Nursing Home News — Page 967

This screening error had cascading effects on the resident's care.

The licensed vocational nurse assigned to the cart admitted she had gone to a resident's room and failed to properly lock the medication cart.

The resident's care plan, updated in January 2025, explicitly stated that a mechanical lift must be used for all transfers with two staff members present.

The 36-year-old resident, admitted in February 2024 with dementia and neurogenic bladder dysfunction, required an indwelling catheter.

The combination medication, prescribed to manage chronic respiratory conditions, had expired on March 17 but remained in the facility's medication cart.

The fall resulted in a fractured right femur requiring surgical repair.

## Dangerous Call Light Response Times The most concerning findings involved extended delays in responding to resident call lights.

Despite his preference for assisted living, staff discharged him to a homeless shelter against his wishes.

Despite these clear requirements, the nursing assistant attempted a manual transfer that resulted in the resident falling to the floor.

The family delivered these orders directly to facility staff.

According to the inspection report, the resident's oxygen saturation levels dropped to 88% and then to a critically dangerous 70%.

The resident's medical history revealed years of abuse by the family member, including verbal, emotional, financial, and physical mistreatment.