Nursing Home News — Page 989

Inspectors discovered that nursing staff failed to obtain physician orders for monitoring these devices when the resident was admitted.

When surveyors requested monthly infection surveillance reports for 2025, nursing staff initially could not provide the documentation.

Inspectors found that residents with diagnosed mental health conditions were not receiving the specialized care outlined in their treatment plans.

The inspection found that The Center at Advocate had been operating without a certified infection preventionist since April 2024.

During this 11-day period without proper monitoring, the resident developed an unstageable pressure ulcer on her sacrum that became necrotic.

Medical records show the resident was prescribed Oxycodone 5 mg every 12 hours as needed for pain on March 1 at 2:00 PM.

During the initial tour on March 10, investigators found an unlocked cart on the 300 hallway containing five opened, undated insulin pens.

Pneumonia poses a particularly serious threat to nursing home residents, who are among the most vulnerable populations for severe respiratory infections.

The citation followed documented incidents involving a resident who managed to leave the facility on multiple occasions due to systemic security breakdowns.

The case reveals a cascade of clinical failures that allowed a minor injury to worsen significantly.

In a separate incident involving a resident with leg wounds, the nurse practitioner again demonstrated poor hand hygiene practices.

On January 9, inspectors observed a nurse performing complex respiratory care while failing to follow basic contamination prevention protocols.