The Rehabilitation Center Of North Hills
Inspection history, citations, penalties and survey trends for this long-term care facility in North Hills, California.
- Location
- 9655 Sepulveda Boulevard, North Hills, California 91343
- CMS Provider Number
- 056367
- Inspections on file
- 81
- Latest survey
- February 27, 2026
- Citations (last 12 mo.)
- 54
Citation history
Health deficiencies cited at The Rehabilitation Center Of North Hills during CMS and state inspections, most recent first.
A resident with polyneuropathy, protein-calorie malnutrition, and myelodysplastic syndrome, who had intact cognition but required maximal assistance with ADLs, had a physician-ordered medical appointment that was missed due to lack of transportation and subsequently rescheduled. The SSD, who was responsible for informing residents and their families or representatives of cancelled or rescheduled MD appointments, did not document any notification to the resident’s family or representative about the missed and rescheduled visit, despite facility policy on resident rights to communication and access to services.
Two residents with severe cognitive impairment and total dependence on staff for ADLs were found with long and dirty fingernails, despite care plans and facility policy requiring regular assistance with personal hygiene. Staff acknowledged the deficiency, and it was noted that reminders to CNAs were given but not verified, resulting in inadequate nail care.
A resident with advanced pressure ulcers and multiple medical conditions was found lying on a low air loss mattress with four layers of linen, including a fitted sheet and a cloth incontinence pad, and was also wearing an incontinence brief. Staff acknowledged that this practice was inconsistent with facility policy and physician orders, which require no more than two layers of linen and discourage the use of incontinence briefs on LALMs to ensure proper airflow for wound healing.
A resident with a history of pneumonia, UTI, and acute respiratory failure with hypoxia was consistently receiving continuous oxygen therapy as ordered by a physician. However, staff and the DON confirmed that no comprehensive, person-centered care plan was developed to address the resident's ongoing oxygen use, despite facility policy requiring such plans.
A licensed nurse failed to document the administration of a PRN Ipratropium-Albuterol Solution on the MAR after giving it to a resident with cognitive impairment and respiratory issues. The nurse admitted to forgetting to chart the medication due to being busy, and the DON confirmed the lack of documentation, which was against facility policy requiring immediate recording of all administered medications.
A resident's assessment was found to be inaccurate, with the MDS failing to document both a deep tissue injury and significant hearing impairment, despite these conditions being present and noted in other records. Staff interviews confirmed the discrepancies, and the DON acknowledged the inaccuracies in the MDS sections for hearing and skin conditions.
A resident with severe cognitive impairment, multiple wounds, an indwelling catheter, and significant hearing loss did not have a comprehensive care plan addressing these needs. Despite documentation of these conditions and acknowledgment by staff that care plans were required, no plans were developed for the resident's hearing difficulty, wounds, or catheter, contrary to facility policy.
A resident with complex medical needs was discharged to a board and care facility with hospice services without the required interdisciplinary team (IDT) meeting to assess discharge readiness and appropriateness, as confirmed by both the DON and Administrator and in violation of facility policy.
Three residents did not have complete, person-centered care plans addressing their specific needs, including the use of bed siderails, preferred language for communication, and management of joint contractures with PROM and splints. These omissions resulted in a lack of clear guidance for staff on safety, communication, and clinical interventions, as confirmed by staff interviews and record reviews.
A resident with severe ROM limitations and contracture risk did not receive adequate PT/OT services to assess and monitor multiple new splints, with only one therapy session provided for five splints before discharge to nursing care. Nursing staff also failed to apply a physician-ordered left hand splint for at least two weeks, with no documentation or notification of the omission, contrary to facility policy.
A nurse left multiple oral medications at the bedside of a resident not assessed as safe for self-administration, while another resident with a seizure history lacked required bed rail padding, and a third high fall-risk resident did not have physician-ordered landing mats in place. These actions did not follow facility policies or physician orders, resulting in deficiencies related to accident hazards and supervision.
Staff failed to properly document and reconcile controlled medications, resulting in missing doses for two residents and an unaccounted volume of liquid medication for another. Additionally, a medication emergency kit containing controlled substances was not reconciled at each shift as required. These deficiencies were identified through medication cart inspections, record reviews, and staff interviews, revealing lapses in following facility policy for controlled medication accountability.
Three residents experienced significant medication errors when staff failed to administer an antihypertensive medication on time, did not follow physician parameters for a hypotensive medication, and administered expired insulin over multiple days. These errors involved improper medication timing, failure to observe ingestion, incorrect documentation, and use of expired medications, all contrary to facility policy and physician orders.
Surveyors found that staff failed to properly label and remove expired medications, including insulin and eye drops, from medication carts. In several cases, open insulin vials and pens were either not dated or not discarded after expiration, and an open bottle of Timolol eye drops was not labeled with an open date. Nurses were unaware of expiration dates and continued to administer expired medications to residents, in violation of facility policy and manufacturer guidelines.
The facility did not follow standardized recipes and prescribed portion sizes, resulting in garlic buttered rice lacking flavor and incorrect serving sizes of braised pork shoulder for residents on small and large portion diets. These actions led to meals not meeting the nutritional and therapeutic needs of multiple residents, as confirmed by staff interviews and review of facility policies.
Food was served at improper temperatures, with desserts and vegetables not meeting safe or appetizing standards, and some items were pre-plated ahead of time. Zucchini was found to be soggy and overcooked, and gravy was observed dripping on the sides of plates, negatively impacting food presentation. The Dietary Supervisor confirmed these issues and noted that residents had previously raised concerns about food temperature and quality.
Surveyors found that pureed foods, including pork and bread, were not prepared to the required smooth, lump-free, and thick consistency for residents with chewing or swallowing difficulties. The pureed pork was runny and did not hold its shape, and the pureed bread contained visible particles, contrary to facility policy and IDDSI guidelines. The Dietary Supervisor confirmed these issues during a test tray evaluation.
Surveyors found that the facility did not maintain safe and sanitary food storage and preparation practices, including lack of internal freezer thermometers, unclean kitchen equipment and vents, improper storage of dented canned goods, failure of staff to perform hand hygiene after contamination, and use of cracked trays and chopping boards. These deficiencies were confirmed by the Dietary Supervisor and were not in compliance with facility policy or the Food Code.
Surveyors found that garbage and refuse, including soiled gloves, empty plastic cups, and liquid spills, were not properly disposed of in the dumpster area. Both the Dietary Supervisor and Housekeeping Supervisor acknowledged the unsanitary conditions, which were attributed to recent staffing shortages. The facility's policies and the Food Code require proper containment and cleanliness of waste areas, but these standards were not met.
Nursing staff failed to document when a left hand splint was not applied for a resident with contractures, despite physician orders, and did not record the absence of the splint in the medical record. Additionally, another resident was administered clonazepam for anxiety without a documented diagnosis of anxiety in the medical record, contrary to facility policy requiring accurate documentation of diagnoses and interventions.
Staff failed to perform hand hygiene between assisting two residents during mealtime, and damaged bed rail padding with gouges and frayed areas was not reported or replaced for a resident dependent on staff for all care. These actions did not follow facility policies for infection prevention and control.
A treatment nurse entered a resident's room without knocking or requesting permission, despite facility policy requiring staff to do so to maintain dignity and respect. The resident was severely cognitively impaired and fully dependent on staff for daily care. The nurse acknowledged the lapse during an interview.
A resident with severe cognitive impairment and total dependence on staff was not provided with information or assistance regarding the formulation of an advance directive, as required by facility policy. Review of medical records and staff interview confirmed the absence of documentation and communication about advance directives to the resident or their representative.
A resident with quadriplegia and contractures did not receive a physician-ordered left hand splint for at least two weeks due to it being missing, and nursing staff failed to document the omission or notify the physician or therapy department, despite facility policy requiring such notification for changes in treatment.
A resident receiving risperidone for schizophrenia was not specifically monitored for paranoid behaviors as required by physician order and facility policy. The monitoring documented was vague and did not detail the specific behaviors exhibited, resulting in a deficiency related to the evaluation and management of psychotropic medication use.
A resident with multiple chronic conditions and impaired cognitive skills did not receive a required quarterly review of their comprehensive care plan. The IDT failed to conduct the scheduled review, as confirmed by a RN Supervisor, which was contrary to facility policy requiring regular assessment and revision of care plans after each assessment.
Two residents at high risk for pressure ulcers did not receive proper care due to failures in setting and maintaining low air loss mattresses (LALM). One resident's LALM was set incorrectly based on an inaccurate weight and not in accordance with the physician's order, while another resident's LALM was missing the pressure adjustment knob, preventing staff from setting the prescribed pressure. Staff and nursing leadership confirmed these deficiencies, which were not in line with facility policy or manufacturer guidelines.
A nurse administered oxycodone to a resident with a history of joint replacement and osteoarthritis for reported pain, but failed to assess and document the pain's location and characteristics prior to administration. The resident had pain in the mouth and right knee, and the facility's policy required a full pain assessment before giving pain medication, which was not completed or documented.
