Additionally, the facility failed to develop individualized care plans addressing smoking activities for residents who smoked.
The staffing crisis extended over multiple weeks.
The electronic medication administration records from June 4-17 revealed an extensive pattern of medication refusals.
The resident, who had severe cognitive impairment and paralysis affecting one side of their body, was discovered at 6:35 a.m.
These dating requirements exist because many medications have limited stability once their original seal is broken.
The incident began when Resident 4 discovered his debit card balance had decreased from $814 to $600 after ordering food with his roommate, Resident 3.
However, facility records revealed no documented weights for the entire months of June and July 2024, despite the care plan requirement for weekly monitoring.
The inspection revealed that staff had failed to secure the catheter tubing with a leg strap, allowing it to pull against sensitive tissue.
The inspection revealed that staff members did not follow established emergency procedures for mental health crises.
This incident marked the facility's second elopement event, revealing a pattern of inadequate supervision and environmental security measures.
Four residents admitted between February and May 2024 experienced significant delays or complete absence of required care planning meetings.
Rather than reporting the allegation to state authorities, administrators referred the matter to the therapy department's corporate compliance office.