According to the inspection report, documentation gaps occurred on multiple dates across three months.
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The resident had been admitted in December 2024 with diagnoses including cerebral palsy, Type II diabetes, and depression.
Resident #47 was missing 60 tablets of oxycodone/acetaminophen 5/325mg, while Resident #57 was missing 30 tablets of oxycodone 5mg.
A resident with ESBL infection remained in a shared room despite facility policies requiring private room placement when beds were available.
Facility records showed the patient's itching symptoms had resolved by June 2024, yet both medications continued to be administered through September.
The facility failed to meet federal standards for tracking and evaluating significant weight changes among residents.
Nursing facility failed to follow ordered care plans for resident hand splints, potentially compromising recovery outcomes.
Similarly, Resident 44's Zosyn medication label didn't match the physician's order.
WanderGuard devices function as electronic monitoring systems that alert staff when residents with cognitive impairment approach exit doors.
After completing the feeding, RN AA moved to another table and fed a fifth resident using the resident's own spoon.
Dialysis patients require specialized monitoring due to the complex medical risks associated with both the treatment and the access site.
The same nurse then handled a germicidal wipe to clean the glucometer without first applying gloves, creating multiple opportunities for cross-contamination.