The Rehabilitation Center Of Oakland
Inspection history, citations, penalties and survey trends for this long-term care facility in Oakland, California.
- Location
- 210 40th Street Way, Oakland, California 94611
- CMS Provider Number
- 555313
- Inspections on file
- 27
- Latest survey
- March 17, 2026
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at The Rehabilitation Center Of Oakland during CMS and state inspections, most recent first.
A resident with depression and intact cognition reported that staff refused to complete an inventory of their personal items and later reported many belongings missing. Review of records showed the resident's Personal Effects Inventory Form was undated, unsigned, and incomplete, and the resident's belongings had not been fully inventoried. A Theft and Loss Report documented alleged loss of multiple boxes of clothing with a stated monetary value. The SW and RN supervisor acknowledged that the inventory should have been completed at admission and that the facility was responsible for safeguarding resident property, as required by facility policies on theft/loss and resident rights.
A resident with multiple chronic conditions was discharged without receiving an inventory of their personal belongings, and several items were reported missing. The responsible party had reported the missing items to Social Services, but there was no documentation in the Theft and Loss Log or in the discharge records. Staff confirmed that required procedures for inventorying and returning personal property at discharge were not followed, resulting in the resident's belongings not being properly accounted for.
A resident with impaired mobility and moderate cognitive impairment was left to navigate a ramp alone in her wheelchair while a CNA assisted another resident, resulting in the resident falling out of her wheelchair and sustaining a nasal fracture and contusion. The care plan required assistance and monitoring for mobility, but these were not followed, leading to the incident.
A resident with a history of aggressive behavior and cognitive impairment physically assaulted another resident with a bed power cord, causing significant injury and hospitalization. Despite documented risks and a behavior care plan, the facility failed to prevent the incident, and staff discovered the assault after hearing a shout from the shared room.
A resident with intact memory alleged physical abuse by a CNA, prompting a 911 call and police response. Despite the facility's policy requiring immediate removal of accused staff, the CNA continued to provide care to the resident and at least 18 others for 12 hours after the allegation. Staff interviews and records confirmed the CNA was not removed from resident care areas as required.
The facility failed to maintain safe and sanitary food storage and preparation practices, leading to Immediate Jeopardy. Fish was improperly thawed and stored at unsafe temperatures, and the kitchen was found to be unsanitary with dirty equipment and expired food items. Staff did not follow proper hygiene protocols, contributing to the risk of foodborne illness.
The facility failed to ensure kitchen staff were trained and evaluated for competency, leading to improper food safety practices. Fish fillets were thawed incorrectly and stored in a freezer at unsafe temperatures. The Dietary Manager and staff lacked knowledge of proper procedures, and competency evaluations were not conducted as required by facility policy.
The facility failed to assist residents with personal hygiene, leaving two residents with long facial hair and two others with overgrown, dirty fingernails. Despite policies emphasizing personal care, documentation was inadequate, and staff did not provide necessary assistance, leading to discomfort and potential infection risks.
The facility failed to ensure appropriate competencies for four CNAs and one LVN due to missing Orientation Evaluation Checklists and Annual Performance Evaluations. The DSD confirmed these evaluations were not conducted, and the DON highlighted their importance for assessing staff competency. The facility lacked a Policy and Procedure for these evaluations.
A facility failed to properly store and label medications, including unlabeled Tuberculin vials, improperly stored activase vials for a discharged resident, and expired Influenza vaccines. Expired medications for three residents were found in a medication cart, and two inhalers were undated. The DON and LVN acknowledged these lapses, which contravened the facility's policies on medication storage and labeling.
The facility failed to adhere to infection control practices, including improper handling of soiled linen by a CNA, inadequate hand hygiene by an LVN during medication administration, and unlabeled, floor-touching nasal cannula tubing for residents. These actions contravened the facility's policies, posing potential infection risks.
A resident was observed in an activity room wearing a facility gown and a disposable undergarment that was soaking wet with urine, causing liquid to drip onto the floor. This was noted during an interview with the AD, who confirmed that the resident's condition affected their dignity. Other residents were wearing personal clothes, highlighting the lack of respect and dignity afforded to this resident.
