Electronic records show the medication wasn't given on February 7, 8, 17, 18, 19, and 20, with an additional evening dose missed on February 18.
Nursing Home News — Page 278
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The replacement catheter also became dislodged the same day, forcing the resident to undergo emergency surgery two days later.
Resident 4 developed a fever of 102.3 degrees and oxygen saturation of just 83 percent on Christmas Day, requiring emergency transport to the hospital.
The violations occurred despite the facility having written policies requiring enhanced safety measures for residents with medical devices.
The crisis began when the facility's primary walk-in refrigerator stopped working properly.
The highly contagious gastrointestinal illness caused nausea, vomiting and diarrhea among residents and workers during the May 2025 outbreak.
A CT scan at the hospital revealed a fractured cervical vertebra.
"I literally spend one third of my time looking for missing items," one staff member told inspectors on January 15.
The violations put 125 residents who receive meals prepared in the kitchen at risk for foodborne illness.
The nurse entered the room, handed R33 her medication cup, and waited in the doorway while the resident took her pills.
Federal inspectors found no documentation of the fall in the resident's medical chart when they arrived August 15.
All three men had been granted approved four-hour passes to leave the facility.