Federal inspectors found that 53 out of 119 nursing staff members completed less than 75 percent of their mandatory annual courses.
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At 12:30 PM on January 28, inspectors watched him drop his cigarette on the ground, lean over to pick it up, and continue smoking it.
Licensed Vocational Nurse A documented the resident's vital signs at 11:14 a.m.
Federal inspectors classified the incident as immediate jeopardy to resident health and safety during a complaint investigation completed July 29.
The 73-bed facility's own policy required physician orders and regular monitoring for physical restraints, but staff could produce neither.
The facility received the telephone orders at 12:23 a.m.
Staff P, the licensed practical nurse, performed wound care on Resident 62, who had venous stasis ulceration caused by damaged valves in leg veins.
On January 19 at 5:20 p.m., a certified nursing aide heard screaming from the room of Resident #2, a man with dementia and violent behavior diagnoses.
Resident 1 had gained nearly 19 pounds in 24 hours before dying.
The resident filed a grievance on November 8, 2024.
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.
Like the first resident, their care plan addressed oxygen therapy for episodes of shortness of breath but omitted any mention of nebulizer therapy.