The April 25, 2022 assault at Willowbrooke CT Skilled Care Center at Bayleigh Chase was witnessed by two staff members, but neither reported it immediately.
Nursing Home News — Page 485
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Agency Licensed Practical Nurse 2 took medications to the beauty salon looking for Resident 93, who lived in one room but was found in another resident's room.
The resident died on June 14, four days after her family was finally notified of the wounds.
Federal inspectors documented the pest infestation during an August inspection that resulted in immediate jeopardy violations for kitchen cleanliness failures.
"Her laboratory tests were not drawn," she explained during an April 24 interview.
The medication error forced the resident into a week-long hospital stay for emergency intravenous steroid treatment to prevent organ rejection.
Water pooled on the floor below both residents' beds in the shared room.
The three-day delay at Franciscan Woods violated the facility's own policies and left the resident without proper treatment orders for her reopened wound.
The March inspection followed a complaint and revealed systemic failures in nursing staff levels that put resident safety at risk.
Cheviot Hills Post Acute took in a patient with obstructive sleep apnea and obesity hypoventilation syndrome who required a BiPAP breathing machine.
Nursing Assistant #2, hired on August 10, 2023, had received only IV therapy education during the entire period from hire through the February inspection.
The dietary manager acknowledged the problems when confronted by inspectors on July 22.