The incident occurred on August 7, 2025, but the Director of Nursing wasn't notified until the following morning.
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The facility's own policy requires all allegations to be thoroughly investigated.
The residents — two with severe cognitive impairment and one with respiratory failure — shared a room where none of their call lights functioned.
Certified nursing assistant #52 witnessed the outburst and immediately reported it to administrators the same day.
Resident 77 had been at the facility for just four days when everything went wrong.
The resident had originally agreed to be discharged to the first assisted living facility.
Federal inspectors found the facility's own care plan explicitly required two-person assistance for bed mobility and toileting.
But the resident didn't have a cuffed tracheostomy and had no physician's order for one.
Resident 99 was admitted on January 2, 2025, with several concerning injuries.
The July 29 incident at River Pointe Post-Acute involved two women sharing a room.
Licensed Practical Nurse #325 first discovered and reported the maggots during a night shift between July 16 and July 17.
The breakdown occurred on July 14, 2025, at Bayview Health Care when the morning nurse discovered no fentanyl patches remained in stock.