Southern Oaks Nursing & Rehabilitation Center Failed to Administer Critical Psychiatric Medication as Prescribed
This meant the resident went 18 days without receiving the full prescribed dosage of their antipsychotic medication....
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This meant the resident went 18 days without receiving the full prescribed dosage of their antipsychotic medication....
Despite the resident experiencing **multiple hospitalizations for dehydration**, staff failed to implement basic preventive measures....
The bruising documentation appeared again two weeks later....
Medical records showed the resident's weight began declining sharply in April, with an 8-pound loss in just one month between April and May....
The April 5 incident was particularly serious - an unwitnessed fall that resulted in a head laceration and emergency room evaluation....
However, documentation revealed a troubling lack of oversight....
The resident's care plan, initiated April 3, 2025, clearly documented a history of suicidal ideation and previous suicide attempts....
This violation affects multiple staff members and poses potential risks to resident safety....
These assessments directly influence the level of care residents receive and determine staffing needs for specific medical conditions....
The resident successfully exited through the main entrance on May 1 at approximately 3:00 PM during a receptionist's break....
Two separate altercations occurred between the same two residents within a week, yet administrators never notified state agencies as required by federal law....
The isolation order was intended to last fourteen days, the standard treatment period for scabies infections....
The violations center on the facility's inability to follow through on promises made after a previous citation in June 2024....
This fundamental breakdown in the admission process left staff without crucial information needed to provide appropriate, individualized care....
The room had clear signage and a PPE cart stationed at the doorway, yet the nurse bypassed these safety measures entirely....
When the staff member called out to Resident 2 and asked what they were doing, the perpetrator stopped and walked back to their own bed....
The April 2025 inspection also revealed problems with cold food service and improper dietary assessments affecting multiple residents....
The same resident experienced multiple documented skin injuries between March and April 2025, including abrasions to the forehead, knees, and scalp....
In this case, the medications were given 34 minutes beyond the acceptable window....
However, documentation shows the records were never provided....