Nursing Home News — Page 1132

This safety protocol was clearly outlined on the CNA Assignment Sheet and in the resident's care plan dated April 28, 2023.

Federal surveyors documented that residents consistently waited **30 to 60 minutes** for staff to respond to call lights, creating serious safety risks.

**Resident 40** faced similar risks while taking apixaban for deep vein thrombosis prevention.

The Memory Care Coordinator reported working despite feeling ill, having "spent the weekend in bed sick" with chills and diarrhea.

The resident was ordered to receive 4 liters of oxygen per minute via nasal cannula to maintain blood oxygen levels above 88%.

## Critical Staffing Shortages Documented Federal inspectors found the facility operating with dangerously low staffing levels across multiple shifts.

Federal regulators classified the violation as affecting "few" residents but requiring urgent corrective action.

## Critical Safety Assessment Gaps The inspection centered on Resident #47, whose bed was equipped with turning bars for positioning purposes.

Within days, nursing staff reported the resident had become unusually lethargic and sleepy.

## Poor Appetite and Inadequate Nutrition Monitoring Daily intake records revealed consistently low food consumption.

The citations affected residents who experienced falls resulting in serious injuries, including ankle and hip fractures.

When food service employees fail to wash hands adequately, they can transfer harmful bacteria, viruses, and parasites directly to foods consumed by residents.