The Rehabilitation Center On Pico
Inspection history, citations, penalties and survey trends for this long-term care facility in Los Angeles, California.
- Location
- 3233 W. Pico Boulevard, Los Angeles, California 90019
- CMS Provider Number
- 056377
- Inspections on file
- 43
- Latest survey
- January 14, 2026
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at The Rehabilitation Center On Pico during CMS and state inspections, most recent first.
A resident with metabolic encephalopathy, moderate to severe cognitive impairment, frequent urinary incontinence, and functional dependence for toileting and other ADLs was readmitted with a UTI and placed on Ciprofloxacin, but the facility did not develop or update a comprehensive care plan to address the UTI. Record review showed no problem statement, goals, monitoring parameters, comfort measures, or physician notification guidelines related to the infection. The MDS nurse acknowledged the care plan had not been updated since a prior assessment and had not been revised upon readmission, despite facility policy requiring the IDT to review and revise the comprehensive care plan after each assessment and to complete it within a specified timeframe after admission. The DON confirmed that a care plan for the UTI should have been initiated but was not.
A resident with left-sided hemiplegia and multiple medical conditions was found twice without access to their call light, despite being dependent on staff for ADLs and having a care plan requiring the call light to be within reach. Staff confirmed the call light was not accessible and repositioned it, in contradiction to facility policy and the resident's care plan.
A resident who was fully dependent on staff and had severe cognitive impairment was left without their ordered oxygen therapy after a CNA removed the nasal cannula during personal care and forgot to replace it. The resident's oxygen saturation dropped to 77% until an LVN reapplied the oxygen, restoring normal levels.
A resident with a history of dementia and a past episode of depression was incorrectly listed as having an active diagnosis of major depressive disorder in facility records. Review of clinical documentation and interviews with the DON confirmed that the depression diagnosis was historical, not current, and the resident was not receiving psychiatric medication. The error was attributed to a typographical mistake, resulting in incomplete and inaccurate medical records.
Multiple residents did not receive critical medications, including anticoagulants, antihypertensives, and antiepileptics, at the prescribed times or intervals, with some doses given hours late or too close together. Staff cited heavy workloads and insufficient support as reasons for the delays, and facility protocols requiring timely administration and physician notification were not followed. These actions led to significant medication errors affecting residents with complex medical needs.
The facility did not update care plans for three residents as required, including failing to revise an elopement/wandering plan for a resident with cognitive impairment, not updating an activities plan to reflect a resident's current preferences, and not revising a pressure ulcer care plan for a resident with paraplegia. Staff confirmed that care plans were not reviewed or revised quarterly, and interventions were not updated to match residents' current needs.
Three residents did not receive medications and treatments according to professional standards, including failure to rotate insulin injection sites for a resident with diabetes and delayed administration of scheduled medications for two other residents. Nursing staff did not follow facility policies for medication timing, site rotation, or physician notification, and blood glucose monitoring was not performed as required.
Surveyors identified multiple failures in kitchen sanitation and food safety, including unclean equipment, damaged utensils, improper storage of dented cans, and inadequate prevention of cross-contamination. Staff did not consistently wash hands or follow proper utensil cleaning procedures, and food cooling logs were incomplete. Pots and pans were stacked wet, and sanitizer concentrations were not checked according to manufacturer guidelines, all of which were confirmed by staff interviews and policy reviews.
A resident with multiple medical conditions reported missing personal items, including clothing and a prescribed leg brace, to the Social Services Assistant. The facility failed to document or investigate the grievance as required by policy, resulting in the loss not being addressed or recorded in the Theft and Loss Report Log.
A resident with Type II diabetes and moderate cognitive impairment repeatedly refused prescribed insulin, with 66 refusals in one month and 41 in the next. Despite this ongoing pattern, staff did not develop a care plan to address the refusals, as confirmed by both nursing staff and the DON. Facility policy requires care plans for residents who decline treatment, but no such plan was created in this case.
A resident with chronic respiratory conditions was observed using oxygen nasal cannula tubing that was resting on the floor, despite care plan instructions and facility policy requiring the tubing to be kept clean and off the floor. Staff acknowledged the tubing was dirty and should have been replaced, but failed to do so, resulting in a deficiency in providing safe respiratory care.
A resident with chronic pain conditions did not receive timely reassessment of pain following administration of pain medication, as required by their care plan and professional standards. Staff failed to consistently evaluate the effectiveness of pain interventions, did not provide all prescribed non-pharmacological treatments, and lacked clear policy guidance on pain reassessment, resulting in episodes of uncontrolled pain.
A medication pass resulted in a 20% error rate when a nurse administered morning medications late and without physician notification, and a resident refused two of the prescribed medications. The resident had multiple complex medical conditions and required significant assistance. Staff interviews indicated that high workload and time constraints contributed to the errors, and facility policy requiring timely administration and physician notification was not followed.
Kitchen staff were not consistently trained or evaluated for competency in food cooling and sanitizer testing procedures, leading to improper monitoring and documentation of food temperatures and incorrect use of QUAT sanitizer solutions. These failures affected the safety of food and dishware provided to medically compromised residents.
Staff failed to measure thickener and follow guidelines when preparing pureed foods, resulting in pureed vegetables that did not hold their shape and pureed rice with chunks, both inconsistent with required smooth, pudding-like texture for residents with dysphagia. Despite having standardized recipes and policies, these were not followed, leading to improper food consistency for multiple residents on puree diets.
Surveyors observed that three dumpsters were not completely closed or covered and were overflowing with trash, including unbroken-down boxes, with one dumpster having a broken lid. The Dietary Supervisor and Maintenance Director confirmed these issues and acknowledged that dumpsters should be closed and not overfilled to prevent pest attraction and infection risks. Facility policy and the Food Code require dumpsters to be covered and maintained in a sanitary condition.
