Complaint Investigation - LIFE CARE CENTER OF MOUNT VERNON

F-F684

Refer to WAC [DATE REDACTED](1)(3)(c)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 4 of 11 505272 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 505272 B. Wing 05/20/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Life Care Center of Mount Vernon 2120 East Division Street Mount Vernon, WA 98273

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0609 Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 47047

Residents Affected - Few Based on interview and record review, the facility failed to identify and report to the State Hotline an unexpected death for 1 of 1 resident (Resident 1), reviewed for unexpected death in the facility. The failure to report an unexpected death prevented the facility from identifying the occurrence of abuse or neglect and placed other residents at risk for harm and decreased quality of life.

Findings included .

According to Nursing Home Guidelines (Purple Book), Sixth Edition, dated [DATE REDACTED] - Reporting Guidelines to be followed for nursing homes on reporting requirements Appendix D, page 27 showed that unexpected deaths need to be:

1. Reported to the Department of Social Health Services (DSHS) State Hotline

2. Logged on the DSHS reporting log within five days

3. Reported to the Law Enforcement (notify the police or call 911)

4. Call or notification of the Coroner or Medical Examiner

Resident 1 admitted to the facility on [DATE REDACTED] with diagnoses to include congestive heart failure (condition in which the heart doesn't pump blood as well as it should) and cellulitis (bacterial skin infection) of the left and right lower limbs. According to the Admission Minimum Data Set (MDS- an assessment tool) assessment dated [DATE REDACTED], the resident was cognitively intact.

Review of Resident 1's Electronic Medical Record (EMR) showed they passed away unexpectedly in the facility on [DATE REDACTED].

Review of the facility incident reporting log dated [DATE REDACTED] showed no logged entries related to Resident 1's death.

In an interview on [DATE REDACTED] at 11:12 AM Staff A, Nursing Assistant Certified (NAC), stated Resident 1 was not acting themselves, presented with slurred speech, a swollen left arm, and was not able to track with their eyes. Staff A stated they notified their nurse, Staff B at around 9:00 AM and again around 12:00 PM. Staff A stated they knew something was Really wrong with Resident 1 and Staff B was not paying attention. Staff A stated Staff B had not checked on Resident 1 during their shift. Staff A stated they did not notify any other nursing staff of Resident 1's change of condition or of Staff B's lack of assessing the resident.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 5 of 11 505272 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 505272 B. Wing 05/20/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Life Care Center of Mount Vernon 2120 East Division Street Mount Vernon, WA 98273

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0609 In an interview on [DATE REDACTED] at 11:40 AM Anonymous Staff D, RN stated they had received a call from Staff B

on [DATE REDACTED] at approximately 6:19 PM. Staff D stated Staff B informed them that Resident 1 had passed away. Level of Harm - Minimal harm or Staff D stated they worked the next day and attempted to gather information about what had happened with potential for actual harm Resident 1 and the information they obtained was inconsistent with the information Staff B provided to them. Staff D stated several NAC's expressed concerns and were visibly emotional about the passing of Resident Residents Affected - Few 1. Staff D stated Resident 1 was not expected to pass away and was anticipated to return home. Staff D stated they had expressed to Staff E, Director of Nursing Services (DNS), several times about the lack of clinical judgement they observed in Staff B. Staff D stated they had thought about making a report to the state agency but hadn't yet.

In an interview on [DATE REDACTED] at 2:02 PM Staff C, NAC stated on [DATE REDACTED] at the start of their shift at approximately 3:30 PM they attempted to get Resident 1's weight. Staff C stated Resident 1 looked terrible and was trying to say something, but they could not understand them. Staff C stated they had to demand that Staff B go to Resident 1's room to assess them. Staff C stated they had to demand Staff B contact 911 or

they were going to. Staff C stated after Resident 1 passed away they spoke with Staff G Director of Nursing Services (DNS), by telephone and expressed concerns about Staff B's lack of urgency, assessment, and assistance during Resident 1's change of condition.

Review of the written statement by Staff K, NAC dated [DATE REDACTED] at 5:40 PM showed they had asked the assistance of Staff C to obtain a weight for Resident 1 earlier in the day. Resident 1 was described as responsive but nonsensical in their speech. Staff K indicated later vital signs were taken of Resident 1 and there was no pulse and no oxygen. Staff K wrote that the other aides had to push Staff B to contact 911.

