Whittier Hills Health Care Ctr
Inspection history, citations, penalties and survey trends for this long-term care facility in Whittier, California.
- Location
- 10426 Bogardus Ave, Whittier, California 90603
- CMS Provider Number
- 055430
- Inspections on file
- 41
- Latest survey
- March 26, 2026
- Citations (last 12 mo.)
- 34
Citation history
Health deficiencies cited at Whittier Hills Health Care Ctr during CMS and state inspections, most recent first.
A resident with Type 2 DM and dementia and the resident’s responsible party requested access to the resident’s medical records during an IDT care plan meeting attended by the SSA, RN, rehab staff, and AD. The SSA verbally agreed to obtain the records but did not document the request, did not complete the process, and did not inform the MRD. In the following weeks, the responsible party repeatedly called the facility, but the receptionist reported the SSA was unavailable and did not connect the caller with other staff. When eventually reached, the MRD stated she had not been informed of the earlier request and explained that a request form was required. The facility’s policy allowed resident access to records within 24 hours of a written or oral request, but this was not followed or explained.
A resident with obesity, multiple comorbidities, impaired mobility, and documented fall risk had a physician’s order and care plan interventions for a bariatric bed with bilateral 1/2 side rails to assist with turning and safety. On readmission, the resident was placed in a regular bed without side rails, despite the bariatric bed being available and previously used, and despite facility policies requiring initiation of physician orders and maintenance of a safe environment. Nursing notes recorded that the resident initially refused the bariatric bed, but later told an LVN that she needed a bigger bed; the LVN did not switch the bed, and the resident remained in the regular bed, which staff stated she barely fit into. During the night, the roommate found the resident on the floor between the beds, unresponsive, and staff initiated emergency protocols; the resident was later pronounced deceased, with the medical examiner listing natural causes related to CHF and obesity.
A resident with multiple medical conditions had physician orders for routine nebulized Ipratropium/Albuterol and subcutaneous Heparin for DVT prophylaxis, but the facility failed to obtain and administer these medications from the resident’s own supply or the Cubex system as ordered. One LVN reported bypassing the Cubex process and using a Heparin vial belonging to another resident without documenting this, while another LVN acknowledged that Albuterol was charted as given on the MAR even though he did not recall administering it and may have clicked "yes" in error. Pharmacy and Cubex records showed no transactions for the resident and documented that the ordered medications were delivered and then returned, demonstrating failures in following the facility’s Six Rights of Medication Administration, including right resident, right medication, and right documentation.
Two residents did not have their care plans updated after an incident where one experienced fear and pain following an interaction with a roommate who had acute neurological symptoms. Despite documented distress, pain, and safety concerns, as well as new medical symptoms, the facility did not revise the care plans to address these events or the residents' needs.
Two residents with significant risk factors for pressure ulcers did not receive care in accordance with physician orders and care plans, including failure to limit sitting time, improper use of pressure-relieving devices, and incorrect settings on low air loss mattresses. Staff did not consistently document or perform required turning and repositioning, and mattress settings were not adjusted to match residents' weights, as confirmed by staff interviews and observations.
A resident with severe dementia and high assistance needs was mistakenly sent alone to a medical appointment intended for another resident, due to staff confusion over similar names and lack of verification. Staff were unaware of the resident's cognitive status and did not notify the responsible party, resulting in the resident being transported unsupervised to a distant clinic, causing distress and a lapse in required supervision.
A resident with a gastrostomy tube and an NPO order was given medications by mouth due to inaccurate physician orders and lack of clarification by nursing staff. The MAR reflected repeated oral administration of Tylenol and Tramadol, despite the resident's need for medications via GT. Nursing leadership confirmed the error and acknowledged that orders and administration routes were not properly verified.
The facility failed to maintain dignity and privacy for two residents. A resident with severe cognitive impairment was exposed during a dressing change due to an open privacy curtain, causing emotional distress. Another resident with an indwelling catheter had an uncovered drainage bag, contrary to facility policy. The Director of Nursing acknowledged the importance of privacy, which was not upheld in these cases.
A facility failed to provide reasonable accommodation for a resident by not ensuring a functional television, impacting her emotional well-being. Additionally, the facility did not ensure call lights were within reach for three residents, increasing the risk of delayed care and falls. These deficiencies were acknowledged by staff, highlighting the need for improved response times.
The facility failed to complete and submit the quarterly MDS assessments for three residents within the required timeframe. A resident with difficulty walking and diabetes had their MDS completed 37 days late. Another resident with severe sepsis and seizures, and a third resident with hyperlipidemia and dementia, had their MDS assessments incomplete and not submitted. The MDSN acknowledged the delays, and the DON emphasized the importance of timely MDS completion for accurate care planning.
The facility failed to create timely, individualized care plans for residents at high risk for elopement, compromising their safety. Despite being identified as high risk, care plans for four residents were delayed, with interventions not documented until months after initial assessments. Staff acknowledged the importance of timely care plans, but facility policies requiring comprehensive plans within 48 hours of admission were not followed.
The facility failed to implement timely care plans for residents at high risk of elopement. Despite assessments indicating high risk, care plans and interventions were delayed for several residents with cognitive impairments, leaving them vulnerable to elopement. Staff acknowledged the importance of these plans, but documentation was lacking.
The facility failed to ensure safe respiratory care for three residents receiving oxygen therapy. A resident's oxygen tubing and nasal cannula were found on the floor, another resident had an empty humidifier bottle, and a third resident's tubing was also on the floor. The ADON and DON confirmed these practices were against facility policy, which requires equipment to be dated, kept off the floor, and stored in labeled bags when not in use.
