resident with mental illness experienced significant behavioral changes, including verbal aggression and agitation, but the facility failed to notify the physician as required by policy. This oversight led to the resident's hospitalization and a psychiatric hold. Staff interviews confirmed the lack of physician notification, despite the facility's policy mandating it for significant condition changes.
A resident with schizophrenia and major depressive disorder experienced behavioral changes, including verbal aggression and agitation, which were not addressed in their care plan. The facility failed to update the care plan with specific interventions for the resident's antipsychotic medication, Seroquel, following changes in the resident's condition. This oversight led to the escalation of behaviors and the resident's subsequent admission to a General Acute Care Hospital.
A facility failed to develop and implement a comprehensive care plan for a resident admitted with a left fibula fracture and osteoporosis. Despite the need for pain management and fracture care, no baseline care plan was initiated or implemented. The Director of Nursing confirmed the absence of care plans, which should have been developed within 48 hours of admission according to facility policies.
A facility failed to assess and monitor a resident's left lower leg splint, risking complications like skin breakdown. The resident, admitted with a fibula fracture and osteoporosis, was at risk for pressure ulcers. Despite this, no documentation of splint assessment was found over several weeks, as confirmed by the DON, violating the facility's Skin Integrity Management policy.
A facility failed to provide adequate nursing staff, resulting in a resident waiting over three hours for incontinence care and two residents missing scheduled showers. The DON acknowledged the delay was unacceptable, and CNAs cited high workloads as the reason for unmet care needs. Facility policies on maintaining ADLs were not followed, impacting residents' hygiene and well-being.
A resident with a history of hemorrhagic disorder experienced a critically low platelet count, but the LTC facility failed to notify the physician immediately or take emergency action. Despite the critical nature of the lab results, staff followed non-emergency procedures, delaying the resident's transfer to a hospital. The resident was eventually transferred but died seven days later.
The facility failed to ensure cleanliness and proper maintenance of dinnerware and water pitchers. Observations revealed cloudy glasses, stained mugs, and worn coffee pots, with CNAs expressing concerns about cleanliness. Additionally, water pitchers were not replaced timely, with some residents lacking pitchers at their bedside. The facility's policy on cleaning and sanitizing was not followed.
The facility failed to provide two residents with their preferred fresh fruits, offering only canned fruits instead. Despite dietary requirements and preferences, the Dietary Manager cited budget and seasonal issues for the lack of fresh fruit, contrary to the facility's policy on food preferences.
A facility failed to create a comprehensive care plan for a resident with bipolar disorder and prescribed Risperidone. The care plan lacked goals, interventions, or monitoring, despite the resident's symptoms of depression and mood swings. Staff interviews revealed the care plan was not completed, and the resident had not been seen by a psychiatrist since admission, contrary to facility policy.
A facility failed to conduct a required yearly performance evaluation for an LVN, hired on 9/22/22, as per their policy. The DON and ADM confirmed the absence of the evaluation, which should have been completed 90 days post-hire and annually. This oversight was acknowledged as a risk to resident safety.
The facility failed to maintain a yearly skills competency checklist for a CNA, hired on 3/12/24, as required by policy. The Administrator confirmed the absence of the checklist, and the DON acknowledged the oversight, emphasizing the importance of documentation to ensure competency. The facility's policy mandates competency evaluations upon hire and annually.
A resident was prescribed Risperidone for bipolar disorder without documented consent, as required by facility policy. Despite being alert and oriented, the resident's chart lacked a signed consent form. Interviews revealed that the admitting nurse was responsible for obtaining consent, but this was not done. The psychiatrist was also not informed of the resident's admission, contributing to the oversight.
Two residents were involved in a verbal altercation where one attempted to strike the other. The facility failed to report the incident to authorities or conduct an investigation, as required by their abuse policy. Additionally, the residents were not separated in a timely manner, with one resident being moved 11 days later.
A resident with visual impairment was mistakenly taken to a skilled nursing facility instead of an ophthalmologist appointment due to an identification error. Despite being accompanied by a CNA and carrying an envelope with his name, the transportation driver took him to the wrong location, causing the resident to miss his appointment and experience distress.
A resident with severe cognitive impairment fell during the night shift, but the LTC facility failed to assess or document the incident immediately. The LVN was informed hours later and notified the NP, but the physician was not contacted right after the fall. The facility did not adhere to its fall management policy, which requires immediate injury observation, neurological evaluation, documentation, and physician notification.
A facility failed to conduct a quarterly Braden scale assessment for a resident with pressure ulcers, who was at severe risk of developing further ulcers. The resident had multiple health issues, including altered mental status and immobility, and was readmitted with unstageable pressure-induced tissue damage. Despite these conditions, the required assessment was not completed, which is crucial for informing staff about the necessary care to prevent worsening of the resident's wounds.
A resident at severe risk for pressure ulcers did not receive adequate care planning, leading to deficiencies in their treatment. The care plan for the resident's sacral coccyx ulcer was not updated when reclassified to Stage IV, and the plan for a heel wound was incomplete. Additionally, no care plan was developed for a new PVD wound. Interviews with staff highlighted the lack of comprehensive interventions, contrary to facility policy.
A CNA in an LTC facility used a derogatory term towards a resident during an altercation over socks, witnessed by another resident and an RN. The resident had mildly impaired cognition and had been feeling depressed. The facility's policy prohibits such language, but the CNA's communication was ineffective, increasing the risk of verbal abuse.
A resident with multiple health conditions experienced seven instances of G-tube dislodgment without an initial care plan or timely revisions. The facility also failed to conduct timely interdisciplinary team meetings following these incidents, contrary to its policies.
A resident was incorrectly billed for a single room while another resident was on bed hold in the same room. The facility's records showed no agreement for the single room, and the resident was not liable for the charges. The DON confirmed the resident was in a semi-private room during the relevant period.
A resident experienced a significant delay in the implementation of a Registered Dietician's recommendations to change their G-tube feeding formula, resulting in a 4% weight loss over 51 days. The resident, with multiple health conditions and dependent on staff for daily activities, did not receive the recommended change from Jevity 1.2 cal/ml to Glucerna 1.5 cal/ml at a higher rate until much later, despite facility policy allowing for such dietary orders to be delegated.
The facility failed to conduct required competency evaluations for two CNAs and an LVN, as revealed during a review of employee files. The absence of 2023 competencies for the CNAs and a missing competency evaluation upon hire for the LVN were confirmed by the DSD and DON, highlighting a deviation from the facility's policy requiring evaluations upon hire, annually, and as needed.
The facility failed to rotate insulin injection sites for two residents, leading to potential risks of complications. Despite standard practices and guidelines, insulin was repeatedly administered on the same sites for both residents. Interviews with staff and residents confirmed the lack of adherence to proper procedures.
The facility failed to provide two residents with the Skilled Nursing Facility Advanced Beneficiary Notice of Non-Coverage (SNF ABN), which is necessary for informing them about potential non-coverage of services by Medicare. Despite having remaining benefit days, the residents only received a Notice of Medicare Non-Coverage (NOMNC). The Assistant Business Office Manager and Director of Nursing acknowledged the oversight, highlighting a lack of awareness about the requirement to issue the SNF ABN.
