That sequence of events is what federal inspectors documented during a January 30 complaint inspection at the Frederick facility.
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On at least 15 separate days between Christmas Eve and late January, the kitchen operated with only two workers.
The resident who struck her, Resident 2, scored 8 out of 15, indicating moderate impairment.
Without those checks, there is no reliable way to know whether the dishes coming out of the machine are sanitized or simply wet and clean-looking.
Cohorting, the practice of grouping patients with the same infection or exposure together, is a standard infection control measure.
It did not specify procedures for putting on and taking off gloves before, during, and after peri-care procedures.
The resident, identified in inspection records as Resident 11, had a Foley catheter for a condition called neurogenic bladder.
The facility could not produce a documented rationale for the prescription when inspectors asked for one on February 10.
The resident, identified in inspection records only as Resident #75, was admitted to the facility with type 2 diabetes.
Nobody had done the required assessment first.
Bins of sugar, flour, and cornmeal sat open with no date markings.
Inspectors noted he had intact cognition.