The violation affected a small number of residents, according to the inspection record.
Nursing Home News — Page 235
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The fall happened on October 3, 2025, at The Villa at Green Lake Estates on Alden Drive.
She was pleasant, the inspector noted, though her words were slurred.
The elopement came to light not because anyone saw R2 leave, but because staff did a head count and he was gone.
A progress note from the former administrator, dated September 11, documented that R25's power of attorney was called that day to discuss the move.
That was the morning of October 10, when state inspectors were present.
Those answers came from the facility's own Assistant Director of Nursing.
The incident at Taylorville Care Center was reported to state regulators and triggered a federal inspection completed October 9, 2025.
She died approximately one week later.
The incident at Rennes Health and Rehab Center-Rhinelander triggered an immediate jeopardy finding during an October 2025 complaint inspection.
The citation at Buena Vida Nursing and Rehab, located at 5027 Pecan Grove, is among the most serious a nursing home can receive.
That call, on September 12, 2025, was the moment his mother demanded he be transferred to the hospital.