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Forest Hill Manor: Dementia Patient Missing 18 Hours - CA
The 65-year-old resident disappeared on June 27, 2025, sometime before 5 p.m....
Latest reports, citations, and penalties from CMS data
The 65-year-old resident disappeared on June 27, 2025, sometime before 5 p.m....
The admission came during a federal inspection on October 2nd at a facility caring for 55 residents....
The resident didn't report the incident until nearly two weeks later....
The patient came back with a PICC line inserted in their arm for long-term intravenous medication delivery....
That's when Resident B heard a pop....
The incident at Putnam Ridge illustrates how equipment meant to help residents can become a barrier when facilities lack proper staffing coordination....
The incident occurred around 11:30 pm on August 3, 2025, when the resident was found crying and complaining of chest pain....
Federal inspectors discovered the training gap during a complaint investigation on September 30, 2024....
The September 21 assault at Legacy Nursing at St....
Resident #101 had weakness on their left side from a stroke and needed maximum assistance for mobility....
Staff heard door alarms going off but didn't immediately investigate the source....
Yet nursing staff failed to document whether the resident ate breakfast on August 3, 4, 9, 15, 22, 23, and September 1, 2025....
The resident also complained that nurses didn't care about him and that some were rough during treatment, making him cry because they weren't gentle....
The ADON explained that care plans must be person-centered so staff understand exactly how to care for each resident....
The facility's own policies outlined detailed requirements for managing medical orders that weren't being followed....
The resident died at 10:40 AM on the inspection date....
The resident scored just six out of 15 on a mental status assessment, indicating significant dementia....
Federal inspectors found the facility violated requirements to immediately report suspected abuse after Resident #98 made the complaint on December 30, 2024....
The September incident at Advanced Center for Nursing & Rehabilitation left doctors unaware that critical lab work had gone undone for nearly two weeks....
The assessment determines what resources are necessary to care for residents competently during daily operations, nights, weekends, and emergencies....