The incident occurred on July 17 at 6:41 PM at Care & Rehab - Ladysmith 1, but facility leaders didn't notify the State Survey Agency until July 24.
Nursing Home News — Page 305
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Resident B told federal inspectors on July 23 that she preferred to be transferred to her wheelchair by 1 p.m.
The facility's director of nursing confirmed that the resident received five wrong doses of the powerful painkiller.
The resident, identified as Resident 4 in federal inspection documents, was admitted with a fracture of the left ilium, part of the pelvic bone.
The resident had a hematoma on his forehead.
The incident occurred on June 28, when the resident told a registered nurse that two certified nursing assistants had injured her during care.
Staff were directed to assist with the seatbelt each time she used her electric wheelchair.
Federal inspectors found the missing documentation at Astoria Place Living & Rehab during an August complaint investigation.
Resident 3 first disappeared on April 6 at 4:01 p.m.
The incident at White Oak Manor-Kings Mountain came to light when the resident's daughter arrived for a visit and found her mother soaking wet.
The resident, identified as R1 in the inspection report, had been living at The Waterview Pines since June 2023.
Her care plan specifically listed watching television as one of her preferred activities.