Two employees, an LVN and a Restorative Nurse Assistant, were found to be working without documented evidence of TB screening or clearance, as required by facility policy. Their files lacked PPD skin test or chest x-ray results, and there was no indication of prior positive TB tests, resulting in a failure to follow infection prevention protocols.
A resident with cognitive and mobility impairments was found to have a non-functioning call light in their bathroom and bathing area. The resident attempted to use the call light, but it did not activate, and staff confirmed it was not working. The care plan required the call light to be accessible, but maintenance was unaware of the issue and did not keep a log of system checks, contrary to facility policy.
Seventeen rooms did not meet the required minimum square footage per resident, as confirmed by room measurements and facility records. Although staff and a resident reported that rooms were clean and allowed for free movement, the documented room sizes were below regulatory standards, despite some rooms having approved waivers.
A resident at risk for pressure ulcers was inaccurately assessed by the facility, leading to potential adverse effects on treatment. The resident's condition, including a red area on the heel, was inconsistently documented, with discrepancies in the Braden Scale assessments. This failure to accurately assess and document the resident's condition could impact the effectiveness of interventions for pressure ulcer prevention.
A resident at risk for pressure ulcers developed a non-blanchable redness on the heel due to the facility's failure to implement preventive measures. Despite a care plan that included repositioning and floating the heels, these interventions were not consistently followed, leading to the injury. Observations confirmed the deficiency, highlighting a lapse in adherence to pressure ulcer prevention protocols.
A resident with multiple health conditions had an IV site that was not changed within the recommended 72 to 96-hour window, as per facility policy and CDC guidelines. The IV line, dated 9/27/24, remained in place beyond the last medication administration on 10/3/24, posing a risk for infection. The DON confirmed the oversight during an observation and interview.
A resident with severe medical conditions and impaired cognition experienced a significant drop in blood oxygen levels and difficulty breathing. The facility failed to provide the appropriate oxygen delivery device, using a simple mask instead of a non-rebreather mask, which is necessary for delivering 100% oxygen in emergencies. The documentation did not specify the type of mask used, leading to concerns about the adequacy of care provided.
A resident with mood affective disorder and unspecified psychosis was not adequately assessed or monitored, leading to an incident where another resident with similar diagnoses became verbally and physically aggressive. The facility failed to conduct comprehensive assessments or review care plan interventions, resulting in an altercation where the aggressive resident threw a cup of juice at the other resident, causing fear and a sense of being unprotected.
A facility failed to create a comprehensive care plan for a resident with psychosis, despite the resident's history of agitation and refusal of medication. The resident exhibited aggressive behavior, and the MDS assessment was incomplete. The DON did not see the need for a psychosis care plan, while the MDS Coordinator stressed its importance for preventing decline and improving outcomes.
The facility failed to protect a resident from physical abuse when another resident slapped her on the face, causing redness and pain. The incident was witnessed by a CNA, and the affected resident received cold packs and Tylenol for pain management. The facility's DON confirmed the occurrence of physical abuse, which violated the facility's abuse prevention policy.
The facility failed to maintain a log for the temperatures of beverages on the snack cart, as observed during an interview with the Dietary Director. Although the temperatures were checked and found to be 142 degrees Fahrenheit, no log was kept, violating the facility's policy that mandates recording food temperatures to ensure safety.
A resident with severe impaired cognition and multiple health issues suffered burns from spilled hot chocolate. The treatment nurse failed to obtain a timely consult for a wound care specialist, delaying the evaluation and placing the resident at risk for worsening wounds.
A resident with a history of falls and various medical conditions did not have an updated, person-centered care plan addressing their fall risk. The care plan was not revised timely, leading to a fall and injuries. Staff interviews and record reviews revealed discrepancies in the resident's fall history and risk assessments.
The facility failed to evaluate hazards and risks for a resident with multiple falls and did not monitor the effectiveness of interventions for a non-compliant resident. Another resident with severely impaired vision did not receive an accurate Fall Risk Assessment or individualized interventions, leading to falls and injuries.
Failure to Develop and Update Comprehensive Care Plan for UTI After Hospital Readmission
Penalty
Summary
The deficiency involves the facility’s failure to develop and update a comprehensive care plan (CP) for a resident’s urinary tract infection (UTI) following readmission from the hospital. The resident was initially admitted with metabolic encephalopathy and later readmitted with a diagnosis of UTI. A Minimum Data Set (MDS) dated 10/25/2025 documented that the resident had moderate to severe cognitive impairment, was independent with several ADLs such as eating and bed mobility, but required maximal assistance for toileting and showering, partial assistance for dressing and transfers, and was frequently incontinent. The Medication Administration Record dated 1/8/2026 showed the resident was receiving Ciprofloxacin 500 mg by mouth in the morning for seven days for treatment of the UTI. Record review revealed no care plan problem, goals, or interventions addressing the UTI, including no documented monitoring parameters, comfort measures, or physician notification requirements related to this condition. The MDS nurse reported that the resident’s CP had not been updated since 10/16/2025 and acknowledged that it should be updated quarterly and upon each admission or readmission, but stated she intended to update the CP upon the resident’s next admission due to frequent hospitalizations. The DON confirmed that there was no CP addressing the UTI after the resident’s return from the hospital and stated that a comprehensive care plan should have been initiated for the UTI diagnosis with appropriate interventions and goals. Review of the facility’s policy on Comprehensive Care Plans – Timing, dated 1/2025, indicated that the interdisciplinary team is responsible for reviewing and revising the comprehensive care plan after each assessment and completing it within seven days and no more than 21 days after admission, which was not followed in this case.
