South Marin Health & Wellness Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Greenbrae, California.
- Location
- 1220 South Eliseo Drive, Greenbrae, California 94904
- CMS Provider Number
- 055093
- Inspections on file
- 19
- Latest survey
- January 23, 2026
- Citations (last 12 mo.)
- 19
Citation history
Health deficiencies cited at South Marin Health & Wellness Center during CMS and state inspections, most recent first.
The facility failed to send a required copy of a facility-initiated discharge notice to the State LTC Ombudsman at the same time it notified a resident’s representative. The resident’s spouse received written notice on the day the resident was expected to leave, but facility records showed the Ombudsman was not faxed the notice until 22 days after the discharge. The SSD, who was responsible for sending such notices, acknowledged that the Ombudsman should have been notified before the discharge. The facility’s own P&P required that a copy of any transfer or discharge notice be sent to the State LTC Ombudsman before the transfer or discharge, but this was not done in this case, and the family reported they had not requested the discharge and wanted the resident to remain.
A resident with chronic pulmonary embolism and atrial fibrillation had a physician’s order for daily rivaroxaban, but nursing staff failed to reorder the medication when the bubble pack indicated a low supply, resulting in the drug being unavailable and not administered on a scheduled day. The MAR reflected the missed dose due to unavailability, and an LPN confirmed the supply had run out and was not available in the E-Kit, requiring the resident to wait for the next pharmacy delivery. The DON stated nurses were responsible for reordering when the bubble pack turned blue and that facility policies required timely reordering and administration of medications as prescribed.
The facility failed to ensure medication carts and the medication room were free of expired medications and supplies. Expired Latanoprost was found in a medication cart, and the medication room contained expired syringes, syringe caps, an insulin syringe, and COVID-19 tests. A medication cart also contained a resident's medication after discharge. The facility's policy requires immediate removal of outdated medications.
The facility failed to follow the prescribed recipe for pureed rice, as observed when a staff member did not add margarine and thickener, using a recipe meant for pureed salads instead. This was confirmed by the staff and acknowledged by the RD and DM, who stressed the importance of following recipes to ensure consistent meal quality and nutritional value.
The facility failed to serve food that was palatable, attractive, and at an appetizing temperature. Observations revealed that food temperatures were below policy requirements, and the food was unappealing and bland. Residents confirmed the food was dry and tasteless, and the dietary manager acknowledged the deficiencies.
The facility failed to properly label and date food items, including a pitcher of tea and vegan chicken nuggets, and did not separate a dented can of vanilla pudding from intact cans. These oversights, confirmed by the dietary manager and registered dietician, posed potential health risks to residents due to the possibility of serving expired or contaminated food.
A facility failed to follow its policy on labeling food items brought by family or visitors, as a resident's refrigerator contained six unlabeled food containers. Staff, including LNs, the IP, and the DON, confirmed the oversight, emphasizing the importance of labeling to prevent serving spoiled food. The resident had a history of hypertension and hyperlipidemia, highlighting the need for strict food safety measures.
The facility failed to maintain proper infection control practices, including processing soiled linens at the correct temperature, ensuring hand hygiene before meals, and adhering to enhanced barrier precautions for a resident with MRSA. Additionally, kitchen utensils were stored wet, increasing the risk of bacterial growth.
A facility failed to provide hot water in shared bathrooms of certain rooms, with temperatures below the required 105 degrees. A resident reported inconvenience and safety concerns due to the cold water, which could deter handwashing and increase infection risk. Staff confirmed the issue, and observations verified the deficiency, with water temperatures recorded between 84 and 87 degrees.
The facility's ineffective pest control program resulted in flies being present, posing health risks to residents. Flies were observed landing on food and residents, with staff acknowledging the potential for disease spread. Two residents with moderate cognitive impairment were notably affected, with flies landing on their food and clothing. The facility's pest control policy was outdated, and staff confirmed the health risks associated with the presence of flies.
Two LNs in an LTC facility failed to follow professional standards, leading to potential medication errors and inaccurate blood glucose tests. One LN left medications at a resident's bedside without a physician's order, allowing the resident's wife to administer them, contrary to facility policy. Another LN did not follow protocol when performing a blood glucose check, using the first drop of blood after cleaning with alcohol, which may alter test results.
