The deterioration wasn't sudden.
Nursing Home News — Page 547
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Immediate jeopardy is the most serious designation federal health inspectors can assign.
"She would rush them and shovel the food too fast," a fellow nursing aide told state inspectors during interviews conducted October 22.
But when the resident refused the device, certified nursing assistants proceeded with transfers anyway without telling supervisors or writing anything down.
Because of the incorrect coding, she said the computer system never prompted her to document the resident's refusal.
The right to self-administer medication is a federally protected provision under the Nursing Home Reform Act.
Inspectors reviewing treatment administration records found blank after blank: day shifts, evening shifts, wounds that were supposed to be treated twice daily.
The resident was diagnosed with seizures and respiratory failure.
Inspectors found those steps weren't consistently happening.
The November 10 attack happened without warning.
The regulation requires that care plans include specific timetables and measurable actions.
The facility has not submitted a plan of correction for the identified deficiencies.