The medication was supposed to be stored between 68 and 77 degrees.
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The tampering went undetected for months.
Resident 34 at Altercare Newark South had requested the shower for Friday morning, November 14th, before her scheduled medical procedure.
Without access to these devices, residents faced the choice of attempting dangerous tasks alone or waiting indefinitely for staff to check on them.
The inspection, completed November 24, 2025, revealed gaps in care delivery despite what appeared to be adequate staffing levels.
Staff immediately intervened and helped the resident back to their room, according to nursing notes.
The director of nursing told inspectors he wasn't aware the residents weren't receiving showers or bed baths.
Resident #105 lived with severe cognitive impairment, epilepsy, heart failure, intellectual disability, and muscle weakness.
She told inspectors she never took the ring off and was very upset when she discovered it missing.
Instead, Licensed Nurse 1 administered a 20-milligram tablet that belonged to a different resident.
"She forgot to sanitize the glucometer, and it should have been done after using the glucometer," the nurse told inspectors when confronted about the lapse.
Moderate pain registers 4-6, while severe pain spans 7-10.