State Findings:
Review of the facility’s regulatory record revealed the facility failed to operate a quality assurance (QA) program in a manner to prevent repeat deficiencies. Repeat deficiencies included:
Cross-reference F578: The facility failed to ensure advanced directives were signed by the appropriate parties.
Cross-reference F610: The facility failed to investigate thoroughly and timely allegations of abuse.
Cross-reference F677: The facility failed to ensure ADL care was provided for dependent residents.
Cross reference F686: The facility failed to prevent the development and or worsening of pressure ulcers.
Cross reference F689: The facility failed to ensure residents were free from accident hazards.
Cross-reference F744: The facility failed to provide appropriate dementia care and services.
Cross reference F758: The facility failed to ensure residents were free from unnecessary [CONDITION(S)] medication.
The facility failed to consistently assess, monitor and document the condition of Resident #8’s feet despite his history of diabetes and toe ulcers until 3/21/22, although wound clinic notes documented a superficial ulceration of the third digit, left foot a week earlier. The 3/21/22 nurses’ note read the resident’s toe was red, inflamed and tender. He was diagnosed with [CONDITION(S)] and antibiotics were started. Resident #8 was taken to the wound clinic on 3/21/22, but the facility did not consistently document and implement the wound physician’s recommendations, revise the resident’s care plan, or document specifics about resident education and follow-up when the resident refused assessments and treatments.
On 4/1/22, less than two months after admission, Resident #8 had a stage 4 pressure injury on his left foot, third digit, with bone exposed. On 4/20/22, the resident was diagnosed with a pseudomonas infection to the wound and [CONDITION(S)], a bone infection. Resident #8 was hospitalized on [DATE] after a fall and change of condition and was readmitted to the facility on [DATE]. His toe was amputated on 4/28/22 while hospitalized.
The facility’s failures contributed to Resident #8’s pressure wound on his third left toe progressing to a stage 4 pressure injury that was associated with infection and pain and amputation.
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NHAA is here to assist families, residents, and the community by sounding the alarm on issues like those found above. This nursing home and many others across the country are cited for abuse and neglect.
If you have or had a loved one living in this nursing home or any other nursing home where you suspect any form of abuse or neglect, contact us immediately.
We have helped many already and we can help you and your loved one as well by filing a state complaint, hiring a specialized nursing home attorney or helping you find a more suitable location for your loved one.
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Personal Note from NHA-Advocates
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