The September incident at Community Care Center began when the resident complained that housekeeping staff had given him toilet paper without wearing gloves.
Nursing Home News — Page 746
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RN B admitted she didn't know how often meals were served late, despite breakfast being scheduled for 7:00 am and lunch at 11:00 am.
The resident, identified as R1 in federal inspection records, was admitted with orders for two heart medications that needed to be given twice daily.
The facility's environmental services director acknowledged they currently have no floor technician and are "stretched thin" on cleaning staff.
The incident began when Resident #1 entered another resident's room despite being told by nursing staff not to go there.
Resident #74 somehow left the building undetected and crossed streets to reach a bus stop.
Federal regulations require nursing homes to report incidents involving potential serious bodily injury within 24 hours.
The facility reported the irregularity itself on September 4, after discovering discrepancies in narcotic sign-out sheets for the two residents.
On August 27, staff recorded four separate diarrhea episodes.
The resident, identified in inspection records as R1, suffered a stroke that left her unable to move her left arm independently.
During the September 11 inspection, the Director of Nursing acknowledged the oversight.
The medication treats nerve pain and controls seizures.