She had just used it minutes earlier on Resident #65.
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The incident happened on March 26, 2025, at Castle Manor Nursing & Rehabilitation Center, a skilled nursing facility on V Avenue in National City.
That sequence, documented by federal inspectors at St.
That is what inspectors found at Aperion Care Forest Park during a complaint inspection on May 19, 2026.
That is what inspectors found at Edgerton Care Center, a nursing facility at 313 Stoughton Road, when they completed their survey on March 31, 2025.
Then a small ice cream container with a plastic lid, also unlabeled, also undated.
The tag was the only thing standing between Resident #1 and an unsupervised exit.
No documentation of the resident's discharge status.
It is not a paperwork violation.
That instruction went unheeded.
Federal inspectors who visited Chulio Hills Health and Rehab on May 22 found that nurses there were not making those calls.
The restorative nursing assistants, called RNAs, were supposed to circle back.