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Grant Cuesta: Resident Walked Out Alone - CA
to give him his noon medication....
Latest reports, citations, and penalties from CMS data
to give him his noon medication....
The incident occurred around 9:30 pm when Resident #1 entered Resident #2's room to visit his friend, who was Resident #2's roommate....
The registered nurse cleaned the sacral wound with Dakins solution, packed it with sponge material, and attached wound vacuum tubing....
The locking mechanism was protruding outward, clearly visible to anyone passing by....
CNA J was pushing the sit-to-stand transfer chair near the nurses' station on November 17 when an inspector spotted the filthy condition....
The incident at Harker Heights Nursing & Rehabilitation unfolded in late September when staff relocated Resident #1 without the family present....
She worked the overnight shift on the 200 hallway, where residents lived with broken furniture, cracked lights, and bugs crawling on them....
The documentation gap becomes more troubling when viewed against the resident's medication regimen....
The facility's own policy requires "NO SMOKING" signs outside every room where oxygen is in use....
The nurse never documented the complaint....
The breakdown in communication left a vulnerable resident without documented protections, according to a November inspection triggered by a complaint....
Each time, licensed nurses documented the fall but left the December 2024 care plan unchanged....
The incident unfolded on July 30, 2025, around 3:30 p.m....
The patient told inspectors two days later: "There was no RT at all....
The November 16 incident at Valley View Care Center involved a resident with severe cognitive impairment who regularly calls out for help in Spanish....
Federal inspectors found the facility failed to follow doctor's orders for wound care treatments between July and August....
The family member didn't recognize the housekeeper and immediately contacted an acquaintance who worked at the facility to retrieve the resident....
Resident 43 suffered the fracture on November 16 at 11:40 a.m....
Resident #2 required partial to moderate assistance for transfers and had fallen before arriving at the facility....
The visitor alerted facility staff, who redirected the resident back inside....