Another resident reported being left in a wet incontinence pad for over two hours on the morning of April 23.
Nursing Home News — Page 1214
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The April 2025 inspection revealed systemic breakdowns in fundamental healthcare practices that exposed vulnerable residents to preventable infections.
The Nurse Manager did follow proper hand hygiene protocols between steps but failed to don the required gown before beginning the procedure.
The inspection also revealed failures in basic hygiene protocols and active pest infestations in the facility's kitchen.
The director acknowledged responsibility for notifying residents or their representatives about scheduled care plan meetings.
These residents had not received timely evaluations or physician notifications as required by federal regulations.
When QAPI committees fail to function properly, patterns of deficiencies can persist unchecked, potentially affecting multiple aspects of resident care.
During the inspection, administrators identified Staff B as the interim Director of Nursing, a position they had assumed in February 2025.
The Director of Nursing (DON) acknowledged during an interview at 3:10 p.m.
The delay is particularly concerning given the resident's complex medical needs.
The resident walked directly onto a busy street with heavy traffic.
Beyond the sink misuse, inspectors documented extensive problems with food storage and quality control.