The facility failed to reseal and replace an IM e-kit within 72 hours after use, as required. Medications were removed from the e-kit for two residents with diabetes and hyperlipidemia. Despite transitioning to CUBEX for emergency medication supply, the e-kit was not returned to the pharmacy, leading to the oversight. Staff acknowledged the failure to reseal the e-kit, which would have indicated the need for replacement and prevented unauthorized access.
The facility failed to complete daily refrigerator temperature logs, compromising its ability to monitor food storage temperatures effectively. During a kitchen tour, it was observed that logs were incomplete, with missing entries for Freezer #1. The Dietary Director acknowledged the oversight, and the Dietary Staff emphasized the importance of recording temperatures twice daily as part of food safety protocols. The facility's policy requires staff to review and record temperatures to ensure safe food storage.
A facility's QAA committee failed to develop an admission policy, resulting in a deficiency in care for a resident with Diabetes Mellitus. The absence of a structured admission process led to a lack of monitoring for blood sugar levels, as there was no checklist to guide RNs in reviewing necessary hospital records. Interviews revealed that the facility relied on RNs' judgment without a formal procedure, leading to the oversight.
A facility failed to maintain infection control standards by not placing contact isolation signage for a resident with shingles and allowing a family member to enter without proper PPE. Additionally, a resident's Foley catheter bag was observed touching the floor, contrary to facility policy. These deficiencies could increase infection risk among residents, staff, and visitors.
A facility failed to maintain a sanitary environment by leaving an unknown back brace in a resident's room, risking cross-contamination. Additionally, a patio door leading to a smoking area was not latching properly, allowing smoke to enter the facility. Staff failed to report the door issue, and maintenance did not conduct routine checks, leading to safety concerns.
A facility failed to include a resident's Advance Directive in their chart, despite it being indicated in the POLST. The document was not found during a review, and the Social Service Assistant suggested it might have been misplaced during a hospital transfer. The Director of Nursing confirmed that facility policy requires the Advance Directive to be in the chart for emergency access.
A facility failed to complete and submit the MDS for a resident with significant medical conditions within the required timeframe. The MDS Nurse was behind schedule, and the DON stressed the importance of timely MDS completion for accurate care planning.
A resident with a history of type 2 DM was admitted to a facility without proper monitoring or management of their condition. The facility failed to review the resident's discharge packet from the GACH, which documented the DM diagnosis and previous insulin administration. The Admitting RN did not clarify the need for blood sugar monitoring with the physician, and no care plan was developed to address the resident's diabetes. This oversight had the potential to lead to serious complications.
A resident with a fractured patella did not receive a properly placed and sized knee immobilizer, as observed by staff. The immobilizer frequently slipped and was loose, failing to provide adequate support. Despite the resident's complaints and staff observations, no action was taken to order a properly sized replacement, placing the resident at risk for injury and discomfort.
A resident at risk for weight loss did not receive the prescribed health shake with meals as ordered by the physician. The oversight was observed when the meal tray lacked the health shake, despite the meal ticket indicating its inclusion. Interviews with staff and family confirmed the importance of the shake for the resident's nutritional needs. The facility's policy requires adherence to physician diet orders.
A facility failed to ensure a NP reviewed a resident's care, leading to an oversight in monitoring the resident's type 2 Diabetes Mellitus. The resident, admitted with multiple diagnoses, had a documented history of DM, but this was not reflected in the NP's initial progress note. The NP did not review the hospital discharge packet, assuming another NP had done so, resulting in a lack of blood sugar monitoring.
A resident was administered a higher than necessary dose of Ativan despite not exhibiting anxiety symptoms. Initially, a PNP recommended reducing the dose based on the resident's behavior records, but the dose was reverted after the resident's request without reassessment. This practice violated the facility's policy on psychotropic medications, which requires administration only when necessary for a specific condition.
A facility failed to implement its smoking policy, resulting in a deficiency related to providing a smoke-free environment for a resident. Despite the resident's grievance about cigarette smoke entering her room from the smoking patio, the issue persisted due to a broken latch on the patio door, which was left open during smoke breaks. Staff confirmed the presence of smoke in the hallway, and the facility's smoking policy was not upheld.
The facility did not ensure that six residents were aware of the Ombudsman's contact information, as revealed during a Resident Council meeting. Interviews with staff confirmed the lack of documentation showing that residents were informed about the Ombudsman's role and contact details, which is a part of their rights.
The facility failed to inform six residents about the location of the Annual Recertification Survey results, including the Plan of Correction. During a Resident Council meeting, these residents expressed their lack of awareness, which was confirmed by staff interviews. The Activity Director and Admission Assistant did not provide documented evidence of informing residents about the survey results, despite the Director of Nurses highlighting its importance as a resident right.
Failure to Provide and Explain Access to Medical Records Upon Request
Penalty
Summary
The facility failed to provide and explain the process for obtaining a copy of a resident’s medical records upon request, in accordance with its policy on Protected Health Information. A resident with Type 2 DM and dementia was admitted in early February, and an IDT care plan review was conducted later that month, authored by the Social Service Assistant (SSA) and attended by an RN, rehabilitation staff, the Activity Director (AD), the resident, and the resident’s responsible party (RP). The IDT documentation did not include the topics discussed during the meeting and was not signed and dated by the SSA. During this IDT meeting, the RP requested the resident’s medical records, and the SSA verbally stated she would obtain the records, but no documentation of this request or follow-through was made. Following the meeting, the RP waited several weeks without receiving the records and repeatedly called the facility to follow up. The receptionist reported the SSA was unavailable and did not connect the RP with another staff member who could assist. After multiple attempts, the RP was eventually transferred to the Medical Records Director (MRD), who stated she had not been informed of the earlier request and told the RP that a request form needed to be completed. The MRD reported that the SSA, who no longer worked at the facility, had not communicated the RP’s request from the IDT meeting. The AD confirmed being present at the IDT meeting and recalled the RP asking for the records and the SSA stating she would get them. The facility’s policy stated that a resident may have access to records within 24 hours of a written or oral request, excluding weekends and holidays, but this process was not followed or explained to the RP.
