The Assistant Director of Nursing called the resident's wife and told her to pick up her husband immediately.
Nursing Home News — Page 439
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Federal inspectors who visited the facility in November found the resident's complaint was accurate.
Both residents had dementia and required physical help with bathing.
Resident #9 had been living at the 39-bed facility since his admission earlier this year.
The September 3 incident between the female resident and a male resident left her with a small cut on her lip.
Instead, nurses working from an incomplete fax never entered the medication into the system.
She told inspectors during a November 18 interview that she realized the error after the wrong medication had been infusing for less than five minutes.
The resident told inspectors on September 29, 2025 that staff had been withholding her medication because her blood pressure was low.
Then comparing those requirements against the actual food delivered.
Enhanced barrier precautions are implemented for residents at higher risk of infection transmission.
Federal inspectors observed the violation during a complaint investigation at the 58-bed facility.
The violation was classified as immediate jeopardy to resident health or safety, the most serious category of nursing home deficiency.