Failure to Ensure Call Light Accessibility for Dependent Resident
Penalty
Summary
A deficiency occurred when staff failed to ensure that a resident with significant physical limitations had access to their call light. The resident, who had hemiplegia and hemiparesis following a stroke affecting the left side, as well as other medical conditions such as diabetes, hypertension, and atrial fibrillation, was dependent on staff for activities of daily living. The resident's care plan specifically required that the call light be within reach and that the resident be encouraged to use it for assistance as needed. During two separate observations, the call light was found out of the resident's reach: once on the floor behind the head of the bed and again attached to the fitted sheet on the resident's left side, which the resident could not access. The resident confirmed that she would use the call light if she could find it. A CNA verified the call light was not within reach and repositioned it appropriately. Facility policies reviewed indicated that residents should have access to the call light when in bed or seated, and interventions should be consistent with the resident's needs and care plan.
Failure to Provide Ordered Oxygen Therapy After Personal Care
Penalty
Summary
A resident with diagnoses including dementia, fibromyalgia, hypertension, and muscle weakness, who was completely dependent on staff for personal care and had severely impaired cognition, was admitted with an order for routine oxygen therapy via nasal cannula at 2-4 liters per minute. During personal hygiene care, a Certified Nursing Assistant (CNA) removed the resident's oxygen tubing to prevent it from pulling while repositioning the resident and subsequently forgot to replace it. The resident was left without the ordered oxygen therapy following this care. Later, a Licensed Vocational Nurse (LVN) was informed that the resident's oxygen tubing was off. Upon assessment, the resident was not in visible distress or short of breath, but their oxygen saturation was found to be 77%, significantly below the normal range of 95%-100%. The LVN immediately reapplied the oxygen, resulting in the resident's oxygen saturation rising to 95%. The facility's policy required oxygen therapy to be administered via nasal cannula, but this was not followed during the incident.
Inaccurate Documentation of Resident Diagnosis in Medical Records
Penalty
Summary
The facility failed to ensure that medical records were accurately documented and complete for one of three sampled residents. Specifically, a resident was admitted with a history of dementia and a past episode of depression, but the face sheet incorrectly listed major depressive disorder as a current diagnosis. Review of the psychiatrist's progress notes and the history and physical indicated that the resident did not have an active diagnosis of depression and was not prescribed psychiatric medication at the time. The Minimum Data Set (MDS) assessment also did not indicate an active diagnosis of major depressive disorder. Interviews with the DON and review of documentation revealed that the depression diagnosis was historical and not current, and the listing of 'recurrent depression' was identified as a typographical error. The DON clarified that the resident only had a history of depression and was not currently exhibiting symptoms or receiving treatment for depression. The facility's documentation policy required relevant findings to be accurately recorded in the clinical record, but this was not followed in this instance, resulting in incomplete and inaccurate medical records for the resident.
Failure to Prevent Significant Medication Errors Due to Delayed and Improper Administration
Penalty
Summary
The facility failed to ensure that multiple residents were free from significant medication errors, as evidenced by the late administration and improper timing of critical medications for 11 out of 20 sampled residents. Several residents did not receive their prescribed medications, such as anticoagulants (Eliquis/apixaban), antihypertensives (Norvasc/amlodipine), aspirin, and antiepileptics (Depakote/valproic acid, Keppra/levetiracetam), in accordance with physician orders and facility policy. In many cases, medications were administered hours after the scheduled time, and in some instances, doses were given too close together, not maintaining the required interval between administrations. For example, one resident received apixaban and other medications up to six hours late, and subsequent doses were administered less than the ordered 12 hours apart. Another resident received Depakote doses within 39 minutes to less than two hours of the next scheduled dose, rather than at the prescribed intervals. The report details that the medication errors were not isolated incidents but occurred repeatedly over several days, affecting residents with complex medical histories, including those with atrial fibrillation, hypertension, diabetes, seizure disorders, and a history of stroke. Residents with cognitive impairments and those dependent on staff for medication administration were particularly affected. Staff interviews revealed that nurses were unable to administer medications on time due to heavy workloads, with some nurses responsible for up to 32 residents and multiple residents requiring time-intensive administration methods, such as gastrostomy tubes. Nurses reported that they often finished morning medication passes hours after the scheduled times and did not always notify physicians when medications were administered outside the prescribed window. The facility's own policies required medications to be administered within 60 minutes of the scheduled time, and for physicians to be notified if this could not be achieved. However, documentation showed that these protocols were not followed, and there was no evidence that physicians were contacted prior to late administration. The facility's pharmacist consultant had previously recommended additional support to prevent late medication passes, but this was not implemented prior to the survey. The cumulative effect of these actions and inactions resulted in significant medication errors for multiple residents, as confirmed by observation, interview, and record review.
Removal Plan
- The Licensed Nurse completed change in condition assessments and reported the medication errors for each resident affected with the related medications.
- The residents would be monitored every shift for adverse reactions.
- Affected residents were monitored by the DON.
- Licensed Nurses would be re-educated by the DON on the standard of practice and facility policy and procedure for administering medications and in accordance with the physician's ordered time to reduce the risk of medication error, serious injury, harm and or death.
- The DON evaluated the resident medication administration assignments, including evaluation of residents on antiseizure, anticoagulants, hypertensive and anticonvulsant medications, including gastrostomy tubes, dialysis, blood pressure parameter checks, diabetics with insulin administration, controlled pain medications and seizure protocol.
- The DON contacted the pharmacy consultant and requested an additional medication cart, which was verified. The cart would be delivered.
- The DON redistributed the resident assignment to ensure the load over four medication carts.
- The Interdisciplinary Team met and developed and implemented a plan of care to closely monitor affected residents for adverse effects related to receiving medications at the wrong time resulting in a medication error.
- The Medical Records staff generated an audit of all in house residents medication administration records including the time of administration for all shifts, identifying any residents who were affected by the medication error. A copy of the audit was provided to the DON for review.
- All licensed nurses in the oncoming shifts were prioritized with re-education with the objective to achieve 100% of the licensed nurses before the start of their shift.
