Complaint·May 8, 2026

Continued from LIC9099 Review of facility procedure for, “Vital Sign Readings to Determine the Need for Medication,” stated the following: · Facility Procedure: residents, who are physically and mentally capable of reading vital signs may take their blood pressure and pulse readings; a Physician or registered nurse (RN); a licensed vocational nurse (LVN) under the direction of an RN or physician. · Per document, unlicensed care staff may not take vital signs but may assist with self-evaluation of vital signs. Interview conducted with Care Services Director stated that R1's PRN "as needed" supplement oxygen was discontinued after they returned from a skilled nursing facility in 2025. Care Services Director further stated that prior to R1's discharge from the hospital in February 2026, the facility received correspondence stating that R1 no longer required scheduled oxygen or oxygen as needed. Review of R1's facility documents showed that on 12/13/2024 and 12/16/2024, R1 received physician orders for supplemental oxygen and for an oxygen concentrator. Review of R1's medication authorization record (MAR) indicated that R1 received their oxygen from 12/17/2024 to 02/20/2025. Review of R1's paperwork showed that R1 was admitted to the hospital on 02/20/2025 for acute respiratory failure. R1's discharge paperwork dated 02/26/2025, stated that R1 briefly required supplemental oxygen during their stay but was weaned off to room air. Review of R1's physician medication lists for 04/10/2025, 01/27/2026, and 02/21/2026 did not show any orders for supplemental oxygen. Based on record review, interviews conducted, and observations made, this allegation is Unfounded . A finding of Unfounded means that the allegation is false, could not have happened, and/or is without a reasonable basis. Exit interview conducted. Copy of report discussed and provided to Hospitality Services Director and Care Services Director. Signature on form confirms receipt of documents. Continued from LIC9099 and R1 was transported to the hospital. Review of R1’s physician orders dated 01/27/2026 stated that R1 had the following routine and PRN “as needed” medication orders for shortness of breath: · Breyna 160-4.5MCG HFA AER AD: Inhale 2 puffs by mouth twice daily for asthma exacerbation – rinse mouth after use · Ipratropium-albuterol outer UD 0.5-3MG/3 Ampul-neb: 1 vial (3ML) via nebulizer inhalation every 8 hours as needed for shortness of breath Review of R1’s medication administration record (MAR) for February 2026 stated that on 02/13/2026, 02/14/2026, and 02/15/2026, facility staff administered R1’s PRN or “as needed” nebulizer treatment for shortness of breath. Review of documentation stated that after receiving their nebulizer treatment on 02/13/2026 and 02/14/2026, R1 reported to facility staff that the treatment helped. On 02/15/2026, documentation stated that R1 was given their nebulizer treatment during the morning shift and later reported to facility staff that they still didn’t feel well. Review of R1’s care tracking log stated that on 02/15/2026, R1 complained of discomfort and requested for their inhaler. Per care log, after receiving their inhaler, R1 reported to facility staff to still to be in discomfort. R1 was then offered their nebulizer treatment. Facility staff checked on R1 an hour later and R1 reported that they were feeling better. Care Tracking Note for 02/15/2026 continued to state that R1 requested another second nebulizer treatment from facility staff, stating that they were having trouble breathing. Facility staff then contacted emergency services for further evaluation. Review of Facility's Policy and Procedure for "Change in Resident Status," indicated that community staff have the responsibility to provide care to each resident and summon medical attention when there is a change in status. If the change in status progresses to a crisis, then facility should contact emergency services. Based on record review and observations made, this allegation is Unsubstantiated . A finding that the complaint allegation is Unsubstantiated means that 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. Exit interview conducted. Copy of report discussed and provided to Hospitality Services Director and Care Services Director. Signature on form confirms receipt of documents.