The resident experienced episodes where he believed he was still in combat or that the U.S.
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The resident was discovered on the facility's loading dock, standing on a hydraulic lift raised 81 inches from the pavement below.
Despite facility policy requiring immediate nursing assessment after any fall, the aide failed to notify nursing staff or supervisors about the incident.
Instead, staff served the meal on a single plate with all items mixed together.
When staff couldn't locate the resident at 6:00 PM, they initiated a facility-wide search and contacted local police.
Additionally, inspectors found a bag labeled "Promethegan" with concerning documentation issues.
In the 100 hall shower room, staff had stored an electric razor filled with gray hair stubble without any resident identification label.
The federal requirements governing medication administration encompass multiple safeguards.
This qualification gap becomes particularly significant when considering the scope of responsibility involved in dietary management.
The resident experienced severe pain for approximately 15 hours before receiving the appropriate pain medication.
Inspectors documented that Resident 67, who tested positive on July 16, continued sharing room 301 with COVID-negative Resident 61.
This positioning failure presents serious medical risks.