The resident weighed 77.4 pounds and could walk independently without assistance.
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The facility's own assessment documents promised annual wound care training and specialized care competencies for staff.
When the physical therapist pressed the call light that morning to get the resident cleaned up for her session, nobody came.
The incident at Decatur Health & Rehab Center triggered immediate jeopardy violations that lasted nearly a month, from January 4 through February 1, 2025.
The problems emerged during a resident council meeting on April 22, when multiple residents complained about conditions during night shifts.
Staff F was hired at Royal Park Health and Rehabilitation Center on November 3, 2022.
Both residents had severe cognitive impairment.
Each time, Resident 66 sat in a wheelchair while the urinary catheter bag remained in contact with contaminated surfaces.
Resident 188 entered the facility on December 6, 2024, weighing 119 pounds.
She said staff only repositioned her when she specifically asked, and if she didn't ask, they provided no help.
The problems extended beyond medication oversight.
Resident #1 arrived at Aviata at Saint Lucie on July 23 with end-stage renal disease, chronic kidney disease, congestive heart failure, and diabetes.