The facility failed to maintain basic room conditions in all five resident rooms examined.
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The medications the facility had missed included Seroquel, insulin on a sliding scale, antibiotics, and lidocaine patches.
That resident later "got much better," according to the administrator.
Resident #2 had a documented history of physical aggression when agitated by other residents.
The October incident exposed multiple safety failures at the facility.
The previous administrator resigned before June, leaving no documentation trail for the incident.
The order, dated October 9, 2024, was designed to prevent the resident from choking on feeding tube contents.
Immediate jeopardy citations are relatively rare and carry significant regulatory weight.
Despite the delivery, nursing staff never retrieved the medications from the machine to give the resident their prescribed morning doses.
The August 28 social media post revealed that Resident #77 was being transferred from the nursing home to a local hospital.
When asked if he could remove the compression wrap himself, the resident shook his head no.
Within two weeks, the attacks began.