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Normal SpO2 on room air is 95-100% for most adults; 90-94% may indicate mild hypoxia and warrants closer monitoring; below 90% is significant hypoxia requiring immediate evaluation and possible supplemental oxygen. Some chronic COPD residents have a baseline of 88-92% and may have a physician-set lower target to avoid suppressing hypoxic drive. Report values outside the resident's individualized parameters to the nurse. Probe placement, motion, nail polish, cold extremities, and poor perfusion can falsely lower the reading.

Lateral position with appropriate pillow support relieves sacral/heel pressure (alternative to supine in the q2h turning schedule), maintains spinal alignment, and prevents hip adduction (pillow between knees) and shoulder compression (top arm pillow). Bad positioning without supports increases trochanter pressure and shoulder strain. Distractors (a, c, d) describe harms that proper technique prevents. Always check skin at pressure points each turn.

Apical pulse is auscultated with a stethoscope at the 5th intercostal space, midclavicular line (left, over the apex of the heart). Counted for a full 60 seconds. Used for infants, irregular rhythms, before digoxin administration, and when peripheral pulses are weak. Wrist (c) is radial; popliteal (d) is behind the knee; temple (a) is temporal. CNAs check apical for accuracy when the radial is irregular or weak.

Accurate weights require consistency: same time of day, same scale, similar clothing, after voiding, with the scale calibrated. Significant changes (≥3 lb in 24 h, ≥5 lb in 7 days, or any unexplained loss) suggest fluid shifts (CHF, dehydration) or nutritional concerns and must be reported. Hospice residents are still weighed per care plan unless comfort indicates otherwise. Distractors (a, b, d) introduce error or omit important monitoring.

Supine: lying flat on the back. Risks include sacral and heel pressure injury, aspiration if HOB low, and back pain. Mitigations: small pillow under head, small support under knees (do NOT fully bend knees long-term—causes contractures), heel float to off-load heels, reposition every 2 hours. Prone (c) is face-down; high-Fowler's (d) is upright; Sims'/lateral (a) is side-lying. Position choice depends on medical condition and care plan.

Stool collection: use a clean dry bedpan or toilet specimen 'hat' to keep stool free of urine and toilet water (both can invalidate testing). Transfer a portion (about 1 tablespoon for routine; more for ova/parasites) using a tongue blade into the labeled container, cap, and send promptly per order. Wear gloves. Contamination (c, d) invalidates testing; bare hands (b) violate Standard Precautions. Document time, characteristics (color, consistency, blood).

Sputum is best collected early morning before eating/drinking/brushing because overnight secretions are most concentrated. Rinse mouth with water (not antibacterial mouthwash, which can alter culture), have the resident take 3-4 deep breaths and then cough from deep in the lungs (saliva is not sputum). Send promptly. Other timings (a, b, d) reduce yield or introduce contamination. Document amount, color, consistency, and odor.

Tympanic technique: apply a clean disposable probe cover, gently pull the pinna up and back for adults (down and back for children under 3) to straighten the ear canal, insert the probe snugly aimed at the tympanic membrane, activate, and wait for the audible/visual signal. Forceful insertion (d) risks ear injury; no cover (a) is unhygienic; cheek (c) measures skin, not core. Cerumen and incorrect aim affect accuracy.

AROM: resident performs the movements independently, maintaining strength, flexibility, and joint health. PROM: CNA moves the joint when the resident cannot. AAROM (active-assistive) is a middle option. The benefits include prevention of contractures, maintenance of circulation, and preservation of function. Distractors (b, c, d) misdescribe the concept; AROM is everyday activity-based or scheduled, not requiring physicians or lifts.

Coughing, choking, wet/gurgly ('wet') voice after swallowing, pocketing food, drooling, and unexplained weight loss are red flags for dysphagia and aspiration risk—the resident needs swallow evaluation (SLP) and likely diet modification. Several days of refused meals signal a clinical change requiring nurse assessment. Normal eating behaviors (b, c, d) are not concerning. Aspiration pneumonia is a leading cause of death in elders with dysphagia; timely reporting saves lives.