In an interview on [DATE REDACTED] at 12:45 PM Anonymous Staff E, LPN stated Staff C, NAC had come to them visibly upset over the passing of Resident 1. Staff E stated it was reported to them that Staff B had been told several times about Resident 1's deteriorating condition and they did not address it. Staff E stated they attempted to discuss the staff's concerns regarding Staff B with Staff G and they were told they needed to keep their mouth shut.

In an interview on [DATE REDACTED] at 4:50 PM Staff G, stated they were kind of familiar with Resident 1 and their care. Staff G stated Resident 1 had respiratory failure and then got a respiratory illness. Staff G stated NACs assisted Resident 1 with all their activities of daily living. Staff G stated they did not know Resident 1's cause of death and they were notified after they had passed away. Staff G stated they completed an incident report, risk management, did not put the statements from staff with it, and had not known they needed to notify the state reporting agency. Staff G stated they had not reported the death the coroner's office or law enforcement. When asked if they had consulted the Purple Book for guidance, Staff G stated they had not.

In an interview on [DATE REDACTED] at 1:00 PM Staff F, Administrator stated Resident 1 was a full code status. Staff F stated the facility staff had performed CPR and used the defibrillator on [DATE REDACTED] and had no concerns. Staff F stated they did not complete an interview with Staff B and no further investigation was completed. Staff F stated the coroner's office was not notified.

Reference WAC [DATE REDACTED](2)(b)(5)(a)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 6 of 11 505272 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 505272 B. Wing 05/20/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Life Care Center of Mount Vernon 2120 East Division Street Mount Vernon, WA 98273

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Level of Harm - Immediate **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 47047 jeopardy to resident health or safety Based on interview and record review, the facility failed to provide a thorough assessment to timely recognize a significant change in condition, take action to notify the medical provider as ordered, and to Residents Affected - Few ensure required staff were certified in Cardiopulmonary Resuscitation (CPR) for 1 of 1 resident (Resident 1) reviewed for an unexpected death in the facility. Resident 1 experienced harm when they had a significant weight gain over a 24-hour period, swelling in their left arm, slurring of their speech, difficulty breathing and change in their mentation throughout the day of [DATE REDACTED], until they were found unresponsive without a pulse when assessment and treatment were delayed for several hours that constituted an immediate jeopardy.

An Immediate Jeopardy (IJ) was identified, and the facility was notified of the noncompliance on [DATE REDACTED]. The IJ was determined to have begun on [DATE REDACTED] when the facility failed to assess and timely act on a resident's significant change in condition. The IJ was removed on [DATE REDACTED] when an on-site inspection validated the facility implemented their removal plan by terminating the staff that failed to assess, treat and timely notify

the physician of Resident 1 regarding their significant change in condition. The facility audited the records of all residents for unidentified changes in condition, educated staff on what to do when a resident has a change in condition, and audited employee Cardiac Pulmonary Resuscitation (CPR) certifications to ensure there were an adequate number of staff working each shift with active CPR certifications.

Findings Included .

Review of the facility policy titled, Changes in Resident's Conditions or Status undated, documented the facility would utilize the Lippincott procedure-change in status, communication and long-term care.

Review of the Lippincott procedures titled, Change in status, identifying and communicating, long-term care, revised [DATE REDACTED], documented the health care team members were responsible for communicating a resident's change in condition from their baseline. A nursing assistant who noticed a change should immediately report them to a nurse and the nurse must communicate a resident's change in status, including assessment findings, to the practitioner. At a minimum, assessment should include:

reviewing the resident's medical record, asking how the resident feels and what symptoms the resident has, obtaining vital signs, observing the resident's overall condition, including function and cognition, exploring the resident's complaints.

Resident 1 was admitted to the facility on [DATE REDACTED] with diagnoses to include congestive heart failure (CHF-condition in which the heart doesn't pump blood as well as it should) and cellulitis (bacterial skin infection) of the left and right lower limbs.

