Based on observation, interview, and record review the facility failed to immediately consult with the resident's physician and notify the residents' representatives when there was a change of condition for 2 of 2 residents reviewed for changes in condition, Resident #29 and #42, resulting in the residents having to be treated by IV (intravenous) antibiotic therapy due to infection. Delay in notifying the physician of a wound, critical labs, and resident change in condition due to infection can result in the spread of the infection into the deeper tissues of the body, the infection can travel through the blood to other parts of the body and could become life threatening.
Findings include:
1. …
Based on interview and record review The facility failed to ensure staff notified the physician of a change in condition for one resident (Resident #114) of seven resident surveyed for falls when after a head injury the resident's systolic blood pressure dropped and the resident's mental status changed.
Findings included:
Resident #114 was an [AGE] year-old male who was admitted to the facility on palliative care with a history of Type 2 Diabetes, Dementia, Anxiety Disorder, Hypertension, Atrial Fibrillation, Makor Depressive Disorder, seizures, Anemia, with a Cardiac Pacemaker.
According to the timeline provided by the facility, on 8/20/24 at 2:40 p.m. Resident #114 was redirected from an exit in the facility and while walking away from the exit had a witnessed fall with a head injury. …
D · No harm, potential for more than minimal, isolatedAugust 20, 2026
Based on interview and record review, the facility failed to ensure the resident's physician and the resident's representative were notified when the resident experienced a significant weight loss for 1 of 6 residents, Resident #46, reviewed for dietary/nutritional concerns.Findings include:Review of Resident #46's weight documentation dated 02/22/2026 the resident's weight was 175.2 lbs (pounds), 03/03/2026 - 171.2 lbs, 06/03/2026 - 164.6 lbs., 07/01/2026 - 160.6 lbs, and 08/01/2026 - 154.4 lbs; a 11.87% weight loss. …
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