42 CFR §483.24 (Quality of Life) and §483.25 (Quality of Care) require facilities to assist each resident to 'attain or maintain his or her highest practicable physical, mental, and psychosocial well-being.' Restorative nursing focuses on preserving and regaining function, preventing decline, and promoting independence in ADLs. Doing tasks FOR the resident (a) fosters dependency and violates restorative principles. Hospital return (c) and preventing departure (b) are unrelated to restorative goals. Title 22 CCR §72315 obligates nursing services to support each resident's functional abilities.

Active-assistive ROM (AAROM) occurs when the resident moves a weaker limb with help from the stronger limb (self-assist) or from the CNA. Passive ROM (a) means the CNA moves the joint while the resident does no work — used when the resident cannot move at all. Active ROM means the resident moves independently with no assistance. Resistive (c) adds external force against motion (rehab/PT). Isometric (d) is muscle tightening without joint movement. Per 42 CFR §483.25(c), facilities must prevent decline in ROM unless clinically unavoidable.

Per Title 22 CCR §72315, transfers must protect both resident and staff. The correct technique: apply a gait belt at the waist, position feet flat and shoulder-width apart, have resident lean forward (nose-over-toes), and rise on a counted cue using their own leg strength. Lifting under the arms (c) can cause shoulder dislocation and removes the active component. Grabbing the CNA's neck (d) risks cervical injury to staff. Skipping the gait belt (a) violates safe-handling policies under 42 CFR §483.25(d) (accident prevention).

The cane is held on the STRONG side, opposite the weak leg, to widen the base of support and shift weight away from the affected limb. Sequence: cane and weak leg advance together, then the strong leg steps past. Placing the cane on the weak side (a, c) reduces stability and increases fall risk. Sequence does matter (b) — incorrect order can cause loss of balance. 42 CFR §483.25(d) requires the facility to ensure residents receive adequate supervision and assistive devices to prevent accidents.

When a resident is falling, the CNA must NEVER try to stop the fall by lifting (causes back injury and may injure resident). The correct procedure is controlled lowering: widen your stance, bend knees, ease the resident down your leg using the gait belt, and protect the head. Yanking (b) can cause rotator-cuff or rib injury. Stepping away (d) breaches duty of care. Lifting solo (c) violates safe-patient-handling policy under 42 CFR §483.25(d) and Title 22 CCR §72315. After the fall, call for help, assess, and complete an incident report.

42 CFR §483.24(b) requires the facility to support each resident's ability to perform ADLs and to prevent decline. Doing tasks for the resident (a) accelerates functional loss. Walking away (c) is dismissive and may be psychological neglect. Documenting refusal (d) mischaracterizes the situation — the resident is asking for support, not refusing. The correct approach uses graded assistance: verbal cueing, hand-over-hand if needed, breaking the task into small steps. This honors the care plan and the resident's dignity per Title 22 CCR §72315.

42 CFR §483.25(e) addresses urinary incontinence and requires facilities to assist residents to maintain or restore continence. Scheduled (prompted) toileting plus positive reinforcement is the evidence-based approach. Immediate briefing (a) defeats the program. Fluid restriction (d) causes dehydration, UTIs, and concentrated urine that worsens incontinence — and is not a CNA decision. Catheterization (c) is a medical order, increases infection risk (CAUTI), and is a last resort under federal regulation. Title 22 CCR §72315 obligates nursing care to support function.

Adaptive utensils (built-up handles, rocker knives), plate guards, and non-slip mats allow residents with limited grip or coordination to feed themselves — preserving independence and dignity. Feeding entirely (b) creates dependency. Diet changes (a) are physician/dietitian decisions; CNAs cannot alter diet orders. Withholding food (d) is neglect under 42 CFR §483.12 (abuse/neglect prohibition). 42 CFR §483.25 requires support of nutritional status and functional ability; Title 22 CCR §72315 requires the nursing service to meet daily living needs.

