The most glaring example involved Resident 59.
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The deficiency was classified under the broader category of **Quality of Life and Care Deficiencies**.
Under federal nursing home regulations, every resident has the legal right to be informed about their medical condition in language they can understand.
The violations occurred across multiple units.
The violation came to light during a complaint inspection on October 1st.
Federal inspectors responding to a complaint in September found that staff violated the facility's own safety procedures during wheelchair transport.
The resident also has chronic blood clots in the lungs and fluid buildup around the heart.
The August 14 attack happened at 4:45 PM when the victim, identified in federal inspection records as Resident #1, tapped Resident #2 on the shoulder.
She provided a photo with her complaint and gave the grievance form to the activities director.
The facility's Director of Nursing conducted a sexual capacity evaluation but failed to properly assess the resident's cognitive ability to consent.
When she got out in November, staff called her daughter, who talked her back inside over the phone.
The medication administration record, which nurses are supposed to fill out every time a controlled substance is given, showed nothing.