The resident reported pain levels between 8 and 10 on a 10-point scale while staff told her "we are not hurting you" during personal care, according to a February complaint investigation that triggered immediate jeopardy violations.
She eventually required emergency hospitalization on January 27 with an infected amputation site and "intractable pain," hospital records show. The emergency room noted "purulent drainage" and "mild skin necrosis" at the amputation site.
Resident 5 was admitted to the facility on January 17 after her left leg was amputated above the knee. Her care plan acknowledged she had "acute pain related to left AKA and sacroiliitis" but nursing staff repeatedly failed to follow through when pain medications proved ineffective.
On her first night, she received hydrocodone at 10:36 PM for pain rated at level 7. The medication was marked "ineffective" in her chart. The next morning at 4:30 AM, she again received the drug for level 6 pain, this time marked "effective."
But the pattern of inadequate pain control continued. On January 18 at 10:03 PM, she received medication for level 10 pain with no effectiveness rating documented. The following morning, she rated her pain at level 8 and the medication was again marked "ineffective."
Throughout her stay, she frequently reported pain levels of 8, 9, and 10 despite receiving prescribed medications. On January 19, she received hydrocodone for level 10 pain at 4:40 PM, which was marked "effective," yet no adjustments were made to her pain management plan.
The facility had ordered a buprenorphine patch on January 18 to be applied weekly for ongoing pain control. Records show she received the patch only once, on January 18. The patch should have been changed every seven days to remain effective, but nursing staff failed to follow the order.
Two CNAs described a particularly disturbing incident on January 23 when they provided personal care to the resident. CNA G told investigators the woman "was swinging at us because of the pain she was in during peri care." She said it took both CNAs at least 30 minutes to complete the care "due to the amount of pain Resident 5 was in."
"They were not purposely trying to hurt her but had to get her clean," CNA G explained. She said the charge nurse, RN J, "had gone in and out of the room" and knew how much pain the resident was experiencing.
Yet no pain medication was administered to the resident until January 26, three days later.
The resident's nurse practitioner told investigators she had never been notified about the inadequate pain control. "She would expect nursing staff to notify her if pain was not being managed or if pain medications were not effective," the inspection report states. "She stated she could have done something about it."
The NP explained that uncontrolled pain can cause "high blood pressure, heavy breathing, or anxiety" and noted the resident "was always anxious" during her stay.
A complaint filed with state health officials on January 24 alleged that night shift CNAs were "rough with her and when she tells them she is hurting they will say we are not hurting you."
The resident's representative told investigators "her severe pain never subsided the whole time she was at the facility." He said staff "agreed the pain medication was not sufficient while she was at the facility, but they were just following the orders given."
When the woman was hospitalized on January 27, emergency room staff documented she was "intolerable of pain and refused exam on leg" due to the severity. The hospital noted she had missed her Friday dialysis appointment because of the pain.
Hospital records show she required a procedure on January 28 where "they put a tube in her wound to drain it due to an infection." The infection had been causing additional pain beyond the amputation itself.
Federal inspectors found the facility violated regulations requiring appropriate pain management for residents who need such services. The facility's own pain policy required staff to "assess the individual's pain and related consequences at regular intervals, at least each shift for acute pain."
The policy also stated that if pain "is not responding to standard interventions, the attending physician may consider additional consultative support." No such consultation was sought during the resident's 10-day stay.
Inspectors identified immediate jeopardy on January 29 at 4:04 PM, finding the violations placed residents "at risk for prolonged and unnecessary pain and suffering and a decreased quality of life."
The facility implemented emergency corrective measures including staff education and enhanced monitoring systems. The immediate jeopardy designation was removed on January 30 at 6:15 PM, though the facility remained out of compliance at a lower severity level.
In a separate immediate jeopardy finding, inspectors discovered the facility failed to provide proper wound care treatment. A resident with a stage 4 pressure ulcer had wound vacuum dressing changes missed on multiple scheduled dates in January.
The wound care physician noted in progress notes dated January 22 that the resident "stated that her wound vac had been changed once weekly" rather than the prescribed three times weekly. The physician had to contact facility leadership about the missed treatments.
Resident 1 had been receiving wound vacuum therapy since July 2024 for a pressure ulcer that initially developed in April 2022. The treatment requires precise scheduling to maintain healing and prevent infection.
Facility staff received emergency training on wound care protocols and physician order implementation on February 11. All nursing staff were required to complete education on following wound care orders and documenting treatments before their next shifts.
The administrator told inspectors the facility would monitor compliance through daily morning meetings and weekly quality assurance reviews. A wound care physician contact number was added to all relevant resident charts for immediate consultation access.
Both immediate jeopardy violations were removed after the facility implemented corrective measures, but inspectors noted the need for ongoing monitoring to ensure the effectiveness of the new systems.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Avir At Weston from 2025-02-12 including all violations, facility responses, and corrective action plans.