Similarly, Resident #42 displayed symptoms starting April 26, progressing to a "congested cough and hoarse voice" by April 29.
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Despite these clear medical orders, the facility's systems failed to ensure consistent delivery of this essential equipment.
This fundamental breach of medication management protocols creates significant health risks.
The violations affected up to 43 residents who regularly ate in the facility's dining areas.
The bacon registered even lower at **77.5°F**, while toast arrived cold at **74.8°F** with unmelted butter still sitting on top.
The kitchen failed to maintain basic food labeling and dating protocols, with multiple items stored without proper identification or expiration dates.
The meatloaf registered at 135°F for regular texture and 127°F for pureed versions, while the spinach au gratin measured only 126°F.
Federal and state regulations mandate that nursing homes maintain an RN on duty for at least eight consecutive hours daily, seven days a week.
QAPI committees serve as the backbone of nursing home quality control, responsible for identifying problems, implementing solutions, and monitoring outcomes.
Despite this known risk and the presence of existing wounds, the facility failed to provide an appropriate pressure-relieving mattress for over a month.
According to the inspection findings, the resident's speech therapist had evaluated her multiple times between admission and discharge from therapy services.
The fall resulted in immediate transport to the emergency room for treatment of injuries sustained in the accident.