Federal inspectors found that certified nursing assistants were supposed to check residents every two hours but failed to do so.
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Resident 2 at Novato Healthcare Center has heart failure and chronic kidney disease.
State inspectors found the portable AC unit operating in a resident room on September 4, its ducts snaking through a window and secured with duct tape.
The resident had been readmitted to the facility with diagnoses of schizoaffective disorder, depression, and anxiety.
The most severe case involved a resident who had no documented bowel movements from July 22 through August 2.
The Assistant Director of Nursing discovered the missing enhanced barrier precaution sign during her monthly audit at 6 a.m.
Two brown bugs crawled up a bathroom wall in an occupied room as inspectors toured the 97-bed facility.
The September 6 complaint investigation revealed systemic breakdowns in fall prevention protocols that put residents at immediate risk of serious harm.
The September 1 incident at Schuylkill Center occurred at 6:30 p.m.
The resident arrived at the facility on May 29, 2025, with multiple conditions that made them vulnerable to injury.
The March 31 fall at Meridian Meadows Transitional Care involved a stroke survivor with paralysis on one side of her body and major depressive disorder.
His admission that he waited days to see the victims contradicted the policy's requirement for immediate social services monitoring.