Wet footprints led from his bedroom door to a puddle at the foot of his bed.
Nursing Home News — Page 347
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Federal inspectors found the August incident violated the resident's fundamental right to dignity during personal care.
On August 27, inspectors watched RN 2 conduct a narcotic drug count on the East unit medication cart at 10:51 a.m.
The incident occurred at Park Avenue Health Center when Resident #1 had requested help getting into a wheelchair earlier that morning.
The most serious case involved Resident #100, who suffered trauma to her right foot's third and fourth toes on June 2.
Emergency room physicians found her right leg was pale and cool to the touch.
The nurse, identified as LVN 1 in inspection records, continued working shifts from June 30 through August 9 despite their license expiring earlier.
The resident had been administering the medication himself.
The incident occurred on April 12, 2025, but administrators weren't notified until three days later.
The incident at Skyline Healthcare Center unfolded on August 24, 2025, when Resident 2 complained she wasn't comfortable with CNA 2 providing her care.
Federal inspectors found the facility violated care planning requirements by not updating the resident's safety plan after the July 22 incident.
Paradigm at the Prairies terminated its social worker on June 25 and had not replaced her by the time federal inspectors arrived August 30.