The residents who qualify are among the most vulnerable in any nursing home.
Nursing Home News — Page 474
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Her discharge instructions from the hospital, dated December 18, 2025, were straightforward.
The resident didn't know where the call light was.
Nobody had documented providing incontinence care on the 7 AM to 3 PM shift.
The facility's Director of Nursing confirmed this practice could cause cross contamination leading to infection and delayed wound healing.
Federal inspectors found that Resident #84 at Dunbar Center missed all his required diabetes medications on December 25, 2025.
The woman, identified in federal inspection documents only as Resident R1, was a patient at Roosevelt Rehabilitation and Healthcare Center in Philadelphia.
The incident happened on the evening of October 31, 2025, at Salem Transitional Care, a nursing and rehabilitation facility on Boone Road SE.
The facility, which had 83 residents at the time of the inspection, was cited for failing to keep resident rooms clean and equipment adequately maintained.
She acknowledged that admission nurses were responsible for reviewing all hospital discharge summaries and updating care plans accordingly.
One resident dropped from 108 pounds to 84.7 pounds, losing 21.57% of her body weight.
The woman, identified as R385 in federal inspection records, was admitted to the facility on December 11, 2024, from an acute care hospital.