The September 29 incident at Oak Hills Living Center began when Resident #2 walked to the kitchen asking for their cup to be washed.
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The June 18 attack occurred at 6:00 p.m.
His care plan from August indicated he could eat independently after staff setup.
The resident had been readmitted with metabolic encephalopathy, brain hemorrhage, and paralysis affecting his left side.
The resident's physician had ordered the powerful opioid painkiller to be given at 6:00 AM, 2:00 PM and 10:00 PM daily, beginning August 27th.
Federal regulations require nursing homes to deliver clear, written communication to residents regarding several critical areas.
Controlled substances must be kept in separately locked storage areas.
The incident involving the resident identified as RI #2 occurred on or around December 6, 2024.
The resident later allowed the aide back in.
While this represents the lower end of the federal severity scale, the underlying failure carries significant clinical implications.
The November 23, 2023 incident at Brigadier General Wendell H.
The loose tiles at Nashua Post Acute Care were curled at the edges and lifted from the floor surface.