On July 13, 2024, at 5:24 a.m., the resident complained of pain extending from his groin down to his thigh.
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Inspectors documented soiled surfaces, contaminated equipment, and improper food storage that violated fundamental food safety protocols.
This cross-contamination scenario represents a fundamental breach of infection control protocols.
However, inspectors found no physician's order authorizing the transfer in the medical record.
The dietitian recommended **Arginaid, an amino acid supplement essential for wound healing**, twice daily for 30 days in December 2024.
According to inspection records, the resident first reported abdominal discomfort on July 22 at 9:45 PM and received antacid medication twice without relief.
Scores typically range from 0-28, with scores above 10 indicating significant fall risk requiring immediate interventions.
Hospital records confirmed the resident sustained a left eyebrow laceration from the unwitnessed fall and required sutures.
The dietitian specifically recommended continuous feeding at 45 ml per hour of Diabetisource AC nutritional formula.
The resident died at an area hospital after experiencing dangerously low blood sugar levels of 27 mg/dL (normal range is 70-100 mg/dL).
Documentation review revealed alarming patterns of missing bowel movement records.
This recurring citation indicates a persistent compliance issue that the facility has failed to adequately address over more than a year.