A resident with multiple chronic conditions reported an allergy to all peppers except black pepper, but this was not documented in the medical record or communicated to the care team. The LVN did not take appropriate action to verify, document, or communicate the allergy, and the Dietary Supervisor only partially entered the information. As a result, the resident was served food containing bell peppers, contrary to the reported allergy, due to lack of staff competency and training on food allergy assessment and documentation.
A resident with significant medical conditions and broken teeth requiring extraction did not receive the recommended dental services due to a lack of coordination between social services, nursing, and the physician. The need to hold anticoagulant medication for safe extractions was not communicated, and staff were unaware of the issue until the survey, resulting in the resident not receiving necessary dental care.
A resident with multiple chronic conditions reported an allergy to all peppers except black pepper, but this was not accurately documented in the medical record or communicated to dietary and nursing staff. The dietary supervisor only entered 'bell pepper' in the meal system and did not update the allergy section, while an LVN failed to document or communicate the allergy after the resident was served food containing bell peppers. Facility policy required comprehensive documentation and communication of allergies, but this process was not followed, resulting in the resident being served an allergen.
A therapy mat in the rehabilitation gym was found with multiple open tears and a detached protective border, which had not been reported to maintenance by therapy staff. The DOR acknowledged the potential for skin injuries, and the IP confirmed that the mat could not be properly sanitized due to its damaged condition. The DMN and DON both stated that equipment issues should be reported and that therapy equipment must be maintained safely.
A resident who was non-verbal and fully dependent on staff was not provided full visual privacy because the ceiling-suspended curtain track near their bed did not extend completely to the wall, leaving a significant gap. Facility staff confirmed the gap prevented the curtain from closing fully, which did not meet the facility's own privacy policies.
A resident admitted with a right tibia fracture, requiring assistance with most ADLs and having intact cognition, had their Discharge MDS assessment completed but not transmitted to CMS within the required timeframe. The MDS was submitted several months late, despite facility policy and federal requirements specifying timely transmission after assessment completion.
A review and inspection revealed that 27 resident rooms did not meet the required minimum square footage per resident, with several rooms falling below the 80 sq ft standard. Despite staff being able to provide care and residents reporting no concerns about room size, the measured dimensions of these rooms were insufficient according to regulations.
A resident with a seizure disorder and severe cognitive impairment did not have timely documentation of levetiracetam administration on the MAR. Nursing staff admitted to documenting medication administration late, sometimes hours after the scheduled time, despite facility policy requiring immediate documentation. The DON confirmed that this practice could lead to confusion about when medications were given.
A resident with severe speech and cognitive impairments, dependent on staff for daily activities, was observed without access to communication boards or assistive tools. Staff confirmed the absence of these aids, making it difficult to determine the resident's needs, despite facility policy requiring assessment and provision of communication assistance for residents with speech disabilities.
A resident with cognitive impairment and multiple medical diagnoses was admitted and assessed as having no venous or arterial ulcers on the MDS, despite wound documentation showing 12 arterial ulcers. The MDSC and DON confirmed the MDS was coded in error and should have reflected the resident's actual wound status, as required by facility policy.
A resident with kidney failure and diabetes, who was cognitively intact, repeatedly consumed outside food brought by family that did not comply with physician-ordered dietary restrictions. Staff were aware of the ongoing noncompliance, but no care plan was developed to address this issue, contrary to facility policy.
During a COVID-19 outbreak, two staff members were observed wearing KN95 masks from home instead of the facility-issued, fit-tested N95 masks as required by policy. Both staff acknowledged using the unapproved masks, and one reported receiving verbal approval from a staffing coordinator, which was later denied. Facility leadership confirmed that all staff had been trained and fit-tested for the correct N95 masks, and that only these should be used during an outbreak.
The facility failed to maintain complete medical records for three residents by not documenting essential information on their Bedhold Information Consent forms. A resident with sepsis and spinal cord injury, another with a dislocated hip prosthesis, and a third with cerebral palsy all had incomplete consent forms missing names, birth dates, and admission dates. This was confirmed by facility staff during record reviews.
A resident with a history of mental health disorders physically assaulted another resident, causing pain and distress. The incident was witnessed by a CNA who intervened. The assaulted resident, who has chronic health conditions, was not adequately protected from harm, highlighting a deficiency in the facility's care protocols.
A resident with chronic conditions and intact cognition experienced a new onset of pain after being hit by another resident. Despite reporting a pain level of 8, the facility failed to develop a care plan to address this new pain, as confirmed by a registered nurse. This was contrary to the facility's policy requiring comprehensive care plans for residents' needs.
A resident with multiple health issues was not monitored for 72 hours after being hit by another resident, as required by the facility's policy. Despite reporting significant pain, there was no documented evidence of monitoring for several days, which was confirmed by interviews with nursing staff. This failure to monitor could have impacted the resident's safety and well-being.
A resident with chronic conditions experienced a new onset of pain after being hit by another resident. The facility failed to conduct required pain assessments quarterly and during a change of condition, as per their policy. The last documented assessment was months prior, and subsequent assessments were missed, as confirmed by the ADON and MDS Nurse.
A facility failed to ensure a resident's attending physician documented an annual History and Physical (H&P) for a resident with multiple mental health diagnoses and severely impaired cognition. The latest H&P was dated several months prior, and interviews with staff confirmed the absence of an updated H&P, which is required by facility policy to ensure proper care coordination.
A resident with a history of severe pain conditions was prescribed hydromorphone hydrochloride, a controlled medication, to manage pain. The medication went missing, and the facility failed to account for 16 tablets. The LVN on duty discovered the absence of the medication and reported it to the DON, who initiated an investigation. The facility's policies for safeguarding controlled substances were not followed, as the medication packet and sign-out sheet were missing.
A facility failed to maintain accurate medical records for two residents with diabetes, leading to missing documentation of blood sugar readings and insulin administration. One resident's blood sugar summary also contained an error, with no documented nursing action or physician notification for a low reading. The lack of documentation raised concerns about the residents' diabetes management.
A resident with significant medical needs experienced a delay in response to their call light, despite the facility's policy requiring prompt attention. The resident, who needed total assistance with daily activities, reported waiting over an hour for help. Observations showed a CNA aware of the call light but prioritizing documentation over responding, leading to the deficiency.
A facility failed to create a comprehensive care plan for a resident with a right foot amputation and peripheral vascular disease. Despite the resident's moderate cognitive impairment and need for assistance with daily activities, no specific care plan was documented. The Director of Nursing confirmed the absence of a care plan, which is required by the facility's policy to address the resident's medical and psychosocial needs.
Failure to Notify Family of Cancelled and Rescheduled Medical Appointment
Penalty
Summary
The facility failed to notify a resident’s family or representative when the resident missed a scheduled medical appointment and it was rescheduled. The resident was admitted with diagnoses including other specified polyneuropathies, moderate protein-calorie malnutrition, and myelodysplastic syndrome, and had intact cognition but required maximal assistance with toileting hygiene, bathing, dressing, personal hygiene, and mobility. A physician’s order documented an appointment with a doctor scheduled for 12/10/2025 in the afternoon, and a subsequent physician’s order documented a new appointment date of 1/8/2025 with the same doctor. During an interview and concurrent record review, the Social Service Director stated she was responsible for informing residents and their families or representatives when doctor’s appointments were cancelled or rescheduled. She reported that the 12/10/2025 appointment had to be rescheduled to 1/8/2026 because transportation did not arrive. She acknowledged there was no documentation that the resident’s family or representative had been notified of the cancelled and rescheduled appointment and stated she should have informed them so they could be involved in the plan of care. The facility’s Resident Rights policy indicated residents have rights under Federal and State law, including self-determination and communication with and access to persons and services inside and outside the facility.
Failure to Maintain Resident Grooming and Personal Hygiene
Penalty
Summary
The facility failed to provide necessary services to maintain good grooming and personal hygiene for two residents who were dependent on staff for activities of daily living (ADLs). Both residents had severe cognitive impairment and required assistance with personal hygiene, as documented in their care plans. Despite these documented needs, observations revealed that both residents had long and dirty fingernails. Treatment Nurse 1 and the Director of Nursing confirmed during interviews and observations that the fingernails were not properly trimmed or cleaned. Further review showed that the facility's policy required staff to assist dependent residents with ADLs, including grooming, every shift and as needed. However, a Licensed Vocational Nurse stated that while she reminded CNAs weekly to trim and clean residents' fingernails, she did not verify that this care was actually provided. This lack of direct oversight and follow-through resulted in the residents not receiving appropriate nail care, as required by their care plans and facility policy.