Failure to Obtain Immunization Consent for Resident Lacking Decision-Making Capacity
Penalty
Summary
The deficiency involves the facility’s failure to implement its infection prevention and control policy and procedures related to immunization consent for one resident. Resident 4 was admitted with diagnoses including benign neoplasm of the meninges, altered mental status, and adult failure to thrive. A history and physical dated 6/17/2025 documented that the resident did not have the capacity to understand and make decisions, and a Minimum Data Set dated 12/24/2025 indicated severe cognitive impairment. The same MDS showed the resident mostly required supervision or touching assistance for ADLs such as oral hygiene, toileting hygiene, showering/bathing, lower body dressing, personal hygiene, and putting on/taking off footwear. During an interview, the Infection Prevention Nurse stated that before administering vaccinations such as influenza, COVID, or pneumonia, a resident or their representative must sign a consent form to indicate they have been educated on the benefits and risks. The IPN confirmed there was no documented evidence that the resident’s representative had been given the consent. Review of the facility’s Infection Prevention and Control Program policy, last reviewed on 12/18/2025, showed that the program included immunization policies and procedures, including obtaining direct and proxy consent and specifying how often this should occur. The lack of documented consent for influenza, pneumonia, and COVID vaccinations for Resident 4, who lacked decision-making capacity, constituted a failure to follow the facility’s infection control policies and procedures.
Failure to Update Fall Risk and Transfer Care Plan Leading to Assisted Fall
Penalty
Summary
The deficiency involves the facility’s failure to update and revise a resident’s fall risk and transfer care plan to reflect current assessments and needs. The resident was admitted with diagnoses including muscle wasting and atrophy, lack of coordination, and end-stage renal disease. A care plan dated 11/12/2025 identified a deficit in activities of daily living and required two staff for transfers using a Hoyer lift with a medium sling. A Lift Transfer Reposition assessment dated 1/22/2026 documented that the resident could not transfer independently or with supervision without a device, was unable to bear at least 50% weight on one or both legs, and required a total (Hoyer) lift with a medium sling. Nursing documentation on the same date noted bilateral leg weakness and fall risk factors, including a history of falls within six months. A subsequent MDS dated 1/29/2026 indicated the resident was alert and oriented with good recall, and was dependent for sit-to-stand and chair/bed-to-chair transfers, requiring assistance of two or more helpers. A physical therapy note dated 1/31/2026 also documented that the resident was dependent with 100% assist or two or more helpers for sit-to-stand and chair/bed-to-chair transfers. However, a Restorative Nursing Weekly/Monthly Progress Report dated 2/24/2026 stated the resident’s function was improving and that the resident could sit and stand with one-person assist using a gait belt. Despite the earlier assessments indicating dependence and need for a total lift, the care plan in effect on 2/26/2026 still listed the resident as at risk for falls/injury due to impaired mobility with interventions including two-person transfers using a Hoyer lift, and this intervention was not created until 2/27/2026, after the assisted fall. On 2/26/2026, the resident experienced an assisted fall while being transferred from a wheelchair to a bed by a CNA using a gait belt with one-person assist. The CNA reported that this one-person gait belt transfer was the usual practice, that the resident was not on fall precautions, and that she was only aware of the second fall. The LVN also stated the resident was a one-person transfer with a gait belt and not on fall precautions. The DON later acknowledged that the Lift Transfer Reposition assessment on readmission indicated the need for a total Hoyer lift and that this status should have been updated in the care plan at admission/readmission, and also stated that the care plan had not been updated after a prior fall on 12/23/2025. Facility policies required that comprehensive care plans be developed within seven days of the comprehensive assessment and be reviewed and revised as the resident’s condition changed, including after significant changes and at least quarterly, but the resident’s fall risk and transfer care plan was not updated to reflect current assessments and prior falls before the assisted fall occurred.
Failure to Accurately Code Depression and Care Plan for Psychotropic Use on MDS
Penalty
Summary
Surveyors identified that the facility failed to ensure an accurate MDS assessment and related care planning for a resident with a documented diagnosis of depression. The resident was admitted with Parkinson’s disease, muscle weakness, and difficulty walking, and had an active order for Mirtazapine 15 mg for depression manifested by overconcern with health issues. The resident’s MDS indicated they felt little interest or pleasure in doing things and felt down, depressed, or hopeless half or more of the days, but depression was not coded as an active diagnosis on the MDS. During interview and record review, an LVN confirmed there was no care plan addressing depression and that the diagnosis of depression was not triggered on the MDS, despite the resident receiving a medication ordered for depression. Further review with the DON and MDS nurse showed that the resident had received a depression diagnosis from the hospital and that a psychiatrist at the GACH had continued the Mirtazapine upon readmission. The MDS nurse stated that once the order was entered into the electronic chart, there was no alert to trigger the depression diagnosis in the MDS. Review of the IDT care conference documentation showed no recorded review of medications, and the DON and MDS nurse confirmed there was no care plan documented for depression or for the use of Mirtazapine. The DON and MDS nurse stated that without a care plan, something could be missed, and that the care plan is the comprehensive plan of care for the resident. The facility’s psychotropic medication use policy required that residents not receive psychotropic medications without a clinically indicated, documented condition and that the IDT evaluate and document the resident’s underlying condition and medications on admission or readmission, which was not reflected in the records reviewed for this resident.
Failure to Develop Comprehensive Diabetes Care Plan for a Resident
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan addressing diabetes mellitus for a resident admitted with type 2 DM and a history of myocardial infarction. The admission record showed the resident was admitted with type 2 DM, and the MDS dated 12/31/2025 documented the resident as alert, oriented, with good recall, and with an active diagnosis of diabetes. Facility policy required that areas of concern triggered during the resident assessment be evaluated and incorporated into an individualized comprehensive care plan with measurable objectives and timetables to meet medical, physical, mental, and psychosocial needs. Despite the diabetes diagnosis being triggered in the MDS, there was no corresponding diabetes care plan in place for this resident. During an interview and concurrent record review with the DON and the MDS nurse on 1/21/2026, the surveyor requested the resident’s diabetes care plan. Initial review of the Care Plan Report under "Diabetes Mellitus" showed no care plan. When the MDS nurse searched under "diabetes," a care plan was visible, but it was dated 1/20/2026 and had been created by the DON after she overheard the surveyor ask for the resident’s diabetes care plan. The DON acknowledged that the diabetes care plan she created was incomplete. The MDS nurse stated there was no indication why the care plan had not been developed when type 2 DM was triggered in the MDS and confirmed that care plans are the comprehensive plan of care for the resident and that, without the diabetes care plan, the resident’s care would be incomplete.
Failure to Provide Timely Access to Resident Medical Records
Penalty
Summary
The facility failed to follow its own policy and procedure for providing timely access to a resident’s medical records when a resident representative requested records for one of the sampled residents. The resident, admitted with rheumatoid arthritis, anemia, HTN, and later documented with dementia without behavioral disturbance, required partial to moderate assistance with ADLs and had a family member designated as DPOA for medical decisions. The facility’s policy, revised in late 2025, stated that residents have the right to access their personal and medical records within 24 hours (excluding weekends and holidays) of a request and to obtain copies within two business days of an oral or written request. The policy also allowed a legal representative to grant others access to the resident’s records through a written request specifying what information should be released and to whom. The Medical Records Director reported that the facility received a written medical records request from the resident’s representative by mail on 12/31/2025. However, the MRD did not begin processing the request until returning from vacation on 1/5/2026 and ultimately provided the records to the resident’s representative on 1/12/2026. The MRD stated that records are typically provided within two business days after corporate office review and approval. The Facility Administrator confirmed that the records were not released within the two-day timeframe specified in the facility’s policy because the facility was waiting for clearance from the corporate office. The FA also stated that a medical records consultant was available when the MRD was off, but that consultant was responsible for 60 other facilities. As a result, the resident’s representative was denied timely access to the requested medical records in accordance with the facility’s own policy.
