Nursing Home News — Page 1139

## Three Falls in Three Days The incident sequence began March 15 when the resident rushed to a shared bathroom without his walker.

The incident occurred on February 11, 2025, at 1:04 p.m.

The recipient was a stroke survivor with multiple complex medical conditions including hemiplegia, aphasia, dysphagia, and major depressive disorder.

The immediate jeopardy designation indicates conditions that pose an immediate threat to resident health and safety.

During the 4:55 AM medication administration, the nurse wore only disposable gloves but failed to don the required protective gown.

This reading, documented at 4:16 PM by medication aide MA C, represents a hypertensive crisis level that requires immediate medical attention.

The incident occurred on March 4, 2025, when the resident exited the facility at 5:09 AM through the front door.

Internal facility audits confirmed these missed treatments, yet administrators remained unaware of the widespread service gaps.

A mental health worker attempted to de-escalate the situation, but the resident pushed the staff member.

The inspection revealed that staff failed to establish adequate preventative measures for a resident identified as R78 who had developed a pressure ulcer.

CNA 1 elevated the resident's bed to approximately three feet off the ground to provide incontinence care.

One resident with a urinary catheter had the drainage tubing dragging on the floor while using a wheelchair.