Improper Use of Linens and Incontinence Briefs on Low Air Loss Mattress
Penalty
Summary
The facility failed to follow proper protocol for the use of a low air loss mattress (LALM) for a resident with significant medical needs, including stage III and later stage IV pressure ulcers, sepsis, dementia, and dependence on a respirator. During observation, it was found that the resident was lying on a LALM with a fitted sheet and a cloth incontinence pad made of two different textures of linen, as well as wearing an incontinence brief. Staff confirmed that there were four layers of linen between the resident's back and the mattress surface, contrary to facility policy and physician orders, which specified no more than two layers and discouraged the use of fitted sheets and incontinence briefs on LALMs. Interviews with nursing staff and the Director of Nursing revealed awareness that multiple layers of linen and the use of incontinence briefs impede the effectiveness of the LALM by blocking airflow, which is essential for wound healing and prevention of further skin breakdown. Review of facility policy confirmed that only a single, loosely placed flat sheet should be used, and non-plastic backed pads should be selected to maintain airflow. The observed practice of using multiple linen layers and incontinence briefs did not align with these requirements, resulting in a deficiency related to pressure ulcer care and prevention.
Failure to Develop Comprehensive Care Plan for Continuous Oxygen Use
Penalty
Summary
The facility failed to develop a comprehensive, person-centered care plan addressing the continuous use of oxygen for one resident. The resident was admitted and later readmitted with diagnoses including pneumonia, urinary tract infection, and acute respiratory failure with hypoxia. Medical records, including the Minimum Data Set and physician's orders, indicated the resident required continuous oxygen via nasal cannula at 2-3 liters per minute. Progress notes and direct observation confirmed the resident was consistently receiving oxygen as ordered. Despite the ongoing administration of oxygen, a review of the resident's care plans revealed that no comprehensive care plan was developed to address the continuous oxygen therapy. Interviews with nursing staff and the Director of Nursing confirmed the absence of such a care plan, even though facility policy required the development and implementation of person-centered care plans to meet residents' medical and physical needs.
Failure to Document PRN Medication Administration on MAR
Penalty
Summary
A deficiency occurred when a licensed vocational nurse (LVN) failed to document the administration of a PRN Ipratropium-Albuterol Solution on the Medication Administration Record (MAR) for a resident with a history of pneumonia, urinary tract infection, and acute respiratory failure with hypoxia. The resident, who had documented short-term memory problems and moderately impaired cognitive skills, was admitted and later readmitted to the facility. The physician's order specified the use of Ipratropium-Albuterol Solution via nebulizer as needed for shortness of breath or wheezing. On the morning in question, the LVN administered the medication due to observed chest congestion but did not record this administration on the MAR. During interviews, the LVN acknowledged forgetting to chart the medication administration because of being occupied with other tasks. The Director of Nursing (DON) confirmed that there was no documentation on the MAR for the PRN medication and stated that facility policy requires immediate documentation of all administered medications. Review of the facility's policy further supported that all medication activities must be documented to ensure resident safety and regulatory compliance.
Inaccurate Resident Assessment Documentation
Penalty
Summary
The facility failed to ensure that the resident assessment accurately reflected the status of one resident. Specifically, the Minimum Data Set (MDS) for this resident indicated that the resident had adequate hearing and no deep tissue injuries, despite multiple sources documenting otherwise. The resident's admission records and weekly wound assessment showed the presence of a deep tissue injury (DTI) on the right heel, and interviews with staff and the resident confirmed significant hearing impairment and the use of hearing aids, which were currently missing. The MDS, however, did not reflect these conditions, listing the resident as having adequate hearing and no DTI. Interviews with facility staff, including the Assistant Administrator, Licensed Vocational Nurse, and Director of Nursing, confirmed the discrepancies between the resident's actual condition and what was documented in the MDS. The Director of Nursing acknowledged that the MDS was inaccurate in the sections related to hearing and skin conditions. The facility's policy requires that assessments be accurate and reflective of the resident's status at the time of assessment, but this was not followed in this case.
Failure to Develop Comprehensive Care Plan for Resident with Complex Needs
Penalty
Summary
The facility failed to develop a comprehensive, person-centered care plan for a resident with multiple complex medical needs. The resident was admitted with diagnoses including chronic obstructive pulmonary disease (COPD), type 2 diabetes mellitus, and a urinary tract infection. Upon admission, the resident was noted to have severely impaired cognition, a Stage 4 pressure ulcer on the sacrum, and a deep tissue injury (DTI) on the right heel. The resident also had an indwelling urinary catheter and significant hearing difficulties, having recently lost his hearing aids. Despite these documented needs, a review of the resident's care plans from admission through several weeks later revealed that there were no care plans addressing the resident's hearing impairment, wounds, or indwelling catheter. Interviews with facility staff, including the Assistant Administrator, Licensed Vocational Nurse, Medical Records Assistant, and Director of Nursing, confirmed that these critical areas were not included in the resident's care planning documentation. Staff acknowledged that care plans should have been developed for these issues and that various team members, such as the MDS coordinator, treatment nurse, or Social Services Director, could have initiated them. The facility's own policy requires the development and implementation of a person-centered comprehensive care plan to address each resident's medical, physical, mental, and psychosocial needs. However, in this case, the absence of care plans for the resident's hearing loss, wounds, and indwelling catheter represented a failure to follow this policy, potentially impacting the delivery of appropriate care and services.
Failure to Conduct Required IDT Meeting Prior to Resident Discharge
Penalty
Summary
The facility failed to ensure that the discharge planning process for one resident included an interdisciplinary team (IDT) meeting prior to the resident's transfer to a board and care facility. The resident in question had significant medical needs, including quadriplegia, sepsis, a stage 4 pressure ulcer, a colostomy, and a urinary tract infection, and was dependent on staff for all activities of daily living. Despite these complex care requirements, there was no documentation or evidence that an IDT meeting was conducted to assess discharge readiness or the appropriateness of the receiving facility. Interviews with the DON and the Administrator confirmed that, according to the facility's policy and procedure, an IDT meeting should have been held before the resident's discharge. Review of the facility's policy indicated that the discharge process should involve the IDT to ensure the resident's needs are met and to facilitate a safe and appropriate transition. The absence of this required meeting was acknowledged by facility leadership and was not supported by any documentation in the resident's clinical record.
Failure to Develop and Implement Person-Centered Care Plans
Penalty
Summary
The facility failed to develop and implement person-centered care plans for three residents, resulting in deficiencies related to communication, safety, and clinical care. For one resident with muscle weakness, schizophrenia, and diabetes, there was a physician's order for the use of half side rails as an enabler for self-positioning and bed mobility. However, no care plan was created to address the use of side rails, including necessary interventions to monitor for entrapment risks, despite facility policy requiring assessment and care planning for bed rail use. Another resident with severe cognitive impairment, cerebral infarction, and right-sided hemiplegia had a care plan that noted a communication problem due to a language barrier, but the care plan did not specify the resident's preferred language of Spanish. Staff interviews confirmed that the omission of the preferred language in the care plan could hinder effective communication and the use of appropriate communication aids or interpreters. A third resident with quadriplegia, multiple joint contractures, and severe cognitive impairment had physician orders for passive range of motion (PROM) exercises and the use of splints. Despite these orders and the resident's significant physical limitations, there was no care plan in place to address contractures, limited range of motion, or the maintenance program until several months after the orders were written. Staff acknowledged that the absence of a care plan meant that interventions and goals for the resident's contractures and ROM could not be consistently communicated or reviewed among the care team.
Failure to Provide and Monitor Splint Therapy and ROM Services
Penalty
Summary
A deficiency occurred when the facility failed to provide appropriate services to prevent a decline in range of motion (ROM) for a resident with significant physical impairments, including quadriplegia, contractures, and a right upper extremity amputation. The resident was admitted with multiple ROM limitations and was at high risk for contracture development. Orders were in place for the application of multiple splints and for passive range of motion (PROM) exercises to be performed daily by licensed nurses. However, the facility did not ensure that the resident received sufficient physical and occupational therapy services to safely assess and monitor the use of new splints on the left elbow, left hand, both knees, and left ankle. Only one therapy session was provided to assess and fit five new splints, after which the resident was discharged to a nursing maintenance program, despite the complexity and high risk associated with multiple new splints. Observations and interviews revealed that the process for introducing and monitoring new splints was not followed according to professional standards. Occupational and physical therapists indicated that a gradual increase in splint-wearing time, with close monitoring for skin integrity and comfort, was necessary and typically required multiple sessions over several weeks. In this case, the resident received only a single session for all five splints, and therapy staff acknowledged that more sessions were needed to ensure safety and proper fit. The Director of Rehabilitation confirmed that the resident was at high risk for complications and that therapy staff, not nursing, had the expertise to assess splint safety and tolerance. Additionally, the facility failed to provide the left hand splint as ordered by the physician. Nursing staff did not apply the left hand splint for at least two weeks, and there was no documentation or communication regarding the missing splint or the inability to apply it. Interviews with nursing staff and review of medical records confirmed that the left hand splint was not applied as ordered, and there was no record of this omission or notification to the physician or family. Facility policies required the application and removal of splints as ordered and the provision of specialized rehabilitative services for the appropriate length of time, but these were not followed in this case.
