complaint·February 9, 2023

During interviews with staff, staff S1 stated that during resident checks on the morning of June 8, 2020, R1 did not look well, and was pale in the face. S1 immediately checked R1’s oxygen level and vitals, and was concerned due to low levels. S1 called the Administrator to inform them that R1 was declining and had a change of condition. The Administrator informed S1 to give R1 oxygen as comfort care per R1’s hospice order for oxygen. S1 immediately called hospice, and hospice informed S1 that they were on the way to the facility. While S1 was calling hospice, the Administrator called R1’s family to inform them of R1’s change of condition. When the hospice nurse arrived at the facility, R1 had already passed, and was officially pronounced deceased upon arrival. For allegation, Staff administered oxygen without a Dr. order: During document review, LPA discovered that R1 had a doctor’s order for Oxygen from the hospice doctor dated April 4, 2020. LPA also discovered that the Administrator and S1 had Oxygen Safety Training completed on December 13, 2019, by a Registered Nurse from a hospice company. Additionally, S1 had a second Oxygen Safety Training and Education completed on April 8, 2020. Based on the evidence gathered during the investigation, the allegations listed above are deemed UNSUBSTANTIATED. A finding that the complaints are UNSUBSTANTIATED means although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. During today’s visit, no deficiencies were cited per Title 22, Division 6, of the California Code of Regulations. An exit interview was conducted, and this report (LIC9099) was discussed and provided Administrator Restituto Calilung, along with a copy of the appeal rights.