Failure to Develop Comprehensive Care Plan for Resident’s Hearing Loss
Penalty
Summary
The deficiency involves the facility’s failure to develop a comprehensive, individualized care plan addressing a resident’s left ear hearing loss. The resident was admitted with diagnoses including epilepsy, a femur fracture, and end stage renal disease, and an MDS assessment dated 10/25/2025 documented that the resident had adequate hearing and cognitive skills for daily decision making, with varying levels of assistance needed for ADLs. An ENT consult dated 12/25/2025 documented a three-year history of hearing loss, wax removal, patient education, and a recommendation for follow-up in six months or more. Despite this documented history and evaluation, the resident’s medical record contained no care plan problem, goals, monitoring parameters, comfort measures, or physician notification requirements related to hearing loss. During an observation and interview, the resident, seated in bed, expressed concern about ongoing hearing loss in the left ear and reported having received treatment once at the facility, but questioned whether additional interventions would be offered since the hearing loss persisted and had begun prior to admission. The MDS nurse confirmed that a review of the record revealed no care plan, orders, or guidance to address the resident’s hearing loss, and stated that the resident should have a care plan for each current diagnosis and problem. The DON similarly stated that a comprehensive care plan should have been initiated for the resident’s hearing loss to guide nurses in monitoring for worsening hearing, communicating effectively with the resident, and notifying the provider if the problem worsened. The facility’s policy required the interdisciplinary team to develop an individualized comprehensive care plan for each identified problem area within seven days of completing the comprehensive MDS and to update it with significant changes or at least quarterly, which was not done for this resident’s hearing loss.
Failure to Implement RNA Feeding Program as Ordered
Penalty
Summary
A deficiency occurred when the facility failed to implement physician orders for a Restorative Nursing Aide (RNA) feeding program for both breakfast and lunch for a resident at risk for dehydration and malnutrition. The resident, who had multiple diagnoses including chronic kidney disease, Alzheimer's disease, anemia, myelodysplastic syndrome, and muscle wasting, experienced significant unplanned weight loss over a three-month period. The resident's care plan and physician orders specifically required RNA assistance with feeding at both breakfast and lunch to address poor oral intake and nutritional risk. Despite these orders, observations and interviews revealed that the RNA feeding program was only provided at breakfast, with Certified Nursing Assistants (CNAs) feeding the resident at lunch instead of RNAs. Staff interviews confirmed that RNAs were not assigned to feed the resident during lunch, and that this practice was not in accordance with the physician's orders or the resident's care plan. Documentation from multiple care conferences and progress notes indicated ongoing poor oral intake and continued weight loss, but did not address whether the RNA feeding program was being fully implemented as ordered. The facility's own policies required that physician orders be accurately transcribed and implemented, and that restorative nursing services be individualized and resident-centered as outlined in the care plan. However, the failure to provide RNA feeding at both prescribed meals resulted in the resident experiencing a 9.4% weight loss over three months, with weights dropping from 82.8 lbs to 75 lbs. Staff acknowledged that not following the physician orders could negatively affect the resident's nutritional status.
Failure to Notify Physician and Adjust Pain Management for Resident
Penalty
Summary
A deficiency occurred when the facility failed to manage pain effectively for a resident with a recent fall and a fractured left arm, as well as other medical conditions including heart failure and hypertension. The resident was prescribed Oxycodone-Acetaminophen 10-325 mg every six hours for moderate to severe pain. Despite this, the resident repeatedly reported that the pain medication wore off after three to four hours and requested more frequent dosing for better pain relief. Staff interviews confirmed that the resident consistently complained of pain and requested medication before the scheduled time, but the physician was not notified of the ongoing pain or the resident's request for a change in medication timing. The care plan for the resident included monitoring the effectiveness of pain interventions and notifying the physician if pain was not controlled. However, the assigned LVN did not report the resident's continued pain or request for more frequent medication to facility leadership or the physician, despite being instructed to do so by the RN and DON. The facility's pain management policy required documentation of the effectiveness of PRN medications and physician notification if pain was not managed, but these steps were not followed, resulting in the resident remaining uncomfortable and waiting for the next scheduled dose while in pain.
Failure to Arrange Timely Transportation for Chemotherapy Appointment
Penalty
Summary
The facility failed to arrange transportation for a resident's scheduled chemotherapy appointment, as required by physician orders and facility policy. The resident, who was admitted with diagnoses including non-Hodgkin lymphoma, a left fibula fracture, and a history of falls, was cognitively intact but required moderate to maximum assistance with activities of daily living. The resident's chart indicated a chemotherapy appointment was scheduled, but on the morning of the appointment, staff discovered that transportation had not been arranged in advance. The resident had to remind staff about the appointment, prompting a last-minute call to the facility's backup transportation service. Interviews with facility staff, including the Registered Nurse Supervisor, Facility Administrator, and Director of Nursing, confirmed that transportation arrangements were not made until the day of the appointment, contrary to facility policy which requires transportation to be scheduled as soon as possible after an appointment is set. The facility's policy and procedures specify that the Social Services Department is responsible for organizing transportation in collaboration with the resident's family representative. The failure to arrange timely transportation could have resulted in the resident missing the chemotherapy treatment.
Failure to Assess and Authorize Resident Self-Administration of Medication
Penalty
Summary
The facility failed to assess and ensure that a resident had an order to self-administer a prescribed medication. The resident, who was admitted with diagnoses including type 2 diabetes mellitus and hyperglycemia, was found to have two tubes of prescription triamcinolone acetonide ointment at her bedside. The resident reported that certified nursing assistants (CNAs) would apply the ointment to her buttocks daily or upon her request, and that the medication was prescribed by her outside physician. The Minimum Data Set indicated the resident had intact cognition and required some assistance with personal care tasks. During interviews, a CNA stated she applied the ointment to multiple areas as directed by the resident, believing it was approved, but did not confirm with a charge nurse. The CNA acknowledged that only licensed nurses should administer medications. An LVN explained that a formal assessment and physician order are required before a resident can self-administer medications, and that leaving medication at the bedside could result in improper use. The Director of Nursing confirmed that medication should not be left at the bedside without an order, as this could be dangerous. Facility policy indicated only licensed personnel may administer medications.
Failure to Honor Resident's Beverage Preference During Meals
Penalty
Summary
A deficiency occurred when the facility failed to provide a resident with warm water to make tea during meals, despite the resident's documented preference for tea at breakfast, lunch, and dinner. The resident, who had muscle weakness, lack of coordination, and chronic kidney disease, required substantial assistance with daily activities and was able to communicate her needs. The Food Preference Interview and dietary records clearly indicated the resident's desire for tea with each meal. However, during an observation, the resident's breakfast tray did not include a tea bag or hot water, and the resident expressed frustration at having to repeatedly request hot water for tea, despite staff being aware of her preference. A Certified Nursing Assistant (CNA) confirmed that she did not provide hot water because the tea bag was missing from the tray, even though she knew the resident regularly wanted tea. The Dietary Manager also acknowledged the resident's preference for tea and stated that CNAs were responsible for providing hot water when trays arrived. Facility policy required that residents' food preferences be honored and reflected on their tray cards, but this was not followed in this instance, resulting in the resident's preference not being honored and causing her frustration.
Failure to Maintain Homelike Environment Due to Chipped Paint
Penalty
Summary
A deficiency was identified when a resident's room was observed to have scattered chipped paint on the wall, which detracted from a homelike environment. The resident, who had been admitted with diagnoses including muscle weakness, lack of coordination, and chronic kidney disease, was assessed as usually able to understand and communicate needs, though unable to make medical decisions. The resident required substantial assistance with daily activities such as showering, dressing, and toileting hygiene. During an interview, the resident expressed feeling upset about the chipped paint in the room. Staff interviews confirmed the presence of chipped paint, with an LVN stating that the issue should be addressed immediately and acknowledging that the condition of the wall was unacceptable and could negatively impact the resident's sense of a homelike environment. The Maintenance Director reported that the chipped paint was brought to his attention recently but indicated that such damage likely did not occur suddenly. Facility policy requires the maintenance department to keep the building in good repair and to provide a safe, clean, and comfortable environment, which was not met in this instance.
