In addition to the December inspection, employees of the Office of Licensure and Certification visited the home in January, March and earlier this month. The surveyors walked the halls, read patient charts, watched how residents were cared for, and talked with staff and families.

Their reports describe a home where the staff was not always properly trained, and where residents sometimes did not get the help they needed.

For example:

In April, a resident, who was described as demented and at risk for falling, accidentally moved her bed to the high position, then fell from it when she tried to stand.

A nurse heard her screaming and found her on the floor with a fractured femur. She was hospitalized and died of a pulmonary embolism while in the hospital.

The inspectors criticized the staff for not monitoring the resident more closely.

In November, a resident received second- and third-degree burns on his inner thighs and scrotum when he spilled hot chocolate in his lap during breakfast.

The resident had no use of his left arm and limited use of his right arm because of a stroke. The resident should have been fed by a staff member, or given a cup with a lid, according to the report.

In 13 rooms, inspectors discovered that the call-bell system was not working. Residents use the call-bells to summon help. Inspectors checked the call bells after a resident became entangled in his call-bell cord and strangled on May 1. The state report of that fatality became public last week and found that the cord had been improperly tied to the resident's bed rail.

The inspectors also found that residents' respiratory equipment was not stored in closed containers when not in use. Closed containers are said to control infection.

When reviewing a sampling of patient charts, the inspectors found that patients had not received protective equipment or clothing ordered by their doctors.

These included a bed alarm, floor mat and "trough" mattress to prevent falls, and a "bunny boot" and "geri sleeve" to reduce irritation to the skin.

Another resident did not receive oxygen in the amount prescribed by her physician. Another had not been receiving aspirin in the ordered dose.