Nursing Home News — Page 823

The man said he became too embarrassed to go to the dining room because of his condition.

The medication error prompted a federal investigation that found the facility failed to ensure proper discharge procedures.

The August 1 incident at Pinnacle Specialty Care involved a resident with cancer, malnutrition, and septicemia — a life-threatening blood infection.

Administrator NHA A told inspectors the positive test result indicated an adverse medication event had occurred.

Resident C's medication records from August showed a pattern of missing documentation.

The resident had an open wound on their left lower extremity and intact mental capacity.

On November 18, inspectors spotted a cockroach crawling across the back of the hand washing sink at 10:25 AM.

The nurse told state inspectors on October 6 that the bottle was already there when she started work at 6:30 AM.

Resident 72 has lived at the 76-bed Springfield facility since July 2021.

The facility uses these precautions specifically to prevent transmission of multi-drug-resistant organisms that can cause life-threatening infections.

But no one assessed the resident after the incident.

The incident at Clara Manor Nursing Home on November 12 exposed a cascade of failures that federal inspectors called an immediate threat to resident safety.