The September 8 complaint inspection found staff had failed to follow the resident's meal ticket, which specifically included coffee with his noon meal.
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The resident had been on the same morphine dosage for several years to manage chronic pain and was physically dependent on the medication.
The resident returned from the hospital on July 2 with new diagnoses of right shoulder dislocation and right humorous fracture.
The wound went undetected at Douglas Cove Health and Rehabilitation until an outside provider discovered it during a routine visit and alerted facility staff.
The violation occurred after the resident reported mistreatment during a weekend emergency room visit.
The administrator at Longview Hill Nursing and Rehabilitation Center did not investigate the allegation further.
Licensed Practical Nurse #135 was among the staff who failed to initial medication records immediately after giving drugs to Resident #10.
The August 17 attack occurred when the victim was falling, according to her own account to staff.
Federal inspectors found the violation during a complaint investigation in September.
The resident's care plan required two staff members to assist with bathing due to their medical conditions.
The facility had simply run out of the drug.
Human Resource Director #410 confirmed during a September 9 interview that the file contained no tuberculosis screening documentation.