- The Director of Staff Development / designee would complete a medication pass observation skill competency with LVN 1 and 2 prior to the start of their shift.
Failure to Revise and Update Resident Care Plans as Required
Penalty
Summary
The facility failed to revise and update care plans for three residents as required by both facility policy and regulatory standards. For one resident with a history of cognitive impairment and wandering, the elopement/wandering care plan was not updated quarterly, despite changes in the resident's wandering behavior as documented in assessments. The care plan continued to include interventions such as a Wander guard device and redirection, but was not revised to reflect the most current assessments, which indicated a change in the resident's wandering status. Another resident with diagnoses including congestive heart failure and chronic kidney disease had an activities care plan that was not updated to reflect current activity preferences. Although assessments indicated the resident participated in a sensory stimulation program, enjoyed wearing headphones, and refused group activities, the care plan did not include these updated preferences or interventions. The Activities Director confirmed that the care plan should have been revised to reflect the resident's current interests and participation. A third resident with paraplegia and a pressure ulcer on the ischium had a pressure ulcer care plan that had not been revised since its initial creation, despite ongoing wound care and changes in the resident's condition. Both the Treatment Nurse and the MDS Nurse confirmed that the care plan was not updated quarterly as required, and that without revision, staff would not know if the interventions were effective. The Director of Nursing also acknowledged that care plans were not being assessed or updated as needed, and that interventions were not revised to reflect the resident's current needs.
Failure to Provide Timely and Proper Medication Administration
Penalty
Summary
Three residents did not receive care and services in accordance with professional standards of practice. One resident with Type II diabetes and morbid obesity received insulin injections without proper rotation of administration sites, as confirmed by review of the Medication Administration Record (MAR) and interviews with nursing staff. The facility's policy required rotation of injection sites to reduce the risk of skin tissue damage, but this was not followed on specific dates, as insulin was repeatedly administered in the same locations. Two other residents did not receive their prescribed medications in a timely manner. One resident with multiple diagnoses, including breast cancer, rheumatoid arthritis, asthma, and a history of stroke, reported not receiving morning medications at the scheduled time. The MAR confirmed that medications due at 9 AM were administered more than two hours late. Staff interviews acknowledged the delay and the lack of documentation or notification to the physician regarding the late administration, despite facility policy requiring timely administration and physician notification for missed or late doses. Another resident with diabetes, atrial fibrillation, and Alzheimer's disease experienced significant delays in receiving oral diabetic medications. The MAR showed that morning doses were administered six hours late, and subsequent doses were given too close together without physician orders to reschedule. Blood sugar monitoring was not performed as indicated in the care plan, and there was no documentation of physician notification regarding the late or closely timed medication administration. Facility policies required medications to be given within a specific time frame and blood glucose monitoring for diabetic residents, but these were not followed.
Widespread Food Safety and Sanitation Failures in Kitchen Operations
Penalty
Summary
The facility failed to maintain safe and sanitary food storage and preparation practices in the kitchen, as evidenced by multiple observations of unclean equipment and areas. Surveyors observed dust and food debris buildup on refrigerator and freezer vents and shelves, as well as in the dry storage area and walk-in refrigerator. Kitchen equipment and utensils, such as freezer gaskets, refrigerator racks, resident trays, and scoop drawers, were found to be damaged, rusted, cracked, or chipped, making them difficult to clean and potentially leading to contamination. Dented cans were stored alongside non-dented cans, contrary to facility policy and food safety standards. Staff did not consistently follow proper procedures to prevent cross-contamination during food preparation. The same whisk was used for multiple pureed foods without proper washing and sanitizing between uses, and the same chopping board and knife were used for both cooked chicken and vegetables without cleaning in between. Staff also failed to perform appropriate hand hygiene, such as washing hands after touching watches during food handling and after handling soiled dishes before touching clean ones. Additionally, staff were observed wearing jewelry, specifically wristwatches, while preparing and serving food, which is not permitted by food safety regulations. Other deficiencies included failure to properly monitor the cooling of potentially hazardous foods, as required by facility policy and food code, with missing temperature and time entries for cooked turkey sausage and breaded chicken. Pots and pans were stacked while still wet, rather than being air-dried as required. Staff did not accurately check the concentration of the quaternary ammonium compound (QUAT) sanitizer, as they did not follow the manufacturer's instructions for test strip use, potentially resulting in improper sanitization of kitchenware. These actions and inactions were confirmed through staff interviews and review of facility policies and relevant food safety codes.
Failure to Document and Investigate Resident's Missing Property
Penalty
Summary
The facility failed to document and investigate a resident's grievance regarding missing personal items, including a pair of shorts, a gown, and a left leg brace. The resident, who was alert, oriented, and had diagnoses of severe obesity, hemiplegia, and gout, reported the missing items to the Social Services Assistant (SSA) but no formal documentation or investigation was initiated. The resident stated that the shorts went missing shortly after admission and the brace disappeared following a hospital stay, with both items not being found or recorded in the Theft and Loss Report Log. Interviews with facility staff revealed a lack of communication and adherence to established procedures for handling missing resident property. The Social Services Director (SSD) was unaware of the missing items and confirmed that there was no documentation of the loss, despite the facility's policy requiring such incidents to be logged and investigated. The SSA acknowledged being informed by the resident about the missing items and stated she searched the resident's closet but did not document the loss or escalate the issue as required by facility policy. Further review of the resident's records showed a prescription for a PRAFO boot, which was also reported missing after the resident's return from the hospital. The facility's policy mandates that missing items be described, valued, and actions taken be documented, but this process was not followed in this case. The lack of documentation and investigation resulted in the resident's grievance being dismissed and the missing items not being addressed in a timely manner.
