The resident should have received only the 80-milligram dose.
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while trying to reach the bathroom.
He was discovered in Resident 1's room, where blood had splattered across the bed sheets, floor, and wall.
The September 24th incident at Agawam West Rehab and Nursing occurred during routine personal care.
Federal inspectors found staff failed to follow the facility's own policies for evaluating residents experiencing changes in condition.
The incident began August 28 when the resident's representative reported to facility staff that money was missing.
The resident had answered yes to every question on an abuse interview form during the earlier investigation.
Resident #7 fell sometime before staff found her on the floor.
The incident occurred on September 16 at Frederick Crossing of Journey, where Resident #1 alleged that geriatric nursing assistant #5 slapped him in the face.
On October 7, 2025, Resident 1 told Licensed Vocational Nurse 1 that Resident 2 had struck her with a water bottle.
The September 8 incident at Linn Manor Care Center began when two certified nursing assistants found Resident #1 in his bathroom during their 6 a.m.
The facility houses 143 residents.