The outbreak on Resident #25's unit had already begun on June 1.
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The insulin error happened during morning medication rounds on July 8.
R58 had no order for fentanyl but received her roommate's 75-microgram patch on May 2, 2022.
Staff had promised to keep him supervised whenever vulnerable women were present.
On April 8, inspectors watched as two certified nursing assistants performed the procedure.
The January inspection at Harrison Nursing and Rehabilitation Center revealed multiple infection control breakdowns that put all 49 residents at risk.
The failures left nursing staff unaware of basic safety measures while caring for vulnerable residents.
The violations posed immediate risk to resident health and safety.
His doctor had ordered podiatry visits every two months starting in February 2024.
Medical records show the resident received insulin doses ranging from 2 to 3 units based on blood sugar levels from October 26 through November 27, 2024.
CNA A was providing incontinence care to Resident #11 on March 28 when the resident became combative, according to federal inspection records.
Federal inspectors found the 136-bed facility violated basic safety and health requirements during a July complaint investigation.