The resident had undergone a breast biopsy that left her with a surgical incision.
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on January 18, 2024, after choking in their room.
The bedpan was typically stored in the bathroom when not in use.
At 8:52 p.m., Pharmacy 1 delivered seven vials of amphotericin B 50 mg along with dextrose solution to RN 3.
According to witness statements obtained by inspectors, the staff raised the bed to hip level and used physical restraint when the resident became combative.
The resident at AVIR at Lancaster hadn't received monthly statements since July 2025, federal inspectors found during a November complaint investigation.
The Director of Nursing told inspectors on November 5 that the facility only made phone calls to let families know their loved ones were being moved.
Her certification expired while she continued working on the floor caring for residents.
AS 1 had been supervising Resident 1 in the Activity Room when her shift ended at 5:00 PM.
The resident had slipped out of Sunset Home's memory care unit early in the morning, triggering a Code Purple missing resident alert.
The altercations at Oakland Manor involved the same resident striking two different people.
Staff described recent resident-to-resident incidents and expressed fear about providing care to at least one particular resident.