Failure to Develop Care Plan for Resident with Hearing Impairment
Penalty
Summary
The facility failed to develop and implement a comprehensive, individualized care plan for a resident who was identified as having difficulty hearing. The resident, admitted with diagnoses including anxiety disorder, major depressive disorder, and atherosclerotic heart disease, was noted in the admission record and history and physical to lack capacity for decision-making. The Minimum Data Set assessment indicated the resident was usually understood by others and required partial to moderate assistance with activities of daily living. However, during observations and interviews, it was consistently noted by staff and social services that the resident had trouble hearing during conversations. Despite these findings, there was no care plan in place to address the resident's hearing impairment. Staff interviews confirmed that interventions such as communication boards, amplified hearing devices, or modified communication techniques had not been documented or implemented. The facility's own policy required the development of a comprehensive care plan with measurable objectives and timetables for each resident, but this was not followed in the case of this resident, resulting in a failure to meet the resident's communication needs.
Failure to Ensure Proper Functioning and Settings of Pressure-Relieving Mattresses
Penalty
Summary
The facility failed to provide necessary treatment and services to minimize the risk of development of pressure injuries for three residents by not ensuring the proper functioning and correct settings of low air loss mattresses (LALMs) as ordered by physicians. For one resident with a history of cerebral infarction and contractures, the LALM was observed to be leaking air and held together with tape, making a loud hissing noise. A nurse confirmed the mattress was not functioning properly, which could prevent adequate pressure relief as required by the resident's care plan and physician orders. Another resident, admitted with an ulcer and open wound of the left lower leg, had a physician order for the LALM to be set at 120 lbs., while the resident's actual weight was 103.5 lbs. However, the LALM was observed to be set at 355 lbs., significantly higher than both the resident's weight and the ordered setting. A registered nurse confirmed that this incorrect setting could add pressure to the resident's back, potentially worsening their skin condition, and the DON stated that such a setting would prevent proper healing. A third resident, with diagnoses including COPD, gastrotomy, and dysphagia, was ordered a LALM with a Level 2 setting for wound prevention, which the DON clarified was intended for residents weighing 120 lbs. The resident's current weight was 82.3 lbs., indicating a mismatch between the mattress setting and the resident's needs. The facility's policy required continuous monitoring and adjustment of interventions to prevent pressure ulcers, but these actions were not consistently implemented for the residents involved.
Unsafe Placement of Extension Cord Creates Fall Hazard
Penalty
Summary
The facility failed to provide a safe environment for two residents by allowing an electrical extension cord to be placed in a walk area shared by both individuals. One resident, admitted with multiple diagnoses including acute kidney failure, muscle weakness, and a history of falls, required assistance with mobility and was identified as being at risk for falls. The care plan for this resident included interventions such as providing verbal cues for safety, repositioning items within the visual field, and educating on safe techniques to prevent falls. The second resident, also cognitively intact, required assistance with personal hygiene and dressing. During observations, an orange extension cord was found taped from a bathroom outlet, running under the bathroom door and across the floor to another resident's bed. Both the Maintenance Director and the DON acknowledged that the placement of the extension cord was unsafe and could cause residents to trip and fall. The facility's policy on electrical safety specified that extension cords should not be placed where they could cause trips or falls, but this policy was not followed, resulting in a hazardous environment for the residents.
Failure to Notify Physician of Catheter Sediment
Penalty
Summary
Facility staff failed to provide necessary care and treatment for a resident with an indwelling catheter by not notifying the physician when sediment was observed in the catheter tubing. The resident had a physician order in place to change the catheter for excessive sedimentation, and both LVN and RN staff acknowledged the presence of sediment and the requirement to report such findings to the physician. Despite this, the physician was not notified, and the catheter was not changed as ordered. The resident involved had multiple diagnoses, including osteomyelitis, diabetes mellitus, and benign prostatic hyperplasia, and required substantial assistance with activities of daily living. Observations on consecutive days confirmed a large amount of sediment in the catheter. Facility policy required notification of the physician for changes in condition, but this protocol was not followed in this instance.
Failure to Label and Date Feeding Tube Syringe
Penalty
Summary
A deficiency was identified when a feeding tube syringe used for a resident with a gastrostomy tube was found to be neither labeled nor dated. The resident, who had diagnoses including chronic obstructive pulmonary disease, gastrostomy, and dysphagia, was dependent on staff for all activities of daily living and received nutrition via a feeding tube. Observation in the resident's room revealed that the syringe used for tube feeding was not marked with a date or label, contrary to facility policy. During an interview and record review, a registered nurse confirmed that the feeding tube syringe should be dated, timed, and changed daily, as per facility policy. The nurse acknowledged that without proper labeling, staff would not be able to determine when the syringe was last changed, which could place the resident at risk for infection. The facility's policy on enteral feeding specified that syringes must be changed daily, and this procedure was not followed in this instance.
Failure to Provide Required Emergency Dialysis Supplies at Bedside
Penalty
Summary
The facility failed to provide necessary emergency equipment and supplies at the bedside for a resident receiving hemodialysis, as required by professional standards and the facility's own policy. The resident, who had end stage renal disease and was dependent on renal dialysis, did not have an emergency kit containing clean gauze, a tourniquet, and tape at the bedside to manage potential bleeding from an AV shunt. This was confirmed during observations and interviews with nursing staff, who acknowledged the absence of the kit and its importance in managing emergencies such as bleeding from the AV fistula. Record review showed that the resident had active physician orders to monitor the AV shunt site for signs of infection, edema, and bleeding, and to apply pressure and notify medical staff if bleeding occurred. Despite these orders and the facility's policy requiring staff to be trained and prepared for dialysis-related emergencies, the necessary emergency kit was not present at the resident's bedside. Interviews with nursing staff and the DON confirmed that the kit should have been available and that its absence could delay emergency care.
Unlicensed Staff Applied Prescription Medication Without Physician Order
Penalty
Summary
Certified Nursing Assistants (CNAs), including CNA 4, applied triamcinolone acetonide ointment 0.1%, a prescription medication, to a resident without a physician's order and in violation of the facility's Administering Medications policy. The resident, who was admitted with diagnoses including type 2 diabetes mellitus and hyperglycemia, had intact cognition and required varying levels of assistance with personal care. The resident reported that CNAs would apply the ointment to her buttocks daily or upon request, and CNA 4 confirmed applying the ointment to multiple areas as directed by the resident, without consulting a licensed nurse or verifying a physician's order. Record review and staff interviews revealed that the resident did not have a current order for the medication, nor was there documentation of a self-administration evaluation or care plan. The facility's policy specified that only licensed or permitted personnel may administer medications. Both CNA 4 and a registered nurse acknowledged that CNAs are not authorized to administer prescription medications, and doing so could potentially cause harm. The deficiency was identified through observation, interview, and record review.
Failure to Securely Store Medications at Bedside
Penalty
Summary
The facility failed to properly store medications for two residents in accordance with its Storage of Medications policy and procedure. For one resident with a diagnosis of cerebral infarction and intact cognition, Preparation H cream was found on the bedside table next to food during an observation. The registered nurse confirmed that medication should not be left at the bedside, as it is not safe and could be misused. The Director of Nursing also stated that medications must be stored securely and not left accessible to residents. For another resident with diagnoses including depressive disorder, epilepsy, and rotator cuff tear, two tablets were observed in a medicine cup on the bedside table. The licensed vocational nurse admitted to leaving the medication at the bedside every night, acknowledging that this practice was not appropriate and could allow the resident to hide or accumulate medication. A registered nurse confirmed that staff are required to ensure residents take their medication before leaving the room and that medications should not be left unattended. The facility's policy requires all drugs and biologicals to be stored in a safe, secure, and orderly manner in locked compartments.
