This violation received an F-level citation, indicating widespread systemic issues with potential for more than minimal harm to residents.
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Yellow dried material consistent with urine was visible on the broken toilet seat, which hung sideways from the fixture.
This practice affected multiple vulnerable residents, including those with severe cognitive impairment, mobility limitations, and histories of falls.
The resident, who had a below-knee amputation and used a wheelchair, left the facility during a day when temperatures reached 95 degrees Fahrenheit.
This delay in medical notification prevented timely interventions that could prevent minor issues from escalating into serious medical emergencies.
The resident, identified as R8, was discovered on December 22, 2024, in a compromised position after attempting to get out of bed.
The facility's response to this incident initially created additional compliance issues.
This type of mold exposure poses serious health risks, particularly for elderly residents with compromised immune systems.
A licensed practical nurse properly performed most aspects of the glucose testing procedure, including hand hygiene, glove use, and finger cleaning.
On the Oceanview unit, the most severe temperature violations occurred when the test tray was received 26 minutes after the food cart arrived.
The carts contained prescription medications for resident treatments and remained accessible without any staff supervision.
On March 9, 2025, R103 attacked another severely cognitively impaired resident (R83) three separate times within a 45-minute period.