Nursing Home News — Page 522

The citation documents a pattern of failures, not an isolated incident.

Inspectors classified the deficiency as isolated, meaning it did not appear to be a pattern running through every unit or shift.

That same morning, inspectors were working through what a three-day stretch of staffing records actually showed.

By 2:50 AM, the nurse had called the Director of Nursing.

On each of those days, meal intake was either missing from the record entirely or the notes contained no explanation for why the resident hadn't eaten.

She needed a walker and a manual wheelchair and required maximum assistance to transfer from one surface to another.

The plan said ten licensed practical nurses were needed to cover a full 24-hour period.

That is what inspectors found when they reviewed records at College Pines Health and Rehabilitation on 95 Locust Street during an April 2026 survey.

The resident, identified in inspection records as R101, was admitted with a foam dressing ordered as a preventative measure.

The inspection report does not identify which resident was affected, what the suspected incident involved, or who was alleged to have done what to whom.

Inspectors reviewed facility incident reports, medical records, and interviewed residents directly.

The facility's written process called for a Behavior Management team to convene when a resident showed new or worsening behaviors.