Nursing Home News — Page 530

Resident 100 had been living at the facility since February with a Foley catheter that required enhanced barrier precautions under his care plan.

The documentation gap emerged when inspectors reviewed the medical record of Resident 9, who developed an open area on her coccyx.

The facility issued an immediate discharge notice on December 19, 2025, but improperly dated it December 16 and listed a hospital as the discharge location.

She was hospitalized the next day with diabetic ketoacidosis, acute kidney injury, encephalopathy, altered mental status, and dehydration.

Yet the facility's Minimum Data Set assessment recorded the same resident as simply "dependent" for bed mobility.

The January 8, 2026 inspection identified a violation categorized as isolated with potential for more than minimal harm, though no actual harm was documented.

Resident U was being transferred with a Hoyer lift on December 8 when the equipment tipped and she hit her forehead on the weight mechanism.

These include antipsychotics, antidepressants, anti-anxiety medications, and mood stabilizers.

The CNA, identified in inspection records as CNA D, had been accused of abusing a resident during a whirlpool bath.

The discharge happened at 7:30 PM, according to the facility's own Discharge Summary.

When inspectors observed the resident's room at 10:37 a.m., no warning signs were posted on the door or wall indicating special precautions were needed.

The resident confirmed she had been physically grabbed and forced into the shower against her will.