Failure to Provide Ordered Bariatric Bed and Side Rails for Obese, High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to reasonably accommodate a resident’s assessed need and physician’s order for a bariatric bed with bilateral 1/2 side rails. The resident had diagnoses including obesity due to excess calories, hyperlipidemia, major depressive disorder, respiratory failure with hypoxia, CKD, HTN, pneumonia, CHF, COPD, asthma, neuropathy, depression, impaired mobility, and incontinence. The resident’s H&P documented capacity to understand and make decisions. The physician’s order summary and the resident’s care plans specified the use of a bariatric bed with bilateral 1/2 side rails as an intervention, including for assistance with turning and as part of fall risk interventions that also called for side rails as ordered and a safe environment. On readmission, the resident was placed in a regular bed without side rails, despite the existing physician’s order and care plan interventions for a bariatric bed with 1/2 side rails. Nursing notes documented that the resident initially refused to change to a bariatric bed, stating a desire to rest. The DON later confirmed that a bariatric bed had been used prior to the recent hospitalization and that the bariatric bed was available and in the hallway at the time of readmission. The Maintenance Supervisor confirmed that the bed in the room at readmission was a regular bed, not a bariatric bed. Staff interviews indicated that the resident was “really big,” almost 300 lbs, and barely fit in the regular bed, and that the readmission bed did not have side rails. During the night shift following readmission, an LVN reported speaking with the resident about the new room and that the resident mentioned needing a bigger bed and that the current bed needed to be switched out. The LVN did not offer to switch the bed and did not change the bed to a bariatric bed despite this request and the existing order. Later that night, the resident’s roommate found the resident on the floor between the two beds, unresponsive, and called for help. Staff found the resident lying on her left side, unresponsive, not breathing, and without a pulse. Emergency protocols were initiated, including CPR, and emergency services were contacted. The resident was later pronounced deceased, with the medical examiner determining the manner of death as natural, caused by congestive heart failure and obesity. The facility’s policies on admissions and resident safety required that physician orders be noted and initiated and that room checks and bedside observations be conducted to ensure a safe environment, but the ordered bariatric bed with side rails was not in place at the time of the event. The facility’s fall risk care plan for the resident identified her as at risk for falls related to multiple comorbidities and impaired mobility and specified that side rails be used as ordered and that a safe environment be maintained, including appropriate assistive devices. The DON stated that the 1/2 side rails were used as an enabler for the resident. Despite this, the resident remained in a regular bed without side rails from the time of readmission through the time she was found on the floor. Multiple staff, including the DON, LVNs, and the Maintenance Supervisor, acknowledged the discrepancy between the physician’s order and care plan interventions and the actual bed provided and maintained for the resident during this period. The nursing progress notes and staff interviews further showed that the resident’s refusal of the bariatric bed at the time of readmission was documented but not followed by any documented reassessment or alternative accommodation when the resident later expressed a need for a bigger bed. The facility’s own policies required that physician orders be initiated at admission and that safety measures, including appropriate assistive devices and room setup, be in place. Nonetheless, the ordered bariatric bed with 1/2 side rails was not implemented, and the resident remained in a regular bed without side rails until she was discovered on the floor, unresponsive.
Medication Borrowing and Inaccurate MAR Documentation for Anticoagulant and Respiratory Medications
Penalty
Summary
The deficiency involves the facility’s failure to provide pharmaceutical services and safe medication administration for a resident in accordance with physician orders and the facility’s “Six Rights of Medication Administration” policy. The resident was initially admitted and later readmitted with diagnoses including obesity due to excess calories, hyperlipidemia, and major depressive disorder, and had documented capacity to understand and make decisions. Physician orders dated 1/2/2026 included routine Ipratropium Albuterol inhalation solution via nebulizer every six hours for respiratory failure and Heparin 5000 units subcutaneously every eight hours for DVT prophylaxis, with the first Heparin dose to be taken from the Cubex automated medication system. Review of the Medication Administration Record for January 2026 showed that Heparin 5000 units was documented as last given on 1/2/2026 at 10 PM and Albuterol inhalation solution was documented as last given on 1/3/2026 at 12 AM. However, Cubex transaction reports from 1/2/2026 to 1/3/2026 indicated no medication transactions for this resident, and a pharmacy delivery receipt dated 1/3/2026 at 5:15 AM showed that multiple medications for the resident, including Ipratropium Albuterol solution and Heparin vials, were delivered but then returned to the pharmacy. This documentation pattern showed that the resident’s ordered medications were not obtained from the Cubex or from the resident’s own supply as intended. In interviews, one LVN stated she attempted to obtain Heparin from the Cubex during her 3 PM to 11 PM shift on 1/2/2026 but did not complete the process because it took too much time, and instead used a Heparin vial belonging to another resident who was receiving the same dose. She acknowledged she did not document that the Heparin administered came from another resident’s supply. Another LVN stated he did not actually administer Albuterol to the resident despite the MAR indicating it was given, explaining that he may have clicked “yes” on the MAR by accident and did not remember administering Albuterol or any other medications to the resident. These actions and documentation errors were inconsistent with the facility’s policy requiring the right resident, right time, right medication order, right dose, right route, and right documentation for medication administration.
