That resident, identified in inspection records only as Resident 1, had a documented history of dementia and had told staff he wanted to go home.
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Immediate jeopardy is the most serious level of harm the federal government assigns during nursing home inspections.
The deficiency, tagged F0678, cited the facility for failures in its Basic Life Support procedures.
That is what federal inspectors found when they arrived at Meadowview Rehabilitation and Nursing Center on October 22, 2025.
The resident had been discharged from physical therapy on September 5, 2025.
The care plan is the document that governs how a resident is treated day to day.
The citation, recorded under F0558, described conditions that affected more than one resident.
A cart stocked with gowns and gloves hung outside the room.
The gowns, required by the facility's own infection control policy when staff change briefs, perform catheter care, or treat wounds, were never put on.
When a bag does touch the floor, the IP said, it should be replaced entirely.
The Director of Nursing placed a call to the facility's Nurse Consultant on speakerphone.
Federal inspectors classified the incident as causing actual harm.