Inspectors classified the deficiency as isolated but carrying potential for more than minimal harm to residents.
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Inspectors classified the violation as isolated but carrying potential for more than minimal harm to residents.
The facility's own policy requires staff to wear gowns and gloves during all "high-contact care activities" for residents with feeding tubes.
These policies must be comprehensive, clearly documented, and actively implemented throughout daily operations.
The facility's Director of Nursing told inspectors she was unaware that Resident 1 had missed her scheduled Lyrica for 48 hours.
The facility reported implementing corrections as of December 2, 2025.
The money was meant to cover his stay, which ran from January 8, 2024, through November 14, 2024.
Inspectors visited the facility on December 30, 2025, as part of a complaint survey.
State inspectors confirmed the allegations during their environmental tour.
Staff member E had just finished transferring resident #4, who had catheter tubing and a drainage bag visible, when inspectors questioned her at 9:54 a.m.
When pressed about whether the follow-up care had been arranged, she said she wasn't sure and would need to check the facility's appointment book.
Inspectors cited the facility on December 30, 2025, under a deficiency that covers professional standards of care.