Nursing Home News — Page 930

The facility's Minimum Data Set Registered Nurse (MDS-RN) acknowledged the errors during an interview with inspectors at 10:34 AM that morning.

The facility submitted an Immediate Jeopardy Removal Plan on March 12, 2025, claiming the dangerous conditions had been addressed as of March 10.

The incident occurred despite the resident having a care plan that explicitly identified them as high-risk for elopement, with a risk score of 20.

Despite these documented precautions, the magnetic lock system on the courtyard gate was left disengaged after routine lawn maintenance.

Medical records revealed that staff repeatedly documented concerning findings about the resident's dialysis access site between December 2024 and March 2025.

The resident's psychiatric medication was ordered to be administered at 9:00 PM daily, but staff failed to provide these doses.

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

When nursing staff initially observed the skin breakdown on March 14, multiple certified nursing assistants reported seeing the affected area.

The April 2025 inspection documented improperly installed and maintained bed equipment throughout the 159-bed facility, prompting emergency corrective actions.

Inspectors observed dried brown smears on bathroom walls near light switches and on bedside commodes, which facility staff confirmed was fecal matter.

The violations affected multiple residents and created risks for medication errors, untreated medical issues, and deteriorating health conditions.

Personnel records examined during the inspection showed Cook D's initial dementia training occurred shortly after their hire date of December 16, 2023.