Nursing Home News — Page 1135

## Missing Critical Assessments The facility failed to complete mandatory nursing assessments for three residents during crucial care transitions.

The 76-year-old patient, who had been diagnosed with Alzheimer's disease and severe cognitive impairment, was unable to explain how the injury occurred.

The contaminated cup was then placed on the nursing station desk, further spreading potential infectious agents throughout the care environment.

## Missing Physician Orders Create Safety Risks The lack of organized medical records extended to critical physician orders.

The previous DON had departed several months earlier, leaving other staff members to assume portions of the critical leadership role's responsibilities.

The agreement waives the resident's right to pursue legal action through the court system.

Pureed diets are prescribed for residents with dysphagia or swallowing disorders, conditions common in nursing home populations.

However, inspection records reveal these critical interventions were not consistently implemented.

Additionally, the position requires one year of supervised social work experience in a healthcare setting working directly with individuals.

The remaining 105 residents received nutrition through feeding tubes.

The inspection resulted in documented violations of federal nursing home regulations.

## Critical Communication Failures Investigation revealed concerning gaps in staff knowledge regarding the resident's care preferences.