Failure to Update Person-Centered Care Plans After Resident Incident
Penalty
Summary
The facility failed to develop and implement person-centered care plans for two residents following a significant incident. For the first resident, who had a history of hemiplegia, hemiparesis, difficulty walking, and falls, multiple staff members reported that she was scared of her roommate after an incident in which the roommate was found standing by her bed, causing her distress and leading to a fall. Despite the resident expressing fear, pain, and a desire not to return to her room, the care plan was not updated to address her emotional response, safety concerns, or the interaction with her roommate. The second resident involved in the incident had diagnoses including metabolic encephalopathy and major depressive disorder, and experienced right arm numbness and sudden vision loss during the event. The care plan for this resident was also not updated to reflect the incident, her acute medical symptoms, or her actions during the event. Documentation showed that the resident had a severe headache, sudden blindness, and accidentally knocked down equipment, which contributed to the other resident's distress and fall. Interviews and record reviews confirmed that the facility's interdisciplinary team did not revise or implement care plans for either resident following the incident, despite facility policy requiring comprehensive, person-centered care plans with measurable objectives and timeframes after each assessment or significant event. The lack of updated care plans meant that the specific needs and responses of both residents were not addressed in their individualized plans of care.
Failure to Follow Physician Orders and Care Plans for Pressure Ulcer Prevention
Penalty
Summary
The facility failed to follow physician's orders and care plans for two residents by not adhering to specific instructions regarding pressure ulcer prevention and management. For one resident with a history of diabetes, dementia, anemia, and moderate risk for pressure ulcers, staff did not limit the resident's sitting time in a wheelchair to one to two hours as ordered, nor did they ensure the use of a gel cushion as specified. Observations showed the resident was seated in a wheelchair for approximately three hours, and staff interviews confirmed that the required documentation for turning and repositioning was incomplete or missing for several shifts. Additionally, the resident's low air loss mattress was not set according to the resident's weight, as required by physician's orders and the care plan, with the analog pressure dial set significantly higher than the resident's actual weight. Staff interviews revealed that the lack of documentation and failure to follow orders could result in the facility being unaware if repositioning was performed, and that the incorrect mattress setting could pose a risk of falls or injury. The treatment nurse and DON both acknowledged that the mattress settings were not correct and that staff were not following the care plan interventions. The care plan for this resident included specific interventions for pressure ulcer prevention, such as limiting sitting time, using a gel cushion, and adjusting the mattress settings according to weight and height, but these were not consistently implemented. For the second resident, who had a stage four pressure ulcer, atrophy, and anemia, the facility also failed to set the low air loss mattress according to the resident's weight as ordered. Observations and interviews confirmed that the mattress was set for a much higher weight than the resident's actual weight. The care plan for this resident required the use of a pressure-relieving device and proper mattress settings, but these interventions were not followed. The DON and treatment nurse both confirmed that the settings were incorrect and that the facility was not adhering to its own policies and procedures for skin and wound management, as well as comprehensive person-centered care planning.
Resident with Dementia Sent Unsupervised to Incorrect Medical Appointment
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment and a diagnosis of dementia was mistakenly sent, unsupervised, to a medical appointment that was actually scheduled for another resident. The resident required maximal assistance with several activities of daily living and was not capable of safely attending appointments alone. The error originated when the Social Service Director (SSD) entered an orthopedic appointment and transportation order for the wrong resident, due to confusion caused by multiple residents sharing the same first name. This resulted in the resident being transported eleven miles away from the facility without proper supervision or notification to the responsible party. Facility staff, including a Licensed Vocational Nurse (LVN), were unaware of the resident's cognitive status and did not verify the appropriateness of the appointment or the need for supervision. The LVN prepared the resident for the appointment based on the facility's appointment calendar and handed the resident an envelope for the doctor, without confirming with the responsible party or ensuring the resident's safety. The responsible party only became aware of the situation after receiving a notification from the transportation company and subsequently alerted the facility, which was not initially aware that the resident had left the premises. Interviews with staff revealed a lack of communication and verification processes regarding off-site appointments for residents with cognitive impairments. The facility's policy required continuity of care during leaves of absence, but this was not followed in this instance. The resident, who was unable to recall details of the event due to her dementia, expressed feelings of anxiety and fear during the unsupervised trip. The incident highlighted failures in resident identification, staff awareness of resident needs, and adherence to established procedures for resident safety during off-site appointments.
Failure to Accurately Document and Administer Medications for NPO Resident with Gastrostomy Tube
Penalty
Summary
A physician failed to accurately document medication orders for a resident with a gastrostomy tube (GT) who was readmitted to the facility with an NPO (nothing by mouth) order. Despite the resident's NPO status and the presence of a GT for medication and nutrition administration, the physician's orders specified that medications such as Tylenol and Tramadol be given orally. This order was not clarified by nursing staff, and the medications were subsequently documented and administered by mouth according to the Medication Administration Record (MAR). Record reviews showed that over several days, the resident received multiple doses of Tylenol and Tramadol by mouth, as indicated on the MAR, even though the resident was not to receive anything orally due to the NPO order. Both the Registered Nurse Supervisor (RNS) and Assistant Director of Nursing (ADON) confirmed during interviews that the medications were given by mouth and acknowledged that this was inconsistent with the resident's NPO status and the correct route for administration via GT. The facility's policy on the six rights of medication administration requires that medications be given according to the prescribed route, and that orders be checked for accuracy before administration. In this case, the nursing staff did not clarify the conflicting orders with the physician or pharmacy, and the medications were administered and documented incorrectly, resulting in a failure to follow accepted professional standards for safeguarding resident care and accurate medical recordkeeping.
