The immediate jeopardy designation is among the most serious outcomes a federal inspection can produce.
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Inspectors classified it as an isolated problem with no documented harm to any resident, but with the potential to cause more than minimal harm.
The citation was one of six deficiencies inspectors documented during the complaint inspection.
The inspection, conducted August 21 and 26, 2025, was a complaint investigation.
The citation was one of five deficiencies inspectors documented during that visit.
He had fallen more than four hours earlier.
The citation, issued August 27, 2025, fell under the category of quality of life and care deficiencies.
The resident, who lives with chronic pain, told inspectors she hadn't noticed a difference in her pain levels during the delay.
A resident identified in inspection records only as R4 had left the facility.
The patient, identified in federal inspection records only as Resident 8, was taken to a general hospital after the fall.
Federal health inspectors cited the facility following a complaint investigation completed on August 25, 2025.
The incident happened on June 16, 2025.