The elevator had already been repaired twice that month.
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The form had been entered into the facility's electronic records system on August 19.
The resident, identified in inspection records only as Resident #1, had returned from dialysis.
Resident 1 arrived at the local emergency department on June 23 at 1:17 PM, complaining of 10/10 pain at their catheter site.
That happened on July 29, 2025.
Five hours later, a second nurse followed up and noted the pain had dropped to a 5.
The first fall happened on August 17, 2025.
The first incident inspectors observed happened at 9:40 that morning.
They also had an order for oxycodone.
The resident, a man with moderate cognitive impairment recovering from surgery, had a stage 3 pressure ulcer on his coccyx.
Federal inspectors who arrived at the facility on August 18 found out she was right.
Licensed Practical Nurse N found the resident on his right side around 4 p.m.