A resident with COPD and muscle weakness, identified as high risk for falls, experienced four falls over ten months due to inadequate supervision and ineffective interventions. Despite being at high risk, the facility did not increase supervision or implement new preventive measures after each fall, as revealed by interviews with the DON and a CNA. The facility's falls management policy was not effectively followed.
A resident with dysphagia was given ice chips by a CNA, contrary to the prescribed dysphagia diet of puree food and honey-thick liquids. The CNA was not informed of the resident's dietary changes, leading to a potential risk of aspiration pneumonia. The facility's RD and DON confirmed the importance of adhering to diet orders, and the attending physician expected compliance with care plans.
The facility failed to report allegations of a staff-to-resident verbal altercation and an incident between two residents within the required two-hour timeframe. These delays in reporting were confirmed during a review of records and interviews with the Administrator and DON, risking physical, mental, or psychosocial harm to the residents involved.
Failure to Timely Notify State LTC Ombudsman of Facility-Initiated Discharge
Penalty
Summary
The facility failed to provide a timely notice of discharge to the Office of the State Long-Term Care Ombudsman for one resident. A written Notice of Transfer or Discharge for Resident 1, dated 10/21/25, showed that the resident’s spouse received the discharge notice on the same day the resident was expected to leave the facility. The notice itself stated that the facility must send a copy of the notice to a representative of the Office of the Long-Term Care Ombudsman. Facility records, including a fax transmission report, showed that the notice was not sent to the Office of the State Long-Term Care Ombudsman until 11/11/25 at 10:01 a.m., which was 22 days after the resident had been discharged. During interviews, the Social Services Director (SSD) acknowledged responsibility for sending transfer or discharge notices to the Ombudsman at the time of this event and confirmed that Resident 1’s discharge was facility-initiated. The SSD also stated she understood that the Ombudsman advocates for residents and that the notice should have been sent before the resident’s discharge. In a separate interview, Resident 1’s family member reported that the family did not request the discharge and wanted the resident to remain at the facility. The facility’s policy and procedure titled “Transfer or Discharge Notice,” dated December 2016, required that a copy of the transfer or discharge notice be sent to the Office of the State Long-Term Care Ombudsman, with notice to be provided as soon as practicable but before the transfer or discharge under certain circumstances. This policy requirement was not followed for Resident 1.
Failure to Reorder and Administer Anticoagulant as Prescribed
Penalty
Summary
The facility failed to ensure that licensed nurses administered a significant medication as ordered for one resident when they did not reorder the medication before the supply ran out. The resident was admitted with diagnoses including wedge compression fracture, chronic pulmonary embolism, atrial fibrillation, and muscle weakness, and had a physician’s order for rivaroxaban 15 mg orally once daily for thromboembolism related to chronic atrial fibrillation. Review of the October 2025 Medication Administration Record showed that on 10/15/25 the rivaroxaban dose was marked with the number 8, which staff stated indicated the medication was not available to be administered that day. During interviews, a licensed nurse reported that on 10/15/25 she did not administer the rivaroxaban because the supply had run out and, if the medication was not available in the emergency medication supply kit, the resident had to wait until the next day for the pharmacy delivery. The DON explained that the medication bubble pack background turned blue at medication number 4 to indicate the supply was low and needed to be reordered, and that nurses were responsible for reordering medications when the supply became low. Facility pharmacy policy required medications to be reordered five days in advance of need to ensure an adequate supply, and the general medication administration policy required medications to be administered safely, in a timely manner, and as prescribed. These policies were not followed, resulting in the missed dose of rivaroxaban on 10/15/25.
Expired Medications and Supplies Found in Facility
Penalty
Summary
The facility failed to ensure that medication carts and the medication room were free of expired and outdated medications and medical supplies. During an observation, a medication cart for Station 2 was found to contain Latanoprost 0.005% with an expiration date of 11/15/24, which was confirmed by a Licensed Nurse (LN) F. The nurse stated that the Infection Preventionist and Director of Staff Development were responsible for weekly checks of the medication carts for expired medications. Additionally, the Director of Nursing (DON) confirmed the presence of more than 10 expired syringes and syringe caps, as well as an expired insulin syringe and COVID-19 tests in the medication room. Further observations revealed that a medication cart for Station 3 contained a bottle of collagen tablets belonging to a resident who had been discharged a week prior. The Director of Staff Development stated that Licensed Nurses were responsible for checking their assigned medication carts for expired medications, while the central supply department was tasked with checking the medication room once a month. The facility's policy on medication storage, last revised in April 2008, indicated that outdated or deteriorated medications should be immediately removed from stock and disposed of according to procedures.
