The breakdown affected some residents, according to the inspection report.
Nursing Home News — Page 558
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The fracture at Collierville Nursing And Rehabilitation came to light only after the resident's family requested an X-ray.
In one video, she lay in a resident's bed next to the patient, talking about cuddling while both she and the person filming giggled.
The facility reported the incident involving two residents to state authorities on September 4, 2025, as required within 24 hours.
The nursing home has not submitted a plan of correction.
The incidents occurred on August 23, 2025, at Four Seasons Health Care Inc, where both residents have severe cognitive impairment and dementia diagnoses.
Staff must also assess any injuries present and observe both resident and staff behaviors during the investigation process.
The resident, admitted on May 12, 2015, carried diagnoses of dementia and depression.
By November 13, sixteen residents and eight staff members had tested positive for COVID-19 in an outbreak that began November 2.
Getting those textures wrong is not a minor paperwork problem.
The defiant stance emerged during a complaint investigation when inspectors sought internal incident reports involving residents #1, #5, #10, #15, and #20.
The November incident exposed multiple failures in the facility's wandering prevention system.