Failure to Properly Label Food and Maintain Dishwashing Sanitizer Levels
Penalty
Summary
Surveyors observed that the facility failed to store food in accordance with professional standards for food service safety. Specifically, sandwiches in the kitchen refrigerator were found without labels or dates, and a bin of expired butter cups was not discarded. Staff interviews confirmed that the absence of labeling made it impossible to determine the age of the food, increasing the risk of serving expired items. Facility policy required all food to be labeled and dated, but this was not followed in these instances. Additionally, the facility did not ensure that the low temperature dishwashing machine had the appropriate concentration of sanitizer. During testing, the sanitizer test strip remained white instead of turning purple, indicating that the correct sanitizer concentration was not present. Staff acknowledged that proper sanitizer levels are necessary to ensure dishware is adequately disinfected. Facility policies required all dishware and utensils to be cleaned and sanitized after each use, but this standard was not met during the survey.
Failure to Maintain Infection Control by Storing Urinal Near Food
Penalty
Summary
A deficiency was identified when a urinal containing urine was observed on a bedside table next to a resident's food and drinks. The resident had a diagnosis of an unspecified mental disorder, moderately impaired cognition, and required varying levels of assistance for activities of daily living, including set up or clean up assistance for eating. The urinal's placement was confirmed during an observation and interview with an LVN, who acknowledged that this was not safe for infection control reasons. The facility's Infection Prevention and Control policy stated that a safe and sanitary environment must be maintained to prevent and manage the transmission of diseases and infections. During a review with the DON, it was confirmed that placing a urinal next to food is not in accordance with the facility's policy and could result in an unsafe and unsanitary environment. The deficiency was based on the failure to keep the urinal away from the resident's food, as required by the facility's infection control procedures.
Non-Functioning Call Light System in Resident Room
Penalty
Summary
A deficiency occurred when the facility failed to ensure that the call light system in a resident's room was functioning properly. The resident, who had diagnoses including muscle weakness, lack of coordination, and chronic kidney disease, required substantial to maximal assistance from staff for showering, dressing, and toileting hygiene. During an observation, the resident pressed the call light, but it did not emit a sound or display a light outside the doorway, indicating it was not operational. Interviews with staff confirmed that the call light was not working, and there was uncertainty about the frequency of maintenance checks for the call light system. The facility's policies required that the call system remain functional at all times and be routinely maintained and tested by the maintenance department. The maintenance supervisor stated that call lights were checked weekly, but the non-functioning call light in the resident's room was not identified or addressed prior to the surveyor's observation. This failure had the potential to prevent the resident from being able to call for assistance when needed.
Resident Rooms Below Required Square Footage
Penalty
Summary
The facility failed to ensure that 14 out of 33 resident rooms met the required minimum space of 80 square feet per resident in multiple occupancy rooms. Observations and measurements confirmed that several rooms, each housing three residents, were below the required 240 square feet total, with actual measurements ranging from 216 to 239.71 square feet. During facility tours, it was noted that the rooms were equipped with privacy curtains and allowed for direct corridor access, and staff reported no issues with space when providing care, including the use of wheelchairs and Hoyer lifts. Interviews with staff, including the Maintenance Director and a CNA, indicated that there had been no complaints from residents or staff regarding room size, and care activities such as transfers and wheelchair use were not hindered. A review of the facility's Client Accommodation Analysis and a letter from the Administrator confirmed the room sizes and noted that a waiver had been requested for these rooms. Despite the waiver request, the rooms did not meet the federal space requirements for multiple occupancy, resulting in a deficiency related to inadequate room size.
Failure to Implement 14-Day Limit on PRN Psychotropic Medication
Penalty
Summary
The facility failed to ensure that a resident's PRN psychotropic medication, Seroquel, had a documented 14-day limit for administration, as required by the facility's policy. The resident, who was admitted with diagnoses including schizophrenia, major depressive disorder, and agitation, was prescribed Seroquel 25 mg every 12 hours as needed without a 14-day stop. This prescription was later increased to 50 mg every six hours as needed, still without the required 14-day stop. The facility's Director of Nursing and the Pharmacy Consultant both acknowledged the absence of the 14-day stop, which is necessary to evaluate the medication's effectiveness. Interviews with the facility Psychiatrist revealed that she did not order the PRN Seroquel for agitation and suggested that the order might have originated from a General Acute Care Hospital. The facility's policy on psychotropic medication use mandates a 14-day limit on PRN orders unless a documented rationale for extension is provided. The lack of a 14-day stop on the resident's medication order increased the risk to the resident's mental and psychosocial well-being, as there was no mechanism to assess the ongoing need or effectiveness of the medication.
Failure to Complete PASRR Level II Assessment for Resident with Schizophrenia
Penalty
Summary
The facility failed to ensure proper assessment and documentation for a resident under the Preadmission Screening and Resident Review (PASARR) process. Specifically, the facility did not complete a PASRR Level II assessment for a resident diagnosed with schizophrenia, major depressive disorder, and metabolic encephalopathy. The PASARR Level I screening was incomplete, as a critical question regarding suspected mental illness was left unanswered, which should have triggered a Level II assessment. The resident exhibited moderate cognitive impairment and had a history of verbal aggression and mood disturbances, as documented in their care plan and Minimum Data Set (MDS). The care plan noted behaviors such as yelling at staff and becoming physical, which were related to cognitive loss and psychiatric disorders. Despite these documented behaviors and diagnoses, the necessary PASRR Level II assessment was not conducted, which would have provided additional support from the Department of Mental Health. Interviews with facility staff, including the Minimal Data Set Nurse (MDSN) and the Director of Nursing (DON), confirmed the oversight. The MDSN acknowledged that the PASRR Level II should have been completed due to the resident's schizophrenia diagnosis. The DON admitted that the incomplete PASARR Level I evaluation was inaccurate and that the facility should have rectified this to ensure appropriate care planning and support for the resident.
Failure to Notify Physician of Resident's Significant Change in Condition
Penalty
Summary
The facility failed to notify a physician after a significant change in the condition of a resident with mental illness, leading to a deficiency. The resident, who had diagnoses including schizophrenia and major depressive disorder, exhibited increased behavioral symptoms and required hospitalization. The facility's policy mandates immediate notification of physicians in such cases, but this was not done. The resident's Minimum Data Set indicated moderate cognitive impairment and feelings of depression. On multiple occasions, the resident displayed behavioral changes, including verbal aggression and agitation, which were documented in the Situation Background Assessment and Recommendation (SBAR) forms. However, there was no evidence that the physician was informed about these changes, as confirmed by interviews with the Licensed Vocational Nurse and the Director of Nursing. The facility's policy requires informing the physician of significant changes in a resident's condition, but this was not adhered to. The resident's condition deteriorated, resulting in an emergency department visit and a psychiatric hold. The failure to notify the physician was acknowledged by the staff, highlighting a lapse in following the established protocol for handling changes in resident conditions.
Failure to Update Care Plan for Resident with Behavioral Changes
Penalty
Summary
The facility failed to update the care plan for a resident who was at risk for physical behavior towards others after experiencing a change of condition on two separate occasions. The resident, who had diagnoses including schizophrenia and major depressive disorder, exhibited verbal aggression and agitation, which were not adequately addressed in the care plan. Despite the resident's behavioral changes and requests for medication schedule adjustments, the care plan was not revised to reflect these changes or to include specific interventions for the antipsychotic medication, Seroquel, prescribed to the resident. The resident's care plan initially included general approaches for managing verbal behaviors and mood symptoms but lacked specific interventions tailored to the resident's needs and medication regimen. The care plan did not incorporate the necessary updates following the resident's change in condition, as indicated by the SBAR forms documenting the resident's agitation and verbal aggression. The facility's policy required care plans to be individualized and updated with measurable objectives and timetables, but this was not adhered to in the resident's case. Interviews with facility staff, including the MDS Nurse, LVN, and DON, confirmed that the care plan should have been updated to address the resident's behavioral changes and to include specific interventions for the medication. The failure to update the care plan resulted in the escalation of the resident's behaviors, ultimately leading to the resident's admission to a General Acute Care Hospital. The facility's policy emphasized the importance of ongoing assessments and revisions to care plans as residents' conditions change, which was not followed in this instance.