A contracture is permanent shortening of muscles, tendons, or joint capsules due to immobility, leading to a fixed deformity. It is a preventable complication; once established, it severely limits function and hygiene. 42 CFR §483.25(c) states a resident with limited ROM must receive appropriate treatment and services to increase ROM or prevent further decrease. Aging alone does not cause contractures (b). It is not strength (a) and does not reverse on its own (d). The CNA must report and document immediately so the nurse can adjust the care plan.

Foot drop (plantar flexion contracture) develops when the foot remains pointed downward. Prevention: keep ankles in dorsiflexion (90 degrees) using a foot board, high-tops, or prescribed splints, with frequent ROM. Feet hanging off the bed (a) causes plantar flexion. Pillows under the knees (b) cause hip and knee flexion contractures and impair circulation. Tight top sheets (d) push toes into plantar flexion — instead, use a bed cradle or loose sheet. 42 CFR §483.25(b)/(c) require prevention of avoidable decline.

NPIAP staging: Stage 1 = intact skin with non-blanchable erythema (redness that does not turn white when pressed). Stage 2 = partial-thickness loss with exposed dermis. Stage 3 = full-thickness loss with visible subcutaneous fat. Stage 4 = full-thickness loss with exposed bone, tendon, or muscle. Unstageable (d) = depth obscured by slough/eschar. DTI (b) = persistent non-blanchable deep red, maroon, or purple discoloration suggesting deeper damage under intact or non-intact skin. CNAs must report any new redness immediately per 42 CFR §483.25(b) and Title 22 CCR §72523 (incident reporting).

The federal and CA standard of care is repositioning at least every 2 hours for bedbound residents, with more frequent turning for higher-risk individuals (cachexia, vasopressors, prior pressure injury). Specialty surfaces do not eliminate the need to turn. Less frequent turning (a, d) allows ischemia and tissue death. Waiting for requests (b) fails residents who cannot communicate and constitutes neglect under 42 CFR §483.12. The CNA documents turning times and any skin findings. Title 22 CCR §72315 requires the nursing care plan to be followed.

Heels have minimal subcutaneous tissue and high pressure injury risk. The standard of care is to FLOAT the heels by placing a pillow lengthwise under the lower legs from below the knee to above the ankle, with heels completely off the surface. A pillow under the Achilles (d) still allows heel contact. Tight stockings (a) may impair circulation and require a physician order. Vigorous massage (b) is contraindicated — it can shear fragile capillaries and worsen tissue damage. 42 CFR §483.25(b) requires prevention of pressure ulcers when avoidable.

Dysphagia care requires upright positioning (90 degrees), small bites, food placed on the UNAFFECTED side (the resident has sensation and motor control there), chin-tuck if ordered, and observation for coughing, pocketing, or wet voice. Feeding lying flat (c) causes aspiration. Mixing foods (a) is unappetizing and does not improve swallow safety. Placing food on the affected side (d) causes pocketing and aspiration. 42 CFR §483.25 and Title 22 CCR §72315 require staff to follow the care plan and prevent avoidable harm such as aspiration pneumonia.

Expressive (Broca's) aphasia means the resident understands but has difficulty producing speech. Best practice: allow processing time, use simple closed-ended questions, offer picture/letter boards, and let the resident finish their own thoughts. Speaking loudly (a) confuses the issue with hearing loss. Avoiding speech (c) violates the resident's right to communication and dignity under 42 CFR §483.10. Forcing writing (d) ignores that writing is often also impaired. Title 22 CCR §72527 protects communication rights.

Parkinson's gait freezing responds to visual or auditory cues — tape lines on the floor, counting aloud, or a marching cadence helps re-initiate movement. Rushing (a) increases falls. Carrying (d) eliminates therapeutic movement and is unsafe. Restricting ambulation between doses (c) is not the CNA's call and ignores fluctuating 'on-off' periods. The CNA should also clear paths, use a gait belt, and report any new freezing or worsening tremor to the nurse per 42 CFR §483.25(d) and Title 22 CCR §72315.

