Resident 67 has severe cerebral palsy with extreme stiffness in all limbs and cannot move.
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The facility operates under a special federal exception that allows them to use a wireless call light system instead of the standard hardwired version.
DON B told the inspector she had been notified of the situation that same morning, December 23, the day the inspector arrived.
Inspectors tagged it under F0684, which covers the standard of care residents are entitled to receive.
The wound care nurse, identified as V3 in the report, said she would need to ask maintenance to fix the setting.
The December 23 inspection revealed nurses ignored basic cardiac emergency protocols when the resident needed immediate intervention.
Federal inspectors found the documentation gaps at Northern Dauphin Nursing and Rehabilitation Center during a December 23 complaint investigation.
LPN #480 was terminated December 25th after a facility investigation revealed multiple medication discrepancies involving controlled substances.
The administrator confirmed he had substantiated that Resident #105 was verbally abused by RN K, according to the inspection report completed December 23.
Resident 1 was found on the floor at 3:50 p.m.
The December 19 incident at Crystal Cove Care Center occurred during wound care for a resident with a serious pressure injury on their tailbone area.
She walked directly to the nurse's station without closing the door.