The facility's Director of Nursing admitted that care plans for three residents should have been revised after each fall, but weren't.
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The resident required multiple daily treatments for wounds on the left upper inner thigh, right lower abdomen, and left lower extremity.
Resident 128's family discovered the undocumented wound only when they took their loved one to the emergency room on July 21.
Federal inspectors documented the violation after observing the assistant providing care without following enhanced barrier precautions.
She requires assistance with all personal care and cannot complete basic mental status interviews.
CNA E told inspectors she heard Resident #1 hollering and rushed to Resident #2's room.
At 8:30 AM, a state inspector watched Licensed Practical Nurse D prepare medications for Resident 5.
Resident #62 left Heatherdowns Rehab & Residential Care Center in July 2025 despite needing a Hoyer lift for every movement since her admission in May.
Federal inspectors found the deteriorating conditions at Heritage Nursing & Rehabilitation during a September complaint investigation.
When the registered nurse supervisor arrived in the room 42 minutes later, she confirmed what inspectors had observed.
Resident 1 was transferred to a general acute care hospital on September 5, 2025, at 5:14 a.m.
Without functioning bracelets, residents could leave the building undetected and unsupervised.