Failure to Maintain Resident Dignity and Privacy
Penalty
Summary
The facility failed to promote dignity and respect for two residents, Resident 18 and Resident 100, by not ensuring privacy during care activities. Resident 100, who was admitted with severe cognitive impairment and dependency in lower body dressing, was exposed from the waist down during a dressing change. The privacy curtain was left open by the Rehabilitation Aide and Physical Therapist Assistant, leading to Resident 100 feeling hurt and expressing that the exposure was unacceptable. The facility's policy required privacy to be maintained, but this was not adhered to during the incident. Resident 18, who had intact cognition and required an indwelling catheter due to obstructive uropathy, was observed with an uncovered catheter drainage bag while sleeping in their room. The Assistant Director of Nursing confirmed the absence of a dignity cover, although the Director of Nursing later stated that the drainage bag should always be covered for privacy. The facility's policy emphasized maintaining privacy during personal hygiene activities, which was not followed in this case. The facility's failure to adhere to its own policies on dignity and privacy resulted in emotional distress for Resident 100 and a potential decline in dignity for Resident 18. The Director of Nursing acknowledged the importance of privacy and the potential for residents to become upset or stressed due to such incidents. The facility's policy and procedure on dignity and privacy, dated November 2021, outlined the expectation for residents to be treated with kindness, dignity, and respect, which was not met in these instances.
Failure to Accommodate Resident Needs and Ensure Call Light Accessibility
Penalty
Summary
The facility failed to provide reasonable accommodation for Resident 72 by not ensuring the resident had a functional television for personal use, as identified in the resident's care plan. Resident 72, who was admitted with diagnoses including asthma and a history of falling, had a care plan indicating enjoyment of watching television. However, the resident's television was not functioning, forcing her to share a television with another resident, which was often unavailable due to privacy curtains being drawn during care. This situation caused frustration and agitation for Resident 72, impacting her emotional well-being. Additionally, the facility failed to ensure that the call lights were within reach for Residents 3, 81, and 93, as required by the facility's policy and each resident's care plan. Resident 3, who was at risk for falls, had a call light hanging between the headboard and wall, out of reach. Resident 81, with severely impaired cognition and a high risk for falls, had a call light on the floor, not accessible. Similarly, Resident 93, also at high risk for falls, had a call light placed on the headboard, beyond reach. These deficiencies in call light accessibility could lead to delayed care and increased risk of falls and injuries. The facility's failure to address these issues promptly was acknowledged by staff, including the maintenance staff and the facility administrator, who recognized the need for faster response times to such deficiencies. The Director of Nursing confirmed the importance of having call lights within reach to ensure residents can call for assistance when needed, as outlined in the facility's policy and procedure.
Failure to Timely Complete and Submit MDS Assessments
Penalty
Summary
The facility failed to ensure that the quarterly Minimum Data Sets (MDS) for three residents were completed and submitted to the CMS database within the required timeframe. Resident 85 was initially admitted on February 21, 2022, and readmitted later with diagnoses including difficulty walking, muscle weakness, and type 2 diabetes mellitus. The quarterly MDS for Resident 85 had an assessment reference date (ARD) of November 18, 2024, but was not completed and signed by the Registered Nurse Assessment Coordinator (RNAC) until January 8, 2025, which was 37 days late. Resident 98, admitted on August 31, 2022, with severe sepsis, seizures, and muscle weakness, had an ARD of November 21, 2024, but the MDS was not completed or submitted by the RNAC. Resident 116, admitted on October 1, 2023, with hyperlipidemia, dementia, and anxiety, had an ARD of November 29, 2024, but the MDS was also not completed or submitted by the RNAC. The MDS Nurse (MDSN) acknowledged during interviews that the assessments for Residents 85, 98, and 116 were not completed and submitted within the required 14-day period following the ARD. The Director of Nursing (DON) confirmed that the MDSN was responsible for updating and transmitting the MDS quarterly and annually, emphasizing the importance of timely completion to ensure accurate and up-to-date resident status for care planning. The facility's policy and procedure, as well as the CMS Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, require that the MDS completion date must be no later than 14 calendar days following the ARD, which was not adhered to in these cases.
Failure to Develop Timely Elopement Care Plans for High-Risk Residents
Penalty
Summary
The facility failed to develop personalized care plans for four residents at high risk for elopement, compromising their safety and supervision. Resident 56, diagnosed with Alzheimer's disease and other conditions, was identified as high risk for elopement on 10/2/2024, but a care plan was not created until 1/7/2025. The MDS Nurse acknowledged the absence of a care plan and interventions following the initial evaluation, indicating a lack of documented evidence in the Interdisciplinary Team's records. Resident 154, with Alzheimer's disease and other diagnoses, was also at high risk for elopement as of 12/25/2024. The Social Services Assistant met with the resident on 1/7/2025 and created a care plan after the resident expressed a desire to leave the facility. However, the SSA did not review the elopement risk assessment or document the conversation, leading to a delay in implementing necessary interventions. Similarly, Resident 89 and Resident 29 were identified as high risk for elopement in September and November 2024, respectively, but care plans were not developed until January 2025. The Assistant Director of Nursing and the Director of Nursing both acknowledged the importance of timely care plans to prevent elopement, yet no interventions were documented in the residents' records. The facility's policies require comprehensive, individualized care plans within 48 hours of admission, but these were not adhered to, resulting in a failure to address the residents' elopement risks effectively.
Failure to Implement Elopement Prevention Plans for High-Risk Residents
Penalty
Summary
The facility failed to provide necessary interventions and supervision for four residents who were at high risk for elopement. Resident 56, diagnosed with Alzheimer's disease and other conditions, was identified as high risk for elopement on 10/2/2024, but no care plan or interventions were documented until 1/7/2025. The MDS Nurse acknowledged the absence of a care plan and interventions, which are crucial for addressing the resident's needs. Similarly, Resident 154, with Alzheimer's disease and other diagnoses, was assessed as high risk for elopement on 12/25/2024. However, a care plan was only created on 1/7/2025 after the Social Services Assistant noted the resident's desire to leave the facility. The Medical Records Director confirmed the lack of documentation in the Interdisciplinary Team's care planning records. Resident 89 and Resident 29 also faced similar issues. Resident 89, with dementia and other conditions, was evaluated as high risk for elopement on 9/4/2024, but no care plan was documented until 1/7/2025. Resident 29, with severe cognitive impairment, was assessed on 11/16/2024, but a care plan was only created on 1/8/2025. The Assistant Director of Nursing and the Director of Nursing both acknowledged the importance of timely care plans to prevent elopement, yet documentation was lacking in the facility's records.
