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She said it the first time at 2:45 in the afternoon.

The citation, issued August 21, 2025, fell under a category regulators call Resident Assessment and Care Planning Deficiencies.

The citation, issued August 21, 2025, covered how the facility procures, stores, prepares, distributes, and serves food to its residents.

The deficiency, cited during a complaint inspection on August 21, 2025, identified what regulators classify as a pattern of insufficient nursing staff.

The facility's own Director of Nursing said it plainly: the facility should not have run out of either drug.

The citation, issued August 22, 2025, falls under the federal tag covering food safety from source to table.

The infection control citation, logged under regulatory tag F0880, was classified as an isolated deficiency with no documented harm to residents.

The resident, identified in inspection records only as R2, was a full code, meaning staff were obligated to pursue all life-saving measures.

The scope rating was F, meaning the problem was widespread, touching more than an isolated pocket of the facility's operations.

The next day, the facility's administrator acknowledged the practice was wrong.

When that screening doesn't happen, the consequences aren't abstract.

The omission surfaced during an August 2025 complaint inspection at the facility, located at 2303 Parke Avenue in Burley.