The resident made allegations of verbal abuse and neglect involving a certified nurse assistant and licensed practical nurse on June 23.
Nursing Home News — Page 323
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Federal inspectors observed the certified nursing assistant violating multiple infection control protocols during routine incontinence care.
The resident required regular dialysis and had developed a stage three pressure ulcer on their right buttock.
When asked whether the resident received prior notification for discharge, she said the administrator told her the ombudsman had been consulted about the move.
During those weeks, multiple staff members documented her obvious distress.
The missed injury at North Starr PostAcute Care prevented Resident 1 from transferring to an assisted living facility as planned.
Resident 11 was supposed to get her shower earlier in the day, but the certified nursing assistant assigned to help her left work early.
The incident unfolded on July 14 during the evening shift when the resident rang their call bell for assistance.
The nurse said this wasn't uncommon for the resident, who had increased anxiety related to her COPD diagnosis.
The fall occurred on June 28, 2025, when Resident #1 walked into the front elevator.
The incident at Chesaning Nursing and Rehabilitation Center violated federal rules governing psychotropic drugs, which affect brain activities and behavior.
Resident #1 had been transported to dialysis on a portable ventilator.