Deficient Respiratory Care Practices in Oxygen Therapy
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for three residents receiving oxygen therapy, as observed during a survey. Resident 27's oxygen tubing and nasal cannula were found on the floor, which was confirmed by the Assistant Director of Nursing (ADON) during an observation. The ADON acknowledged that the nasal cannula and tubing should be placed in a bag when not in use to prevent infection. Resident 201 was observed receiving oxygen therapy with an empty humidifier bottle, which was supposed to be changed weekly. The ADON confirmed the empty humidifier bottle and stated it should be changed every week. Resident 201's medical history included lobar pneumonia, sepsis, and acute erythroid leukemia in relapse, and the resident had the capacity to understand and make decisions. Resident 202's oxygen tubing was also observed touching the floor, which was verified by a licensed vocational nurse (LVN). The LVN stated that the tubing should not be on the floor to prevent infection spread. The Director of Nursing (DON) confirmed that oxygen equipment should not touch the floor and should be replaced immediately. The facility's policy indicated that oxygen equipment should be dated and kept off the floor, and labeled bags should be used for storage when not in use.
Failure to Reseal and Replace Emergency Kit
Penalty
Summary
The facility failed to reseal an intramuscular emergency kit (IM e-kit) and replace it within 72 hours after use, as required by their policy. This deficiency was identified during a review of the facility's IM/E-KIT log and interviews with staff. The report highlights two instances where medications were removed from the e-kit for residents with specific medical conditions. Resident 251, who had diabetes mellitus and hyperlipidemia, received a dose of Furosemide from the e-kit on December 5, 2024. Similarly, Resident 48, who also had diabetes mellitus and hyperlipidemia, was administered Glucagon from the e-kit on December 30, 2024, due to low blood sugar levels. The facility had transitioned to using CUBEX, an automated unit dose system, for emergency medication supply as of December 20, 2024, and was expected to discontinue the use of physical e-kits. However, the IM e-kit was not returned to the pharmacy and was still in use, leading to the oversight. The Registered Nurse (RN) and Director of Nursing (DON) acknowledged the failure to reseal the e-kit with the required orange zip ties, which would have indicated the need for replacement and prevented unauthorized access. The pharmacist was unaware that the facility still had the e-kit, resulting in the pharmacy not replacing it as needed.
Incomplete Refrigerator Temperature Logs
Penalty
Summary
The facility failed to ensure the completion of daily refrigerator temperature logs as required by its policy, which compromised its ability to effectively monitor food storage temperatures. During an initial kitchen tour with the Dietary Director (DD), it was observed that the refrigerator temperature logs were incomplete, with no temperature entries documented for the AM and PM shifts on 1/4/2025 for Freezer #1. In a subsequent interview and record review, the DD acknowledged the missing entries and stated that she should have followed up on the completion of the log. Additionally, during an interview, the Dietary Staff (DS) stated that staff are expected to record refrigerator temperatures twice a day as part of the facility's food safety protocols. The absence of these logs means there is no way to verify if food has been stored at safe temperatures, potentially leading to food spoilage or bacterial growth. The facility's policy and procedure on cold storage temperature monitoring and record-keeping requires Food and Nutrition staff to review and record temperatures of all refrigerators and freezers to ensure they are at the correct temperature for food storage and handling.
Lack of Admission Policy Leads to Deficiency in Resident Care
Penalty
Summary
The facility's Quality Assessment and Assurance (QAA) committee failed to develop a policy and procedure related to the admission process, which led to a deficiency in the care provided to a resident. The resident, who was admitted with a diagnosis of Diabetes Mellitus (DM) among other conditions, was not monitored for signs and symptoms of high or low blood sugar levels. The admission process lacked a structured approach, as there was no prefilled area in the Admission Report Check List to remind Registered Nurses (RNs) to ask for vital signs, including blood sugar checks, or if insulin was administered during the hospital stay. Interviews with facility staff revealed that there was no written procedure or checklist for RNs to follow during the admission process. The Director of Nurses (DON) confirmed the absence of a policy and procedure guide for admissions, relying instead on the RNs' judgment to know which hospital records to review. This lack of structured guidance and documentation led to the oversight in monitoring the resident's blood sugar levels, as there were no physician orders or progress notes indicating the need for such monitoring. The deficiency was identified through a review of the resident's admission records and interviews with the facility's nursing staff.
Infection Control Deficiencies in PPE Use and Foley Catheter Management
Penalty
Summary
The facility failed to maintain a safe and sanitary environment to prevent the transmission of infections, as evidenced by two specific incidents. In the first incident, the facility did not place contact isolation precaution signage at the entrance of a resident's room who was under contact isolation due to shingles. Additionally, a family member visiting the resident was not wearing the required personal protective equipment (PPE), specifically an isolation gown, while in the room. The Infection Prevention Nurse (IPN) acknowledged the oversight and emphasized the importance of proper signage and PPE to prevent exposure to infections. In the second incident, a resident's Foley catheter bag was observed touching the floor, which is against the facility's policy. The Licensed Vocational Nurse (LVN) present during the observation confirmed that the Foley bag should not be in contact with the floor to avoid contamination. The Director of Nursing (DON) reiterated that the facility's policy requires catheter drainage bags to be kept off the floor to prevent cross-contamination. Both incidents highlight deficiencies in the facility's infection prevention and control practices, which could potentially increase the risk of infection spread among residents, staff, and visitors. The facility's policies and procedures were not adequately followed, leading to these lapses in infection control measures.