Failure to Prevent Accident Hazards and Ensure Adequate Supervision
Penalty
Summary
A licensed nurse left 11 oral medications at the bedside of a resident who had been assessed as not safe to self-administer oral medications. The resident, who had impaired cognitive skills and required assistance with activities of daily living, was observed with the medications and a cup of applesauce, some of which had been crushed and mixed in. The nurse admitted to leaving the medications unattended after being distracted by another staff member, and the Director of Nursing confirmed that the resident was only assessed as safe to self-administer inhalers and eyedrops, not oral medications. Facility policy required that medications be administered within 60 minutes of the scheduled time and that residents be observed to ensure ingestion, which was not followed in this instance. Another deficiency involved a resident with a history of epileptic seizures who did not have bed rail padding in place as ordered by the physician. The resident's bed rails were observed to be metal and unpadded, and the Assistant Director of Nursing acknowledged that the required padding was not present. The facility's policy indicated that padded side rails may be used for residents with a seizure history to provide protection, but this was not implemented for the resident in question. A third deficiency was identified when a resident at high risk for falls, with diagnoses including anoxic brain damage and seizures, did not have landing mats at the bedside as ordered by the physician and outlined in the care plan. The resident was assessed as being at high risk for falls, and the order for a low bed with landing mats was not followed. The Director of Nursing confirmed the absence of landing mats and stated their importance in preventing or lessening injuries from falls. Facility policy required adequate supervision and assistive devices to minimize fall risks, which was not adhered to in this case.
Failure to Account for and Reconcile Controlled Medications
Penalty
Summary
The facility failed to properly account for and document the administration of controlled medications (CMs) for multiple residents, as observed during medication cart inspections and staff interviews. In one medication cart, there was a discrepancy between the Drug Control Receipt Record accountability log and the actual number of tablets remaining in the medication bubble packs for two residents. Specifically, one dose of oxycodone 5 mg was missing for a resident with a history of fracture and joint replacement, and one dose of oxycodone with acetaminophen 10-325 mg was missing for a resident with chronic pain. The responsible nurse admitted to administering the medications but failing to sign the accountability logs as required by facility policy. In another medication cart, a discrepancy was found in the count of liquid clobazam for a resident with a seizure disorder. The Liquid Controlled Drug Receipt log indicated that 48 ml should have been present, but only 30 ml remained, with no documentation of additional administrations. The nurse responsible for the reconciliation failed to identify and report this discrepancy during the shift change count, despite signing off that no discrepancies were present. The Director of Nursing confirmed that the required reconciliation process was not followed, and the discrepancy was not reported as required. Additionally, in one medication room, a medication emergency kit (eKIT) containing controlled medications was found without an accountability log for shift-by-shift reconciliation throughout the month. The registered nurse confirmed that the eKIT had not been reconciled at every shift, contrary to facility policy. The facility's policy and procedures require immediate documentation of controlled substance administration and reconciliation of all CMs at each shift change, which was not followed in these instances.
Significant Medication Errors in Administration of Antihypertensive, Hypotensive, and Insulin Medications
Penalty
Summary
The facility failed to ensure residents were free from significant medication errors in three separate incidents involving antihypertensive, hypotensive, and insulin medications. In the first incident, a resident with hypertension and impaired cognitive skills was not administered their prescribed Norvasc (an antihypertensive medication) within the required timeframe. The medication was left at the bedside by an LVN, who became distracted and did not witness the resident ingesting the medication. The resident had not been assessed as safe for self-administration of oral medications, and facility policy required medications to be administered within 60 minutes of the scheduled time and for staff to observe ingestion. In the second incident, a resident with hypotension and moderately impaired cognition did not receive midodrine (a medication for low blood pressure) in accordance with the physician's prescribed parameters. Review of the Medication Administration Record and medication packaging revealed multiple instances where the medication was either given when it should have been held, held when it should have been given, or documentation did not match actual administration. The DON confirmed the importance of following prescribed parameters to prevent complications, and facility policy required medications to be administered as prescribed and in accordance with written orders. The third incident involved a resident with Type 2 Diabetes Mellitus who received 31 doses of expired Humulin N insulin from seven different licensed nursing staff over a period of more than two weeks. The expired insulin was not removed from the medication cart as required by facility policy and manufacturer guidelines, which state that Humulin N Kwikpen should be discarded 14 days after opening. The DON acknowledged that the expired insulin was administered and that this constituted a significant medication error. Facility policies required checking expiration dates prior to administration and prompt removal of expired medications.
Failure to Properly Label and Remove Expired Medications
Penalty
Summary
Surveyors identified multiple deficiencies related to the labeling and storage of medications and biologicals. In one instance, an open vial of Humulin R insulin for a resident was found stored at room temperature without a date indicating when storage or use at room temperature began. The nurse responsible was unaware of when the insulin was opened or when it would expire, and acknowledged that the vial should have been labeled and replaced to prevent the administration of expired medication. The facility's policy and the manufacturer's instructions both require opened insulin vials to be dated and discarded within a specified period, which was not followed in this case. Another deficiency involved an open Humulin N Kwikpen insulin for a different resident, which was labeled with an open date and a discard date, but was not removed from use after the discard date had passed. The expired insulin pen continued to be stored and administered to the resident beyond the recommended 14-day period, as confirmed by the nurse. The nurse acknowledged that several doses of expired insulin were given to the resident, constituting a significant medication error. Facility policy and manufacturer guidelines both require the removal and disposal of expired insulin pens, which was not done. Additionally, an open bottle of Timolol eye drops for another resident was found stored at room temperature without a label indicating the date of opening. The nurse interviewed stated that eye drops are typically good for 28 days after opening, but without a date, it was impossible to determine if the medication was expired. The Director of Nursing confirmed that the failure to label the medication with an open date was contrary to facility policy and could result in the use of expired medication. The facility's policies and the manufacturer's instructions both require multi-dose medications to be labeled with the date of opening to ensure timely disposal.
Failure to Follow Menu Recipes and Portion Sizes for Therapeutic Diets
Penalty
Summary
The facility failed to follow its established menus and standardized recipes, resulting in food items not meeting the nutritional needs and preferences of residents. Specifically, the garlic buttered rice served did not have the required garlic flavor because the recipe was not followed, as confirmed by both observation and the Dietary Supervisor. The facility's policies and procedures require that menus and recipes be followed to ensure meals are flavorful and meet residents' nutritional, cultural, and personal preferences. However, the garlic buttered rice was prepared without the specified amount of garlic, leading to a bland product that could cause dissatisfaction and decreased food intake among residents. Additionally, the facility did not adhere to prescribed portion sizes for residents on small and large portion diets. Instead of serving two ounces for small portions and four ounces for large portions of braised pork shoulder, three ounces were served regardless of the diet order. This was confirmed through observation and staff interviews, where it was acknowledged that portion sizes were not being adjusted according to the dietary spreadsheet or residents' specific needs. The facility's policies and diet manual require that portion sizes be tailored to individual dietary orders, with small and large portions provided only with a physician or healthcare provider's order. Failure to follow these orders resulted in residents not receiving the appropriate amount of food as prescribed.
Deficient Food Preparation and Presentation Affecting Palatability and Safety
Penalty
Summary
The facility failed to ensure that food was prepared and served in a manner that conserved temperature, flavor, and appearance, as evidenced by multiple observations and interviews. Food temperatures were found to be outside of safe and appetizing ranges, with pound cake with strawberries and whip cream measured at 56.5°F and 60°F for regular and puree diets, respectively, and zucchini at 115°F. Staff were observed pre-plating desserts ahead of time, contrary to best practices, and the Dietary Supervisor acknowledged that residents had previously expressed concerns about food temperatures. The Dietary Supervisor also stated that delays in meal distribution contributed to the temperature issues and was unaware of the pre-plating practice. Facility policy required food to be served at appetizing temperatures to ensure resident satisfaction and safety, particularly for dairy products. Additionally, the quality and presentation of food were compromised. Zucchini was observed to be soggy and overcooked, which the Dietary Supervisor confirmed affected both the appearance and flavor, and could result in nutrient loss. Gravy was observed dripping on the sides of plates, detracting from the food's presentation. The Dietary Supervisor acknowledged that poor presentation could lead to residents refusing to eat. Facility policies required that food be palatable, attractive, and prepared in a way that preserved its nutritive value and appearance. These deficiencies placed a significant number of residents at risk for poor food intake and unplanned weight loss.
Failure to Provide Properly Prepared Pureed Foods for Residents with Swallowing Difficulties
Penalty
Summary
The facility failed to prepare pureed foods in a form designed to meet the individual needs of residents requiring texture-modified diets. Observations revealed that pureed roast pork was runny and did not hold its shape on the plate, while pureed bread contained visible bread particles and lacked a smooth, pudding-like consistency. During a test tray evaluation, the Dietary Supervisor confirmed that the pureed pork was too runny and the pureed bread was not properly blended, stating that these foods should be smooth, lump-free, and able to hold their shape to meet the needs of residents with chewing or swallowing difficulties. A review of the facility's menu, diet manual, and standardized recipes indicated that pureed foods are intended for residents with severe chewing and/or swallowing problems and must be processed to a smooth, extremely thick consistency without lumps. The facility's diet manual and recipes specify that pureed foods should pass the IDDSI appearance, fork drip, and spoon tilt tests, and should not have liquid separation or visible lumps. The observed deficiencies affected all residents on pureed diets, as the foods provided did not meet the required consistency standards outlined in facility policies and the IDDSI guidelines.
