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Heritage Center: Pressure Ulcer Care Delays - WV
The resident, identified as #164, entered the facility on an unspecified date in March....
Latest reports, citations, and penalties from CMS data
The resident, identified as #164, entered the facility on an unspecified date in March....
The incident occurred in the early morning hours of September 16....
A small film floated on the water's surface alongside multiple floating substances....
The resident at Great Lakes Healthcare Center suffers from hemiplegia, which paralyzed one side of his body following his stroke....
CNA A was suspended the same day during the facility's investigation....
But the nursing aide care card was never updated to reflect the resident's deteriorated condition....
The woman's family member discovered the neglect during a September 29 visit to Aliya of Crestwood....
The tray included an 8-ounce carton of whole milk and a 4-ounce cup of orange juice....
The only record LPN B could locate showed the wound vacuum was in place on September 10....
Resident #16 was discovered by a passing motorist who stopped to help....
The facility terminated the nursing assistant within two hours and reported the abuse to authorities....
The facility admitted the 83-year-old resident in August with vascular dementia....
She walked to the medication cart near the first-floor dining room and requested anti-anxiety medication from Staff E, a trained medication assistant....
Federal inspectors discovered the oversight during a complaint investigation completed in October....
Federal inspectors found the same scene during three separate visits to Avir at Rose Trail between September 28 and October 2....
But the facility's original screening form indicated the resident had no primary diagnosis of cerebral palsy....
Licensed Practical Nurse #2 abandoned the cart at 10:17 AM on September 25 to attend to another resident behind a closed door....
The injuries prompted a complaint investigation that concluded October 2, 2025....
The 65-year-old resident disappeared on June 27, 2025, sometime before 5 p.m....
The admission came during a federal inspection on October 2nd at a facility caring for 55 residents....