The physician had been clear in orders dated June 3rd: call for blood sugar readings below 70 or above 400.
Nursing Home News — Page 375
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The September 16 inspection revealed systemic problems with medication administration that triggered the most serious level of nursing home violations.
The screening process, known as PASRR, determines whether incoming residents need the level of care the facility provides.
Federal inspectors discovered the hiring failure during a September complaint investigation at the 11620 West Washington Boulevard facility.
"Resident 2 just stayed in bed and had nothing to do," the family member told inspectors.
Licensed Practical Nurse #220 found the resident with blood still wet on her leg after the botched transfer.
The falsified records were discovered during routine review.
When inspectors arrived at 11:23 a.m., they found the window open for ventilation with a large hole torn through the lower corner of the screen.
Resident 13 told inspectors that two certified nursing assistants the previous night had turned off call lights without meeting anyone's needs.
The crisis unfolded at Bridgeway Senior Living on September 6 at 10:40 PM.
Licensed nurses documented none of these interventions on August 28.
The complaint never reached the administrator at Hadley Pointe Nursing Rehab & Care for three days.