Nursing Home News — Page 1123

The resident told inspectors they felt nursing staff was not monitoring their surgical incision properly.

The resident remains hospitalized as of the inspection date.

The resident was later transferred to the hospital in January 2025 for neurologic changes.

This created a dangerous gap in the medical record that could lead to medication errors, including potential double-dosing or missed medications.

The nurse administered two different eye drops at 8:26 AM and 8:27 AM without the required waiting period.

The discovery prompted immediate action to protect residents' health and safety.

## **Critical Reporting Protocol Failures** The inspection revealed significant breakdowns in the facility's abuse reporting system.

The inspection found residents who had consented to receive pneumonia vaccines but never received them.

The facility, located at 501 W Austin Street, also faced citations for inadequate registered nurse coverage on weekends.

## Medical Necessity of Adaptive Equipment The prescribed No Spill 360 Grip and Sip cup serves critical medical purposes for residents with cerebral palsy.

Medical orders were issued to treat the injuries with normal saline and antibiotic ointment.

On August 23, 2024, staff discovered an open area on the resident's buttocks during routine skin observations.