The resident had been admitted with osteopenia, a femur fracture, and gait abnormalities.
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The incident involved Resident #7, who had a documented allergy but was prescribed methylprednisolone anyway.
Federal inspectors found the facility in immediate jeopardy on October 14, 2025, after discovering the nursing home failed to protect residents from abuse.
Neither the resident nor any staff member was present.
Federal inspectors observed the breach on December 10, 2025, at 10:53 a.m.
Federal inspectors found Staff A had removed narcotic pills on multiple occasions while failing to record the medications as administered to residents.
Federal inspectors found the facility failed to immediately report the abuse allegation to state authorities.
The mix-up left the actual decision-maker uninformed about multiple falls and the resident's declining health.
The security breach occurred between 7:20 p.m.
The violation came to light during a federal complaint inspection completed October 14.
On May 30, 2025, the aide was changing the resident's brief when they positioned the patient on their left side and noticed a stain on the draw sheet.
CNA #4 had been assigned to watch the resident during the evening shift and knew he needed constant supervision.