Nursing Home News — Page 929

Three of these individuals had been employed in nursing roles since 2021, while two others had worked without proper licensing since 2023.

The resident reported experiencing pain at a 7 out of 10 level during wound dressing changes.

Despite this nurse providing a written statement about what she observed, facility administration conducted no thorough investigation.

This admission came after surveyors observed the protocol violation during their inspection.

The resident, who required complete staff assistance for movement and changing of incontinence products, was observed at 12:19 p.m., 4:29 p.m., and 4:51 p.m.

When blood oxygen saturation falls below 90%, tissues and organs begin receiving insufficient oxygen, a condition called hypoxemia.

No documentation was provided before the inspection concluded.

Resident 37, diagnosed with Huntington's Disease and dementia, had documented behaviors of banging their head against walls and punching walls.

Controlled substances require strict monitoring because of their potential for abuse and dependency.

The administrator, identified as S1ADM in the report, acknowledged to inspectors that **a 51-minute wait for changing soiled clothing was unacceptable**.

The inspection revealed systemic breakdowns in basic safety protocols affecting multiple areas of resident care.

The inspection, conducted from February 24 through March 3, 2025, resulted in an immediate jeopardy declaration affecting all 72 residents at the facility.