The resident, identified as R1 in inspection records, requires a cough assist machine three times daily to clear their airways and maintain breathing.
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But nurses skipped documentation for the evening shift on February 7 and the night shift on February 8.
The facility's own policy requires staff to notify responsible parties of changes in condition or medical occurrences.
Yet documentation consistently listed dementia as her condition.
The violation occurred during care for a 72-year-old woman with multiple health conditions including congestive heart failure, diabetes, and morbid obesity.
Federal inspectors found the facility violated residents' rights to access their personal records during a complaint investigation completed August 28.
The licensed vocational nurse heard a sound in the hallway around 6:15 PM on August 12 and looked up to see Resident 1 on the floor.
The incident at Colonial Manor of Elma involved a resident whose cognitive assessment scored just 2 out of 15 points, indicating severe impairment.
Resident 1 developed a fever on August 4 and received a COVID test at the facility before being transferred to a hospital.
Three days later, during psychiatric evaluations, both spouses made the same request.
The violations occurred despite facility policies requiring immediate documentation both before and after giving medications.
The facility's own policy, dated May 2024 and titled "Outbreak of Communicable Diseases," could not have been clearer.