The first fall happened on October 20, 2025, at 10:43 in the morning.
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Over six weeks in the spring of 2026, inspectors found that nurses and aides skipped the daily weigh-ins at least eleven times.
Pressure ulcers, sometimes called bedsores, are wounds that develop when sustained pressure cuts off blood flow to skin and tissue.
That detail came from LPN B, a nurse at the facility who told inspectors during a May 26 interview that the behavior was a known pattern.
When inspectors visited Ridgeview Health Services, Inc.
The problem did not emerge without warning.
Her death certificate listed sepsis and hemorrhagic shock as causes of death.
On the morning of May 26, inspectors walked into the room and found a trash can sitting on top of it.
He knew what was happening to him.
Her pathology report was dated December 13, 2024.
The missed doses were not scattered accidents.
That is what federal inspectors found at Autumn Lake Healthcare at Calvert Manor during a complaint investigation completed in May 2026.