Agency CNA Employee E1 was positioned between the resident's bed and their roommate's bed when attempting to roll Resident R1.
Nursing Home News — Page 408
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The problems began with Resident #1, who suffered a witnessed fall on February 20.
Yet the inspection revealed systemic breakdowns in how these critical updates were communicated and implemented.
The resident was admitted to the facility with paraplegia and an indwelling Foley catheter that remained in place continuously.
Staff had failed to implement basic fall prevention measures despite the resident's high risk status and recent fall history.
The patient at CareView Health and Rehab of Minocqua was supposed to receive vancomycin starting June 30, but the first dose wasn't administered until July 2.
Federal inspectors found that nursing staff failed to follow established procedures for contacting medical providers during emergencies.
The resident developed the sacral pressure ulcer while at the facility in late August.
Federal inspectors witnessed the violation during morning medication rounds at Scioto Rehabilitation & Care Center on October 22.
The October 23, 2025 complaint inspection revealed safety failures serious enough to pose immediate threats to resident health and safety.
The chain of events began when one nursing assistant witnessed another yelling at a pediatric resident.
The facility's own policy required reporting suspected abuse to state agencies within 24 hours.