The resident, who weighed more than 260 pounds and had Class III obesity, was admitted with congestive heart failure and varicose veins.
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The violation came to light on July 17, 2024, when a state surveyor observed Staff 3 performing blood glucose checks.
Federal inspectors documented the splint misplacement during their January 30 visit to the facility on South Fairfax Avenue.
Resident #3 entered hospice care at Amarillo Center for Skilled Care on Friday, March 28th.
Certified Nursing Assistant 5 put on gloves but skipped the required isolation gown when Resident 8 complained of abdominal and buttock pain on March 11.
QMA 3 and LPN 6 were still observed working on the floor at 3:35 p.m.
A small plastic cup of water sat next to it.
Federal inspectors found the 99-bed facility's Quality Assessment and Assurance Committee operated without basic oversight mechanisms.
The June inspection at Treasure Isle Care Center found multiple infection control breakdowns that put the facility's 136 residents at risk.
Federal inspectors found that staff administered oxycodone to two residents well before the required four-hour intervals between doses.
The incident began around 2:38 a.m.
The outbreak on Resident #25's unit had already begun on June 1.