Failure to Develop Care Plan for Insulin Refusal
Penalty
Summary
The facility failed to develop an individualized, person-centered care plan addressing a resident's repeated refusal of prescribed insulin. The resident, who was admitted with diagnoses including Type II diabetes and morbid obesity, had physician orders for Lispro Insulin to be administered per sliding scale before meals and at bedtime. Despite the resident's moderate cognitive impairment and a documented history of refusing insulin—66 refusals in one month and 41 refusals in the following month—there was no care plan created to address this pattern of refusal. The care plan did not include goals or interventions related to the resident's non-compliance with insulin therapy. Interviews with facility staff, including a registered nurse and the Director of Nursing, confirmed that a care plan should have been developed for the resident's refusal of insulin, as per facility policy. The facility's policies require that care plans be person-centered, comprehensive, and address situations where a resident declines care or treatment, including identifying the risk and documenting efforts to educate the resident and seek alternative interventions. The absence of such a care plan was acknowledged by staff and was not in accordance with the facility's established procedures.
Failure to Maintain Clean Oxygen Tubing for Resident
Penalty
Summary
Facility staff failed to provide necessary respiratory care services for a resident by not ensuring that the resident's oxygen nasal cannula tubing was kept off the floor while in use. The resident, who had a history of chronic obstructive pulmonary disease (COPD), acute and chronic respiratory failure with hypoxia and hypercapnia, and anemia, was observed sleeping in bed with the oxygen nasal cannula tubing resting on the floor. The care plan for this resident specifically indicated that staff should prevent the oxygen nasal cannula from touching the floor and should store it properly when not in use. However, during observation, the tubing was found on the floor and described as dirty by a Certified Nurse Assistant (CNA), who acknowledged the need to replace it with a clean one. Interviews with facility staff, including a Licensed Vocational Nurse (LVN) and the Director of Nursing (DON), confirmed that oxygen tubing left on the floor should be considered contaminated and must be exchanged for a new, dated one to prevent infection. The facility's policy and procedures for oxygen therapy also required changing visibly soiled oxygen tubing. Despite these protocols, the staff did not ensure the tubing was kept clean and off the floor, resulting in a failure to provide safe and appropriate respiratory care as required.
Failure to Reassess and Manage Resident Pain After Medication Administration
Penalty
Summary
The facility failed to provide safe and appropriate pain management for a resident with chronic pain conditions, including fibromyalgia, arthritis, and migraines. The resident's care plan required staff to administer analgesics as ordered, anticipate pain needs, respond immediately to complaints of pain, and evaluate the effectiveness of pain interventions every shift. Despite these interventions, documentation and interviews revealed that staff did not consistently reassess the resident's pain after administering pain medication, nor did they document or address episodes of uncontrolled pain. On one occasion, the resident reported a pain level of 10 after receiving Norco in the early morning, but there was no timely follow-up to assess the effectiveness of the medication. The Medication Administration Record (MAR) showed that the resident received various pain medications and non-pharmacological interventions, but not all prescribed interventions were provided, and there was a lack of documentation regarding the resident's ongoing pain and communication with the physician. Staff interviews confirmed uncertainty about the facility's policy for reassessing pain after medication administration, and there were discrepancies in pain assessments documented by different nurses. The facility's only pain management policy addressed general pain assessment but did not specify the required timeframe for reassessment after administering oral pain medication. The Director of Nursing acknowledged that the policy was inadequate for guiding staff on timely pain reassessment and that staff did not follow the standard of care for evaluating pain relief within an hour of medication administration. As a result, the resident experienced episodes of uncontrolled pain without appropriate follow-up or intervention.
Medication Error Rate Exceeds Acceptable Threshold Due to Delayed and Incomplete Administration
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, as required, resulting in a 20% error rate during a medication pass for one resident. During observation, six medication errors were identified out of 30 opportunities while a licensed vocational nurse was administering morning medications. The nurse prepared and attempted to administer seven medications, including both scheduled and as-needed drugs, but the resident refused two of them. The nurse did not notify the physician about the late administration of medications, which was outside the facility's policy of administering medications within one hour of the scheduled time. The resident involved had a complex medical history, including hemiplegia and hemiparesis following a stroke, hypertension, cardiomegaly, atrial fibrillation, and major depressive disorder. The resident required significant assistance with daily activities and had care plans in place for multiple conditions, including hypertension, anticoagulant therapy, and depression. The care plans specified that medications should be administered as ordered and at consistent times, with monitoring for side effects and interactions. Interviews with nursing staff revealed that heavy workloads and the need to administer medications to residents with gastrostomy tubes contributed to delays in medication administration. Both the nurse and the DON acknowledged that medications were not given within the required time frame and that the physician was not contacted as required by facility policy. The facility's policy and procedure on medication administration emphasized the need for sufficient staffing and timely administration of medications according to prescriber orders.
Failure to Ensure Food Safety Competency Among Kitchen Staff
Penalty
Summary
The facility failed to ensure that kitchen staff were routinely trained and evaluated for competency in critical food safety procedures. During observations and interviews, staff were unable to accurately verbalize or demonstrate the correct process for cooling cooked foods, such as turkey sausage and breaded chicken. Review of the Cooling Monitoring Form revealed missing entries for time and temperature monitoring of these foods, and staff provided inconsistent and incorrect information regarding required cooling times and temperatures. The Dietary Supervisor confirmed that proper cooling procedures were not followed or documented, which is necessary to prevent bacterial growth in food. Additionally, staff demonstrated a lack of understanding and inconsistent practices regarding the use and testing of quaternary ammonium compound (QUAT) sanitizer solutions used for dishwashing. During demonstrations, a dietary aide and the Dietary Supervisor used different methods and times for testing the sanitizer concentration, and both provided incorrect information about acceptable concentration ranges. Review of manufacturer guidelines and facility policies indicated that the correct procedure was not being followed, and staff competency checklists showed areas needing improvement in these critical tasks. These failures were observed in the context of providing food and ice to 90 of 92 medically compromised residents. The facility's own policies, job descriptions, and competency checklists outlined the required procedures for food cooling and sanitizer testing, but staff were not consistently trained or evaluated to ensure compliance. The lack of proper training and competency assessment in these areas had the potential to result in harmful bacterial growth and cross-contamination.
