The resident at Horsham Center for Jewish Life had been showing escalating signs of agitation for weeks.
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A June assessment indicated she had moderate cognitive impairment and required substantial to maximum assistance from staff with toileting.
The incident at Sunnycrest Manor occurred during the evening meal on July 29, when the resident insisted he had more chicken on his plate.
These sanitation failures violated the facility's own written policies.
The facility's own staffing coordinator confirmed the practice during an interview on August 14.
The hospital specifically noted the resident should receive care for the condition.
The Certified Nursing Assistants were observed at 10:14 a.m.
Her nasal cannula lay wrapped on top of the shut-off oxygen machine.
The incident at Dinwiddie Health and Rehab Center occurred on July 9, 2025, when CNAs attempted to move a resident using a U-shaped sling.
The August 20th incident at Fort Worth Transitional Care Center revealed systematic failures in fall prevention protocols.
The family's power of attorney learned about Resident 24's discharge only when another family member told her.
Resident 3 missed pain medication patches on two consecutive days.