Nursing Home News — Page 1143

The resident experienced episodes where he believed he was still in combat or that the U.S.

The resident was discovered on the facility's loading dock, standing on a hydraulic lift raised 81 inches from the pavement below.

Despite facility policy requiring immediate nursing assessment after any fall, the aide failed to notify nursing staff or supervisors about the incident.

Medical records revealed nursing staff administered the medication on multiple occasions when blood pressure readings were well above these thresholds.

Instead, staff served the meal on a single plate with all items mixed together.

However, documentation revealed this critical recommendation was never implemented.

Despite the first elopement incident, facility staff failed to develop any care plan to prevent future occurrences.

Proper nutritional monitoring in nursing homes requires regular weight checks, laboratory assessments of protein levels, and documentation of food intake.

Three residents experienced significant medication errors that could have resulted in serious medical complications.

On March 24, inspectors found the resident sitting in his wheelchair with a nasal cannula connected to a portable oxygen tank that **was not turned on**.

When staff couldn't locate the resident at 6:00 PM, they initiated a facility-wide search and contacted local police.

The inspection narrative documents that three residents were subjected to this treatment during this extended period.