The previous administrator resigned before June, leaving no documentation trail for the incident.
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The order, dated October 9, 2024, was designed to prevent the resident from choking on feeding tube contents.
Immediate jeopardy citations are relatively rare and carry significant regulatory weight.
Despite the delivery, nursing staff never retrieved the medications from the machine to give the resident their prescribed morning doses.
The August 28 social media post revealed that Resident #77 was being transferred from the nursing home to a local hospital.
When asked if he could remove the compression wrap himself, the resident shook his head no.
Within two weeks, the attacks began.
The resident had a jejunostomy tube, which feeds directly into the small intestine through a surgical opening in the abdomen.
Nursing home residents face elevated fall and injury risks compared to the general population.
The facility has not submitted a plan of correction.
The BIPAP breathing equipment belonged to Resident #3, who used the device nightly to help them breathe.
The aide walked back to the door, read the isolation sign she had ignored, and then put on the protective gear.