Review of Resident 1's Minimum Data Set (MDS-an assessment tool) dated [DATE REDACTED] showed they were administered the Brief Interview for Mental Status (BIMS-tool to screen for cognitive impairment) with a score of 13 out of 15 which indicated intact cognition.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 7 of 11 505272 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 505272 B. Wing 05/20/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Life Care Center of Mount Vernon 2120 East Division Street Mount Vernon, WA 98273

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Review of Resident 1's electronic medical record (EMR) documented the resident had passed away unexpectedly in the facility on [DATE REDACTED]. Level of Harm - Immediate jeopardy to resident health or Review of the care conference record dated [DATE REDACTED], Resident 1 was planning to return home after safety rehabilitation services at the facility.

Residents Affected - Few Review of Resident 1's care plan dated [DATE REDACTED] showed they were at risk for rehospitalization due to their history of CHF with an intervention for staff to provide timely communication to the physician regarding any change of condition. The care plan also showed Resident 1 may experience weight fluctuations with interventions to include observation and report, as needed, dependent edema of legs and feet, weight gain unrelated to intake, disorientation, cool skin, and weakness and daily weight monitoring before breakfast.

Review of Resident 1's EMR documented weights on [DATE REDACTED] that showed they weighed 324.8 pounds (lbs.) and on [DATE REDACTED] they weighed 343.5 lbs., a weight gain of 18.7 lbs. in a 24-hour period.

Review of Resident 1's Medication Administration Record (MAR) dated [DATE REDACTED], documented a physician order dated [DATE REDACTED] to weigh the resident every day shift before breakfast and report a three lb. weight gain

in a day or five lb. weight gain in a week to the physician. The weight documented on [DATE REDACTED] was 324.8 lbs., and on [DATE REDACTED] the resident's weight was 343.5 lbs. There was no documented weight for [DATE REDACTED].

Resident 1's EMR showed no documentation of the physician being notified of Resident 1's significant weight gain.

Review of Resident 1's MAR for [DATE REDACTED], dated [DATE REDACTED], showed a monitor for edema (swelling that occurs when fluid builds up in the body's tissues) and a documented 3+ (a moderate to severe degree of swelling). [DATE REDACTED] MAR showed no refusals for Resident 1's Lasix (a medication to treat fluid retention).

Review of Resident 1's EMR documented the last vitals for the resident were taken [DATE REDACTED] at 8:49 AM.

Review of Resident 1's progress notes dated [DATE REDACTED] at 5:31 PM documented an entry by Staff B, Registered Nurse (RN), stating the resident had developed difficulty breathing at 3:20 PM and was assessed (oxygen saturations at 96 percent-a measurement of how much oxygen the blood is carrying), resident's oxygen was increased to four liters per minute(lpm-flow rate of oxygen administered to a patient) and provided a nebulizer treatment. The progress note showed Resident 1 stabilized for about an hour, then developed shortness of breath again and was given an inhaler (a device that delivers medication directly to the lungs). At 5:30 PM Resident 1's condition was noted to deteriorate and the NAC's reported they had no pulse. Emergency services were contacted and Resident 1 passed away at 6:18 PM at which time the Director of Nursing Services (DNS) was notified and the provider.

Review of Resident 1's physician orders for [DATE REDACTED], showed there was no order in the residents record to titrate (increase) the oxygen up to four liters a minute.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 8 of 11 505272 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 505272 B. Wing 05/20/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Life Care Center of Mount Vernon 2120 East Division Street Mount Vernon, WA 98273

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Review of Resident 1's MARs dated [DATE REDACTED], documented that the resident had an order for Ipratropium-Albuterol solution 3 milliliters (mL) inhaled orally via nebulizer two times daily AM and bedtime. Level of Harm - Immediate The review showed that on [DATE REDACTED], [DATE REDACTED] and [DATE REDACTED] at AM the resident refused this medication. Staff B jeopardy to resident health or documented in their progress note dated [DATE REDACTED] at 5:31 PM that nebulizer was provided to the resident, safety however this is not reflected on the MAR. The [DATE REDACTED] MAR also documented an order for continuous oxygen to be administered at two L per minute. There was no order or documentation the physician was notified with Residents Affected - Few request to increase the resident's oxygen to four L as documented in Staff B's progress note on [DATE REDACTED] at 5:31 PM.