Deficient Food Storage, Sanitation, and Hand Hygiene Practices in Kitchen
Penalty
Summary
The facility failed to ensure safe and sanitary food storage and preparation practices in the kitchen, as evidenced by multiple observations and interviews. There was no thermometer inside the reach-in freezer for temperature monitoring, contrary to both facility policy and the Food Code, which require temperature measuring devices to be located inside refrigeration units. The Dietary Supervisor initially stated that an external digital thermometer was sufficient, but later acknowledged the need for an internal thermometer after reviewing the Food Code. This lack of proper temperature monitoring could result in food spoilage. Kitchen equipment and areas were observed to be unclean and not sanitized. The walk-in freezer curtains had stickers, sticker residues, and food spills, while the walk-in refrigerator and dry storage vents had dust and web build-up. The Dietary Supervisor confirmed these findings and stated that cleaning needed to be more frequent to prevent contamination. Additionally, eight dented canned goods were stored alongside non-dented cans in the dry storage room, with no clear separation, which the Dietary Supervisor acknowledged could lead to contamination and potential foodborne illness. Staff were observed failing to perform proper hand hygiene after picking up items from the floor, touching trash can lids, and resuming food preparation without washing their hands. The Dietary Supervisor confirmed that staff should wash hands after such activities to prevent cross-contamination. Furthermore, all resident meal trays observed were cracked, and chopping boards had cracks and scratches, making them difficult to clean and increasing the risk of bacterial growth. The facility's policies and the Food Code require that food-contact surfaces be smooth, free of cracks, and easily cleanable, which was not adhered to in these instances.
Improper Disposal of Garbage and Refuse in Dumpster Area
Penalty
Summary
Surveyors observed that the facility failed to properly dispose of garbage and refuse in accordance with its own policies and regulatory requirements. During an observation with the Dietary Supervisor, soiled gloves, empty plastic cups, liquid spills, and other debris were found on the floor and surrounding areas of the dumpster bin. The Dietary Supervisor acknowledged that the presence of these materials was not acceptable, as it could attract pests and compromise infection control standards. The Housekeeping Supervisor also confirmed that the area should be clean and free of trash, but noted that soiled gloves and empty cups were present on the floor. The Housekeeping Supervisor attributed the lapse in cleanliness to recent staffing shortages, although they stated that staffing levels had since returned to normal. A review of the facility's policies and procedures indicated that garbage and refuse containers should be maintained in good condition, with waste properly contained and storage areas kept sanitary to prevent pest harborage. Additionally, the Food Code 2022 requires that outside receptacles have tight-fitting lids and that garbage storage areas be kept clean to prevent attracting pests and creating unsanitary conditions. The facility's failure to maintain the cleanliness of the dumpster area and properly contain waste materials constituted a deficiency, as it did not comply with established policies or regulatory standards.
Failure to Maintain Accurate and Complete Medical Records
Penalty
Summary
Nursing staff failed to maintain accurate and complete medical records for two residents. For one resident with quadriplegia and multiple contractures, there was a physician's order for the application of left elbow, left hand, and bilateral knee splints for three to four hours daily, as well as passive range of motion (PROM) exercises. Observations revealed that the left hand splint was not applied for at least two weeks, and staff interviews confirmed the splint was missing and not used. Despite this, there was no documentation in the resident's medical record indicating the left hand splint was not applied, nor any record of the missing splint or communication to the physician or family. The care plan and physician's orders clearly required this intervention, but the lack of documentation resulted in incomplete and inaccurate records regarding the resident's care. For another resident, the facility failed to ensure a diagnosis of anxiety was documented prior to the initiation of a routine anti-anxiety medication, clonazepam. The resident's admission record and Minimum Data Set (MDS) did not list anxiety as a diagnosis, even though the resident was receiving clonazepam for anxiety manifested by agitation and restlessness. The Assistant Director of Nursing confirmed that the medication was being administered without the required supporting diagnosis in the medical record, which is necessary to validate the use of psychotropic medication. Facility policy required documentation of relevant findings in the clinical record and comprehensive, accurate assessments that include disease diagnoses and health conditions. In both cases, the failure to document either the omission of a prescribed intervention or the diagnosis supporting medication administration resulted in medical records that were not accurate or complete, as required by facility policy and professional standards.
Failure to Maintain Infection Control: Hand Hygiene and Damaged Equipment
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program as evidenced by two main deficiencies. First, a licensed nurse did not perform hand hygiene between assisting two residents during a dining observation. One resident, with a history of hemiplegia and severely impaired cognition, was being assisted with eating by a nurse. Another resident, with dysphagia and moderately impaired cognition, was seated next to the first and began coughing. The nurse assisted the coughing resident by tapping his chest and then immediately returned to feeding the first resident, wiping his mouth without performing hand hygiene in between. The nurse later acknowledged that hand hygiene should have been performed between contacts. The DON confirmed that staff are expected to perform hand hygiene before and after resident contact to prevent infection, and the facility's policy also requires hand hygiene to prevent the spread of infection. Secondly, the facility did not ensure that bed rail padding was free of gouges and frayed areas for a resident who was non-verbal, unable to follow commands, and dependent on staff for all activities of daily living. During observation, the resident's bed rails were found to have a large gouge and multiple smaller gouges and frayed areas. A registered nurse confirmed that such damage to the padding prevents proper sanitation and could lead to infection, and stated that staff are required to report any integrity issues with bed rail padding so they can be replaced immediately. The administrator also stated that intact padding is designed to resist bacteria, but damaged padding must be replaced right away. The facility's policies require prompt reporting and replacement of damaged equipment and adherence to hand hygiene protocols. However, these procedures were not followed, as evidenced by the lack of hand hygiene between resident contacts and the failure to report and replace damaged bed rail padding. These actions and inactions resulted in deficiencies in the facility's infection prevention and control program.
Failure to Knock or Request Permission Before Entering Resident Room
Penalty
Summary
A deficiency was identified when a treatment nurse entered a resident's room without knocking or requesting permission. The resident involved had a history of chronic respiratory failure and sepsis, was severely cognitively impaired, and was totally dependent on staff for activities of daily living. The incident was observed during a survey, and the nurse acknowledged during an interview that she did not knock or ask permission before entering, stating that she should have done so to show respect and promote privacy, as the facility is the resident's home. A review of the facility's policy on dignity and respect confirmed that staff are required to knock and request permission before entering residents' rooms. The policy also emphasizes caring for residents in a manner that promotes dignity, respect, and individuality. The failure to follow this policy resulted in a violation of the resident's rights to be treated with respect and dignity.
Failure to Provide Advance Directive Information to Resident and Representative
Penalty
Summary
The facility failed to provide a resident and their representative with information regarding the formulation of an advance directive. Upon review of the resident's admission record, it was found that there was no documented evidence that the resident had completed an advance directive or that the facility had provided the necessary information or assistance to the resident or their representative about creating one. This was confirmed during an interview and record review with a registered nurse, who acknowledged the absence of documentation and information provided. The resident in question had a history of chronic respiratory failure and sepsis, and was assessed as having severely impaired cognition, being totally dependent on staff for activities of daily living. The facility's own policy, last reviewed in January 2025, states that residents have the right to formulate an advance directive. However, the lack of documentation and failure to provide information to the resident or their representative constituted a violation of this right.
Failure to Notify Physician and Apply Ordered Splint
Penalty
Summary
Licensed nursing staff failed to follow a physician's order for a resident who required left elbow, left hand, and bilateral knee splints to be applied for three to four hours daily, seven days a week, as tolerated. The resident, who had diagnoses including quadriplegia, contractures, and a history of traumatic amputation, was dependent on staff for all activities of daily living and had significant cognitive impairment. Observations and interviews revealed that while the elbow and knee splints were applied, the left hand splint was not put on for at least two weeks, and possibly longer, due to it being missing. Staff interviews indicated a lack of awareness or misunderstanding of the physician's order, with one nurse stating there was no order for a left hand splint and another confirming the splint had not been applied for an extended period. Documentation in the resident's medical record did not reflect the omission of the left hand splint, nor was there evidence that the physician or therapy department had been notified about the missing or unused splint. The Director of Nursing confirmed that such omissions should be documented and reported to the physician and family, but this did not occur. A review of facility policy confirmed the requirement to notify the physician and resident representative of significant changes or the need to alter treatment. Despite this, there was no documentation or notification regarding the failure to apply the left hand splint as ordered, constituting a deficiency in following physician orders and in communication regarding changes in the resident's care.
