The resident, identified as Resident B, has rhabdomyolysis, a condition where skeletal muscle breaks down and releases harmful substances into the bloodstream.
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Federal inspectors documented the sequence through facility surveillance footage and witness accounts.
When she left, staff failed to provide her with those medications plus oxycodone-acetaminophen for pain management.
"It wasn't an unusual occurrence," the facility administrator told federal inspectors when asked why the fall went unreported.
Hours later, worsening ankle pain sent her to the hospital for X-rays.
The resident at Avante at Ocala believes he's back in Vietnam.
By October, administrator couldn't locate the plan of correction documents that supposedly showed how these problems were resolved.
The Director of Nursing acknowledged the violation during the October 14 inspection.
Staff signed out Ativan doses from the facility's controlled substance accounting system but left the corresponding medication administration records blank.
Heritage Park Rehabilitation and Skilled Nursing Center's error triggered an immediate jeopardy citation from federal inspectors on October 14, 2025.
When a certified nursing assistant tried to push the resident's wheelchair, he grabbed her hand and ripped off her fingernail.
The October inspection revealed that particles of dirt had also settled on top of the bed linens where the cognitively intact resident rested.