Each time, licensed nurses documented the fall but left the December 2024 care plan unchanged.
Nursing Home News — Page 434
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The incident unfolded on July 30, 2025, around 3:30 p.m.
The patient told inspectors two days later: "There was no RT at all.
The November 16 incident at Valley View Care Center involved a resident with severe cognitive impairment who regularly calls out for help in Spanish.
Federal inspectors found the facility failed to follow doctor's orders for wound care treatments between July and August.
The family member didn't recognize the housekeeper and immediately contacted an acquaintance who worked at the facility to retrieve the resident.
Resident 43 suffered the fracture on November 16 at 11:40 a.m.
Resident #2 required partial to moderate assistance for transfers and had fallen before arriving at the facility.
The visitor alerted facility staff, who redirected the resident back inside.
Federal inspectors documented the hand hygiene failures during an October 29 observation at Azalea Health Center by Harborview.
The employee at Focused Care of Center admitted during questioning that she knew her actions constituted theft.
Federal inspectors found the resident on September 29 at 11 a.m., lying in bedding saturated with urine from her lower back to mid-thighs.