Nursing Home News — Page 1204

This failure represents a fundamental breakdown in the facility's internal quality control mechanisms designed to protect resident safety and wellbeing.

Medical records show the resident was admitted with diagnoses including confirmed physical abuse, major depressive disorder, and anxiety disorder.

The timing failure is particularly concerning given current Centers for Disease Control and Prevention guidelines.

The communication breakdown extended beyond individual staff members.

The resident, who had dementia and exhibited physical behaviors, rejection of care, and wandering, began hospice services on January 17, 2025.

The **resident's precarious positioning created immediate risks for injury**.

The immediate jeopardy citation, classified at the highest severity level L, centered on failures in facility administration under federal regulation F688.

This meant the resident went 18 days without receiving the full prescribed dosage of their antipsychotic medication.

Despite the resident experiencing **multiple hospitalizations for dehydration**, staff failed to implement basic preventive measures.

The bruising documentation appeared again two weeks later.

Medical records showed the resident's weight began declining sharply in April, with an 8-pound loss in just one month between April and May.

The April 5 incident was particularly serious - an unwitnessed fall that resulted in a head laceration and emergency room evaluation.