Validation therapy (Naomi Feil) honors the emotional reality behind the words rather than correcting facts. The CNA acknowledges the underlying feeling (love for her children) and offers reminiscence and gentle redirection. Direct contradiction (a) increases agitation. Reality orientation (c) is appropriate only in early dementia or delirium; in moderate-to-severe dementia it causes distress. Ignoring (d) is dismissive and may be psychological neglect under 42 CFR §483.12. 42 CFR §483.40 requires behavioral health services that meet each resident's needs.

Sundowning is increased confusion, agitation, restlessness, or anxiety occurring in the late afternoon or evening in residents with dementia. Contributing factors: fatigue, lighting changes, hunger, unmet toileting needs. CNA interventions: maintain routine, increase daytime light, reduce noise, offer a snack, and engage in calming activities. Delirium (d) is an acute, fluctuating confusion usually from infection or medication and requires nurse evaluation. A 'stage 4 plateau' (b) is not a clinical term. Normal fatigue (c) does not explain consistent agitation. 42 CFR §483.40 requires individualized behavioral interventions.

Therapeutic activities for residents with dementia should match retained abilities, draw on lifelong interests, and offer sensory engagement and success. Hands-on planting honors her identity and provides tactile, olfactory, and visual stimulation. A long lecture (d) exceeds attention span and causes frustration. Isolated movie watching (c) increases agitation and provides no engagement. A 1000-piece puzzle (a) is far beyond cognitive capacity and causes failure. 42 CFR §483.24 requires activities that maintain psychosocial well-being; 42 CFR §483.10 protects the right to make choices about activities.

Loneliness and isolation accelerate cognitive and functional decline. 42 CFR §483.24(c) requires the facility to support psychosocial well-being and meaningful activities. The CNA's role: report the statement to the nurse for care-plan revision, learn about the resident's culture, language, faith, and hobbies, and offer graduated socialization. Documenting without action (a) is neglectful. Forcing attendance (c) violates the right to choose under 42 CFR §483.10. Transfer (b) is not a CNA decision and does not address the underlying need. Title 22 CCR §72381 covers activity programs.

Normal age-related cognitive change includes slower processing speed, occasional 'tip-of-the-tongue' word retrieval, and minor short-term forgetfulness — without loss of judgment, ADL independence, or recognition of loved ones. Failure to recognize family (c), getting lost on familiar routes (a), and decline in self-care (b) are red flags for dementia and must be reported. The CNA should never assume cognitive symptoms are 'just aging.' Per 42 CFR §483.40 the facility must assess and address behavioral and cognitive changes; Title 22 CCR §72315 requires ongoing nursing assessment of resident status.

Depression in older adults is common, often missed, and dangerous — it raises suicide risk and accelerates physical decline. Warning signs: anhedonia, sleep/appetite change, weight loss, hopeless statements. The CNA must report observations and verbatim resident statements to the nurse without delay so the resident can be assessed by the IDT and physician for depression and suicide risk. Waiting (d) risks deterioration or suicide. 'Cheer up' messages (b) shame the resident and worsen depression. Unilateral room changes (c) exceed CNA scope. 42 CFR §483.40 mandates behavioral health services.

Suicide warning signs in older adults include giving away possessions, saying goodbye, hopeless statements, sudden calmness after depression, hoarding medications, and refusing care or medications. Older adults — especially older white men — have the highest suicide completion rate in the U.S. Any warning sign MUST be reported immediately to the nurse who will arrange physician assessment and safety measures. Routine requests (b, d) and exercising the right to choose activities (a) per 42 CFR §483.10 are not warning signs. 42 CFR §483.40 requires behavioral health support.

Wandering is common in dementia and is best managed with redirection, supervised walking, scheduled activity, environmental cues (clear signage, safe walking paths), and care-plan review. Restraints (a, d) without medical necessity and informed consent constitute false imprisonment and abuse under 42 CFR §483.12 and 42 CFR §483.10(e) (right to be free from restraints). Locking residents in (b) is also unlawful restraint. The CNA reports patterns so the IDT can identify triggers (boredom, pain, toileting needs) and adjust the plan.

