Staff noted that Resident 2 "had been drinking that morning," according to the facility's own investigation summary.
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The resident's extremities were mottled, cold, and pulseless with associated cyanotic changes, according to hospital records reviewed by inspectors.
The resident's room displayed a clear sign directing staff to put on gloves and gown before entering and to clean hands before entering and leaving.
The scene at University Park Rehabilitation and Healthcare on June 2 was so pungent that the urine odor radiated into the hallway.
The facility's 238 residents went without kitchen service for a day while staff cleaned and sanitized contaminated surfaces.
Employee 11 accompanied Resident 79 to a bank in August 2023 to cash a check worth $3,925.77.
The resident wiped away tears as she recounted the incident to state inspectors at Villa Las Palmas Healthcare Center.
The violation centered on Resident #63, who was placed on Enhanced Barrier Precautions due to their colostomy.
The resident has moderate cognitive impairment and legal blindness following a stroke.
The resident, identified as Resident #14, had been given a urinalysis on July 29, 2024.
The June 6 incident at Woodbury Health Care Center left the resident hospitalized for three days with fractured tibia and fibula bones.
The victim didn't speak to administrators about the incident until the next day.