Nursing Home News — Page 560

The resident, identified in inspection records only as R1, was transferred to the facility's rehabilitation unit after a hospital stay in early August 2025.

The failures affected a small number of residents.

Two separate care plans also required weight monitoring.

According to the facility's Director of Nursing, Resident #4 placed his hands on the back of Resident #2's wheelchair, prompting her to yell at him to stop.

The resident, identified in inspection records as R1, had suffered a displaced intertrochanteric fracture of the right femur before arriving at the facility.

She sent the wrong medical record.

Resident 35 has severe cognitive impairment, scoring just three out of 15 points on a mental status assessment.

The inspection, completed December 1, 2025, flagged the practice under infection control standards and identified many residents as affected.

The medication errors at Dells Nursing and Rehab Center went undetected until federal inspectors arrived in late October following a complaint.

Inspectors documented the sequence during a complaint investigation completed November 25, 2025.

The citation was one of **two deficiencies** documented during the inspection.

The deficiency was classified at **Scope/Severity Level D**, meaning it was isolated in nature and did not result in documented actual harm.