Facility policy requires two staff members to operate mechanical lifts safely.
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The incident at Trinity Grove involved Resident #65, who had lived at the facility for six years without any previous problems.
Resident 38 arrived at the facility on July 25 with multiple serious conditions.
In a 30-minute tour, they documented peeling paint, gouged walls, and torn wallpaper in 12 of the 41 resident rooms currently occupied in the 70-bed facility.
Hospital discharge instructions specifically stated the resident should be re-evaluated by an ENT specialist within a week.
The resident at Avir at San Antonio told inspectors she felt something on her shoulder around 6:00 am and called for help from a certified nursing assistant.
She had been living at the facility since October 2023 following a cerebral infarction that left her with paralysis affecting both sides of her body.
LPN #4 was suspended on August 17 and terminated four days later when she wouldn't assist administrators trying to account for the missing pain medication.
She never reported the incidents to the administrator or outside agencies as required by both facility policy and federal regulations.
A physician ordered Ceftin 500 milligrams twice daily for seven days the same day the culture results came back positive.
The resident came to the facility from the hospital with a five-day order for Dilaudid, a powerful opioid pain medication.
His physician had ordered the boots to be applied every shift to prevent further skin breakdown.