The cascade of falls began on June 7, when staff found the resident on her bedroom floor with a moderate amount of bright red blood.
Nursing Home News — Page 333
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The woman had suffered the spinal compression fracture and a broken right wrist in a fall.
The August 15 incident involved Resident 1, a diabetic patient with Alzheimer's disease who cannot consent to contact.
Two days later, the resident received notifications on her phone that her credit card had been used for purchases she never authorized.
The resident's family representative confirmed during an August 18 interview that the facility never told her about any of the three room changes.
The medication error occurred on July 21.
Federal inspectors visiting Country Village Care on August 25 discovered multiple residents whose catheter bags were visible to anyone entering their rooms.
The facility's own policy required returning all resident money within 30 days of discharge or death.
The resident arrived at the facility in October after losing his right great toe.
Federal inspectors determined the facility failed to follow mandatory reporting requirements for suspected abuse or neglect, placing other residents at risk.
Resident #4 was found bleeding on the floor next to her bed on August 19, with a laceration on the back of her head.
The incident involved two residents, identified in the inspection report as Resident #71 and Resident #38.