Nursing Home News — Page 410

None of these assessments appeared in the resident's official care plan or MDS evaluation upon admission.

Instead, multiple visit notes sat unsigned and unrecorded until the physician uploaded them in batches weeks later.

Resident #15 had a suprapubic catheter that required a securement device to prevent dangerous dislodgement.

The man has Alzheimer's disease, kidney disease, and requires maximum assistance with nearly every daily activity.

But the care plan told a different story.

Federal inspectors examining the facility's Treatment Administration Records found systematic gaps in documentation spanning July and August 2025.

The facility's own assessment classified the resident as high risk for wandering, with a score of 14 on their Wandering Risk Scale.

The medication error came to light only after Resident #2 fell and staff discovered two rivastigmine patches on his body during examination.

The MOLST documents guide critical decisions about cardiopulmonary resuscitation and other emergency interventions.

CNA #20 admitted multiple safety violations during her interview with inspectors.

The October 23 complaint investigation centered on Resident #3, who developed blisters on both hips during their stay.

Yet the family remained unaware until they happened to be present when the wound care provider came to the resident's room.