Failure to Prepare Pureed Foods to Required Consistency for Residents on Puree Diet
Penalty
Summary
The facility failed to prepare and serve pureed foods in a form designed to meet the individual needs of residents on a puree diet. During food preparation, a staff member was observed adding thickener to pureed foods without measuring, and stated there was no guideline for the appearance or amount of thickener to use. This resulted in pureed yellow zucchini that did not hold its shape and pureed Spanish rice that contained chunks of rice, both of which were not consistent with the required smooth, pudding-like texture for pureed diets. The Dietary Supervisor confirmed that the pureed yellow zucchini was too flat and did not hold its shape, and that the pureed Spanish rice contained rice particles, which should not occur. The supervisor acknowledged that standardized recipes and portion sizes, including the amount of thickener, were available and should be followed to achieve the correct consistency. The Registered Dietitian also stated that the facility was using the outdated National Dysphagia Diet guidelines instead of the more current IDDSI standards, and confirmed that pureed foods should be smooth, homogenous, and free of lumps or particles. A review of facility policies, procedures, and recipes indicated that standardized recipes with specific instructions for consistency and thickener amounts were available and required for use. The diet manual and recipes specified that pureed foods must be smooth, moist, and free of chunks or particles. Despite these guidelines, the observed practices did not align with the facility's own standards, resulting in pureed foods that did not meet the required consistency for residents with dysphagia or chewing difficulties.
Improper Disposal and Overflowing of Garbage Dumpsters
Penalty
Summary
The facility failed to properly dispose of garbage and refuse as evidenced by observations of three dumpsters that were not completely closed or covered when not actively in use. On multiple occasions, surveyors observed that two to three dumpsters were overflowing with trash and not fully covered, with one dumpster having a broken cover resulting in an uncovered gap, and another overflowing due to unbroken-down boxes. These conditions were confirmed during interviews with the Dietary Supervisor and Maintenance Director, who acknowledged that the dumpsters should be closed and not overfilled to prevent pest attraction and infection risks. A review of the facility's policies and procedures indicated that garbage and refuse containers are to be maintained in good condition, properly contained, and covered to prevent pest harborage. Additionally, the Food Code 2022 requires outside receptacles to have tight-fitting lids or covers to prevent the attraction and breeding of pests and to maintain sanitary conditions. The facility's failure to adhere to these standards was observed to have the potential to affect 90 of 92 residents.
Failure to Document TB Screening and Clearance for Staff
Penalty
Summary
The facility failed to ensure that two of nine sampled employees, a Licensed Vocational Nurse and a Restorative Nurse Assistant, had documented evidence of tuberculosis (TB) screening and clearance as required by the facility's policy. Review of their employee files showed that both had completed the facility's TB symptom screening questionnaires, but there was no documentation of a PPD skin test or chest x-ray, nor any indication of previous positive TB tests. This lack of documentation meant there was no proof that these employees were negative for or free of TB symptoms. Interviews with facility leadership, including a Registered Nurse Consultant, the Administrator, and the Director of Nursing, confirmed that employees should not be allowed to work without proof of TB screening and clearance. The facility's policy required annual TB screening for healthcare workers, with a skin test or IGRA unless previously positive, in which case a questionnaire and chest x-ray if symptomatic were required. The absence of required documentation for these two employees constituted a failure to follow established infection prevention and control protocols.
Failure to Maintain Functioning Call Light System in Resident Bathroom
Penalty
Summary
A deficiency was identified when a resident with Parkinson's disease, schizophrenia, muscle weakness, and mobility abnormalities was found to have a non-functioning call light in their bathroom and bathing area. The resident, who had moderate cognitive impairment and required assistance with toileting, personal hygiene, and bathing, attempted to use the call light, but there was no visual or audible signal to alert staff. A certified nursing assistant confirmed the call light was not working during the observation. The resident's care plan included interventions to keep the call light within reach and encourage its use for assistance. However, the maintenance director stated that although call lights were supposed to be checked monthly and as needed, he was unaware of the malfunction and there was no log documenting when the last check occurred. Facility policy required routine audits and maintenance of the call system, but this was not followed, resulting in the deficiency.
Resident Room Size Below Regulatory Requirements
Penalty
Summary
The facility failed to ensure that 17 out of 38 resident rooms met the required minimum square footage per resident, as specified by regulations. Multiple rooms designed for more than one resident did not provide at least 80 square feet of useable living space per resident, and single rooms did not provide at least 100 square feet. This was confirmed through observation, interviews, and a review of the Client Accommodations Analysis, which detailed the square footage and number of beds in each room. The analysis showed that several rooms, including those with three or more beds, were below the required space per resident. A review of the facility's Room Variance Waiver indicated that some rooms had been approved for a waiver due to their size, but these rooms still did not meet the standard requirements. During the survey, staff and residents reported that rooms were clean, free from clutter, and allowed for free movement, with no obstructions noted during care delivery. However, the documented measurements confirmed the deficiency in room size. The facility's policy and procedure stated that rooms should meet the minimum square footage requirements, but the actual room sizes in the affected rooms did not comply with these standards.
