Inspectors watched the entire process unfold during lunch service on September 15.
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Resident #03 hit her head during the fall on August 20th and sustained a laceration above her right eyebrow that required five sutures.
The resident had been declared mentally incapacitated by two physicians on March 31, making the children surrogate decision makers.
The resident initiated both 911 calls himself after engaging in angry outbursts with staff who could not provide relief.
Resident #9 managed to leave the building and travel 375 feet from the front door before being located.
Federal inspectors found the facility failed to develop a person-centered care plan for Resident 1, who had developed a paralyzing fear of falling.
The resident, identified as R3 in inspection records, has taken Tramadol 50 milligrams daily since April 2023.
Resident 1 takes Metoprolol, a heart medication prescribed at 667mg twice daily at 7 a.m., 1 p.m., and 5 p.m.
His assessment revealed severe cognitive impairment.
The missing documentation occurred on August 15 during the evening shift and August 22 during the night shift at Huntington Valley Healthcare Center.
Staff were instructed to remove the device at bedtime on the second shift.
But she wasn't receiving any antibiotic treatment.