The resident's psychiatric medication was ordered to be administered at 9:00 PM daily, but staff failed to provide these doses.
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Water at 127 degrees Fahrenheit can cause first-degree burns in just one minute of exposure.
When nursing staff initially observed the skin breakdown on March 14, multiple certified nursing assistants reported seeing the affected area.
The April 2025 inspection documented improperly installed and maintained bed equipment throughout the 159-bed facility, prompting emergency corrective actions.
Inspectors observed dried brown smears on bathroom walls near light switches and on bedside commodes, which facility staff confirmed was fecal matter.
The violations affected multiple residents and created risks for medication errors, untreated medical issues, and deteriorating health conditions.
Personnel records examined during the inspection showed Cook D's initial dementia training occurred shortly after their hire date of December 16, 2023.
Long, untreated toenails in elderly residents create significant health risks beyond discomfort.
These specialized medical devices require precise monitoring and regular maintenance to prevent life-threatening complications.
By May 2025, the 58-year-old resident reported she could no longer see faces, read books, or even see her food during meals.
This oversight represents a fundamental breach of infection control protocols.
He speculated the medication was "probably on the medication due to R34's medical history" but had no documentation to support this assumption.