Nursing Home News — Page 925

Critically, **the administrator was not made aware of the specific verbal threats** during the initial investigation, according to her own testimony.

The incident, which occurred around 6:15 p.m., resulted in facial lacerations and a painful hematoma on the resident's back.

The resident, identified as R1, had signed state DNR forms, active physician orders documenting DNR status, and was wearing a DNR bracelet on their left wrist.

The F 0679 citation typically relates to quality of care standards that nursing facilities must maintain to ensure resident safety and proper treatment.

For Resident 51, medication records showed insulin injections were administered to the same body areas repeatedly over several weeks.

During multiple observations over four days in April, inspectors found the resident lying in bed, moaning with facial grimacing and labored breathing.

The violations centered on the facility's failure to ensure that practitioners entered orders directly into the EMR system as required by federal regulations.

Resident 6, diagnosed with dementia and cognitive impairment, was receiving Quetiapine Fumarate for behavioral control without an accompanying care plan.

On February 13, the Administrator entered the surveyor's room without a mask and was later observed at the nurse's station without face covering.

The March 12, 2025 inspection revealed widespread failures in food safety, infection control, and staff training that put the facility's 91 residents at risk.

This ensures that medical interventions can be ordered promptly, potentially preventing serious complications or death.

The facility's failure to meet these standards represents a fundamental breakdown in basic medical care.