She also didn't know her dietary manager wasn't certified to do the job.
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The January 15 incident at Grandview Nursing and Rehabilitation violated the resident's right to dignity and respect, federal inspectors found.
She also felt cold air coming through the hallway.
Federal inspectors observed the violation during their review of infection control practices at the 541 V Avenue facility.
His cognitive assessment scored a 3 out of 15, indicating severe impairment.
Resident 64 was found wearing a nasal cannula connected to an oxygen concentrator set at 2 liters per minute during an August inspection.
The resident's family finally removed them from The Foley Center at Chestnut Ridge at 4:47 pm and drove straight to the emergency department.
The resident at The Care Center of Honolulu explained his situation during an August inspection.
The incident occurred on March 26 at 8:45 AM during the morning medication pass to Resident 169.
Federal inspectors cited Edgerton Care Center for failing to provide appropriate treatment and care for four residents between January and March.
The facility's system for monitoring controlled substances broke down across multiple levels during a June inspection.
Federal inspectors observed Employee 10 on June 28, 2024, at 8:15 a.m., preparing medications for a resident.