A resident with Acute and Chronic Respiratory Failure was observed using an oxygen concentrator without a Doctor's Order. The facility's policy requires oxygen to be administered per physician orders, which was not adhered to, as confirmed by the ADON.
A resident's call light was found on the floor, out of reach, leading to a delay in care. The resident, who required extensive assistance due to multiple health issues, was unable to request help. A CNA admitted to not checking the call light, and the DON confirmed the expectation for staff to ensure call lights are accessible.
The facility failed to ensure that staff members, including registry staff, wore identification (ID) badges while providing care to a resident with multiple diagnoses, including arthritis and anxiety disorder. This oversight led to the resident's emotional distress and anxiety, as they were unable to identify the staff members caring for them. Interviews and observations confirmed that several staff members were not wearing ID badges, despite the facility's policy requiring them.
Failure to Complete and Verify Resident Personal Effects Inventory
Penalty
Summary
The facility failed to honor a resident's right to retain personal possessions by not completing and verifying a detailed personal effects inventory at admission. The resident, who had a diagnosis of depression and an intact cognitive status as evidenced by a BIMS score of 14, reported that staff refused to complete an inventory of their items. The resident stated they were missing many items and felt upset, disrespected, and insulted. Review of the resident's admission record confirmed the admission occurred in 2024, and the resident's cognitive status was intact at the time of the deficiency. During review of the resident's Personal Effects Inventory Form and Theft and Loss Report with the social worker, it was found that the inventory form was undated, not signed, and not completed, and the resident's belongings had not been fully inventoried. The Theft and Loss Report documented an alleged loss of four boxes of clothes valued at $971.17, with the social worker indicating they were waiting for receipts from the resident to resolve the claim. The RN supervisor stated that the resident's personal items should have been inventoried and the inventory form completed at admission, readmission, or return from the hospital, and acknowledged the facility's responsibility to safeguard residents' belongings. Facility policies on Theft and Loss and Resident Rights required completion and updating of inventory lists and affirmed residents' rights to retain and use personal possessions.
Failure to Account for and Protect Resident's Personal Belongings at Discharge
Penalty
Summary
The facility failed to protect and account for the personal belongings of a resident who was admitted with multiple diagnoses, including diabetes, hypertension, and end-stage kidney disease on dialysis. Upon discharge, the resident and their responsible party reported missing personal items, which had been previously reported to the Social Services Director during the resident's stay. There was no inventory of the resident's personal items provided to the resident or family at discharge, and the facility's Theft and Loss Log did not contain any record of the missing items. The Medical Records Director was able to provide an inventory list from admission, but not from discharge, and an additional inventory form was found to be incomplete, lacking a date and signature. Interviews with facility staff, including the current Social Services Director and the Director of Nursing, confirmed that there was no documented inventory of the resident's belongings at discharge, and no information about the inventory was included in the discharge summary. Facility policy required that all personal belongings be accounted for and documented upon discharge, with the resident or representative signing the inventory form. The failure to follow these procedures resulted in the resident's personal items not being properly tracked or returned, compromising the resident's right to retain their possessions.
Resident Fall Due to Inadequate Wheelchair Assistance on Ramp
Penalty
Summary
A deficiency occurred when a resident with impaired physical mobility and moderate cognitive impairment was not adequately assisted while using a wheelchair to access the facility's smoking patio. The resident, who had a history of falls and was at high risk for further incidents, was being escorted to the smoking area by a CNA. The ramp leading to the patio had uneven boards and cracks, and although it was equipped with nonskid straps, the first two boards created a divot that could pose a hazard. On the day of the incident, the CNA attempted to assist two wheelchair-bound residents simultaneously, pushing one while the other, who believed she was being assisted, was left to navigate the ramp alone. The resident lost control of her wheelchair, went down the ramp too quickly, and fell out, sustaining a nasal contusion and a closed fracture of the nasal bone. The resident expressed embarrassment and required emergency medical attention for her injuries. Interviews with staff confirmed that it was not safe for one staff member to push two wheelchairs at once, as both hands are needed to safely assist a single resident. The care plan for the resident indicated a need for assistance with mobility and monitoring for environmental barriers, but these measures were not effectively implemented at the time of the incident, directly leading to the resident's fall and injury.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
A resident with vascular dementia and moderate cognitive impairment was physically abused by another resident who had a known history of aggressive behavior. The aggressor, who was cognitively intact but had diagnoses of dementia, psychosis, and anxiety, struck the victim with a bed power cord, resulting in a bleeding facial and scalp wound that required hospitalization. The incident occurred in a shared room, and staff responded after hearing a shout and found the aggressor swinging the cord and the victim bleeding heavily. Prior documentation indicated that the aggressor had a behavior care plan noting a potential for physical aggression and a history of conflicts with previous roommates, including threats of violence. Despite these known risks, the two residents were placed together, and the facility failed to prevent the incident. The facility's abuse prevention policy prohibits all forms of abuse and requires systems to promote an environment free from abuse, but these measures were not effectively implemented in this case.
