Federal inspectors found the documentation gaps at Concho Health & Rehabilitation Center during a December 19 complaint investigation.
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The medication error occurred on May 14, 2024, at 5:30 PM.
The facility also lacked required metal containers with self-closing covers in any of its smoking areas.
Despite this reading, staff administered the scheduled 10-unit Humalog insulin injection.
The incident occurred on December 4, 2024, when a certified nursing assistant locked her medication cart and rushed to assess what she had witnessed.
A nutritional assessment dated December 8 confirmed she had dentures.
The resident was upset enough to call police herself, and officers arrived at Pasadena Grove Health Center that same day to speak with her.
Licensed Vocational Nurse 2 administered sacubitril-valsartan to Resident 3 on December 16 at 5 p.m., even though the patient's blood pressure measured 109/77.
"Hand washing was important to prevent cross contamination and food borne illness," the Dietary Manager told inspectors.
Resident 4 had been admitted to the facility in October 2023 with epilepsy, generalized muscle weakness, dementia, hemiplegia, hemiparesis, and diabetes.
The September 18 admission assessment for Resident #1 was missing the most basic requirement: acknowledging the person had diabetes.
The outdated policies left residents vulnerable to consuming expired or unsafe food items.