Inspectors classified the violations as having "minimal harm or potential for actual harm" affecting "some" residents.
Nursing Home News — Page 395
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Resident #2 left the facility grounds and walked to his previous residence, where his son found him.
Resident #117 disappeared from Greenbrier Health Center sometime after 10:30 p.m.
Federal inspectors discovered the unauthorized room change during an October complaint investigation.
Primary Care Physician 500 told inspectors he was never informed about the medication discrepancies.
The October 7 incident at Omaha Nursing and Rehabilitation Center involved treating a softball-sized stage four pressure ulcer on the resident's sacrum.
The resident died with conflicting instructions in their medical record.
The facility's administrator didn't notify proper authorities until October 7 — six days after the abuse occurred.
The incident occurred at Brittany Manor on September 14, 2025, at 3:30 PM in the activity room.
The resident reported a pain level of 8 out of 10 throughout the ordeal.
Federal inspectors found Resident #4 at Aviata at Seminole on October 7 in the facility's parking lot at 10:58 a.m., openly smoking marijuana.
That's where her involvement ended.