The resident, identified in inspection records as R401, showed a change in condition on February 27, 2025.
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Care plans serve as the fundamental blueprint for resident treatment in nursing facilities.
The patient cannot swallow food or liquids due to dysphagia and receives nutrition through a surgical opening in her stomach.
The November inspection at NHC Healthcare found staff routinely ignored transfer protocols designed to prevent falls among vulnerable residents.
In one room, inspectors documented four cracked tiles with brown discoloration near the doorway, with one tile raised slightly above floor level.
This requirement exists to ensure all stakeholders can participate in care decisions and respond appropriately to changing health conditions.
The medication was already under revision because the resident had experienced significant recent weight loss and a decline in mobility.
The violence peaked on September 19 during what was supposed to be a therapeutic nature ride.
The gaps included no records of help with combing hair, shaving, applying makeup, or washing and drying face and hands.
Federal inspectors arrived on January 2, 2026, and found the doors that way.
The resident who walked back into the room was identified in inspection records only as R8.
On December 10, the medication administration record showed Midodrine given at 2:00 p.m.