Failure to Specifically Monitor Psychotropic Medication Use
Penalty
Summary
A resident with a history of schizophrenia, muscle weakness, and type 2 diabetes mellitus was admitted and later readmitted to the facility. The resident was prescribed risperidone to treat schizophrenia manifested by paranoia, with a physician's order to monitor episodes of paranoia every shift. However, the monitoring documented in the Medication Administration Record was found to be vague and not specific to the paranoid behaviors exhibited by the resident. The registered nurse acknowledged that the monitoring lacked specificity, which is necessary to properly evaluate the efficacy and appropriateness of the medication. Facility policy requires that each resident's drug regimen be free from unnecessary drugs and that medication management includes recognition of the resident's problem, assessment, diagnosis, root cause identification, and monitoring. The failure to specifically monitor and document the resident's paranoid behaviors as required by the physician's order and facility policy resulted in a deficiency, as it could lead to inaccurate evaluation of the medication's effectiveness and appropriateness for the resident.
Missed Quarterly Review of Comprehensive Care Plan
Penalty
Summary
The facility failed to conduct a quarterly review of a resident's comprehensive care plan as required. The resident in question was originally admitted with diagnoses including muscle weakness, schizophrenia, and type 2 diabetes mellitus, and was noted to have impaired cognitive skills and required assistance with daily activities such as oral hygiene, toileting, and personal hygiene. Review of the resident's records showed that the last Interdisciplinary Team (IDT) care planning meeting was conducted in March, and there was no evidence of a required quarterly review in December. During an interview and record review, the Registered Nurse Supervisor confirmed that the quarterly IDT care plan meeting was missed and acknowledged that facility policy requires such reviews to evaluate and revise care plans as needed. The facility's policy also states that the comprehensive care plan must be reviewed and revised by the IDT after each assessment, including quarterly reviews. The absence of this review could result in the resident's needs not being identified or met, as stated by the RN Supervisor.
Failure to Ensure Proper Low Air Loss Mattress Settings and Maintenance
Penalty
Summary
The facility failed to ensure proper use and maintenance of low air loss mattresses (LALM) for two residents with significant risk factors for pressure ulcers. For one resident with chronic respiratory failure, sepsis, severely impaired cognition, and total dependence on staff for activities of daily living, the LALM was set incorrectly. The mattress was observed at a setting and weight of 180 lbs, while the resident's actual weight was 115 lbs, and the physician's order specified a different setting. The treatment nurse confirmed the discrepancy and acknowledged that the incorrect setting could compromise skin integrity. For another resident with tracheostomy and gastrostomy status, non-verbal and fully dependent on staff, the LALM device was missing the pressure adjustment knob, making it impossible for staff to set the mattress pressure as ordered by the physician. The registered nurse confirmed the absence of the knob and stated that it should have been reported immediately to prevent further skin breakdown, especially since the resident already had a stage 1 pressure ulcer on the sacrum. The director of nursing also acknowledged that staff should have noticed and reported the missing knob during routine checks. Facility policy and manufacturer instructions require proper assessment, monitoring, and maintenance of LALM equipment to prevent pressure injuries. In both cases, the facility did not follow these protocols, resulting in the use of improperly set or unadjustable mattresses for residents at high risk for pressure ulcers.
Failure to Assess and Document Pain Characteristics Prior to Medication Administration
Penalty
Summary
A deficiency was identified when a nurse failed to assess and document the location and characteristics of a resident's pain prior to administering pain medication. The resident, who had a history of joint replacement surgery, intracerebral hemorrhage, and right knee osteoarthritis, reported pain in his mouth due to repeated accidental biting and in his right knee related to arthritis and recent surgery. The resident was cognitively intact and required some assistance with activities of daily living. On a specific occasion, the resident was administered oxycodone for a reported pain level of 6/10, but the nurse did not assess or document the pain's location or quality before giving the medication. The nurse acknowledged that she should have performed and documented a full pain assessment, including site and type of pain, but did not do so. The facility's policy required such assessments to ensure effective pain management, but this was not followed in this instance.
Failure to Assess and Document Resident Food Allergy
Penalty
Summary
Licensed Vocational Nurse 8 (LVN 8) failed to demonstrate the necessary knowledge and skills to properly assess and document a resident's reported food allergy. The resident, who had a medical history including multiple sclerosis, hypertension, and diabetes, reported being allergic to all types of pepper except black pepper. However, the resident's admission record, allergy report, and diet type report did not indicate any food allergies, and the care plan only noted a no added salt diet without mention of a pepper allergy. Despite the resident informing both the Dietary Supervisor and LVN 8 about the pepper allergy, the information was not accurately entered into the medical record or communicated to the interdisciplinary team. The Dietary Supervisor only entered 'bell pepper' in the menu system, as that was the only type of pepper served, and did not update the allergy section of the electronic medical record. LVN 8 did not document the allergy, notify the physician, update the Medication Administration Record, or communicate the allergy to other staff, as he believed the resident was joking and relied solely on the history and physical records, which did not list any allergies. Interviews with facility leadership revealed that there was no specific training provided to staff regarding food allergies, only training on data entry into the medical record system. The facility's policies required comprehensive assessment and documentation of allergies, as well as communication among the interdisciplinary team, but these procedures were not followed in this case. As a result, the resident was served food containing bell peppers, contrary to his reported allergy.
Failure to Coordinate and Provide Needed Dental Extractions
Penalty
Summary
The facility failed to ensure that a resident received necessary dental services as recommended by a dentist. The resident, who was cognitively intact and dependent on staff for several activities of daily living, had a history of congestive heart failure and end stage renal disease, and was on a mechanically altered diet due to difficulty chewing. The dental assessment indicated a need for multiple tooth extractions, but these extractions were not coordinated or completed. The resident reported that all his teeth were broken and needed to be pulled, and he required his food to be cut into very small pieces to eat. The process for coordinating dental extractions was not followed, as social services did not ensure that nursing or the physician were notified about the need for extractions and the requirement to hold anticoagulant medication. Documentation confirming physician notification was not available, and nursing staff were unaware of the need for extractions until the day of the survey. The facility's policy required assistance in obtaining needed dental services, but this was not carried out, resulting in the resident not receiving the recommended dental care.
Failure to Accurately Document and Communicate Resident Food Allergy
Penalty
Summary
The facility failed to ensure that a resident's food allergy was accurately identified, documented, and communicated to all relevant staff. Upon admission, the resident's records, including the Allergy Report, Diet Type Report, and Care Plan, did not indicate any food allergies, despite the resident reporting an allergy to all peppers except black pepper. The dietary supervisor interviewed the resident and was informed of the allergy but only entered 'bell pepper' in the menu system, as that was the only type of pepper typically served, and did not update the allergy section of the medical record. The dietary supervisor also stated she did not have the capacity to enter allergies into the electronic medical record (EMR), and assumed nursing staff would handle this task. A licensed vocational nurse (LVN) was informed by the resident about the pepper allergy after the resident was served food containing bell peppers. The LVN did not take the resident's report seriously, did not document the allergy in the medical record, and did not communicate the information to other healthcare team members. The LVN relied solely on the history and physical records, which did not list any allergies, and failed to notify the physician or update the Medication Administration Record (MAR). The LVN also did not inform the kitchen staff or endorse the allergy to other nursing staff, and admitted to lacking specific training on food allergies. The facility's policy required comprehensive assessment and documentation of resident allergies, as well as communication among the interdisciplinary team and updates to care plans. However, the process was not followed in this case, resulting in the resident being served a food item containing an allergen. The deficiency was further compounded by a lack of clear responsibility for entering allergy information into the EMR and insufficient staff training regarding food allergy management.
Failure to Maintain Therapy Mat in Safe Condition
Penalty
Summary
The facility failed to maintain a therapy mat in safe operating condition for resident use in the rehabilitation gym. During an observation with the Director of Rehabilitation (DOR), five open tears and a detached black plastic protective border were found on the therapy mat. The DOR confirmed that therapy staff had not reported these issues to maintenance, and acknowledged that the tears could cause skin tears or irritation for residents using the mat. The DOR also stated that therapy staff attempted to clean the mat and its open tears with sanitizing wipes or alcohol sprays. The Infection Prevention Nurse (IP) stated that a torn therapy mat could not be effectively cleaned, as bacteria could enter the inside of the mat and the cleaning products used would not be effective on porous surfaces. The Director of Maintenance (DMN) confirmed there were no maintenance reports regarding the mat's condition, and emphasized that staff should report such issues. The Director of Nursing (DON) stated that therapy equipment should be safely maintained and that tears in the mat could cause injuries. Review of the facility's policy indicated that all resident care equipment must be kept in safe operating condition.
Failure to Provide Full Visual Privacy Due to Incomplete Curtain Coverage
Penalty
Summary
The facility failed to provide full visual privacy for a resident who was non-verbal, unable to follow commands, and dependent on staff for all activities of daily living. The resident's bed was positioned closest to the entrance of the room, with the right side of the bed nearest to the door. The ceiling-suspended privacy curtain track on the right side did not extend fully to the wall, leaving a gap that prevented the curtain from closing completely and ensuring privacy. During observations and interviews, both a maintenance worker and the director of maintenance confirmed that the gap between the end of the curtain track and the wall measured eight and a half inches, which did not allow for full privacy as required. Facility policies reviewed indicated that residents have the right to personal privacy, including accommodations, but the physical setup of the curtain track did not meet this standard for the resident in question.