In an interview on [DATE REDACTED] at 11:12 AM Anonymous Staff A, Nursing Assistant Certified (NAC), stated that on [DATE REDACTED] they were the assigned NAC for Resident 1 and the resident was not acting themselves. The resident had slurred speech, a swollen left arm, and was not able to track with their eyes. Staff A stated they notified their nurse, Staff B, Registered Nurse (RN) at around 9:00 AM and again around 12:00 PM. Staff A stated they knew something was Really wrong with Resident 1 and they felt that Staff B was not paying attention. Staff A stated Staff B had not checked on Resident 1 during their shift. Staff A stated they did not notify any other nursing staff of Resident 1's change of condition.

In an interview on [DATE REDACTED] at 12:16 PM Staff B stated they were the assigned nurse to care for Resident 1 on [DATE REDACTED] and had worked a double shift that day, 6:00 AM-10:00 PM. Staff B stated they recalled Resident 1 and their diagnoses of Chronic Obstructive Pulmonary Disease (COPD-a group of chronic lung diseases) and high blood pressure. Staff B stated they were notified at approximately 3:00 PM on [DATE REDACTED] of Resident 1's change of condition by an NAC. Staff B stated they assessed Resident 1's lungs and they were clear, and

the oxygen saturations were at 90%. Staff B stated Resident 1 used continuous oxygen therapy, had shortness of breath and provided breathing treatment by inhaler per physician orders. Staff B stated they directed the NAC to keep a close eye on Resident 1. Staff B stated they were called back to Resident 1's room between 4:,d+[DATE REDACTED]:00 PM and stated the resident had deteriorated and was pulseless. Staff B stated they checked Resident 1 for a pulse, found one, and provided them with an ordered nebulizer (physician ordered treatment which administers a fine mist of respiratory medication through a medical device to improve breathing) breathing treatment before exiting the room and calling 911. Staff B stated Resident 1 passed away in the facility after CPR was provided by the NAC's and emergency medical services (EMS). Staff B stated Resident 1 had refused medication for the last two shifts, which included Lasix and Albuterol. Staff B stated they had not called the physician during their shift regarding Resident 1 but had notified the Resident Care Manager and the Director of Nursing Services after they passed away. Staff B stated they did not perform CPR on Resident 1 and stated there were NAC's in the room to initiate it. When asked about Resident 1's swollen left arm, they stated Resident 1 their left arm was not new, and they had that for a while.

In an interview on [DATE REDACTED] at 2:00 PM Staff F, Administrator, stated Staff B did not have a current Cardiopulmonary Resuscitation certification.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 9 of 11 505272 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 505272 B. Wing 05/20/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Life Care Center of Mount Vernon 2120 East Division Street Mount Vernon, WA 98273

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 In an interview on [DATE REDACTED] at 11:40 AM Anonymous Staff D, RN stated they had received a call from Staff B

on [DATE REDACTED] at approximately 6:19 PM. Staff D stated Staff B informed them that Resident 1 had passed away. Level of Harm - Immediate Staff D stated Staff B was difficult to understand because they were scattered. Staff D stated Staff B reported jeopardy to resident health or Resident 1 had been having breathing problems and they had given them a nebulizer. Staff D stated Staff B safety then hung up. Staff D stated they worked the next day and attempted to gather information about what had happened with Resident 1 and the information they obtained was inconsistent with the information Staff B Residents Affected - Few provided to them. Staff D stated several NAC's expressed concerns and were visibly emotional about the passing of Resident 1. Staff D stated Resident 1 was not expected to pass away and was anticipated to return home. Staff D stated they had expressed to Staff E, Director of Nursing Services (DNS), several times about the lack of clinical judgement they observed in Staff B. Staff D stated they were unaware of the weight gain Resident 1 had from ,d+[DATE REDACTED]-[DATE REDACTED] and stated the physician should have been notified after reweighing them.

In an interview on [DATE REDACTED] at 1:14 PM Staff H, NAC stated they worked with another NAC on [DATE REDACTED] and took care of Resident 1. Staff H stated they assisted with a brief change on [DATE REDACTED] at approximately 12:00 PM. Staff H stated Resident 1 was incoherent, was not making sense and this was unusual for them. Staff H stated the other NAC stated they were going to notify the nurse of Resident 1's change in condition. Staff H stated they did not notify anyone of Resident 1's change in presentation.

