Nursing Home News — Page 577

Posted schedules for January 25 showed only eight CNAs working the morning shift, six on the evening shift, and four during the overnight hours.

This represented a 7.01% weight loss, exceeding the clinical threshold of 5% that triggers heightened monitoring and intervention.

## December Immediate Jeopardy Period An immediate jeopardy situation occurred at the facility beginning December 20, 2024.

## Federal Oversight Process The Centers for Medicare & Medicaid Services conducted a complaint investigation at the facility on July 12, 2024.

to arrive for treatments beginning at 4:15 a.m.

This documentation failure revealed a systemic breakdown in the facility's ability to track resident whereabouts.

However, staffing records showed they were consistently short by 0.5 to 1 CNA across multiple shifts.

Thirty residents were supposed to be on EBP protocols, but inspectors found widespread non-compliance with safety requirements.

However, inspectors found **no documentation** of these critical safety measures in the resident's medical record.

The most concerning finding involved Lorazepam Injectable, a controlled substance used to treat anxiety symptoms and prevent seizures.

The staff who ignored the emergency signal included the Director of Nursing, two licensed nursing personnel, and the Activities Director.

During interviews, the DSS admitted she had started the required dietary manager course but failed to complete the certification process.