Nursing Home News — Page 932

According to nursing notes from December 25, 2024, staff observed the resident "curse and holler at her roommate" during a disagreement.

On February 4, 2025, the facility's administrator received a report that CNA #1 had been physically rough with a resident during a transfer attempt.

The incident involved two residents with significant mental health diagnoses.

during a March 2025 inspection, raising concerns about the facility's ability to maintain accurate records and ensure resident safety.

This violation of federal regulation F655 represents a fundamental breakdown in the facility's care coordination system.

However, **no evidence existed that the serum level was ever drawn**, and neither the physician nor nurse practitioner followed up on the missing results.

The investigation revealed this staff member, hired on December 16, 2023, had not received the mandatory annual QAPI training within the required timeframe.

The resident required partial to moderate assistance with basic activities including toileting and bathing.

The severity of this incident cannot be overstated.

For example, the left lower quadrant was used for injections on February 22 at both 9:40 a.m.

The meal remained at room temperature for nearly three hours.

This service disruption directly impacted at least four residents who required essential blood work and diagnostic testing.