De-escalation: stop the trigger task, give the resident space, lower voice and posture, validate feelings, and remove yourself if unsafe to summon help. Pushing the resident's hand down (a) or holding her arms down to finish the bath (d) is physical restraint without a physician order and informed consent, violating 42 CFR §483.12 (right to be free from abuse and unnecessary restraint); unconsented physical force during care is also battery (PC §242) and abuse — grounds for immediate termination, criminal prosecution, and CDPH license revocation. Arguing (c) escalates. Title 22 CCR §72319 requires policies on resident behavior management without abuse.

42 CFR §483.10(e) and §483.12(a)(2) prohibit physical or chemical restraints imposed for discipline or staff convenience. Restraints are permitted only to treat a documented medical symptom, with a physician's written order specifying type, location, and duration, after less restrictive interventions have failed, and with informed consent. Staff convenience combined with wandering frequency (b), family preference (c), and a staff member's own judgment that the behavior is disruptive (d) are not legal justifications. Unauthorized restraint is false imprisonment and abuse, reportable to CDPH and law enforcement, and can result in license revocation.

Loneliness is a serious health risk in LTC, linked to depression, dementia progression, and increased mortality. 42 CFR §483.24(c) requires support of psychosocial well-being. The CNA provides presence and reports to social services who can arrange volunteer visitor programs, intergenerational visits, video calls with family, faith community visits, and pet therapy. Minimizing (c) and changing the subject (a) dismiss the resident's emotional reality. Documenting without action (b) is passive neglect. The CNA's compassionate listening is itself a meaningful intervention.

Difficult family dynamics are common and rarely about the CNA personally. The CNA should remain professional, use active listening, acknowledge feelings, and invite a private conversation that includes the nurse or social worker. Arguing (a) escalates and risks complaints. Ordering family out (c) exceeds CNA authority and may violate visitation rights under 42 CFR §483.10(f)(4). Withdrawing care (d) is abandonment. The charge nurse documents the interaction and coordinates with social services per Title 22 CCR §72527 (resident rights).

Substance use disorder in older adults is under-recognized and dangerous (falls, GI bleed, drug interactions). Ingesting alcohol-containing mouthwash is a red flag. The CNA must report observations to the nurse so the physician can assess and the IDT can revise the plan (alcohol-free mouthwash, screening, possibly addiction medicine consult). Ignoring (c) abandons clinical duty. Confronting (b) is shaming and outside CNA scope. Hiding without reporting (d) defeats care planning and may itself be a form of self-neglect facilitation. Under W&I §15610.07 self-neglect is a form of reportable elder abuse.

W&I §15610.07 defines elder/dependent adult abuse to include physical abuse (§15610.63), sexual abuse, neglect (§15610.57), financial abuse (§15610.30), abandonment, abduction, isolation, and the deprivation of goods or services necessary to avoid physical harm or mental suffering. Self-neglect is included. A resident's voluntary refusal of an offered dessert (b) is the exercise of the right to refuse — not abuse. CNAs are mandated reporters under W&I §15630 and must report suspected abuse, including by other staff, family, or visitors.

Under W&I §15630, a CNA in a long-term care facility is a mandated reporter of suspected elder/dependent adult abuse. The reporting flow: report immediately to the charge nurse and administrator AND personally ensure a report is made by phone to the local LTC Ombudsman or law enforcement (immediately for physical abuse) and a written report (SOC 341) within 2 working days. Confronting the suspected abuser (d) risks evidence destruction and retaliation. Waiting (b) or gossiping (c) violates mandated reporter duty and may expose the CNA to criminal penalty under §15630(h).

W&I §15630(b)(1)(A) requires immediate telephone (or via confidential internet report) notification, or as soon as practicably possible, to the local ombudsman, law enforcement, or APS depending on setting (in an LTC facility, ombudsman/law enforcement for physical abuse and serious bodily injury). A written report (form SOC 341) must follow within 2 working days. The resident's consent is NOT required. Delaying for family (c) or resident permission (a) violates the statute. Failure to report is a misdemeanor with fines up to $5,000 and possible jail time under W&I §15630(h).