Failure to Implement Baseline Care Plan for Resident's Pain Management and Fracture
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for a resident who was admitted with a fracture of the left fibula and osteoporosis. Despite the resident's need for pain management and care for the left lower leg fracture with a splint, no baseline care plan was initiated or implemented from the time of admission until the survey date. This oversight was confirmed during an interview with the Director of Nursing, who acknowledged the absence of care plans for the resident's pain management and fracture care. The facility's policy and procedures require that a baseline care plan be developed within 48 hours of a resident's admission to ensure individualized care. Additionally, the facility's policies on pain management and skin integrity management emphasize the need for an interdisciplinary plan of care that addresses underlying causes of pain and includes both non-pharmacological and pharmacological approaches. The failure to adhere to these policies resulted in a deficiency that could negatively impact the resident's health and safety.
Failure to Monitor and Document Leg Splint Assessment
Penalty
Summary
The facility failed to ensure proper assessment and monitoring of a resident's left lower leg splint, which was necessary to prevent complications such as skin breakdown and potentially compartment syndrome. The resident, who was admitted with a fracture of the left fibula and osteoporosis, was identified as being at risk for developing pressure ulcers. Despite this risk, there was no documentation of assessment and monitoring of the splint from February 9, 2025, to March 5, 2025. During an observation on March 5, 2025, the resident was seen with the left lower leg splint, and the Director of Nursing confirmed the lack of documentation regarding the splint's assessment and monitoring. The facility's policy on Skin Integrity Management required daily monitoring of wounds or dressings for complications, which was not adhered to in this case. This oversight in documentation and monitoring was verified by the Director of Nursing during an interview and record review.
Insufficient Staffing Leads to Delays in Resident Care
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of its residents, resulting in significant delays in care and unmet scheduled services. Resident 1, who was admitted with a fracture and osteoporosis, required moderate to maximal assistance for activities of daily living (ADLs) and experienced frequent episodes of incontinence. Despite these needs, Resident 1 reported waiting over three hours for incontinence care, which was confirmed by a Certified Nursing Assistant (CNA) who stated that the delay was due to being unable to assist sooner. The Director of Nursing (DON) acknowledged that such a delay was unacceptable. Additionally, the facility did not ensure that scheduled showers were provided to Residents 4 and 5. Resident 4, diagnosed with Parkinson's Disease, epilepsy, and dementia, required maximal assistance for ADLs and was scheduled for a shower every Wednesday. However, there was no documentation of a shower being provided, and a CNA admitted to being unable to shower Resident 4 due to time constraints and a high workload. Similarly, Resident 5, who had atrial fibrillation and required moderate assistance for ADLs, was also not showered as scheduled, with another CNA citing an excessive number of residents to care for as the reason. The facility's policies and procedures, which emphasize the importance of providing care to maintain or improve residents' ability to carry out ADLs, were not adhered to in these instances. The lack of sufficient staffing led to delays and omissions in basic care, such as incontinence management and scheduled showers, which are essential for maintaining residents' personal hygiene and overall well-being.
Failure to Act on Critical Lab Results
Penalty
Summary
The facility failed to ensure that licensed nurses had the necessary skills and knowledge to identify a change in condition for a resident with a critically low platelet count. The resident, who had a history of hemorrhagic disorder due to circulating oral anticoagulants, was admitted with a platelet count of 95,000 uL, which later dropped to 33,000 uL. Despite the critical nature of this lab result, the facility did not immediately inform the physician or take appropriate emergency action, resulting in a delay in transferring the resident to a General Acute Care Hospital (GACH) for treatment. Interviews with facility staff revealed a lack of understanding and adherence to emergency protocols. A Licensed Vocational Nurse (LVN) stated that in emergency situations, residents should be sent via 911, but admitted to following a supervisor's recommendation for non-emergency transport despite the resident's unstable condition. Another LVN indicated that they would wait for a supervisor's directive even in critical situations, such as cardiac arrest. The Director of Nursing (DON) acknowledged that the critical platelet count constituted a change in condition and that the physician should have been notified immediately, but this was not done. The facility's policy and procedure for lab and diagnostic test results required prompt physician notification for critical results, but this was not followed. The Medical Doctor (MD) involved was not aware of the second critical lab result until later and had ordered an emergency transfer via 911, which was not executed by the facility. The failure to act promptly on the critical lab results and the lack of proper communication and emergency response placed the resident at risk for spontaneous bleeding, which could result in death. The resident was eventually transferred to GACH but died seven days later.
Deficiency in Cleanliness and Maintenance of Dinnerware and Water Pitchers
Penalty
Summary
The facility failed to maintain cleanliness and proper condition of dinnerware and food service equipment, as observed during a survey. Clear plastic glasses were found to be cloudy with dishwasher cleaning buildup, and some plastic mugs were stained with coffee or tea. The Dietary Manager acknowledged that these items should have been replaced. Additionally, Certified Nursing Assistants (CNAs) expressed concerns about the cleanliness of residents' cups, noting milk residue and lipstick marks. They also reported that the thermoses and coffee pots were old and worn, with lids that did not stay on, posing a hazard when pouring hot beverages. Furthermore, the facility did not ensure timely replacement of residents' water pitchers for washing. During an observation, some residents were found without water pitchers at their bedside, and the pitchers present were yellow, indicating they had not been swapped out as required. The Dietary Manager confirmed that CNAs were responsible for changing the pitchers daily, and on the day of the interview, all pitchers should have been gray. The facility's policy stated that all dishware, serviceware, and utensils should be cleaned and sanitized after each use, which was not adhered to in these instances.
Failure to Honor Resident Food Preferences
Penalty
Summary
The facility failed to honor the food preferences of two residents, resulting in them receiving canned fruits instead of the fresh fruits they preferred. Resident 2, who was admitted with conditions including hypertension, anemia, muscle weakness, and diabetes mellitus, was on a consistent carbohydrate diet with specific dietary requirements. Resident 3, admitted with chronic obstructive pulmonary disease, anemia, hemiplegia, hemiparesis, and muscle weakness, was on a regular diet with additional fortified foods. Both residents expressed during interviews that they were no longer receiving fresh fruits like bananas and grapes, which they had previously been provided. The Dietary Manager confirmed that fresh fruits were no longer available due to budget constraints and seasonal availability. The facility's policy on resident food preferences stated that meals should be consistent with residents' preferences, and if a preferred item was unavailable, a suitable substitute should be provided. However, this policy was not adhered to, as the residents were not given fresh fruits or suitable substitutes, leading to the deficiency noted in the report.
Failure to Develop Comprehensive Care Plan for Resident with Bipolar Disorder
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for a resident diagnosed with bipolar disorder and prescribed Risperidone, a psychotropic medication. The resident was admitted with multiple diagnoses, including bipolar disorder, but the care plan lacked goals, interventions, or monitoring for the disorder and the medication. The Minimum Data Set (MDS) indicated the resident experienced symptoms of depression and mood swings, yet these were not addressed in the care plan. Interviews with facility staff, including the MDS Nurse, Administrator, Psychiatrist, and Director of Nursing, revealed that the care plan was not completed, and the resident had not been seen by a psychiatrist since admission. The facility's policy required the Interdisciplinary Team to develop a comprehensive care plan with measurable objectives and timetables to meet the resident's needs. However, the admitting nurse did not initiate the necessary care plan, and the psychiatrist was not informed of the resident's admission. This oversight resulted in the absence of a care plan to monitor the effectiveness of interventions for the resident's bipolar disorder and psychotropic medication, increasing the risk of untreated adverse reactions.
