Resident R9 had asked for a blanket.
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The resident who first raised the alarm had intact cognition and knew exactly what he was seeing.
The resident at the center of the citation, identified in inspection records only as R2, was a patient whose tracheostomy tube required active management.
The complaint inspection, completed November 22, identified the violation as carrying potential for actual harm, affecting a small number of residents.
Federal inspectors cited the facility for causing actual harm to the resident, identified in inspection records only as R1.
The November 2025 inspection, triggered by a complaint, turned up medication gaps affecting multiple residents.
The incident happened on October 8, 2025, around 1:30 in the afternoon at Reformed Presbyterian Home on Perrysville Avenue in Pittsburgh.
That is the core of what federal inspectors documented at Horsham Center for Jewish Life following a complaint inspection completed November 24, 2025.
That was the core finding when inspectors arrived at the facility at 625 36th Street SW on November 21, 2025.
The missing narcotics came to light in a sequence that a licensed practical nurse described in detail to inspectors on November 21, 2025.
It said staff should use three-compartment trays, serve his diet as ordered, and give him his supplements.
That is what inspectors found at Evercare at Stearns after a complaint investigation completed in November 2025.