Nursing Home News — Page 1181

**Resident #529** faced the most severe consequences from these monitoring failures.

The nurse was observed removing contaminated gloves and immediately putting on new gloves without sanitizing her hands between the glove changes.

The consequences of inadequate supervision can be catastrophic.

The incident revealed multiple breakdowns in communication and medical care that put the resident at significant risk.

When investigators returned nearly an hour later, the temperature remained at the same unsafe level.

Licensed Vocational Nurse 1 (LVN 1) completed the transfer form but failed to document whether or when the resident's emergency contact was notified.

Care conferences are mandatory meetings where healthcare teams, residents, and families discuss treatment plans, goals, and care needs.

The incidents involved taking residents' walkers, pushing residents, punching, spitting, and **knocking pictures off walls to throw them**.

## Medication Management Failures The facility faced significant citations related to proper medication administration and monitoring.

Inspectors observed three separate incidents where nursing staff provided direct care to residents without proper hand sanitization.

Documentation shows the medication was administered inappropriately on March 3, March 4, March 15, March 19, May 9, and May 11, 2025.

In one case, a low air loss mattress designed to prevent pressure sores was set at 550 pounds for a resident who weighed only 138 pounds.