Missing Performance Evaluation for LVN
Penalty
Summary
The facility failed to ensure that a Licensed Vocational Nurse (LVN 1) had a yearly performance evaluation documented in their employee file. LVN 1 was hired on 9/22/22, and there was no performance evaluation completed since the date of hire. During an interview, the Director of Nursing (DON) stated that performance evaluations should be conducted 90 days after the start of employment and then annually. However, the DON could not explain why LVN 1's performance evaluation was missing. The Administrator (ADM) also confirmed the absence of the evaluation and agreed that it should have been performed. The facility's policy, dated 9/20, mandates performance evaluations at the end of a 90-day probationary period and annually thereafter. The lack of a performance evaluation for LVN 1 was acknowledged by the DON as creating a risk to resident safety.
Missing Skills Competency Checklist for CNA
Penalty
Summary
The facility failed to ensure that the employee file of one of two sampled Certified Nurse Assistants (CNA 2) contained a yearly skills competency checklist. CNA 2 was hired on 3/12/24, but the skills competency checklist was missing from their file. During an interview, the Administrator confirmed the absence of the checklist, and the Director of Nursing (DON) acknowledged that the skills competency should have been completed upon hire and annually. The DON emphasized that without written documentation, it is assumed that the competency was not completed. The facility's policy and procedure, dated 5/19, required competency evaluations upon hire, annually, and as necessary, to ensure nursing staff demonstrate the skills needed to care for residents.
Failure to Obtain Consent for Psychotropic Medication
Penalty
Summary
The facility failed to ensure that a resident, identified as Resident 3, had a documented consent for psychotropic medications, specifically Risperidone, which was prescribed for bipolar disorder mood swings. The resident was admitted with diagnoses including Type II diabetes mellitus, bipolar disorder, and cellulitis. Despite being alert, oriented, and having good recall, the resident did not have a signed Psychotropic Medication Administration Disclosure for consent in their physical chart. This oversight was identified during a review of the resident's records and confirmed through interviews with facility staff. Interviews with the Medical Records Department, a Registered Nurse, and the Director of Nursing revealed that it was the responsibility of the admitting nurse to obtain consent for psychotropic medications within a day or two of admission. However, this was not done for Resident 3. The facility's policy indicated that informed consent should be obtained by the prescriber prior to the initiation of psychotropic medications, but this procedure was not followed. The psychiatrist, who visits the facility monthly, was not informed of the resident's admission, further contributing to the lack of consent documentation.
Failure to Report and Investigate Resident Altercation
Penalty
Summary
The facility failed to adhere to its abuse policy and procedures in handling an incident involving two residents, resulting in a deficiency. The incident involved a verbal altercation between two residents, where one resident attempted to strike the other. Despite the altercation, the facility did not report the incident to the state licensing/certification office, police, or ombudsman, nor did it conduct an investigation as required by their policy. Additionally, the residents were not separated in a timely manner, with one resident being moved to a different room 11 days after the incident. Resident 1, who was involved in the incident, was admitted to the facility with multiple diagnoses, including chronic obstructive pulmonary disease, pneumonia, and mild cognitive issues. The resident required assistance with daily activities such as eating, toileting, and personal hygiene. On the day of the incident, Resident 1 was involved in a shouting match with their roommate, Resident 7, who attempted to strike them. Despite the altercation, Resident 1 initially declined a room change, preferring to stay in their current room. Resident 7, the other party involved, had a history of moderate cognitive issues and required substantial assistance with daily activities. The resident also exhibited fluctuating behaviors of inattention. During the incident, Resident 7 was redirected after attempting to strike Resident 1 and was offered a room change, which they agreed to. However, the facility failed to follow through with the room change for Resident 7, and no investigation or reporting of the incident was conducted, contrary to the facility's abuse prohibition policy.
Resident Identification Error Leads to Missed Appointment
Penalty
Summary
The facility failed to ensure proper resident identification, resulting in a mix-up between two residents with the same first name. Resident 1, who had severe cognitive impairment and required substantial assistance, was scheduled for transfer to another skilled nursing facility (SNF). Meanwhile, Resident 2, who was legally blind and had moderately impaired cognitive function, was supposed to attend an ophthalmologist appointment. However, due to the identification error, Resident 2 was mistakenly taken to the SNF instead of the eye specialist. The incident occurred when a transportation driver arrived at the facility and incorrectly identified Resident 2 as the individual to be transferred to the SNF. Despite Resident 2 carrying an envelope with his name and being accompanied by a certified nursing assistant (CNA), the driver took him to the wrong location. This error led to Resident 2 missing his scheduled appointment with the ophthalmologist, causing him distress and requiring the appointment to be rescheduled. The facility's policy on resident identification, which includes a photo and/or wristband system, was not effectively implemented to prevent this mix-up.
Failure to Provide Immediate Care After Resident Fall
Penalty
Summary
The facility failed to provide care in accordance with professional standards of practice for a resident who experienced a fall. The resident, admitted with diagnoses including metabolic encephalopathy and generalized muscle weakness, fell during the night shift. Despite the fall occurring, there was no immediate assessment or documentation of the incident. The resident, who had severe cognitive impairment and required substantial assistance with daily activities, was found on the floor in a sitting position without pain or swelling, and denied hitting their head. However, the fall was not documented until later in the day, and the resident's physician was not notified immediately. Interviews with facility staff revealed that the licensed vocational nurse (LVN) was informed of the fall around noon, several hours after it occurred, and subsequently notified the nurse practitioner. The facility's policy and procedure for fall management, which requires immediate observation for injury, neurological evaluation, documentation, and notification of the physician and responsible party, was not followed. The director of nursing confirmed the lack of documentation and immediate notification, which are critical steps outlined in the facility's policies for managing falls and changes in resident condition.
Failure to Conduct Quarterly Braden Scale Assessment for Resident with Pressure Ulcers
Penalty
Summary
The facility failed to ensure that a resident with pressure ulcers was assessed quarterly using the Braden scale assessment, which is crucial for evaluating the risk of developing pressure ulcers. The resident, who was at risk of developing pressure ulcers according to their Minimum Data Set, was readmitted with several diagnoses, including altered mental status, hemiplegia, hemiparesis, muscle wasting, and a gastrostomy. Despite these conditions, the facility did not complete a Braden scale assessment for the resident on the required quarterly date. The resident's care plan, initiated after readmission, noted unstageable pressure-induced tissue damage on the sacral coccyx extending to the left buttock, with a goal for the wound to heal. However, the care plan lacked comprehensive interventions. A subsequent Braden scale assessment indicated the resident was at severe risk of developing pressure ulcers, with a score of 8, highlighting issues such as limited sensory perception, constant moisture, immobility, and friction problems. The Director of Nursing acknowledged the oversight in completing the Braden scale assessment, which is essential for informing staff about the necessary care to prevent the worsening of the resident's wounds.
Inadequate Care Planning for Pressure Ulcers
Penalty
Summary
The facility failed to provide adequate care for a resident at severe risk of developing pressure ulcers, leading to deficiencies in the resident's care plan. The resident, who was readmitted with multiple diagnoses including altered mental status and hemiplegia, had an unstageable pressure ulcer on the sacral coccyx and a right lateral heel vascular wound. The care plan for these wounds was not adequately developed or revised, lacking necessary interventions and updates when the sacral coccyx wound was reclassified as a Stage IV pressure ulcer. The care plan for the resident's sacral coccyx pressure ulcer did not include sufficient interventions, and the plan was not updated when the wound was reclassified from unstageable to Stage IV. Additionally, the care plan for the right lateral heel vascular wound was incomplete, listing only one intervention without further details. The facility also failed to develop a care plan for a new PVD wound on the resident's right lateral lower leg, which was identified during a skin check. Interviews with the Treatment Nurse and the Director of Nursing revealed that the care plans were lacking in substance and did not reflect the resident's current wound status. The facility's policies required comprehensive and individualized care plans, which were not adhered to in this case. The lack of proper care planning increased the risk of the resident's skin integrity worsening and hindered the healing process.
