The 89-year-old resident with severe cognitive impairment lay sleeping nearby while the prescription medications remained easily accessible.
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According to the visitor's account, a staff member responded by yelling at the resident: "We hear you.
## Pattern of Narcotic Tracking Discrepancies Federal inspectors uncovered a concerning pattern of medication tracking failures spanning several months.
The breakdown extended to nursing assistants who provide direct resident care.
Bank statements showed the resident's account balance plummeted from $9,539.98 in July 2024 to just $496.46 by October 2024.
One resident with spinal stenosis and muscle weakness reported waiting **up to 2 hours** during nighttime shifts for staff to respond to calls for help.
## Food Contamination Incident Raises Infection Control Concerns The most alarming violation occurred during breakfast service in the secure dementia unit.
The facility's director of nursing approached and questioned why the door remained open during such intimate care.
Despite this clear requirement, the certified nursing assistant was performing bed linen changes alone.
When inspectors contacted the listed physician, **the doctor stated the facility was not one where he sees residents**.
During the inspection, surveyors observed a nurse aide exiting a COVID patient's room wearing only a blue surgical mask after performing close-contact care.
## **Facility's Inadequate Response Exposed** Federal inspection records reveal significant gaps in how administrators handled the abuse allegation.