Failure to Remove CNA from Resident Care After Abuse Allegation
Penalty
Summary
The facility failed to ensure that a Certified Nursing Assistant (CNA) was immediately removed from resident care duties after an allegation of physical abuse was made by a resident. The resident, who had intact short-term memory and was admitted in April 2022, called 911 and reported being physically hurt by the CNA. Paramedics and police responded to the incident, and the resident specifically alleged that the CNA had kicked him. Despite this, facility records and interviews confirmed that the CNA continued to work both the evening and night shifts, providing care to the resident who made the allegation as well as at least 18 other residents for approximately 12 hours after the incident was reported. Interviews with facility staff, including the Director of Nursing (DON) and Licensed Vocational Nurse (LVN), revealed a lack of clarity and communication regarding the removal of the CNA from resident care areas. The DON was under the impression that the CNA had been sent home, but sign-in records showed otherwise. The CNA himself stated that he was not informed by facility staff about the abuse allegation and continued his assigned duties. Facility policy required immediate removal and suspension of any employee accused of abuse pending investigation, but this protocol was not followed in this case.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to store, prepare, and distribute food in a safe and sanitary manner, leading to a situation of Immediate Jeopardy. Fish intended for lunch was improperly thawed and stored in a freezer with a temperature of 30 degrees Fahrenheit, which is above the safe storage temperature of 0 degrees Fahrenheit. This improper storage and thawing of fish posed a risk of bacterial growth and foodborne illness. The surveyors identified this issue during an observation and interview with the Dietary Manager, who acknowledged the improper practices. Additionally, the facility's kitchen and food storage areas were found to be unsanitary and not in compliance with professional standards. The three-compartment sink, meant for cleaning and sanitizing utensils, was used for food preparation. Equipment such as the industrial can opener and blender were dirty, and the reach-in freezer contained food items that were not frozen solid. Moldy and unusable foods were not discarded, and multiple refrigerated items were stored beyond their use-by dates. These conditions were observed during interviews and inspections with the Dietary Manager and other staff members. Furthermore, staff members did not adhere to proper hygiene practices. The Activity Director and other staff did not wear hair coverings or wash their hands upon entering the kitchen. A scoop was improperly stored inside a powdered thickener container, and the garbage disposal and bin were found to be dirty and malodorous. These lapses in hygiene and sanitation were noted during observations and interviews with the facility's staff, highlighting a systemic issue in maintaining a safe and sanitary food service environment.
Deficiencies in Kitchen Staff Training and Food Safety Practices
Penalty
Summary
The facility failed to ensure that kitchen staff were routinely trained and evaluated for competency skills, leading to several deficiencies in food safety practices. During an interview, the Dietary Manager (DM) and a cook (CK 1) revealed that fish fillets were improperly thawed in a sink and were intended to be served for lunch. The fish was taken from a freezer with a temperature reading of 30 degrees Fahrenheit, which is above the safe storage temperature of zero degrees Fahrenheit. The Registered Dietician (RD 1) confirmed that the fish was not safe to serve due to the risk of bacterial growth. Further observations and interviews highlighted that the DM and kitchen staff lacked knowledge of proper food safety procedures. The DM was unable to state appropriate thawing procedures or the importance of maintaining the freezer at the correct temperature. Additionally, CK 1 admitted to not thawing fish under running water, which is a recommended practice to prevent bacterial growth. The RD 1 emphasized that the fish prepared for lunch was unsafe, and produce with freezer burns should not be used. The report also revealed that there was a lack of competency evaluations for the dietary staff. CK 1 stated she had not been evaluated since the current DM's employment, and the DM admitted to not conducting competency checks for the staff. The facility's policy required competency assessments upon hire, annually, and as needed, but these were not being performed. The Dietary Quality Control Review indicated that staff and DM competencies were not met, highlighting a systemic issue in ensuring food safety and staff competency in the facility.
