The failure came to light during a complaint inspection completed May 27, 2026.
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That number, drawn from the facility's own staffing documentation, sits at the center of what inspectors flagged during the visit.
The facility cited the inspection report as affecting one of five residents reviewed for vaccinations.
The resident, identified in inspection records only as Resident 86, had been admitted to the facility in July 2025 following a right femur fracture.
The citation, issued April 24, 2026, found that the facility failed to provide safe and appropriate respiratory care to a resident who needed it.
The resident, identified in inspection records only as Resident 38, had been living at Galion Meadows Skilled Nursing and Rehabilitation since February 14.
At Desert Springs Post Acute, nobody had written down what to do about any of it.
The resident, identified only as R1 in the report, had been admitted to Aperion Care Oak Lawn with a serious cluster of conditions: diabetes, C.
Inspectors who visited on May 17, 2026 found no date marked on the tubing.
The inspection, conducted as a complaint survey, found that Avir at Golfcrest had failed to provide adequate supervision to prevent the fall.
The resident, identified in inspection records only as Resident 1, began yelling "owe, owe, owe" before anyone had touched her or attempted to turn her.
The three residents, identified in the inspection report only by number, all lived on Hall 100 and relied on oxygen concentrators around the clock.