Federal inspectors found the misdiagnosis placed the resident at risk for wound deterioration.
Nursing Home News — Page 437
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Staff witnessed the destructive behavior repeatedly.
Two residents required hemodialysis three times weekly through surgically implanted chest catheters.
His blood pressure was dangerously low when responders found him.
As Resident 1 walked down the corridor, she extended her right arm, blocking his passage.
The resident at Lakeside Health and Wellness told inspectors he had been receiving "baby food for a while now" when they observed his lunch on November 19.
The first resident was found on the floor and later developed blood in his catheter bag.
The friend found the pills during a visit and immediately alerted nursing staff.
The incident occurred on August 26, 2025, when Resident #1's BIPAP machine stopped working between 2 and 3 AM.
The facility's own policy required staff to request specialized services within 20 business days of interdisciplinary team meetings.
"Staff could miss resident care needs." The facility's own policy requires care plans to be updated whenever incidents occur.
Federal inspectors cited the nursing home for deficiencies in elopement management following a complaint investigation completed November 19.