Staff had promised to keep him supervised whenever vulnerable women were present.
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On April 8, inspectors watched as two certified nursing assistants performed the procedure.
The January inspection at Harrison Nursing and Rehabilitation Center revealed multiple infection control breakdowns that put all 49 residents at risk.
The failures left nursing staff unaware of basic safety measures while caring for vulnerable residents.
The violations posed immediate risk to resident health and safety.
His doctor had ordered podiatry visits every two months starting in February 2024.
Medical records show the resident received insulin doses ranging from 2 to 3 units based on blood sugar levels from October 26 through November 27, 2024.
CNA A was providing incontinence care to Resident #11 on March 28 when the resident became combative, according to federal inspection records.
Federal inspectors found the 136-bed facility violated basic safety and health requirements during a July complaint investigation.
Federal inspectors found that Resident 65 at Hadley Pointe Nursing Rehab & Care lost 24.5 percent of his body weight between October 2024 and January 2025.
When a certified nursing assistant walked to his car during his break around 2:45 PM, he found the resident sitting in his passenger seat.
When asked about the protocol hours later, Staff A admitted the failure.