The resident had been at Spring Hills Post Acute Hamilton since late November 2024.
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Resident 37 at Twin Oaks Center had been deteriorating for days before the January hospitalization.
The resident's roommate witnessed the incident and confirmed seeing the nursing assistant give Resident 16 the middle finger while leaving the room.
Inspectors documented the violations under federal tag F600, which addresses resident safety and protection from harm.
The resident's blood sugar spiked to 446 mg/dL before her family member called the facility to ask why she wasn't receiving insulin.
Resident 1 had lived at the facility since July 2021 with diagnoses including Parkinson's disease, Alzheimer's disease, and dementia.
On January 15, 2025, at 8:14 A.M., the surveyor observed the unlocked medication cart on the dementia unit and was able to open and access it.
Resident 75 at Millennium Post Acute Rehabilitation was ordered Mighty Shakes with each meal on January 23 to address significant weight loss.
LPN8 had signed acknowledgment of receiving the employee handbook, according to facility records reviewed by inspectors.
The March 13 inspection found actual harm to residents and deficient practices related to modified diets, menu cards, and meal assistance.
All three ulcers extended 0.2cm deep into tissue.
The woman, identified in inspection records as R3, arrived at the facility with existing pressure wounds and moisture-associated skin damage on her coccyx.