The assistant administrator described the situation plainly.
Nursing Home News — Page 521
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Federal inspectors found multiple documentation failures in wound care at Center at Park West during an October 2025 complaint investigation.
The resident had arrived with multiple wounds, including pressure injuries at the sacrococcyx, both heels, and the left lower leg.
The missing equipment violated the facility's own care plans for residents who needed the rails to turn, reposition themselves, and transfer in and out of bed.
Resident #5 at Stone Cottage Care Center had negotiated an unusual arrangement with staff.
A patient with dementia and a documented history of wandering had walked off the secured unit with a group of visitors on November 19.
The administrator confirmed the shower should be clean and maintained in good condition.
The resident required a mechanical lift to move from bed to wheelchair.
The resident admitted he had smoked a THC vape that he obtained from another resident inside the facility.
The facility's policy required investigation results to be submitted within five working days.
The December 29 inspection revealed widespread maintenance failures across two of the facility's three units.
Specifically, federal regulations require that nursing homes allow residents to share a room with a spouse or a roommate of their choosing.