The food was failing residents before it ever reached their rooms.
Nursing Home News — Page 687
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The incident at Willows of Greensburg involved a severely cognitively impaired resident with non-Alzheimer's dementia, atrial fibrillation, and hypertension.
Nobody noticed Resident #203 was gone until lunchtime.
The resident, identified in inspection records only as Resident 4, was admitted with a diagnosis of muscle weakness.
The violations involved antipsychotic drugs, antidepressants and anxiety medications administered to newly admitted residents starting August 12.
The Director of Nursing was called.
A nursing aide, CNA #133, said he helped get her up before the nurse arrived because her husband had already started to lift her.
Her federally mandated assessment from June 29 showed no memory impairment.
Federal inspectors rated the failure immediate jeopardy, meaning the lapse created a situation likely to cause serious harm or death.
The audible portion of the call bell system, the sound that travels down the hall and into the nurses station, was not working.
The finding came out of a complaint inspection completed August 15, 2025.
The cup went onto the shelf with everything else.