Federal inspectors found that Resident 65 at Hadley Pointe Nursing Rehab & Care lost 24.5 percent of his body weight between October 2024 and January 2025.
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When a certified nursing assistant walked to his car during his break around 2:45 PM, he found the resident sitting in his passenger seat.
When asked about the protocol hours later, Staff A admitted the failure.
The incident occurred on the morning of May 8, 2024, when Certified Nursing Assistant 2 was assisting Resident 28 to the shower.
Staff noted that Resident 2 "had been drinking that morning," according to the facility's own investigation summary.
The resident's extremities were mottled, cold, and pulseless with associated cyanotic changes, according to hospital records reviewed by inspectors.
The resident's room displayed a clear sign directing staff to put on gloves and gown before entering and to clean hands before entering and leaving.
The scene at University Park Rehabilitation and Healthcare on June 2 was so pungent that the urine odor radiated into the hallway.
The facility's 238 residents went without kitchen service for a day while staff cleaned and sanitized contaminated surfaces.
Employee 11 accompanied Resident 79 to a bank in August 2023 to cash a check worth $3,925.77.
The resident wiped away tears as she recounted the incident to state inspectors at Villa Las Palmas Healthcare Center.
The violation centered on Resident #63, who was placed on Enhanced Barrier Precautions due to their colostomy.