Sanitation and Safety Deficiencies in Resident Room and Patio Door
Penalty
Summary
The facility failed to provide a sanitary environment for a resident by allowing an unknown black back brace to remain in the resident's room. The resident, who was admitted with diagnoses including generalized epilepsy and severe cognitive impairment, did not have the back brace listed among their personal belongings. Observations and interviews revealed that the back brace was not the resident's property and had been left in the room since the start of a CNA's shift. The Director of Nurses acknowledged that staff should not leave personal items in residents' rooms due to the risk of cross-contamination. Additionally, the facility did not maintain a functional door with locks that latch, leading to the patio area. Observations showed that the door was not latching properly, allowing cigarette smoke from the designated smoking area to enter the facility. The activities assistant supervising the smoke break admitted to being unable to close the door completely and failed to report the issue to maintenance. The Maintenance Supervisor confirmed the door's malfunction and stated that it was not part of routine maintenance checks. The facility's policies and procedures indicated that faulty equipment should be reported immediately and that routine inspections should be recorded. However, the Maintenance Supervisor did not have a log for routine inspections and relied on visual observations and staff reports to address maintenance issues. The Administrator and Director of Nursing were unaware of the door's malfunction until it was brought to their attention, highlighting a lapse in communication and adherence to safety protocols.
Failure to Maintain Resident's Advance Directive in Chart
Penalty
Summary
The facility failed to ensure that a resident's Advance Directive was included in their chart, which is a critical document specifying the resident's healthcare wishes in case they become unable to make decisions. This deficiency was identified during a review of the resident's records, which showed that although the Physician Orders for Life Sustaining Treatment (POLST) indicated the existence of an Advance Directive, the document was not found in the resident's chart. The Social Service Assistant acknowledged the absence of the Advance Directive and suggested it might have been misplaced during the resident's transfer to the hospital and subsequent readmission. The Director of Nursing confirmed that the facility's policy requires a copy of the Advance Directive to be kept in the resident's chart to ensure accessibility during emergencies. The facility's policy, revised in December 2023, mandates that all adult residents be informed and provided with written information regarding their right to obtain a copy of their Advance Directive, which should be placed in their health record. The failure to adhere to this policy could lead to misinformation regarding medical care and treatment, potentially not honoring the resident's wishes if they or their responsible party are unable to make healthcare decisions.
Failure to Timely Complete and Submit MDS for a Resident
Penalty
Summary
The facility failed to ensure the timely completion and submission of the comprehensive Minimum Data Set (MDS) for Resident 22, as required by federal regulations. Resident 22 was admitted with significant medical conditions, including hemiplegia, hemiparesis, abnormal posture, muscle weakness, and dysphagia. The MDS Nurse acknowledged that the annual comprehensive MDS for Resident 22, with an Assessment Reference Date (ARD) of December 1, 2024, was not completed and submitted within the mandated 14-day period, which should have been by December 15, 2024. Interviews with the MDS Nurse and the Director of Nursing (DON) revealed that the MDS Nurse was behind schedule in completing and submitting MDS assessments to the CMS database. The DON emphasized the importance of timely MDS completion and submission to ensure accurate and updated resident status, which is crucial for revising or initiating care plans based on the resident's current conditions. The facility's policy and procedure documents also highlighted the responsibility of the MDS Coordinator to adhere to state and federal requirements for the Resident Assessment Instrument (RAI) process.
Failure to Monitor and Manage Diabetes Mellitus
Penalty
Summary
The facility failed to provide adequate care and services to a resident with a diagnosis of Diabetes Mellitus (DM). The deficiency involved the failure to monitor the resident's blood sugar levels and to clarify the need for such monitoring and treatment with the resident's physician. The resident was admitted with a history of type 2 DM, as documented in the General Acute Hospital (GACH) discharge packet, but this information was not adequately reviewed or acted upon by the facility's staff. Upon admission, the resident's medical records from the GACH indicated a history of type 2 DM and previous administration of insulin Lispro. However, the facility's Admission Record did not reflect this diagnosis, and no care plan was developed to address the resident's diabetes. The Admitting Registered Nurse (RN) failed to clarify the resident's blood sugar monitoring and treatment needs with the physician, and the Nurse Practitioner (NP) who took over care did not thoroughly review the discharge packet to justify the continuation or discontinuation of blood sugar monitoring and treatment. The facility's Director of Nurses (DON) acknowledged that the admitting RN should have reviewed the discharge packet thoroughly and clarified the orders and diagnosis. The facility lacked a policy and procedure guide for RNs to follow during resident admissions, which contributed to the oversight. The failure to monitor and manage the resident's blood sugar levels had the potential to result in uncontrolled blood sugar levels, leading to serious complications such as ketoacidosis, coma, hospitalization, or death.
Improperly Fitted Knee Immobilizer for Resident
Penalty
Summary
The facility failed to provide a properly placed and sized knee immobilizer for a resident, identified as Resident 351, who was admitted with a fracture of the right patella and a history of falling. The resident had the mental capacity to make medical decisions and was dependent on staff for activities of daily living. During observations, the knee immobilizer was found to be improperly positioned, either at the resident's ankle or loose around the knee and thigh, which was confirmed by a Licensed Vocational Nurse (LVN 3) and a Physical Therapist (PT 1). The resident reported that the immobilizer frequently slipped and did not provide adequate support. Despite the resident's complaints and the observations made by staff, no action was taken to order a properly sized replacement immobilizer. The Director of Nursing (DON) acknowledged the importance of a properly fitting immobilizer for stabilizing the joint and preventing further injury. However, there were no reports made to nursing leadership regarding the improper fit, and no corrective actions were initiated to address the issue. This inaction placed the resident at risk for injury, discomfort, and complications such as impaired mobility and skin breakdown.
