Nursing Home News — Page 1157

During the March 27, 2025 inspection, facility leadership acknowledged they could not locate either required document in the resident's medical record.

The case involved a resident with muscle weakness and osteoporosis who had been identified as at-risk for pressure injuries based on facility assessments.

One resident with diabetes was found with fingernails measuring approximately one inch long and jagged edges, with brown substances accumulated underneath.

Rather than retrieving the mechanical lift as specified in the care plan, the assistant proceeded with a manual transfer approach.

Twenty-two minutes later, the resident was located walking in a field roughly two blocks from the facility.

The ceiling above one resident's bed showed visible deterioration including a dent, cracks, and water staining.

However, a review of the resident's medication administration records revealed these critical recommendations were never implemented.

These services were deemed necessary to reduce mental health symptoms and provide essential supports for the resident's safety and wellbeing.

The resident's care plan, initiated in July 2023, acknowledged limited physical mobility related to pain, wounds, and deconditioning secondary to sepsis.

During testing on July 9, 2024, inspectors measured food temperatures on the last meal cart delivered to residents.

During that hospitalization, a urologist placed a stent in the resident's ureter to allow urine drainage.

Injuries of unknown origin represent critical red flags in long-term care settings.