Verbal Abuse Incident Involving CNA and Resident
Penalty
Summary
The facility failed to protect a resident's right to be free from verbal abuse when a Certified Nurse Assistant (CNA) used a derogatory term in the presence of a resident. On the morning of August 12, 2024, CNA 1 was involved in an altercation with a resident over a pair of socks. During this interaction, the resident called CNA 1 a liar and used a derogatory term, to which CNA 1 responded by repeating the derogatory term as she left the room. This incident was witnessed by another resident and a Registered Nurse (RN), who confirmed hearing the exchange. The resident involved in the incident had a history of mildly impaired cognition and had been feeling down, depressed, or hopeless in the weeks leading up to the event. The facility's policy on abuse prohibition, which was reviewed by the Director of Nursing and the Administrator, clearly states that verbal abuse includes the use of disparaging and derogatory terms. Despite this policy, the CNA's communication with the resident was deemed ineffective and increased the risk of verbal abuse, as noted by the Administrator.
Failure to Develop and Revise Care Plan for G-tube Dislodgment
Penalty
Summary
The facility failed to ensure that a resident with a G-tube had an initial care plan developed for G-tube dislodgment and that it was revised after subsequent dislodgments to include new interventions. This oversight resulted in seven instances where the resident's G-tube was dislodged and required replacement. The resident, who was admitted with multiple diagnoses including hypertension, type two diabetes mellitus, heart failure, muscle weakness, dysphagia, and encephalopathy, experienced cognitive impairment and was dependent on staff for various activities of daily living. Despite these conditions, the facility did not have a care plan addressing the G-tube dislodgment until several months after the resident's admission. Additionally, the facility did not conduct interdisciplinary team (IDT) meetings in a timely manner following the G-tube dislodgments. The progress notes for the resident indicated no entries for IDT meeting notes regarding the G-tube dislodgment until several months after the initial incident. This lack of timely IDT meetings and care plan revisions was contrary to the facility's policy and procedures, which required care plans to be reviewed and revised by the interdisciplinary team after each assessment and as needed to reflect the response to care and changing needs and goals.
Resident Incorrectly Charged for Single Room
Penalty
Summary
The facility failed to ensure that a resident was not billed for a single room while another resident was on bed hold in the same room. This deficiency was identified during a review of the resident's admission record and financial statements. The resident, who was independent in decision-making and required assistance with certain activities of daily living, was charged for a single room despite the presence of another resident on bed hold in the room. The Business Office Assistant confirmed that there was no documentation of an agreement for the single room, and the resident was not liable for the charges. Further investigation by the Director of Nursing revealed that the facility's census records indicated the resident was in a semi-private room with another resident on bed hold during the relevant dates. The Director of Nursing confirmed that the resident should not have been charged for a single room under these circumstances. The lack of proper documentation and billing practices led to the resident being incorrectly charged for a single room they did not receive.
Delayed Implementation of Dietician's Recommendations for G-tube Feeding
Penalty
Summary
The facility failed to implement the recommendations made by the Registered Dietician (RD) during an interdisciplinary team meeting regarding a change in a resident's gastrostomy (G-tube) feeding formula. This oversight resulted in a delay of 51 days before the recommended change was made, during which time the resident experienced a weight loss of six pounds, equivalent to 4% of their body weight. The resident, who was admitted with multiple diagnoses including hypertension, type two diabetes mellitus, heart failure, muscle weakness, dysphagia, and encephalopathy, was dependent on staff for various activities of daily living. The deficiency was identified through interviews and record reviews, which revealed that the Director of Nursing (DON) acknowledged the failure to follow up on the RD's recommendations. The recommendations included changing the G-tube feeding formula from Jevity 1.2 cal/ml to Glucerna 1.5 cal/ml at a higher rate, which was not implemented until much later. The facility's policy indicated that dietary orders could be delegated to a qualified dietitian, but the necessary steps to obtain a physician's order for the change were not taken in a timely manner.
Failure to Conduct Staff Competency Evaluations
Penalty
Summary
The facility failed to perform staff competencies upon hire and/or annually for three of five sampled staff members, including two Certified Nursing Assistants (CNAs) and one Licensed Vocational Nurse (LVN). This deficiency was identified during a review of employee files, which revealed that CNA 8, hired in 2018, and CNA 10, hired in 2022, did not have competencies for the year 2023 available for review. Additionally, LVN 4, hired in 2024, did not have a competency evaluation completed upon hire. These omissions were confirmed during interviews with the Director of Staff Development (DSD) and the Director of Nursing (DON), who acknowledged the absence of required competencies in the employee files. The facility's policy, revised in 2019, mandates that all nursing staff meet specific competency requirements upon hire, annually, and as needed. The DSD and DON both emphasized the importance of these evaluations to ensure staff possess the necessary skills to provide appropriate care to residents. The lack of completed competencies for the identified staff members suggests a failure to adhere to the facility's policy, potentially impacting the quality of care provided to residents.
Failure to Rotate Insulin Injection Sites
Penalty
Summary
The facility failed to ensure proper rotation of insulin injection sites for two residents, leading to a potential risk of adverse effects. Resident 21, who was admitted with diabetes mellitus and other related conditions, received multiple insulin injections on the same site, specifically the right arm, over several days in April and May 2024. Similarly, Resident 75, admitted with diabetes mellitus and muscle weakness, also received insulin injections repeatedly on the same site, the left arm, during the same period. This practice contradicts the standard procedure of rotating injection sites to prevent complications such as lipohypertrophy and localized cutaneous amyloidosis. Interviews with facility staff, including LVNs and the DON, confirmed that the standard practice was to rotate injection sites to avoid harm. However, the MARs for both residents indicated that this practice was not followed. Additionally, Resident 75 reported that staff did not inquire about his preferred injection site, which he stated was his stomach. The facility's failure to adhere to these practices was corroborated by the pharmacist and the insulin manufacturer's guide, which both emphasized the importance of site rotation to reduce risks associated with repeated injections at the same site.
Failure to Provide SNF ABN to Residents
Penalty
Summary
The facility failed to provide two residents, identified as Residents 11 and 55, with the Skilled Nursing Facility Advanced Beneficiary Notice of Non-Coverage (SNF ABN). This notice is crucial for transferring financial liability to beneficiaries before the facility provides services that Medicare may not cover. Resident 11 was admitted with multiple diagnoses, including an unspecified fall, urinary tract infection, hypertension, muscle weakness, anxiety, schizophrenia, and major depressive disorder. The review indicated that the resident's last covered Medicare Part A Skilled Services was on 5/29/2024, and although a Notice of Medicare Non-Coverage (NOMNC) was provided, the SNF ABN was not issued. Similarly, Resident 55, admitted with conditions such as diverticulitis, hyperlipidemia, difficulty in walking, dysphagia, major depressive disorder, hypertension, and dementia, also did not receive the SNF ABN despite having remaining benefit days. During interviews, the Assistant Business Office Manager (ABOM) acknowledged the oversight, stating they were unaware of the requirement to provide the SNF ABN alongside the NOMNC. The Director of Nursing (DON) confirmed that the residents should have received the SNF ABN to ensure they were informed about their care and the nearing end of their Medicare Part A days. The facility's policy and procedure, as well as the Centers for Medicare and Medicaid Services guidelines, require the issuance of the SNF ABN to inform beneficiaries about potential non-coverage and financial responsibility, which was not adhered to in these cases.
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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