The area serves 78 residents who use it for physical therapy, vending machine access, and puzzle activities.
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Federal inspectors found the facility had allowed trainees to perform direct resident care tasks alone, despite written policies mandating supervision.
The resident spilled coffee on himself in the dining area on February 20.
But the physician assistant's required History and Physical examination, completed August 8, contained no documentation of any mental status assessment.
I got upset," the resident told inspectors.
Staff 1 had worked at the facility since January 8, 2024, giving narcotic medications to residents with bone infections, fractures, and severe back pain.
The resident, identified in inspection records as R1, was taken to the emergency room at 3:12 a.m.
Resident 2's troubles began in late July when his daughter requested removal of SMART alarms that detect when patients get out of bed or chairs.
Resident 2 never received a scheduled dose of Warfarin on August 7, despite having a doctor's order for the blood thinner to treat atrial fibrillation.
Staff discovered Resident 1 missing around 12:18 p.m.
The resident, identified only as Resident #1 in inspection records, was admitted to the North Road facility on May 28.
Federal inspectors found the gas relief pills during three separate visits to The Oaks-Bethany Skilled Nursing between July 30 and August 19.