Deficiency in Personal Hygiene Assistance
Penalty
Summary
The facility failed to assist four out of eight sampled residents with personal hygiene, specifically in shaving facial hair and maintaining clean and trimmed fingernails. Resident 30 and Resident 46 were observed with long facial hair, which they expressed discomfort about, stating that staff did not offer assistance with shaving. The facility's documentation system for recording shaving assistance was found to be inadequate, with missing records and unclear procedures for documenting such care. Resident 48 and Resident 52 were found with overgrown and dirty fingernails, which posed a risk of infection, especially for Resident 48, who had undergone surgery and required substantial assistance with personal hygiene. Despite being cognitively intact, Resident 48 reported discomfort and lack of assistance from staff in maintaining nail hygiene. Staff members acknowledged the issue but indicated a lack of directive to include nail care in their routine assistance. The facility's policies on resident rights and grooming emphasize the importance of personal care and hygiene, yet the implementation was lacking. The Director of Nursing confirmed the absence of documentation for nail care and acknowledged the expectation for staff to maintain residents' nail hygiene. The failure to adhere to these policies resulted in residents feeling unkempt and at risk for infections due to inadequate personal hygiene care.
Lack of Competency Evaluations for Nursing Staff
Penalty
Summary
The facility failed to ensure that four Certified Nursing Assistants (CNAs) and one Licensed Vocational Nurse (LVN) had the appropriate competencies to care for residents. This was due to the absence of completed Orientation Evaluation Checklists for LVN 1 and CNA 3, and the lack of Annual Performance Evaluations for CNAs 1, 2, and 4. The Director of Staffing Development (DSD) confirmed during interviews and record reviews that these evaluations were not conducted as required. The DSD acknowledged that these evaluations are crucial for assessing the competency of the staff and identifying areas where training is needed. The Director of Nursing (DON) further stated that the DSD was responsible for completing the Annual Performance Evaluations annually from the date of hire and more frequently if there were resident concerns. The DON emphasized the importance of these evaluations in verifying the competency of CNAs and LVNs before they begin working on the floor. However, it was revealed that the facility did not have a Policy and Procedure in place for conducting Annual Performance Evaluations or Orientation Evaluation Checklists, which contributed to the oversight.
Improper Storage and Labeling of Medications in LTC Facility
Penalty
Summary
The facility failed to ensure proper storage and labeling of medications and biologicals, as observed in the medication room and on medication carts. Three opened vials of Tuberculin Purified Protein Derivative (PPD) were found unlabeled and undated, lacking an open date, which is crucial as the vials expire 30 days after opening. The Director of Nursing (DON) acknowledged that the nurse responsible should have labeled the vials with the open date. Additionally, two activase vials for a discharged resident were improperly stored in the refrigerator, and the DON confirmed that these should have been placed in the medication destruction container, as per the facility's policy. Further observations revealed thirteen expired Influenza vaccine vials stored in the refrigerator, which should have been moved to the medication destruction container. The facility's policy mandates that expired medications be stored separately and destroyed. Moreover, expired medications for three active residents were found in the medication cart, including Sertraline, Metformin, and Humulin R insulin, with the latter being uncapped and past its 31-day usage period. The Licensed Vocational Nurse (LVN) stated that the medication cart is checked monthly for expired medications, but these were overlooked. Lastly, two opened inhalers for a resident were found undated and unlabeled with an open date. The facility's policy requires medications to be stored following the manufacturer's recommendations, which include discarding the inhaler six weeks after opening or when the counter reads zero. The LVN confirmed the absence of an open date on the inhalers, indicating a lapse in adherence to proper medication storage protocols.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain proper infection control practices in several instances. A Certified Nursing Assistant (CNA) was observed picking up soiled linen from the floor in a resident's room and disposing of it in a cart without using a plastic bag, contrary to the facility's policy. This action could potentially lead to the spread of infection as the soiled linen was not contained during transport. A Licensed Vocational Nurse (LVN) did not perform hand hygiene or change gloves before administering eye drops to a resident. The LVN used the same gloves to touch the resident's surroundings and then proceeded to administer the medication, which is against the facility's policy that requires hand hygiene before and after administering eye drops. Additionally, the LVN did not remove gloves after applying topical medication to another resident, which is also a breach of the facility's guidelines. Furthermore, the nasal cannula tubing for three residents was found to be undated, unlabeled, and touching the floor. This oversight poses an infection control issue as the tubing should be labeled with the date of change and should not be in contact with the floor. The facility's policy mandates that oxygen tubing be changed and labeled every seven days to ensure sanitary conditions.
