Garden View Care Center had developed detailed procedures five years earlier for evaluating whether residents could consent to sexual activity.
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The resident's clinical record showed diagnoses of nicotine dependence and major depressive disorder.
The incident involved a resident with Alzheimer's disease and a seizure disorder who was completely dependent on staff for all daily care activities.
Resident #6 had a physician's order from October 9 for Midodrine, a medication to raise blood pressure when readings fell below specific thresholds.
The receptionist entered the code to open the gate without speaking to anyone or verifying their identity.
Resident #186 entered the facility in March 2020 with Alzheimer's disease, major depressive disorder, and hypertension.
Resident #11's injury was discovered on September 22 when staff noticed discoloration on her left hand and wrist.
The missing documentation raises fundamental questions about whether residents actually received prescribed treatments.
The incident occurred when the agency CNA lined up a shower stretcher next to the resident's bed and pulled them across using a sheet.
The worker resigned November 5 after state inspectors began asking questions.
The resident cannot walk independently and requires assistance with transfers, according to her most recent assessment.
The facility only assigned round-the-clock supervision after the September 29 incident involving two residents.