Failure to Follow Pureed Rice Recipe
Penalty
Summary
The facility failed to adhere to the prescribed recipe for pureed rice, which is a critical component of ensuring that residents receive meals that meet their nutritional needs. During an observation, it was noted that a staff member did not add margarine and thickener to the pureed rice as required by the recipe. This deviation from the recipe was confirmed during an interview with the staff member, who admitted to using the wrong recipe intended for pureed salads instead of the one for pureed rice. The Registered Dietician and Dietary Manager both emphasized the importance of following recipes to maintain consistent quality and nutritional value of meals served to residents. The facility's policy and procedure on food preparation mandates the use of approved and standardized recipes to meet the dietary needs of residents. However, the staff's failure to follow the correct recipe for pureed rice could lead to inconsistent meal quality and potential nutritional deficiencies for the residents. The Dietary Manager acknowledged that using the incorrect recipe could result in improper portion control and meals not meeting the dietary requirements of the residents.
Deficiency in Food Quality and Temperature
Penalty
Summary
The facility failed to ensure that residents were served food that was palatable, attractive, and at an appetizing temperature, as observed during a survey. The dietary manager (DM) did not sample the food prepared, and the food served was found to be unappealing and unappetizing. The temperatures of the food items on the test tray were below the facility's policy requirements, with rice and chicken at 130 degrees and a burger patty at 118 degrees, while the policy required hot foods to be held at 140 degrees or above. The chicken with lemon and thyme was described as dry and bland, lacking the taste of lemon, and both the rice and chicken were lukewarm when sampled. Interviews with residents confirmed the observations, with one resident stating that the chicken was dry and lacked flavor, and another resident describing the chicken as dry as straw and tasteless. Both residents noted that the food was lukewarm upon receipt. The DM acknowledged that the food temperatures were not appetizing and verified that the food did not appear appealing. The facility's policy and procedure for food preparation emphasized the importance of conserving nutritive value, flavor, and appearance, and required that prepared food be sampled to ensure satisfactory flavor and consistency.
Food Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure proper labeling and dating of food items in their storage areas, which could lead to potential health risks for residents. During an observation, it was noted that a pitcher of tea in the refrigerator was not discarded by its use-by date, and a bag of vegan chicken nuggets in the freezer was not labeled or dated. The dietary manager confirmed these oversights and acknowledged the potential risks of serving expired or unidentified food items, which could lead to allergic reactions or gastrointestinal illnesses among residents. Additionally, the facility did not separate a dented can of vanilla pudding from intact cans, posing a risk of bacterial contamination. The dietary manager and registered dietician both confirmed that dented cans should be stored separately to prevent accidental use, as they could harbor bacteria that might cause illness if consumed by residents. The facility's policy requires proper storage and labeling of food items, including the separation of dented cans, but these procedures were not followed. Interviews with staff, including the registered dietician and another staff member, reiterated the importance of labeling and dating food items to ensure the safety and dietary compliance for residents. The failure to adhere to these protocols was identified as a safety risk, as it could lead to the consumption of spoiled or inappropriate food items, potentially causing health issues for the residents.
Failure to Label Food Items Brought by Family
Penalty
Summary
The facility failed to adhere to its policy regarding the labeling of food items brought by family or visitors for residents. During an observation, it was noted that a resident's refrigerator by the nursing station contained six food containers, including chilis, meatloaf, egg salad, and potato salads, none of which had a use-by date as required by the facility's policy. This policy mandates that all containers be labeled with the resident's name, the item, and the use-by date to ensure food safety and prevent the consumption of spoiled food. Multiple staff members, including licensed nurses, the Infection Preventionist, and the Director of Nursing, confirmed that the policy was not followed. They acknowledged the importance of labeling food with a use-by date to prevent serving spoiled food, which could lead to foodborne illnesses. The resident involved had a medical history of essential hypertension and hyperlipidemia, which underscores the importance of maintaining strict food safety standards to protect their health and well-being.
