Nursing Home News — Page 667

The woman, identified in inspection records only as R1, had been assessed just two days earlier as having no elopement risk factors.

Federal inspectors found the facility knew about the resident's condition but took no meaningful steps to prevent access to alcohol.

The charge nurse found blood on his mouth and nose, soot covering his face, and his beard burned off and still smoking.

R146 was admitted March 30 with altered mental status.

The woman had activated her call light at 8:15 a.m.

Jefferson Healthcare Center created a quality improvement plan on March 25 specifically targeting medication cart audit problems.

"The kitchen does not have enough sippy cups to go on residents' meal trays," one dietary aide told inspectors.

The patient, identified as Resident 35, dropped from 163 pounds in July 2024 to 129.4 pounds by February 2025.

Her boyfriend had been with her for several years before the brain injury that left her severely cognitively impaired.

The incident at Avantara Norton occurred on May 27 when the aide woke the resident at 7:10 a.m.

The February inspection revealed a cascade of medication safety failures affecting multiple residents at the 13000 Victory Boulevard facility.

Both residents had cognitive scores so low they indicated severe impairment.