Late Submission of Discharge MDS Assessment
Penalty
Summary
The facility failed to transmit a resident's Discharge Minimum Data Set (MDS) assessment within the required timeframe for one sampled resident. The resident was admitted with a right tibia fracture and required supervision or assistance with most activities of daily living, while maintaining intact cognition. The Discharge MDS had an Assessment Reference Date (ARD) of 2/24/2025 and was completed on 3/10/2025. According to facility policy and federal requirements, the MDS should have been transmitted within 14 days of completion, but it was not submitted until 6/17/2025. During interviews and record reviews, the MDS nurse confirmed the late submission and acknowledged the correct timeframes for completion and transmission. The Director of Nursing also stated the importance of timely submission to ensure CMS has accurate records of resident discharges. The facility's policy, last reviewed in January 2025, aligns with the required assessment and transmission timeframes, but was not followed in this instance.
Resident Rooms Below Minimum Square Footage Requirement
Penalty
Summary
The facility failed to ensure that 27 out of 55 resident rooms met the required minimum square footage per resident, as specified by regulatory standards. Specifically, multiple rooms designated for two or three residents each were found to be below the minimum required 80 square feet per resident, with some rooms measuring as low as approximately 69.40 square feet per resident. This deficiency was identified through a review of the facility's waiver request letter, which acknowledged the shortfall in room sizes, and was confirmed by direct measurement of the affected rooms. During the initial observation tour, surveyors noted that nursing staff had sufficient space to provide care and that privacy curtains and direct corridor access were present in the rooms. Additionally, interviews with the resident council revealed no concerns regarding room size. However, the documented room dimensions did not meet the regulatory requirements for resident living space.
Failure to Timely Document Medication Administration on MAR
Penalty
Summary
The facility failed to ensure that a licensed nurse documented the administration of levetiracetam, an anti-seizure medication, on the Medication Administration Record (MAR) immediately after giving the medication to a resident. The resident in question had a history of intracerebral hemorrhage, seizure disorder, and required gastrostomy feeding due to dysphagia. The resident was severely cognitively impaired and dependent on staff for all activities of daily living. Review of the resident's electronic MAR revealed multiple instances where the documentation of medication administration was recorded significantly later than the scheduled time, with some entries made hours after the medication was due. Interviews with nursing staff confirmed that although the medication was reportedly administered within the allowed window, documentation was delayed to save time during medication passes. Both the LVN and RN involved acknowledged that documentation should occur immediately after administration, as per facility policy, but admitted to late entries. The Director of Nursing also confirmed that immediate documentation is required to avoid confusion regarding medication administration times. Facility policy reviewed indicated that medications should be administered and documented within 60 minutes of the scheduled time, except for specific meal-related orders.
Failure to Provide Communication Tools for Resident with Speech Disabilities
Penalty
Summary
A resident with a history of intracerebral hemorrhage, seizures, gastrostomy with dysphagia, and severely impaired cognitive skills was admitted and readmitted to the facility. The resident's Minimum Data Set indicated unclear speech and dependence on staff for daily activities. During observation, the resident was unable to verbally express needs and could only respond to yes/no questions. Staff, including a CNA and an RN, confirmed that the resident could not communicate needs verbally and that no communication boards or assistive tools were available in the resident's room. The RN acknowledged that a communication board would be helpful but was not present at the time. The facility's policy required staff to assess communication barriers and provide appropriate aids or services for residents with speech disabilities. Despite this, the resident did not have access to any communication tools, and staff were unable to determine the resident's needs during the observed incident. The lack of communication aids was confirmed by both the staff and the DON, who stated that the resident's declining condition warranted such tools, but none were provided at the time of the survey.
Inaccurate MDS Coding for Resident with Multiple Arterial Ulcers
Penalty
Summary
The facility failed to ensure the accuracy of a resident's Minimum Data Set (MDS) assessment regarding the presence of venous and arterial ulcers. Specifically, the MDS for a resident admitted with diagnoses including sepsis, metabolic encephalopathy, and acute respiratory failure with hypoxia, was coded to indicate zero venous and arterial ulcers. However, a review of the resident's Wound Weekly Monitoring Assessment Non-Pressure, dated the day after admission, documented the presence of 12 arterial ulcers. During interviews and record reviews, the MDS Coordinator acknowledged that the MDS was coded in error and should have reflected the number of arterial ulcers as documented in the wound assessment. The Director of Nursing also confirmed that the MDS should have been coded accurately to ensure the resident received timely care and treatment. The facility's policy required that assessments represent an accurate picture of the resident's status during the observation period, which was not followed in this instance.
Failure to Develop Care Plan for Dietary Noncompliance
Penalty
Summary
The facility failed to develop a comprehensive, person-centered care plan to address a resident's noncompliance with a physician-ordered diet. The resident, who had diagnoses including acute kidney failure, stage 4 chronic kidney disease, and type 2 diabetes mellitus, was admitted with specific dietary orders: a controlled carbohydrate diet, a liberal renal diet, and no added salt. Despite these orders, interviews with staff revealed that the resident frequently obtained and consumed outside food, often brought in by family, which did not comply with the prescribed dietary restrictions. The resident was cognitively intact and regularly requested fast food, such as fried chicken, which was high in salt and not aligned with his dietary needs. Record review and staff interviews confirmed that there was no care plan in place to address the resident's ongoing noncompliance with his prescribed diet, even though this behavior was well known among staff. The Director of Nursing, newly hired at the time, was unaware of the issue and confirmed upon review that the care plan did not address the resident's dietary noncompliance. The facility's policy required the development and implementation of a person-centered care plan to meet each resident's needs, but this was not done in this case.
Failure to Ensure Staff Use of Fit-Tested N95 Masks During COVID-19 Outbreak
Penalty
Summary
The facility failed to implement proper infection control practices during a COVID-19 outbreak by not ensuring that staff wore the appropriate N95 masks as required by facility policy. Observations showed that a respiratory therapist and a licensed vocational nurse were both wearing KN95 masks with ear loops, which were brought from home and not approved or fit-tested by the facility, instead of the facility-issued N95 masks with head straps. Both staff members acknowledged using the KN95 masks and confirmed they were not the masks they had been fit-tested for. The respiratory therapist was observed switching to the correct N95 mask after being informed of the difference, while the nurse stated she had received verbal approval from the Nursing Staffing Coordinator to use the KN95, which the coordinator later denied. Interviews with the Nursing Staffing Coordinator and the Infection Preventionist confirmed that the facility's policy during a COVID-19 outbreak requires all staff to wear the specific N95 mask they have been fit-tested for, and that all staff had been in-serviced on this requirement. The facility's infection prevention and control policy, last revised in October 2022, mandates maintaining a safe environment and preventing the transmission of infection in accordance with federal and state requirements. The failure to ensure staff compliance with the use of proper, fit-tested N95 masks constituted a breach of the facility's infection control program during an active outbreak.
Incomplete Medical Records for Three Residents
Penalty
Summary
The facility failed to maintain complete and accurate medical records for three residents by not documenting essential information on their Bedhold Information Consent forms. For Resident 1, the Admission Record indicated admission on February 7, 2025, with diagnoses including sepsis, cervical spinal cord injury, paraplegia, and a pressure ulcer. However, during a review on March 6, 2025, it was found that Resident 1's Bedhold Information Consent form, dated February 12, 2025, was missing the resident's name, date of birth, and admission date. The Admission Coordinator confirmed that the form was incomplete. Similarly, Resident 2's Bedhold Information Consent form, dated February 6, 2025, was missing the resident's name, date of birth, and admission date. Resident 2 had been readmitted with diagnoses including a dislocated hip prosthesis and difficulty walking. The Assistant Director of Nursing confirmed the form's incompleteness. For Resident 3, admitted with cerebral palsy, the Bedhold Information Consent form dated February 2, 2025, also lacked the necessary resident information. The facility's policy on medical record completion, revised in 2019, emphasizes the importance of complete and accurate documentation, which was not adhered to in these cases.
Resident-to-Resident Physical Abuse Incident
Penalty
Summary
The facility failed to protect a resident from physical abuse by another resident. On February 2, 2025, a Certified Nursing Assistant (CNA) witnessed Resident 2 physically assault Resident 1 by punching them three times on the left side of the chest. This incident occurred while Resident 1 was on their way to the kitchen, and Resident 2 was passing by. The CNA immediately intervened to separate the residents. Resident 1, who was admitted to the facility with chronic obstructive pulmonary disease, chronic respiratory failure, and major depressive disorder, was reported to have intact cognition and required assistance with various daily activities. During the incident, Resident 1 experienced pain in the chest area due to the assault. Interviews with staff, including the Activities Director and Registered Nurse, confirmed the occurrence of physical abuse, as residents are not supposed to engage in violent behavior towards each other. Resident 2, who has a history of bipolar disorder, paranoid personality disorder, and schizoaffective disorder, was noted to have severely impaired cognition and required substantial assistance with personal care. The Assistant Director of Nursing acknowledged that the incident was a result of Resident 2's aggressive behavior, which was not adequately addressed or monitored, leading to the avoidable assault on Resident 1. The facility's policy on abuse and neglect emphasizes the residents' right to be free from such incidents, highlighting the deficiency in protecting Resident 1 from harm.