Infection Control Deficiencies in Linen Processing, Hand Hygiene, and Barrier Precautions
Penalty
Summary
The facility failed to properly process soiled linens, as observed during a survey where the washing machine's temperature gauge was malfunctioning, showing 0 degrees Fahrenheit instead of the required 160 degrees Fahrenheit. The laundry staff did not maintain a log of washing machine temperatures, and the facility's policy required washing linens at a minimum of 160 degrees Fahrenheit for high-temperature processing. This failure to maintain proper washing temperatures could lead to the spread of infections due to inadequately sanitized linens. The facility also failed to ensure proper hand hygiene practices among staff and residents. Several residents were not offered or reminded to perform hand hygiene before meals, and a dietary staff member did not perform hand hygiene before donning new gloves. The facility's policy required hand hygiene before and after eating and before donning gloves, but these practices were not consistently followed, increasing the risk of infection transmission. Additionally, the facility did not adhere to enhanced barrier precautions for a resident with a history of MRSA. Staff members were observed not wearing the required gowns and gloves while in close contact with the resident, despite the facility's policy and posted notices indicating the need for such precautions. Furthermore, kitchen utensils were stored while still wet, contrary to best practices that require air drying to prevent bacterial growth. These failures collectively posed a risk of infection transmission to residents.
Deficiency in Hot Water Availability in Shared Bathrooms
Penalty
Summary
The facility failed to ensure that hot water was available in the shared bathrooms of rooms 26-28 and 27-29, with water temperatures recorded below the required 105 degrees. This deficiency was observed over a period of more than a week, during which Resident 48, who was cognitively intact and had conditions such as essential hypertension and anxiety disorder, reported the inconvenience and unpleasantness of using cold water for handwashing. The resident expressed concerns about the safety hazard posed by the lack of hot water, which could deter residents from washing their hands and potentially lead to the spread of infections. Interviews with staff, including a CNA, LN, and the DON, confirmed the absence of hot water and highlighted the importance of having hot water available to encourage proper hand hygiene and prevent infections. The DON and other staff members acknowledged the risk of infection transmission due to inadequate handwashing facilities. Observations by the surveyor and the ADM further verified the insufficient water temperatures, which were significantly below the facility's policy requirement of at least 105 degrees, with recorded temperatures of 84 to 87 degrees.
Ineffective Pest Control Program Leads to Health Risks
Penalty
Summary
The facility failed to maintain an effective pest control program, as evidenced by the presence of flies within the facility, which posed a health risk to residents. Observations and interviews revealed that flies were seen landing on food and residents, which could potentially spread diseases. Specifically, a fly was observed landing on the rim of a cup of pudding belonging to a resident with moderate cognitive impairment and a history of sepsis. This incident was verified by multiple staff members, including a Licensed Nurse, Registered Dietician, Dietary Manager, Infection Preventionist, and Director of Nursing, all of whom acknowledged the health risks associated with flies in the facility. Another resident, also with moderate cognitive impairment and medical diagnoses including COPD and diabetes, was observed with flies on his clothing and hair on multiple occasions. The resident reported that the issue with flies was ongoing. The facility's pest control policy, last revised in 2008, was reviewed, indicating an ongoing pest control program, yet the presence of flies suggests the program was ineffective. The staff, including the Infection Preventionist, acknowledged that flies could spread germs and cause infection control issues.
Failure to Follow Medication and Blood Glucose Testing Protocols
Penalty
Summary
The facility failed to ensure that two licensed nurses adhered to professional standards of practice, resulting in potential medication administration errors and inaccurate blood glucose tests. Licensed Nurse H left medications, specifically Atorvastatin and Melatonin, at Resident 67's bedside without a physician's order, allowing the resident's wife to administer them. This practice was not authorized by the attending physician and was contrary to the facility's medication administration policy, which requires medications to be administered by licensed personnel and within a specific time frame. The medications were administered more than an hour before the scheduled time, indicating a daily medication administration error when the wife was present. Licensed Nurse O did not follow the facility's policy when performing a blood glucose check for Resident 170. The nurse used an alcohol wipe to clean the resident's finger and did not allow it to dry before obtaining a blood sample, using the first drop of blood for the test. This action was against the facility's policy, which states that the first drop should be discarded if alcohol is used, as it may alter the test results. The care plan for Resident 170 did not specify the steps for obtaining a blood sample or indicate that the resident was difficult to bleed, which contributed to the nurse's decision to use the first drop of blood.