In an interview on [DATE REDACTED] at 1:25 PM Staff I, Licensed Practical Nurse (LPN) stated they were not familiar with Resident 1's care. Staff I stated they were notified on [DATE REDACTED] by an NAC that Staff B, RN needed help with Resident 1 who had no pulse. Staff I stated they went to the nurse's station and Staff B was on the phone with 911. Staff I stated they did not assess Resident 1 and their only involvement was when Staff B handed them the phone with 911 still on. Staff I stated if a resident had no pulse and was a full code, CPR should start immediately.

On [DATE REDACTED] at 11:38 AM a staff list of CPR certifications was requested and there were 86 nursing staff without certifications. Staff B and I did not have current CPR certifications, and there was no documentation as to when they had prior certification or when their certifications expired.

Review of facility LPN and RN job descriptions, undated, showed LPN's and RN's must have a CPR certification upon hire and remain current during employment.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 10 of 11 505272 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 505272 B. Wing 05/20/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Life Care Center of Mount Vernon 2120 East Division Street Mount Vernon, WA 98273

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 In an interview on [DATE REDACTED] at 2:02 PM Staff C, NAC stated on [DATE REDACTED] at the start of their shift at approximately 3:30 PM they attempted to get Resident 1's weight. Staff C stated Resident 1 looked terrible Level of Harm - Immediate and was trying to say something, but they could not understand them. Staff C stated they decided to hold off jeopardy to resident health or on getting the resident's weight and notified the nurse. Staff C described Resident 1 as not looking well and safety being pale in color. Staff C stated when they notified Staff B of the resident's changes Staff B stated Resident 1 just needed their inhaler. Staff C stated they had to ask Staff B to come into Resident 1's room Residents Affected - Few and assess them and Staff B did not take their concerns as urgent or serious. Staff C stated they checked on Resident 1 again at approximately 4:00 PM and they were not speaking anymore, their breathing was very slow, and their skin was waxy and yellow in color. Staff C stated they directed the NAC with them to get Staff B and Staff B returned with nebulizer treatment. Staff C stated they told Staff B something was wrong, but

they proceeded with placing a nebulizer mask on the resident. Staff C described Resident 1 as having their eyes rolled back in their head, their tongue was sticking out of their mouth, and they did not appear to be breathing when Staff B placed the nebulizer mask on them. Staff C stated they told Staff B to call 911multiple times and finally told them if they did not call for EMS, they would. Staff C stated when Staff B returned to the room, another aide had asked Staff B if they should start CPR and Staff B did not respond and left the room again. Staff C stated Resident 1 was not expected to pass away, they were planning on returning home. Staff C stated they were interviewed by Staff G on the evening of [DATE REDACTED] over the telephone regarding this incident.

Review of the Fire Department EMS patient care record for Resident 1, dated [DATE REDACTED] at 5:47 PM showed the staff present stated they had completed seven rounds of CPR and Resident 1 had been seen 40 minutes prior and had complained of shortness of breath. Resident 1 was documented to be unresponsive, pulseless, was cool to touch and pale in color, and their lower extremities revealed cellulitis (serious bacterial infection) and pitting edema (a type of swelling where a pit remains after applying pressure indicating fluid buildup in

the tissues).

In an interview on [DATE REDACTED] at 4:50 PM Staff G stated Resident 1 had respiratory failure and then got a respiratory illness. Staff G stated NACs assisted Resident 1 with all their activities of daily living. Staff G stated they did not know Resident 1's cause of death and they were notified after they had passed away. Staff G stated Resident 1 did not have a history of refusing care or treatments and their death was not expected. Staff G stated they were unaware of any weight changes for Resident 1, changes in weight were to be reported to the provider, and the provider should have been notified of the resident's weight increase from ,d+[DATE REDACTED]-[DATE REDACTED].

In an interview on [DATE REDACTED] at 1:00 PM Staff F, Administrator stated Resident 1 was a full code status. Staff F stated the facility staff had performed CPR and used the defibrillator on [DATE REDACTED] and had no concerns. Staff F stated information had come to them about Resident 1 after they passed away. Staff F stated they did not complete an interview with Staff B and relied upon their progress note in Resident 1's EMR. Staff F stated

they did not think Staff B notified the doctor, did not contact them, and lacked communication with the proper individuals regarding Resident 1's change of condition. Staff F stated they did not know why the NACs did not seek out another nurse after informing Staff B of Resident 1's change of condition and getting no response.

Cross reference