Federal inspectors observed the violations at 5:24 a.m.
Nursing Home News — Page 464
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Resident 40 arrived at the facility with a stage IV pressure ulcer on the sacrum that measured 4 centimeters by 6 centimeters.
The 30-bed facility admitted Resident #31 on November 11 after he reported losing 45 pounds in three months.
The facility only filed the required report on September 11th after the resident's family raised concerns during a care conference.
Federal inspectors observed Licensed Practical Nurse #652 give him his prescribed Symbicort inhaler at 10:02 A.M.
Resident 12 requires complete assistance with all bed mobility according to his medical assessment.
Federal assessments showed the resident had severely impaired cognitive skills and could not understand or make decisions about their care.
But no such signs appeared on the doors of residents receiving oxygen therapy.
The resident's diagnoses included schizoaffective disorder, schizophrenia, and depression.
RN 2 told inspectors the facility's protocol requires nursing staff to inform Psychiatrist 1 of any consultation order the same day it's written.
The Director of Nursing placed a verbal order to the pharmacy the same day, but complications quickly emerged.
The former employee hadn't worked at the facility since May 2025, according to the administrator interviewed during a December inspection.