The resident, identified in inspection records only as R8, had fallen nine times between June 15 and August 16, 2025.
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Federal inspectors arrived at the facility on August 15, 2025, and what they found was a problem already in progress.
Resident B has chronic obstructive pulmonary disease and depression.
That is what inspectors found when they visited Touchpoints at Chestnut on August 18, 2025, following a complaint.
The missed meals happened on April 20, 2025.
Federal inspectors classified the failures as Immediate Jeopardy, the most serious level of harm recognized under the Medicare inspection system.
When staff left his room for five to ten minutes and returned, they found him half on the floor with his arm wrapped around the bed's side rail.
The inspection, completed August 15, 2025, was triggered by a complaint.
The resident who left with the wrong prescription was not the one it belonged to.
The nursing assistant, identified in federal inspection records as CNA #1, was the one who spotted it.
Both aides acknowledged what they had seen.
Residents discharged back to the community, or transferred to another nursing facility altogether, were not included.