Federal inspectors found multiple medication safety violations during their April 24 visit to the facility on North Assembly Street.
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The resident was alert, oriented, and had intact cognition according to medical assessments.
Resident 316 was admitted with fractured vertebrae and muscle weakness.
"While the resident was being lowered down, NA B let go of the wheelchair to straighten Resident #1," CNA A told inspectors.
Sometimes meals contained almost nothing.
Federal inspectors found the facility's quality assurance program failed to prevent the error or implement effective corrections afterward.
The resident, identified as B3 in inspection records, experienced nausea and vomiting after taking the wrong drug.
LPN #1 administered pantoprazole to Resident #8 on the morning of August 7, six days after the medication had expired.
None of those services were provided.
The resident, who suffered from palliative care conditions including brain hemorrhage and paralysis on one side of his body, left the facility at 6:35 a.m.
Licensed Vocational Nurse A discovered the dangerously low blood pressure at 10:23 a.m.
Kitchen staff couldn't explain basic dishwashing procedures.