Inaccurate Pressure Ulcer Assessment in Resident
Penalty
Summary
The facility failed to accurately assess the risk and condition of a pressure ulcer for a resident, leading to inaccurate documentation and potential adverse effects on treatment. The resident, who was admitted with multiple diagnoses including COPD, muscle weakness, and major depressive disorder, was identified as being at risk for pressure ulcers. Despite this, the facility's assessments were inconsistent and did not accurately reflect the resident's condition. During observations, it was noted that the resident had a red area on the left lateral heel, which was initially assessed as blanchable by a treatment nurse. However, a subsequent wound assessment inaccurately documented the area as non-blanchable, indicating a possible deep tissue injury. This discrepancy in assessment could have significant implications for the resident's care and treatment. The facility's policy on pressure ulcer prevention emphasizes the importance of accurate risk identification and individualized interventions. However, the resident's Braden Scale assessments were inconsistent, with inaccuracies in sensory perception, moisture, and mobility ratings. These inaccuracies resulted in the resident being assessed as moderate risk rather than high risk, potentially affecting the interventions implemented to prevent pressure ulcers.
Failure to Prevent Pressure Ulcer in Resident
Penalty
Summary
The facility failed to implement measures to prevent pressure ulcers for a resident, leading to the development of a non-blanchable redness on the resident's left lateral heel, indicating a possible deep tissue injury. The resident was admitted with multiple diagnoses, including chronic obstructive pulmonary disease, muscle weakness, and major depressive disorder, and was identified as being at risk for pressure ulcers due to immobility, incontinence, and other health conditions. The care plan included interventions such as encouraging frequent repositioning and floating the heels in bed, but these measures were not consistently followed. During an observation, a Certified Nursing Assistant (CNA) noted a red area on the resident's heel, which was confirmed by the Treatment Nurse (TXN) and the Director of Nursing (DON). The DON identified the area as non-blanchable, indicating an injury that required offloading the heels and notifying the doctor. The facility's policy on pressure ulcer prevention emphasized the importance of redistributing pressure and protecting the skin, but these guidelines were not adequately implemented for the resident. The failure to adhere to the care plan and facility policies resulted in the resident developing a pressure ulcer. The resident's care plan specifically called for interventions to prevent such injuries, but observations revealed that the resident's left leg and heel were not properly supported, contributing to the development of the ulcer. This deficiency highlights a lapse in the facility's adherence to established protocols for pressure ulcer prevention.
Failure to Change IV Site Within Recommended Timeframe
Penalty
Summary
The facility failed to adhere to its policy and procedures for intravenous (IV) catheter care by not changing the IV site within the recommended 72 to 96-hour window for a resident. This oversight was identified during an observation and interview with the resident, who had an IV line on the left hand with a dressing dated 9/27/24, despite the last administration of IV medication being on 10/3/24. The Director of Nursing confirmed that the IV site had not been changed within the required timeframe, acknowledging the risk for infection. The resident involved had multiple diagnoses, including a urinary tract infection, diabetes mellitus, chronic obstructive pulmonary disease, quadriplegia, and muscle weakness, and required substantial assistance for daily activities. The facility's policy, aligned with CDC guidelines, mandates that peripheral IV sites be changed every 72 to 96 hours to prevent catheter-related infections. However, the facility did not follow these guidelines, as evidenced by the unchanged IV site, which posed a potential risk for infection.
Inadequate Oxygen Therapy for Resident in Distress
Penalty
Summary
The facility failed to provide appropriate respiratory care for a resident who was experiencing a decrease in blood oxygen levels and difficulty breathing. The resident, who had a history of hemiplegia, hemiparesis, hypertension, diabetes mellitus, and pneumonia, was found to be desaturating with a blood oxygen saturation level of 78%. Despite the critical condition, the resident was administered oxygen via a simple mask, which delivers 40 to 60% oxygen, instead of a non-rebreather mask that delivers 100% oxygen, which is more appropriate for emergency situations. The deficiency was identified during a review of the resident's change of condition note, which lacked clarity on whether the correct oxygen delivery device was used. The Director of Nursing confirmed that the documentation did not specify the type of mask used, raising concerns about the adequacy of the treatment provided. The facility's policy on oxygen therapy was reviewed, which outlined the use of an oxygen mask but did not ensure the correct type of mask was used in this instance.
Failure to Protect Resident from Abuse
Penalty
Summary
The facility failed to protect a resident's right to be free from abuse, specifically involving two residents with complex mental health diagnoses. One resident, diagnosed with mood affective disorder and unspecified psychosis, was not adequately assessed or monitored, leading to an incident where another resident, who also had mood affective disorder and unspecified psychosis, became verbally and physically aggressive. The facility did not conduct a comprehensive assessment of the aggressive resident's cognitive patterns, mood, behaviors, and active diagnoses, nor did they review and reassess the care plan interventions as required by their policies. The aggressive resident had a history of verbal aggression and had been transferred to a General Acute Care Hospital for evaluation due to similar behaviors. Despite this history, the facility did not develop a comprehensive person-centered care plan for the resident's psychosis, nor did they provide adequate supervision or monitoring as outlined in their policies. This lack of action resulted in an incident where the aggressive resident threw a cup of juice at the other resident, causing fear and a sense of being unprotected. Interviews with staff and a review of the facility's policies revealed that the facility did not take reasonable precautions to prevent resident-to-resident altercations. The facility's policies required regular reassessment of interventions and adequate supervision for residents at risk of abusive behavior, which were not followed. Additionally, the facility's MDS assessments were incomplete, failing to capture the aggressive resident's cognitive skills and active diagnoses, further contributing to the deficiency.
Failure to Develop Comprehensive Care Plan for Resident with Psychosis
Penalty
Summary
The facility failed to develop a comprehensive person-centered care plan for a resident diagnosed with psychosis, which is characterized by a disconnection from reality. The resident, who was admitted with multiple diagnoses including unspecified psychosis, had a psychology assessment indicating a need for emotional processing to achieve calmness. Despite this, the psychiatric intake note revealed the resident's refusal to continue medication and participation in interviews, showing signs of irritability and agitation. The Minimum Data Set (MDS) assessment did not document any symptoms of hallucinations or delusions, and the section for behavior was left incomplete. An incident occurred where the resident exhibited aggressive behavior by throwing objects at another resident and a Licensed Vocational Nurse (LVN). The Director of Nursing (DON) acknowledged the resident's refusal of medication and uncooperative behavior but did not see the need for a psychosis care plan due to the absence of psychotic behaviors. However, the MDS Coordinator emphasized the importance of such a care plan to establish a baseline, prevent decline, and improve behavioral and psychosocial outcomes. The facility's policy mandates the development of person-centered care plans that address medical, physical, mental, and psychosocial needs, which was not adhered to in this case.