Inadequate Fall Prevention Measures for High-Risk Resident
Penalty
Summary
The facility failed to implement adequate interventions and supervision to prevent falls for a resident, identified as Resident 21, who experienced four falls over a ten-month period. Resident 21 was admitted with medical diagnoses including Chronic Obstructive Pulmonary Disease and muscle weakness, and was assessed to have moderately impaired cognition. Despite being identified as high risk for falls through the Morse Fall Risk Screen, the facility did not increase supervision or implement effective interventions after each fall. The first fall occurred when Resident 21 was found on the bathroom floor, unwitnessed, with no injury. The care plan was updated to include continued physical and occupational therapy and assistance during toileting, but supervision was not increased. The second fall happened outside the facility, resulting in minor injuries, and the care plan was revised to remind the resident to have a companion when leaving the facility. However, there was no documentation that this intervention was consistently communicated to or implemented by the staff. The third fall was assisted by a CNA while the resident was standing next to the bed, and the care plan was revised without adding new preventive interventions. The fourth fall was unwitnessed, resulting in a minor injury, and the care plan was updated to ensure items were within reach, but supervision was not increased. Interviews with the DON and a CNA revealed inconsistencies in the understanding and implementation of fall prevention measures, and the facility's policy on falls management was not effectively followed, as evidenced by the lack of increased supervision and new interventions after each fall.
Failure to Follow Dysphagia Diet Orders
Penalty
Summary
The facility failed to provide care in accordance with a resident's comprehensive person-centered care plan and physician's orders. The resident, who had a medical diagnosis of dysphagia, was given ice chips by a Certified Nursing Assistant (CNA), despite being on a prescribed dysphagia diet with specific food and liquid consistencies. The resident had been discharged from the hospital with a history of recurrent aspiration pneumonia and was ordered to follow a Level 4 puree diet with Level 3 honey-thick liquids. The CNA admitted to giving the resident ice chips, which are classified as transitional foods, after not being informed of the resident's updated dietary restrictions. Interviews with facility staff, including the Registered Dietitian (RD) and Director of Nursing (DON), revealed that the CNA was not informed of the resident's dietary changes. The RD confirmed that ice chips do not meet the honey-thick consistency requirement and could lead to aspiration pneumonia. The DON stated that it was the responsibility of the nurse in charge to communicate any changes in diet orders to the CNAs. The attending physician also expected the facility staff to adhere to the prescribed care plans and diet orders. The facility's policy on therapeutic diets emphasizes the importance of following physician-prescribed diets to support the resident's treatment and care plan.
Failure to Timely Report Allegations of Abuse and Resident Incidents
Penalty
Summary
The facility failed to report allegations of a staff-to-resident verbal altercation and an incident between two residents within the required two-hour timeframe. Specifically, an incident between a Certified Nursing Assistant (CNA) and a resident occurred on 3/10/24 at 3:00 PM, but the report was not sent to the Department until 3/11/24 at 0:34 AM. Additionally, an incident between two residents occurred on 3/9/24 at 3:00 AM, but the report was not sent until 3/9/24 at 9:39 AM. These delays in reporting were confirmed during a review of records and interviews with the Administrator and Director of Nursing (DON) on 3/18/24 at 10:42 AM. The facility's policy, effective 1/1/24, mandates that all allegations of abuse be reported to the appropriate agencies within two hours. The Director of Nursing (DON) acknowledged that the incidents were reported late, with one incident being reported by a CNA to a Licensed Nurse at 5:00 AM, who then sent the report. The failure to report these incidents promptly had the potential to prevent timely investigation and correction, thereby risking physical, mental, or psychosocial harm to the residents involved.
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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