Shoreline Care Center admitted the resident with diagnoses including Alzheimer's disease, psychosis and depression.
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Driftwood Healthcare Center staff admitted they had no idea the resident had a conservator when they processed the November 7 discharge.
Inspectors found call lights positioned beyond the reach of residents in both the 100-hall and 600-hall during their complaint investigation.
LPN #303 left Resident #12 alone with seven remaining pills after confirming he had water available.
The 188-pound man required all nutrition through a feeding tube surgically placed in his stomach.
Resident #43 arrived at the 51-bed facility on February 26 with type II diabetes and generalized anxiety.
The incident occurred on August 1, 2025, when the night nurse discovered blood in Resident #1's catheter bag but failed to contact the doctor.
Nobody caught the missing order.
The incident occurred on November 24, 2025, when CNA D removed a meal tray from Resident 1's room, causing the resident to become upset.
The incident occurred on October 16 at Foundation Park Care Center when Resident 12 got his arm under the lift's support sling while being transferred.
RN-A, the nurse providing care, told inspectors he was completely unaware R5 required enhanced barrier precautions.
The incident occurred at Civita Care Center at Milford when Resident #1 experienced shortness of breath and declining oxygen levels that dropped to 88 percent.