Nursing Home News — Page 974

A resident with severe cognitive impairment and dementia was taking multiple medications that the facility's pharmacist identified as problematic.

The medications were labeled with the resident's name but came from an outside pharmacy, violating facility policies.

The resident had a 7.5 size tracheostomy tube in place, but facility records incorrectly indicated it was a 6.5 size.

Any changes in a resident's condition or oxygen needs should be immediately reported to the attending physician for potential order modifications.

Normal oxygen saturation ranges from 96 to 100 percent.

On August 13, 2024, inspectors observed a registered nurse hanging IV fluids for the resident without wearing the required protective gown.

Within days of admission, staff completed a PHQ-9 depression screening that revealed a score of 17 - indicating moderately severe depression symptoms.

The dirty laundry area contained a large bin with an askew lid that was full of dirty laundry, some of which was unbagged.

A colleague who witnessed the incident reported that the CNA used the resident's personal beard shaver to perform the grooming.

## Medication Storage and Safety Failures Federal inspectors documented serious medication management issues throughout the facility.

The facility holds monthly QAPI meetings with quarterly participation from the medical director and pharmacist, as required by regulations.

After removing the old dressing and cleaning fecal matter from the resident's anal area, the nurse changed gloves but failed to sanitize hands between steps.