The facility's own Director of Nursing admitted she was unaware of the missing documentation until inspectors pointed it out.
Nursing Home News — Page 406
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Federal inspectors cited the facility for immediate jeopardy to resident health and safety after the October 20 incident.
Staff B, a registered nurse, committed multiple infection control breaches during an 11:30 AM wound care session on October 19.
Resident 2 fell from his wheelchair on September 30, 2025, sliding slowly to the floor despite having his brakes locked.
Video from June 6 shows the aide at Jennings Hall using a ceiling lift by herself to move Resident #74 from a recliner to her bed.
The resident would plead "please don't drop me" during these interactions.
This technique violates manufacturer guidelines for safe operation.
Federal inspectors found the facility violated safety standards for mechanical lifts and wheelchair transport, causing actual harm to the resident.
The resident's indwelling catheter became occluded frequently, and sediment in the urine was common, the nurse told federal inspectors.
The resident was eating a breakfast sandwich and drinking coffee when the nursing assistant left to help a colleague with another resident transfer.
The complaint that triggered the October inspection centered on what should have been a straightforward records request.
The incident occurred during what inspectors described as a documented change in the resident's condition.