One resident was moved four times during their stay at the facility.
Nursing Home News — Page 403
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The resident first reported pain on March 27.
Staff last changed the catheter on September 2.
The October 13 incident occurred at 2:30 a.m.
Two days later, the resident complained of rib pain and was vomiting a coffee-brown substance.
Director of Nursing confirmed during an October 15 interview that no orders existed for the resident's J-tube site care until that day.
The patient at CHI Franciscan Villa had been readmitted with acute respiratory failure, anoxic brain damage, and congestive heart failure.
The facility's Director of Nursing acknowledged that no registered nurse completed required weekly assessments with measurements from April 30 through June 11.
The resident developed a UTI that went undiagnosed from September 4 through September 13 at Methodist Manor Retirement Community.
The administrator confirmed to inspectors that no discharge notice was issued.
Twelve residents at the facility had been identified as being at risk for wandering.
Arlington Gardens Care Center sent Resident 1 to the placement facility despite knowing she required assistance going to the bathroom to prevent falls.