Nursing Home News — Page 1191

The investigation revealed that the CNA admitted to striking the resident's hand in response to the resident's behavior.

Records show the resident had been repeatedly getting out of bed unassisted throughout the evening.

The facility's medication error rate reached **6.06%**, exceeding the federal standard requiring error rates below 5%.

**Resident 41**, who was diagnosed with dementia, major depressive disorder, and schizoaffective disorder, exemplified this critical oversight.

More concerning, the facility administrator was not informed of the sexual abuse incident until February 4, 2025 - months after it occurred in September 2024.

During the first incident on May 20, 2024, at 1:30 a.m., the resident was discovered outside the facility at 2:34 a.m.

This represents a fundamental breakdown in medical care protocols that govern how nursing homes provide respiratory treatments to residents.

During this observation at 1:46 PM, two staff members were seen passing the unsecured cart before the responsible Registered Nurse returned and locked it.

The resident, admitted in September 2024 with diagnoses including diabetes and kidney disorders, had been placed on hospice care in January 2025.

Incomplete or inaccurate assessments can lead to several concerning outcomes.

When facilities fail to maintain adequate quality assurance programs, it can lead to systemic problems affecting multiple aspects of care delivery.

Similar patterns emerged with other residents.