Nursing Home News — Page 581

The resident clearly communicated his wishes during the inspection, stating **he wanted to be resuscitated and wanted to be Full Code**.

Four residents specifically identified in the report experienced gaps in critical care that could have resulted in severe health consequences.

The resident, identified as R1 in the inspection report, subsequently died at the hospital after sustaining injuries from the fall.

QAPI programs serve as the backbone of nursing home operations, designed to continuously monitor and improve care quality.

## Critical Security System Failures The elopement incident exposed multiple systemic failures in the facility's safety protocols.

This federal regulation requires facilities to maintain comprehensive medication administration protocols and report any errors that occur.

Federal regulations require nursing homes to provide at least 80 square feet per resident in multiple-occupancy rooms and 100 square feet for single rooms.

In September 2024, R22 sustained a **pelvis fracture** during a fall.

These reporting failures prevent state agencies from conducting proper oversight and additional investigations when necessary.

The deficiency was rated as causing minimal harm with potential for actual harm, affecting few residents.

However, the facility failed to carry out this laboratory order before the resident required hospitalization on February 17, 2025.

The medication administration record showed the drug was "on order from pharmacy" during this period, indicating it was unavailable at the facility.