Nursing Home News — Page 933

The facility demonstrated multiple failures in outbreak management.

The facility's medical records showed troubling gaps in monitoring.

The violations represented fundamental breakdowns in activities of daily living (ADL) assistance that nursing homes are required to provide.

During the inspection, surveyors discovered an opened Lispro Kwikpen insulin pen in Medication Cart Station 2 that had expired but remained in active use.

Their presence ensures residents receive appropriate medical oversight, particularly during critical situations requiring immediate clinical judgment.

Despite this known temperature failure, kitchen staff continued using vegetables from the compromised freezer to prepare meals for residents.

The wound was first documented on July 3, 2024, but **staff never measured the wound** and failed to track its progression over the following month.

Continuing an unauthorized antibiotic treatment creates significant risks.

The investigation revealed a pattern of basic care failures affecting numerous residents throughout the nursing home.

Comprehensive assessments form the foundation of nursing home care, determining everything from medication management to fall prevention strategies.

The incident occurred on April 2, 2025, when CNA #4 entered Resident #78's room to empty the urinary drainage bag.

The physician ordered a Depakote serum level test to be collected on February 25, 2025, following the pharmacist's recommendation.