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What went wrong?
First there were the numerous complaint investigations, among some of them: An 86 year old resident felt violated when a male nurse placed his hand on her vaginal area. He claimed he was checking for a urinary tract infection. He was fired but the problem was the alleged sexual abuse incident was not timely reported to the state. A 76 year old resident fell five times in one month eventually developing a hematoma; procedures were not in place to prevent falling Shower stalls were soiled with feces.
Part of the problem cited is the rapid change of administrative and supervisory employees and the prevalent use of temporary staff who doesn't know the patients. .
The nursing home has two years to improve its rating.
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