Federal inspectors found that Resident #84 at Dunbar Center missed all his required diabetes medications on December 25, 2025.
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The woman, identified in federal inspection documents only as Resident R1, was a patient at Roosevelt Rehabilitation and Healthcare Center in Philadelphia.
The incident happened on the evening of October 31, 2025, at Salem Transitional Care, a nursing and rehabilitation facility on Boone Road SE.
The facility, which had 83 residents at the time of the inspection, was cited for failing to keep resident rooms clean and equipment adequately maintained.
She acknowledged that admission nurses were responsible for reviewing all hospital discharge summaries and updating care plans accordingly.
One resident dropped from 108 pounds to 84.7 pounds, losing 21.57% of her body weight.
The woman, identified as R385 in federal inspection records, was admitted to the facility on December 11, 2024, from an acute care hospital.
The resident, identified as Resident B, was supposed to receive physician notification whenever blood glucose levels reached 351 or higher.
The facility's nursing home administrator went on administrative leave January 31 and still hadn't returned when state inspectors arrived March 20.
The incident occurred on February 3rd at 10:35 a.m.
The violations spanned three separate time periods.
Licensed Practical Nurse #1 mixed potassium chloride liquid into thickened water and brought it to the resident's room with other medications.