The medication wasn't in the building either day.
Nursing Home News — Page 336
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The resident, identified only as Resident 1, was supposed to receive physical therapy and occupational therapy one hour each day, five days a week.
Forest Glen Health Campus sent Resident #74 home on May 31 with a potassium level of 2.5 milliequivalents per liter from blood work taken two days earlier.
The patient, identified as R1 in federal inspection records, was admitted on August 5, 2025, for rehabilitation following left total hip replacement surgery.
The incident at Sandstone of Tucson Rehab Centre involved two residents who shared a room.
The document he signed stated he would receive account statements at least quarterly.
The breakdown began with a pharmacist recommendation dated June 18, 2025.
The aide discovered 911 dispatch was on the line.
The mix-up at Mercy Retirement & Care Center exposed how the facility handles basic record-keeping.
But when federal inspectors reviewed the medical file nearly two weeks later, they found nothing documenting the transfer had occurred.
Resident 1 had been admitted with osteoporosis and rheumatoid arthritis.
The incident occurred on July 5 at approximately 9:15 PM when Licensed Practical Nurse 1 allegedly forced a resident to take medication.