Resident 40 lay on the floor of his room at Crestview Health & Rehabilitation on May 27, 2024, at 10:40 pm when his roommate yelled for help.
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Like the first resident, their care plan addressed oxygen therapy for episodes of shortness of breath but omitted any mention of nebulizer therapy.
Federal inspectors found the pattern during a May inspection at Astoria Healthcare Center on Astoria Street.
A nurse documented the condition and noted that the nurse practitioner had been notified.
LPN #7 continued providing care to the resident after the alleged incident.
Resident #1 told inspectors the facility lacked adequate staff to meet her needs.
R114's fluid consumption dropped from 1,560 milliliters daily to just 300 milliliters in the days before her January transfer to the hospital.
One aide admitted he "forgot" to cover his mustache and goatee while scooping watermelon and placing silverware.
"Employee 1 indicated she was never educated at the facility on the administration of intravenous medications," inspectors wrote.
Resident 16 remained on the restrictive mattress at North Long Beach Post Acute despite his physician canceling the order on July 18, 2023.
Federal inspectors cited the facility for immediate jeopardy violations, finding a likelihood of serious injury, harm, or death from the unlicensed care.
The patient had been admitted with diagnoses including asthma, dependence on supplemental oxygen, and malignant neoplasm of unspecified bronchus or lung.