Nursing Home News — Page 1127

## Dangerous Laundry Practices Exposed Surveyors observed laundry rooms on three separate units with no separation between clean and dirty areas.

The facility was required to submit an emergency removal plan within days to address the critical safety concerns.

The physician's order contained a potentially fatal error in the hold parameters - the instructions for when nurses should withhold the medication.

Inspectors documented the nurse pouring 2.5 ml of the suspension into a dosage cup at 8:08 AM without first shaking the pharmacy bottle as required.

Inspectors observed these medical devices stored at residents' bedsides without protective covering over multiple days of observation.

This represents a fundamental failure in the facility's internal oversight system designed to protect residents from preventable injuries.

The violation was documented under federal regulation F 0880, which governs infection prevention and control standards.

Despite facility protocols requiring 72-hour alert monitoring after falls to watch for latent injuries, staff failed to implement these safety measures.

When staff returned one minute later, the resident was found unresponsive with his upper body on the bed and lower extremities hanging off the side.

The immediate jeopardy period lasted from December 13, 2024, to January 22, 2024, before being downgraded after the facility implemented corrective measures.

The funding structure presented additional obstacles to comprehensive programming.

Federal inspectors discovered that Villa Del Sol had no Legionella testing results for 2024 or 2025, despite facility policies requiring annual testing.