Resident Dignity Compromised Due to Inadequate Care
Penalty
Summary
The facility failed to ensure that a resident was treated with dignity and respect, as observed during an activity session. The resident was found sitting in a wheelchair wearing a facility gown, with a disposable undergarment that was soaking wet with urine, causing liquid to drip onto the floor. This was in contrast to other residents in the room who were wearing personal clothes. During an interview with the Activity Director, it was confirmed that the resident's condition affected their dignity. The facility's policy on Resident Rights, dated 1/1/12, mandates that employees treat all residents with kindness, respect, and dignity, which was not adhered to in this instance.
Failure to Obtain Doctor's Order for Oxygen Therapy
Penalty
Summary
The facility failed to ensure that a resident, identified as Resident 11, had a Doctor's Order for supplemental oxygen before receiving it. Resident 11 was admitted with multiple diagnoses, including Acute and Chronic Respiratory Failure with Hypoxia. During an observation, Resident 11 was seen using an oxygen concentrator at a rate of 2 liters via nasal cannula without a prior Doctor's Order. Upon review of Resident 11's records, it was confirmed that there was no Doctor's Order for the oxygen concentrator until a later date. The Assistant Director of Nursing confirmed that residents require a Doctor's Order for oxygen to prevent potential harm. The facility's policy on oxygen therapy mandates that oxygen be administered per physician orders, which was not followed in this instance.
Failure to Ensure Call Light Accessibility
Penalty
Summary
The facility failed to ensure that the call light was within reach for Resident 56, leading to a delay in care and services. During an observation, the call light was found on the floor behind the resident's bed, and the resident's urinary collection bag was full and heavy. The resident, who had intact cognitive status and required extensive assistance due to multiple diagnoses including muscle weakness and polyneuropathy, stated that they could not ask for help because the call light was not within reach. This situation was confirmed by a Certified Nursing Assistant (CNA) who admitted to not checking the call light upon arrival. The Director of Nursing (DON) acknowledged that the nursing staff is expected to ensure that call lights are within reach, especially for residents like Resident 56 who require extensive assistance. The resident's care plan highlighted the importance of having the call light within reach and responding promptly to requests for assistance. The facility's policy on the communication-call system also mandates that call cords be placed within the resident's reach to enable prompt communication with nursing staff.
Failure to Ensure Staff Wore Identification Badges
Penalty
Summary
The facility failed to ensure that staff members, including registry staff, wore identification (ID) badges while providing care to residents. This deficiency was observed in the case of a resident who had multiple diagnoses, including arthritis and anxiety disorder, and had a perfect score on the Brief Interview for Mental Status (BIMS), indicating full cognitive function. The resident and their responsible party reported issues with staff not identifying themselves, which contributed to the resident's emotional distress and anxiety. During interviews and observations, it was confirmed that several staff members, including registry staff, were not wearing ID badges, and the facility had previously received deficiencies related to this issue. The facility's administrator and scheduling staff acknowledged the importance of wearing ID badges for resident identification and confirmed that all staff, including registry staff, were supposed to wear them. Despite this, registry staff were not provided with ID badges, and this oversight led to the resident's inability to identify the staff members caring for them. The facility schedule confirmed the assignment of registry staff to the resident, further highlighting the failure to ensure proper identification of caregivers.
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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