Nursing Home News — Page 788

The finding triggered an emergency state survey that confirmed the facility had implemented corrective measures by October 15.

The contradiction emerged during an October complaint investigation that revealed systemic failures in the facility's elopement prevention program.

Federal inspectors found that both the charge nurse and assistant director of nursing assumed the other would make the required family notification call.

The inspection revealed a broader pattern of call bell failures throughout the facility.

Inspectors found four separate medication carts that failed to lock properly during their October investigation.

Nobody at the nursing home noticed Resident #127 was missing until nearly two hours after the 8:55 PM escape on May 11, 2025.

The resident, identified in inspection records as CR #1, left the facility during an afternoon shift change without staff knowledge.

Staff had been serving meals without proper verification that food matched physician-ordered diet restrictions.

The resident also had suffered a stroke with right-sided weakness and malnutrition.

Resident 105 had been at the facility for just two days when the incident occurred.

She didn't receive a single dose until October 20.

Nobody weighed the resident when he was readmitted in September.