42 CFR §483.10(f)(11) protects each resident's right to religious and spiritual practice. The CNA may read the passage or, if uncomfortable, arrange another staff member, volunteer, or chaplain. Refusing without alternatives (a, b) is denial of spiritual care. Proselytizing (d) violates the resident's rights and may be psychosocial abuse. Spiritual care reduces anxiety and improves coping in LTC. The CNA respects each resident's faith, dietary practices, and rituals without judgment, consistent with 42 CFR §483.40 (behavioral and psychosocial care).

Title VI (42 USC §2000d) prohibits discrimination based on national origin in any program receiving federal funds, including Medicare/Medicaid facilities. Facilities must provide meaningful language access (qualified interpreters, translated materials). 42 CFR §483.10(b)(3) requires care plan information in a language the resident understands. Speaking louder (c) is ineffective and demeaning. Relying solely on family (b) breaches privacy and may be unreliable. Skipping communication (a) is neglect and violates dignity. Culturally responsive care includes greetings in the resident's language, foods, and customs.

California's LGBTQ Long-Term Care Facility Resident's Bill of Rights (HSC §1439.50 et seq.) prohibits discrimination, mistreatment, or denial of services based on actual or perceived sexual orientation, gender identity, gender expression, or HIV status in LTC. The CNA affirms identity, uses chosen name and pronouns, protects privacy, and reports concerns. Silencing the resident (c) is itself harm. Casual disclosure (d) violates privacy. Refusing care (b) is discrimination and abandonment. Facilities must ensure equal access; violations may trigger CDPH enforcement and civil liability.

Under HSC §1439.50 (Lesbian, Gay, Bisexual, Transgender Long-Term Care Facility Resident's Bill of Rights), willful and repeated failure to use a resident's preferred name or pronouns can constitute prohibited mistreatment. Facilities must address residents by chosen name and pronoun and provide bathing, clothing, and rooming accommodations consistent with gender identity. The CNA documents preferences and reports any staff or roommate harassment. Using the legal name only (b, c) or polling others (a) violates dignity, identity, and CA law. Compliance is also a 42 CFR §483.10 dignity obligation.

Delirium is an acute, fluctuating disturbance in attention and cognition, often caused by infection (UTI, pneumonia), medication, dehydration, or pain. In elders, a UTI commonly presents with new confusion plus fever and incontinence. Delirium is a medical emergency — the CNA must report immediately. Dementia progresses slowly over months/years, not 24 hours (b). Sundowning (a) recurs late afternoon and does not include fever. It is never a 'choice' (c). 42 CFR §483.40 requires prompt response to behavioral and cognitive change.

W&I §15610.30 defines financial abuse as taking, secreting, appropriating, obtaining, or retaining real or personal property of an elder or dependent adult for a wrongful use, with intent to defraud, or by undue influence. Even a person with power of attorney commits abuse if the use is unauthorized or against the resident's interests. CNAs are mandated reporters (W&I §15630) and must report suspected financial abuse to APS or the LTC ombudsman. It is not a 'private matter' (d). POA does not authorize theft (c). The resident need not file written objection (a).

Under PC §11165.7, health practitioners (including CNAs) are mandated reporters of suspected child abuse or neglect, in addition to their elder abuse duties under W&I §15630. PC §11166 requires an immediate telephone report to a child protective agency (police, sheriff, or CPS) as soon as practicably possible, followed by a written report within 36 hours. Waiting for family (a) or only telling the principal (c) does not satisfy the statute. The duty applies whenever the mandated reporter, in their professional capacity OR within the scope of employment, learns of or observes suspected abuse.

Established under the federal Older Americans Act (42 USC §3058g) and codified in California's HSC §9700 et seq., the LTC Ombudsman investigates complaints from or on behalf of LTC residents, advocates for resident rights and quality of care, and is authorized to receive abuse reports under W&I §15630. Ombudsmen do not provide medical care (c), license CNAs (a — that is CDPH), or manage facility operations (d). The CNA must know how to contact the local Ombudsman and post their contact information conspicuously.