Resident #1 consistently refused care from S8CNA, his assigned nursing assistant, because of their prior relationship outside the facility.
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The December 30, 2025 inspection resulted in a citation under federal regulatory tag F0689, which governs accident prevention and resident safety.
The resident's foot slipped from the sit-to-stand platform at 6:30 a.m.
The facility received an allegation of sexual abuse involving Resident #5 on September 18, 2025, at 2:30 PM.
The administrator acknowledged he was unaware that Residents #4, #5, #7, #8, and #9 had not been care planned following their falls.
LPN3 had also taken another medication from the same delivery to a different nurse, LPN8, before discarding the bag.
The facility knew about the wandering from the moment he arrived.
That gap sits at the center of a complaint inspection completed at the facility on December 31, 2025.
Two days later, the resident set his bed on fire.
On December 25, 2025, he had his breakfast.
Whether their hands are steady enough.
The incident, documented in a January 2, 2026 complaint inspection, began on a morning the resident described as his exercise day.