The oxygen failures involved two residents with serious respiratory conditions.
Nursing Home News — Page 296
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Three residents were affected by staff who skipped hand hygiene steps or failed to wear required protective equipment.
The incident at Ingleside Manor involved two residents in December 2024.
She never washed her hands before putting on gloves.
The protections apply regardless of whether residents are known to carry resistant bacteria.
The woman, identified in inspection records only as R1, had been assessed just two days earlier as having no elopement risk factors.
Federal inspectors found the facility knew about the resident's condition but took no meaningful steps to prevent access to alcohol.
The charge nurse found blood on his mouth and nose, soot covering his face, and his beard burned off and still smoking.
R146 was admitted March 30 with altered mental status.
The woman had activated her call light at 8:15 a.m.
Jefferson Healthcare Center created a quality improvement plan on March 25 specifically targeting medication cart audit problems.
"The kitchen does not have enough sippy cups to go on residents' meal trays," one dietary aide told inspectors.