F684 · Quality of care

Based on observation, interview, and record review, the facility failed to ensure a resident on dual antiplatelet therapy who had a fall from bed, landed on her face, and sustained a visible head injury was assessed for a change in condition and promptly sent to the hospital for 1 of 3 residents reviewed for accidents (Resident B). The immediate Jeapardy began on [DATE], at approximately 8:00 p.m., when Resident B with previous history of cerebrovascular accident (CVA, commonly called a stroke is a condition where blood flow to a part of the brain is blocked or a blood vessel bursts, causing brain cells to die from a lack of oxygen), subdural hemorrhage in December of 2025, and was taking two antiplatelets (drugs that stop blood cells from sticking together), rolled off her bed during… …

Zionsville Meadows · Indiana

Based on interview and record review the facility failed to follow physicians orders for weight monitoring and reporting of weight gain for a resident with Congested Heart Failure for 1 of 2 resident (R51) reviewed for respiratory care in sample of 54. This failure resulted in R51 being sent to the hospital for weight gain, wheezing, shortness of breath, with 11 lbs of excess fluid. Findings include:R51's admission record documents an admission date 03/30/23 with diagnoses including: chronic obstructive pulmonary disease (COPD), heart failure, type 2 diabetes mellitus, benign neoplasm of cranial nerves, chronic respiratory failure with hypoxia, venous insufficiency, chronic respiratory failure with hypercapnia, morbid obesity due to excess calories, anxiety disorder, polyosteoarthritis,… …

Shawnee Senior Living · Illinois

Based on interview and record review, the facility failed to administer long-acting insulin at consistent times according to the manufacturer's instructions and short-acting insulin prior to meals in accordance with professional standards for 1 of 1 resident (R46) reviewed for insulin use. In addition, the facility failed to provide necessary care and services in accordance with physician orders and residents' assessed needs when the facility failed to implement and monitor a physician-ordered fluid restriction for 1 of 1 resident (R13) reviewed for fluid restriction, implement physician-ordered interventions for edema management for 2 of 2 residents (R13, R4) reviewed for edema, and administer medication in accordance with the physician's order for 1 of 1 resident (R107) reviewed for… …

The Villas at the Cedars · Minnesota

Based on interview, medical record review, and facility P&P review, the facility failed to provide the services to attain or maintain the highest practicable well-being for one of five sampled residents (Resident 1). * The facility failed to ensure Resident 1 had a physician's order for podiatry appointment on 1/5/26. This failure had the potential for the resident to not receive the necessary care and services to maintain their highest physical well-being and potentially delay the necessary care and treatment.Findings: Review of the facility's P&P titled Transportation revised 1/23/24, showed the facility shall help arrange transportation for residents as needed. …

Bonita Hills Post Acute · California