The resident had a 7.5 size tracheostomy tube in place, but facility records incorrectly indicated it was a 6.5 size.
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Any changes in a resident's condition or oxygen needs should be immediately reported to the attending physician for potential order modifications.
During the inspection, federal surveyors observed the injury measured approximately 3.8 centimeters by 2.5 centimeters under the resident's left eye.
Normal oxygen saturation ranges from 96 to 100 percent.
On August 13, 2024, inspectors observed a registered nurse hanging IV fluids for the resident without wearing the required protective gown.
The attending physician ordered a urinalysis and urine culture test to identify any infection.
Within days of admission, staff completed a PHQ-9 depression screening that revealed a score of 17 - indicating moderately severe depression symptoms.
The resident required assistance with all personal care activities including toileting, dressing, and hygiene.
The resident, who spoke only Spanish, repeatedly struggled to interact with nursing staff and access basic services.
The February 2025 inspection revealed a facility operating with dangerously inadequate staffing levels that compromised resident safety and dignity.
The dirty laundry area contained a large bin with an askew lid that was full of dirty laundry, some of which was unbagged.
Federal regulations require nursing homes to monitor residents continuously and notify physicians promptly when conditions change.