Nursing Facility Faces Scrutiny After Resident Develops Extensive Blood Clots in Both Legs
The facility's medical provider ordered a venous doppler study, a diagnostic ultrasound procedure used to detect blood clots in veins....
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The facility's medical provider ordered a venous doppler study, a diagnostic ultrasound procedure used to detect blood clots in veins....
The electronic medication administration records from June 4-17 revealed an extensive pattern of medication refusals....
## Inadequate Pain Management Protocols Inspectors identified concerning gaps in pain management for a resident experiencing chronic, severe pain....
The incident occurred when a Certified Nursing Assistant (CNA) was turning and repositioning the resident, who grabbed onto the facility's bed remote control....
Within days of admission, staff documented that the resident had an unsteady gait, poor balance, and was at risk for falls....
A second resident with a history of heart disease, ischemic cardiomyopathy, and previous myocardial infarction received only partial pneumococcal vaccination....
One resident reported lying in a urine-soaked brief for hours while waiting for staff assistance....
One resident recovering from COVID-19 in isolation received breakfast in a foam tray containing fried eggs, toast, and cream of wheat....
The inability to provide documentation represented more than an administrative oversight....
The facility incorporated this intervention into the resident's care plan for preventing skin breakdown, acknowledging the importance of this measure....
An immediate jeopardy designation indicates conditions exist that could cause serious injury, harm, impairment, or death to residents at any time....
The inspection revealed gaps in the facility's assessment process for restraint use....
The inspection revealed that only two residents in the facility were receiving fentanyl patches at the time of the survey....
The resident was treated with antibiotics on January 2-9, January 22-27, February 8-19, February 13-21, April 29-May 6, and May 21-28....
Despite this significant deficit, the facility's initial Elopement Risk Tool assessment rated R1 at zero out of nine points for elopement risk....
Enhanced barrier precautions represent a critical defense against healthcare-associated infections, particularly for residents with indwelling medical devices....
One resident with diabetes was found with fingernails measuring approximately one inch long and jagged edges, with brown substances accumulated underneath....
During testing on July 9, 2024, inspectors measured food temperatures on the last meal cart delivered to residents....
These violations represented fundamental failures to protect residents from medication errors and potential harm....
This modification was in place for multiple residents and had been standard practice at the facility for years....