complaint·August 21, 2023

...continued from LIC9099 UNSUBSTANTIATED : Facility staff did not ensure that resident's oxygen canister was full. Facility staff did not implement resident's doctor's orders. Facility staff did not administer resident new prescription medications timely. For the allegation, facility staff did not ensure that resident's oxygen canister was full. LPA interview S1 and S2 that both stated R1 received oxygen from a concentrator and canister daily. On 03/31/23, R1 was in the common area when W5 arrived who stated that R1’s Oxygen Saturation (SO2) was about 70% which was unacceptable and life threatening. LPA asked were the paramedic’s contacted; W5 stated, “No, I happen to catch it in time” W5 did not provide LPA with any documentation for R1’s OS and said that R1 would be moving after the incident. S1 provided LPA with R1’s Service Plan Details, charted eMar and Vital Signs Trends Report for R1’s SO2. R1’s SO2 remained constant on 03/31/23; at 6:22 AM 96% was recorded, at 1:26 PM 96% was recorded, and at 9:03 PM 97% was recorded. W5 did not provide any documentation of R1’s SO2 levels. On 03/31/23, S2 provided R1 with a replacement cannister and S1 stated that it would be impossible for R1 to walk or breathe if R1’s SO2 was at 70%. Records reviewed revealed that R1’s doctor’s orders were being followed. Oxygentank, R1's SO2 distributor, delivered twelve (12) canisters on 03/02/23 and twelve (12) on 03/16/23. W1 did not return LPA’s phone calls prior, during or after the investigation on 05/01/2023 to confirm R1’s new prescription that was alleged to not being administered. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED . Exit interview and a copy of this report provided to ADM.