One of the residents never returned to the facility.
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This assessment, known as the Minimum Data Set (MDS), serves as the foundation for every aspect of a resident's care plan.
The charge nurse responsible for one resident was terminated September 11 for failing to report an injury of unknown origin.
Inspectors visiting Autumn Lake Healthcare Post-Acute Care Center on November 24, 2025 reviewed records for residents discharged within the last six months.
The resident in the next bed heard it happen.
The nurse had documented information about the changes themselves.
The resident developed deep tissue injuries on both buttocks by September 25.
Federal inspectors discovered the missing Iowa Statutory Power of Attorney documents during a November 25 complaint investigation.
The resident at Center Point Health Care and Rehab had dropped from 139.4 pounds in late August to 128.8 pounds by mid-November.
The Director of Nursing confirmed to federal inspectors that staff had not been trained specifically on orthostatic hypotension fall prevention techniques.
"She rolled out of the bed on to her face," the aide said.
Inspectors documented the burn through a series of wound assessments.