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Highland Hills Post Acute: Elopement Immediate Jeopardy - PA
The resident elopement was not a surprise failure of an otherwise sound system....
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The resident elopement was not a surprise failure of an otherwise sound system....
The incident, which occurred on or around August 23, 2025, came to light during a complaint inspection on September 24....
On the evening of September 22, 2025, inspectors at Woodstock Valley Health and Rehabilitation followed a dinner cart from the kitchen to the Rosewood Unit....
In one room, the damage behind the head of a bed stretched four feet wide and two feet high....
The Director of Nursing confirmed it....
The resident, identified in inspection records only as R1, received doses of Morphine Sulfate and Lorazepam at approximately 7:30 p.m....
That admission came during a complaint inspection completed September 26, 2025, at the 803 South Main Street facility....
Thirty-two residents lived on those hallways....
The director of nursing, identified in inspection records only as ASM #2, had been in the role since April 2025....
Not one item on the dinner tray was served in the correct amount....
Police and EMS responded to the facility that day....
Inspectors were at Edenbrook on Second Ave on September 25, 2025, responding to a complaint....
She said police should be notified immediately in those cases, and that staff who missed a deadline should receive re-education on the abuse policy....
The posted sheet, as it existed for those 31 days, made that distinction invisible....
That finding sat at the center of a complaint inspection completed September 26, 2025, at the 803 South Main Street facility....
RB was not a patient whose condition left much room for error....
Three consecutive quarters came and went....
She came back to Ignite Medical Resort Chesterton days later with a prescription for Cephalexin, 500 milligrams, four times a day for seven days....
The milk in the large chest-style refrigerator at Cassville Health Care Center had a best-by date of September 19....
The inspection was a complaint visit, meaning someone had already raised a concern before inspectors walked through the door at 499 Alternate Keene Road....