Despite working with Resident 1 from July through September 2025, the resident's physical therapy goals had remained completely unchanged.
Nursing Home News — Page 366
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The resident, who has dementia and severe cognitive impairment, depends entirely on facility staff for basic activities like bathing, dressing and toileting.
Resident 2 told inspectors he immediately reported the incident to the charge nurse on duty.
The altercation began when one resident grabbed belongings from another resident's table.
Neither supervisor informed the regional administrator that thermostats weren't working properly in resident rooms.
Federal inspectors found the equipment violation during a September 11 complaint investigation at University Rehabilitation Center.
The administrator thought the infection preventionist had reported it.
The designation means inspectors found conditions that could cause serious injury, harm, impairment or death to residents.
That day, Resident 2 grabbed the harasser's neck and punched him in the stomach after being called names and having his personal space invaded.
The doctor's order, dated August 25, specified the resident must wear the collar until a follow-up appointment in six weeks.
The incident occurred on August 29, 2025, when LVN D observed Resident 87 tell Resident 49 "I'm going to hit you" during what she described as an argument.
Resident #1 fell in his room during the overnight shift on August 10.