Federal inspectors cited the facility on December 1, 2025, following a complaint investigation.
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A separate citation under **F-Tag 725** addressed the insufficient staffing levels that drove those care failures.
The facility, located at 5943 Telegraph Road, was also cited for wound care documentation failures and gaps in tuberculosis screening for employees.
Transmission-based precautions are a foundational element of infection control in congregate care settings.
According to the inspection report, the resident left the building in an attempt to locate his wife.
His diagnoses included **dementia and Alzheimer's disease**.
The goal was to ensure the facility maintained ongoing compliance with federal care planning requirements.
A licensed practical nurse on duty asked CNA #3 to assist CNA #1 with providing care to Resident #1, who had been described as combative.
PTSD affects a notable portion of the elderly population, including veterans and individuals who have experienced trauma throughout their lives.
Turning and repositioning is one of the most basic and well-established interventions in long-term care.
At 11:10 AM, inspectors watched as a certified nurse aide transferred Resident #82 out of bed using a stand lift.
Medical records from May 2024 confirmed the resident was confused, had dementia, and **lacked the capacity to make healthcare decisions**.