Failure to Implement Care Plan for Resident's New Onset Pain
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident who experienced a new onset of pain. The resident, who was admitted with diagnoses including chronic obstructive pulmonary disease, chronic respiratory failure, unspecified severe protein-calorie malnutrition, and major depressive disorder, reported a pain level of 8 after being hit three times on the left upper chest area by another resident. Despite this significant change in condition, no care plan was created to address the resident's new onset of left chest pain. During a review of the resident's care plans, a registered nurse confirmed the absence of a specific care plan for the resident's new pain, which was necessary for monitoring and ensuring the pain did not worsen. The facility's policy requires the development of person-centered comprehensive care plans that address the resident's medical, physical, mental, and psychosocial needs, but this was not adhered to in this instance.
Failure to Monitor Resident After Change of Condition
Penalty
Summary
The facility failed to monitor a resident for 72 hours following a Change of Condition (COC) as required by their policy. The resident, who was admitted with diagnoses including chronic obstructive pulmonary disease, chronic respiratory failure, severe protein-calorie malnutrition, and major depressive disorder, experienced a significant change in condition when another resident hit them three times on the left upper chest area. This incident resulted in the resident reporting a pain level of 8. Despite the facility's policy requiring monitoring every shift for 72 hours after such an event, there was no documented evidence of monitoring from February 3 to February 5, 2025. Interviews with the Registered Nurse and the Assistant Director of Nursing confirmed the lack of documentation and monitoring, which was necessary to ensure the resident's safety and psychosocial well-being. The facility's policy, revised in November 2024, mandates 72-hour charting following a significant change in a resident's physical, mental, or psychosocial status. The failure to adhere to this policy had the potential to negatively impact the resident's well-being.
Failure to Conduct Required Pain Assessments
Penalty
Summary
The facility failed to adhere to its policy on pain assessments, resulting in a deficiency related to the management of a resident's pain. Resident 1, who was admitted with chronic obstructive pulmonary disease, chronic respiratory failure, and major depressive disorder, experienced a new onset of pain after being hit by another resident. Despite the facility's policy requiring pain assessments upon admission, quarterly, annually, and during a change of condition, the necessary assessments were not completed. Specifically, the last documented pain assessment for Resident 1 was on 10/8/2024, and subsequent assessments due on 1/8/2025 and 2/2/2025 were missed. Interviews with the Assistant Director of Nursing and the MDS Nurse revealed that the responsibility for conducting these assessments was not fulfilled. The MDS Nurse acknowledged missing the annual comprehensive pain assessment due on 1/8/2025, and the Assistant Director of Nursing confirmed that a pain assessment should have been conducted on 2/2/2025 following the incident that caused Resident 1's new pain. The facility's policy, revised in 3/2023, emphasizes the importance of conducting comprehensive pain assessments to identify pain and develop appropriate interventions, which was not followed in this case.
Failure to Document Annual History and Physical for Resident
Penalty
Summary
The facility failed to ensure that a resident's attending physician documented an annual History and Physical (H&P) for a resident, which is a formal assessment involving a resident interview, physical exam, and documentation of findings. This deficiency was identified for one of two sampled residents, specifically Resident 2, who was admitted to the facility on 5/13/2022 and readmitted on 8/5/2023. Resident 2 had multiple diagnoses, including bipolar disorder, paranoid personality disorder, and schizoaffective disorder, and was noted to have severely impaired cognition. The Minimum Data Set (MDS) dated 11/14/2024 indicated that Resident 2 required varying levels of assistance with daily activities, highlighting the importance of having an updated H&P to ensure proper care coordination. During a review of Resident 2's medical records, it was found that the latest H&P was dated 8/7/2023, and there was no updated H&P documented annually as required. Interviews with the Medical Records Director and the Assistant Director of Nursing confirmed the absence of an updated H&P and emphasized the importance of having current documentation to address the resident's needs. The facility's policies on physician visits and documentation require that the physician reviews the resident's total program of care during each visit and that relevant findings are documented in the clinical record. The lack of an updated H&P for Resident 2 represents a failure to adhere to these policies, potentially leading to inconsistent care coordination.
Missing Controlled Medication in LTC Facility
Penalty
Summary
The facility failed to account for 16 tablets of hydromorphone hydrochloride, a controlled medication used to treat severe pain, for a resident. The resident, who had a history of pelvic fracture, lumbar vertebra fracture, septic shock, chronic kidney disease, and chronic pain syndrome, was admitted to the facility with a physician's order for hydromorphone hydrochloride to be administered as needed for severe pain. The resident's Minimum Data Set indicated moderately impaired cognition, requiring assistance with daily activities. On a specific day, the resident requested a Dilaudid tablet due to increased pain, but the medication packet was missing from the medication cart, and the sign-out sheet could not be located. The Licensed Vocational Nurse (LVN) on duty reported the missing medication to the Director of Nursing and obtained the medication through the emergency system to provide it to the resident. The facility's Administrator was informed of the missing medication and initiated an investigation, which confirmed the absence of the 16 tablets. The facility's policies and procedures for safeguarding controlled substances require a controlled log record for each prescription, including details such as the resident's name, medication strength, quantity, and administration details. However, the facility was unable to locate the packet or the sign-out sheet, indicating a failure to adhere to these procedures.
Deficiency in Medical Record Documentation for Diabetes Management
Penalty
Summary
The facility failed to maintain complete and accurate medical records for two residents, leading to a deficiency in the management of diabetes mellitus. For one resident, the Medication Administration Records (MAR) lacked documentation of blood sugar readings and insulin administration on multiple occasions in January 2025. This resident had a history of diabetes mellitus and required insulin administration based on a sliding scale. The absence of documentation meant there was no record of whether the resident's blood sugar levels were monitored or if insulin was administered as per the physician's orders. Similarly, another resident's MAR also showed missing entries for blood sugar readings and insulin administration on specific dates in January 2025. This resident also had a history of diabetes mellitus and required insulin administration according to a sliding scale. The lack of documentation raised concerns about whether the resident received appropriate care and treatment for diabetes management. Additionally, there was an error in documenting a blood sugar reading for one of the residents. The blood sugar summary indicated a low reading, but there was no documentation of any nursing action taken or notification to the physician, as required by the facility's protocol. The Assistant Director of Nursing (ADON) acknowledged the importance of accurate documentation to ensure continuity of care and resident safety, emphasizing that incorrect information could affect the resident's plan of care.
Delayed Response to Resident Call Light
Penalty
Summary
The facility failed to ensure that a resident's call light was answered promptly, which is a device used by residents to signal their need for assistance from staff. This deficiency was observed in the case of a resident who had been admitted with diagnoses including angina pectoris, acute respiratory failure, and chronic pain syndrome. The resident's Minimum Data Set indicated moderately impaired cognitive skills and a need for total assistance with various activities of daily living. The care plan for the resident included an intervention to encourage the use of a bell to call for assistance and to keep call lights within reach at all times. During an observation and interview, the resident expressed concerns about the staff's response time to call lights, stating that there was an instance where she waited for more than an hour for assistance. The observation confirmed that after the resident pressed the call button, no staff responded within five minutes, despite the call light indicator being on. At the nurse station, a Certified Nursing Assistant (CNA) was observed talking with other staff and then working on the computer, aware of the call lights but not responding immediately. The facility's policy and procedure on the resident call system, last reviewed in 2024, indicated that the facility is equipped to allow residents to call for staff assistance and that staff should respond to residents' requests and needs. The Administrator confirmed that all staff are responsible for answering call lights promptly to assess whether the resident's needs are emergent. However, the CNA admitted to prioritizing documentation over responding to the call lights, which contributed to the delay in service provision for the resident.
Failure to Develop Comprehensive Care Plan for Amputee Resident
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident who had undergone a partial traumatic amputation of the right mid-foot and was diagnosed with peripheral vascular disease. The resident was originally admitted on June 10, 2024, and readmitted on September 5, 2024. The Minimum Data Set (MDS) assessment dated September 12, 2024, indicated that the resident had moderately impaired cognitive skills and required assistance with daily activities such as eating, oral hygiene, personal hygiene, and toileting. Despite these needs, there was no documented evidence of a care plan specifically addressing the resident's right foot amputation. During an interview and record review on December 30, 2024, the Director of Nursing (DON) confirmed the absence of a comprehensive care plan for the resident's amputation. The facility's policy, last revised in October 2023, mandates the development of person-centered care plans that address the resident's medical, physical, mental, and psychosocial needs. The lack of a specific care plan for the resident's amputation was identified as a deficiency, as it is crucial for guiding staff in providing personalized interventions.
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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