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Neighborhoods Rehab: Resident Dies Trapped in Bed Rail - MO
The resident had been alone for hours....
Latest reports, citations, and penalties from CMS data
The resident had been alone for hours....
Nobody on the care staff had seen it happen....
Inspectors reviewed the August Treatment Administration Records for three residents during a complaint inspection completed September 5, 2025....
A staff member, V11, said she wasn't familiar with the policy and called her supervisor, V2, to check....
He called the condition unsanitary and unacceptable....
That morning, he soiled himself before breakfast....
She cleaned the site, removed those gloves, skipped hand hygiene again, and redressed the wound with bare hands....
The resident, identified in the inspection report as R41, is a man with a kidney transplant and type 2 diabetes who has lived at the facility since July 2024....
The September 2025 inspection, triggered by a complaint, cited the facility for failures in identifying and addressing hazards in the resident environment....
When he was discharged on August 26, his orders required Ceftriaxone to continue daily beginning the following morning....
That is what inspectors found when they visited Oakhurst Health & Rehabilitation on September 9, 2025, the day before the survey closed....
Three people live in Room A at Mesa Glen Care Center....
Her doctor found out after the fact....
Inspectors who visited the facility on September 5, 2025 reviewed the clinical records of five residents and found the same problem in all five....
The resident was wearing a pink elopement band on his ankle....
The contradiction sat at the center of a complaint inspection completed September 5, 2025....
The punch landed at approximately 11:00 p.m....
A physician had ordered midodrine 5 mg to be given whenever the resident's systolic blood pressure dropped below 90....
The resident, identified in inspection records only as Resident #1, was nonverbal and entirely dependent on staff for her care....
That language, minimal harm, is the regulatory floor....