The June 9 accident at Liberty Care and Rehabilitation Center sent the 89-year-old woman to two hospitals.
Nursing Home News — Page 481
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The UTI case involved a resident who had been at the facility since November 2023.
ProAmatine treats low blood pressure with instructions to hold the dose if blood pressure rises above 130.
The resident lacked capacity to understand decisions or communicate effectively, according to assessment records.
The violations earned the facility an immediate jeopardy citation — the most serious level of harm — during an April inspection.
Two residents received improper pain management that violated basic medical protocols.
Nye Summit switched Resident 7 from Elavil to Quetiapine on November 5, 2024, for a diagnosis of primary insomnia.
Three of those falls resulted in major injuries.
From 7:15 PM to 9:45 PM, two licensed practical nurses handled all resident care alone — medications, treatments, personal hygiene, and call bells.
The violations placed the resident at risk for hypoglycemia, seizures, coma and death.
The insulin error occurred April 19 when a licensed practical nurse gave the injection to the wrong resident after patients switched rooms.
The maintenance director told inspectors during a July interview that some of the nursing home's plumbing is more than 100 years old.