on September 10, inspectors observed the housekeeper removing trash from a resident restroom without gloves.
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Resident 143 was prescribed gabapentin 800 mg four times daily at specific hours to treat nerve pain from her injuries.
She said staff typically changed her at least twice per shift.
The resident's weight dropped from 192.4 pounds in June to 171.6 pounds by August.
The physician had ordered the 10 milligram opioid only when Resident 111's pain reached a level of 7 to 10 on the standard pain scale.
On June 28, the resident's morning blood pressure measured 96 — well below the safety threshold.
The system's failure created potential escape routes for residents with dementia or other conditions requiring supervised care.
For three days, nursing staff administered nothing.
The resident had been waiting since lunchtime when staff started making the bed but never returned to complete it.
The resident told staff that an aide had grabbed her roughly during a transfer the night before.
CNA 2 immediately reported the finding to LVN 2, who went to assess the resident.
The resident, identified as R101 in state inspection records, had sustained trauma that led to necrotizing fasciitis of the left arm and leg.