Resident 2 had been on constant supervision since June 2025 following repeated fights with other residents at Oak Grove Post Acute.
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The resident at The Earlwood told inspectors during their November visit that he would like to see a dentist.
The CNA had been serving as the facility's activities director for four to five weeks when federal inspectors arrived in November.
She was not allowed to keep any medications in her room because staff worried other residents might access them.
The water crisis lasted anywhere from one week to a month, depending on which resident you asked.
Federal inspectors watched LVN B and CNA A enter her room to reposition her and provide incontinent care at 10:03 am.
His care plan from May 21, 2025, specifically placed him on Enhanced Barrier Precautions due to his gastric tube and leg wounds.
The resident had been admitted with a history of stroke that left them with paralysis on their left side and difficulty swallowing.
Resident #85 fell twice on the day before their death at Onondaga Center for Rehabilitation and Nursing.
The 88-year-old woman, identified only as R1 in inspection records, had fallen twice at The Villas at Robbinsdale in mid-November.
The resident has chronic obstructive pulmonary disease, hypertensive heart disease and chronic respiratory failure.
The August incident remained unreported for hours until evening staff discovered what had happened, according to a state inspection completed in November.