Failure to Provide Prescribed Nutritional Supplement
Penalty
Summary
The facility failed to ensure that a resident identified as at risk for weight loss received the prescribed health shake three times a day as ordered by the physician. This oversight was observed during a meal service when the resident's meal tray did not include the health shake, despite the meal ticket indicating it should be provided. The resident, who was admitted with multiple diagnoses including hypertension, difficulty in walking, and cognitive impairment, was at risk for nutritional problems and weight loss. The care plan for the resident included the provision of health shakes with meals to maintain adequate nutritional status. During interviews, the family member of the resident, a registered nurse, the dietary supervisor, and the director of nursing all confirmed the importance of the health shake in addressing the resident's nutritional needs. The dietary supervisor acknowledged that the omission was accidental, and the director of nursing emphasized the necessity of following physician diet orders to maintain the nutritional health of residents, particularly those with weight loss concerns. The facility's policy and procedure on diet orders, revised in 2023, mandates that diet orders prescribed by the physician be provided by the Food & Nutrition Services Department.
Failure to Monitor Resident's Diabetes Mellitus
Penalty
Summary
The facility failed to ensure that a Nurse Practitioner (NP) thoroughly reviewed the overall care needed for a resident with a history of type 2 Diabetes Mellitus (DM). The resident was admitted with multiple diagnoses, including hemiplegia, hemiparesis, hyperparathyroidism, hyperlipidemia, and Alzheimer's disease. Despite the resident's documented history of DM in various admission records, the NP's initial progress note did not reflect this history, nor did it indicate that blood sugar levels were monitored. The deficiency occurred because NP 1, who took over the resident's care after returning from vacation, did not review the hospital discharge packet or clarify the resident's diagnosis and orders. NP 1 assumed that NP 2, who covered during her absence, had reviewed the necessary documents and informed her of the resident's DM history. The Director of Nurses confirmed that NP 1 should have reviewed the hospital record and clarified the diagnosis and orders upon taking over the resident's care. This oversight had the potential to result in uncontrolled blood sugar levels for the resident.
Inappropriate Administration of Ativan
Penalty
Summary
The facility was found to have administered a higher than necessary dose of Ativan to a resident who did not exhibit any behaviors of anxiety disorder. The resident, identified as Resident 73, was receiving Ativan 1 mg twice daily despite not showing signs of anxiety, as documented in the Medication Administration Record for December 2024 and January 2025, which indicated no episodes of anxiety. This practice was contrary to the facility's policy, which requires that psychotropic medications be used only when necessary to treat a specific condition. The Psychiatric Nurse Practitioner (PNP) had initially recommended a gradual dose reduction of Ativan from 1 mg twice daily to 0.5 mg as needed, based on her assessment and the resident's behavior monitoring records. However, the resident requested to revert to the previous dosage, and the PNP authorized the change without reassessing the resident. This decision was made despite the resident's agreement to the initial dose reduction plan and the absence of documented anxiety symptoms. The facility's policy on psychotropic medications, revised in December 2023, emphasizes that such drugs should not be administered for convenience or discipline. The failure to adhere to this policy and the subsequent administration of a higher dose of Ativan without documented necessity put the resident at risk of adverse effects, impacting their overall well-being.
Failure to Implement Smoking Policy
Penalty
Summary
The facility failed to implement its smoking policy and procedure, resulting in a deficiency related to providing a smoke-free environment for Resident 97. The resident, who was admitted with a stress fracture and morbid obesity, had intact cognition and the capacity to make decisions. Despite filing a grievance about the strong smell of cigarette smoke entering her room from the smoking patio, the issue persisted. The facility attempted to address the grievance by offering a room change and posting a sign to keep the door closed during smoke breaks, but these measures were ineffective. Observations revealed that the patio door across from Resident 97's room was often left open during smoke breaks, allowing smoke to enter the facility. Interviews with staff confirmed the presence of smoke in the hallway and identified a broken latch on the patio door as the cause. The maintenance assistant was unaware of the broken latch, and the Director of Nursing acknowledged the potential health risks of secondhand smoke but was not informed of the door issue until later. The facility's smoking policy, revised in 2016, mandates a smoke-free environment, which was not upheld in this instance.
Failure to Inform Residents of Ombudsman Contact Information
Penalty
Summary
The facility failed to ensure that six out of twelve residents who attended a Resident Council meeting were aware of the Ombudsman's contact information. During a group interview, these residents expressed that they did not know who the Ombudsman was or how to contact them, and they indicated that having this information would be beneficial for addressing unresolved issues within the facility. The Activity Director admitted that there was no documented evidence of providing this information during the Resident Council meetings. Further interviews revealed that the Admission Assistant also lacked documentation showing that residents were informed about the Ombudsman's role and contact information upon admission. The Director of Nurses acknowledged the importance of residents having access to the Ombudsman's contact details as part of their rights, emphasizing that it allows residents to voice concerns and seek assistance outside the facility. The facility's policy on Resident Rights supports this, stating that residents should have access to contact information for relevant state agencies and advocacy groups.
Residents Unaware of Survey Results Location
Penalty
Summary
The facility failed to ensure that six out of twelve residents who attended a Resident Council meeting were aware of where to find and how to read the facility's previous Annual Recertification Survey results, including the Plan of Correction (POC). During a group interview, these six residents expressed that they were not informed about the location of the survey results and indicated that having this information would be beneficial. This lack of awareness among residents was identified during a Resident Council meeting. Interviews with facility staff revealed that there was no documented evidence of communication to residents regarding the location of the survey results. The Activity Director confirmed that she did not inform or remind residents about the survey results during the monthly Resident Council meetings. Similarly, the Admission Assistant acknowledged that information about the survey results was not included when explaining resident rights upon admission. The Director of Nurses emphasized the importance of residents knowing where to find the survey results, as it is a resident right. The facility's policy on Resident Rights also supports this, indicating that residents have the right to examine the results of the most recent survey and any plan of correction in effect.
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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