Nursing Home News — Page 963

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.

The April 18, 2025 complaint investigation revealed systemic failures in fall prevention protocols that put residents at immediate risk of harm.

During their morning inspection at 7:57 a.m., surveyors documented multiple safety hazards in the bathing room.

Medical records showed the resident lacks mental capacity to understand and make medical decisions.

**FB_POST:** BREAKING: Mansfield nursing home cited for immediate jeopardy after failing to protect suicidal resident with proper safety protocols.

One patient receiving hospice care for stage 5 kidney failure missed four fentanyl patch applications over 13 days.

Inspectors found two residents with pressure ulcers were not receiving the enhanced barrier precautions required by federal regulations updated in April 2024.

Despite having clear protocols in place, inspectors observed multiple instances where nursing staff failed to follow these critical safety measures.