Nursing Home News — Page 619

The facility's own assessment indicated a need for 12-18 nursing assistants per day to properly care for an average census of 109 residents.

## Serious Medication Security Violations The most concerning findings involved **medication cart security breaches** throughout the facility.

The bathing schedule showed concerning gaps, including the entire month of August 2024 and January 2025 when no showers were documented at all.

Federal inspectors observed nursing staff using the same glucose meter on multiple diabetic residents without proper disinfection between uses.

The violations affected staff across multiple departments, including certified nursing aides, housekeeping, and maintenance personnel.

On October 3, 2024, nursing staff discovered maggots in the resident's right heel wound during a routine dressing change.

Three of these individuals had been employed in nursing roles since 2021, while two others had worked without proper licensing since 2023.

Despite this nurse providing a written statement about what she observed, facility administration conducted no thorough investigation.

The inspection revealed systemic breakdowns in basic safety protocols affecting multiple areas of resident care.

The violations involved improper handling of medical equipment and inadequate use of protective equipment when caring for vulnerable residents.

The most recent documented assault had occurred just weeks before the transfer.

Water at 127 degrees Fahrenheit can cause first-degree burns in just one minute of exposure.