Failure to Protect Resident from Physical Abuse
Penalty
Summary
The facility failed to protect Resident 5 from physical abuse when Resident 4 slapped Resident 5 with an open hand on the right side of her face. This incident occurred on 4/16/2024 and was witnessed by CNA 3, who heard a slap followed by Resident 5 crying loudly. Upon assessment, Resident 5's right cheek was noted to be red. Resident 5, who has severe cognitive impairments and multiple diagnoses including cerebral infarction, Down syndrome, and Alzheimer's Disease, required maximal assistance with daily activities and was feeling down, depressed, or hopeless according to her MDS dated 3/12/2024. Resident 4, who has intact cognitive skills and no prior behavioral issues, denied the incident but was educated that physical abuse is unacceptable in the facility. Following the incident, Resident 5 received cold packs and Tylenol for pain management. The facility's Director of Nursing confirmed that physical abuse had occurred and acknowledged that it should not have happened according to the facility's abuse policy and regulations. The facility's current policy, titled 'Abuse Prohibition and Prevention Program,' aims to provide an environment that prohibits and prevents abuse, but this policy was not effectively implemented in this case.
Failure to Maintain Temperature Logs for Snack Cart Beverages
Penalty
Summary
The facility failed to ensure proper food handling practices by not maintaining a log for the temperatures of beverages on the snack cart. During an observation and interview with the Dietary Director (DD), it was noted that two thermoses of hot drinks intended for snack time in the activities room were checked for temperature, which was recorded as 142 degrees Fahrenheit. However, the DD admitted that there was no log maintained for these temperature checks. The facility's policy, revised on 9/1/21, mandates that food temperatures be recorded to ensure safety, with acceptable serving temperatures for coffee being above 140 degrees Fahrenheit. This lapse in documentation could potentially compromise food quality and safety, leading to foodborne illnesses.
Failure to Obtain Timely Wound Care Specialist Consult
Penalty
Summary
The facility failed to ensure that a consult for a wound care specialist was ordered for one of the residents. The resident, who had severe impaired cognition and required substantial assistance for daily activities, accidentally spilled hot chocolate on their abdomen and inner thighs, resulting in redness and blisters. Although a topical burn treatment gel was ordered, the treatment nurse failed to obtain an order for a wound care specialist consult, which delayed the specialist's evaluation of the resident's wounds. During an interview and record review with the Director of Nursing (DON), it was revealed that the treatment nurse, who is no longer employed at the facility, did not secure the necessary order for the wound care specialist. As a result, the resident was not seen by the specialist until a week later than they should have been. This delay placed the resident at risk for worsening wounds.
Failure to Update Fall Risk Care Plan
Penalty
Summary
The facility failed to ensure a comprehensive, person-centered care plan for a resident who was at high risk for falls. The resident, who had a history of falls and various medical conditions including generalized anxiety disorder, major depressive disorder, and muscle weakness, did not have an updated and specific care plan addressing their fall risk. The care plan was not revised or updated in a timely manner, leading to an increased risk of falls for the resident. This deficiency was highlighted when the resident fell and sustained injuries, including a displaced fracture of the clavicle and a laceration to the forehead, after being found in another resident's room. The resident's care plan initially included interventions such as educating the resident, family, and caregivers about safety reminders, but it was not person-centered as the resident did not have family involved in their care. Additionally, the care plan was not updated to reflect the resident's current condition and needs, as evidenced by discrepancies in the resident's fall history and risk assessments. The facility's policy required care plans to be person-centered and updated within a specific timeframe, which was not adhered to in this case. Interviews with staff members, including CNAs and the RN Supervisor, revealed that the resident was known to be at high risk for falls but did not have a history of falls according to some staff members. The MDS Coordinator and DON acknowledged that the care plan was not person-centered and was not updated in a timely manner. The facility's policies on screening and care plan development emphasized the need for comprehensive and individualized care plans, which were not followed in this instance.
Failure to Prevent Falls and Implement Effective Interventions
Penalty
Summary
The facility failed to evaluate and analyze hazards and risks for Resident 1, who had multiple falls, and did not monitor the effectiveness of interventions for a non-compliant resident. Despite being educated to call for assistance, Resident 1 continued to perform activities beyond his ability, leading to several falls. On one occasion, Resident 1 fell from his wheelchair while attempting to transfer himself to his bed, resulting in a right ankle fracture. The facility did not develop care plans addressing Resident 1's non-compliance with care and calling for assistance, and there was no documentation that Resident 1's family was informed about his non-compliance. For Resident 2, who had severely impaired vision, the facility failed to complete an accurate Fall Risk Assessment and did not implement individualized, resident-centered interventions to reduce the risk of falls. Resident 2 had a history of falls and was legally blind, yet the fall risk assessments were completed inaccurately, and appropriate interventions were not implemented. As a result, Resident 2 fell from her bed, sustaining multiple rib fractures. The facility did not revise Resident 2's care plan quarterly or when there was a change in condition, and the necessary person-centered interventions for a blind resident were not included. Interviews with staff revealed that both residents were non-compliant with calling for assistance and wanted to be independent beyond their abilities. The facility's policies and procedures for post-fall evaluation and fall management were not followed, leading to inadequate supervision and failure to implement effective interventions. The deficiencies in care planning, risk assessment, and monitoring contributed to the falls and injuries sustained by both residents.
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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