The citation, issued August 26, 2025, fell under a category regulators call an administration deficiency.
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Surveyors do not use that label lightly.
The violation surfaced during a complaint inspection conducted on August 27, 2025, one of six deficiencies inspectors documented before they left the building.
Inspectors arrived at the facility on August 27, 2025, following a complaint.
Pattern-level findings carry a specific weight in federal inspection language.
Inspectors rated the violation at scope and severity level D, meaning it was isolated in nature but carried potential for more than minimal harm.
The incident began with an argument.
The aide's own words, recorded by inspectors during an interview on August 1, 2025, at 11:20 a.m., were unambiguous.
Inspectors found the facility had failed on both counts.
The August 26 complaint investigation ended with a citation under the category reserved for freedom from abuse, neglect, and exploitation.
The deficiency was one of 13 cited during the August 27 inspection.
She isn't aware of her own safety needs, according to a nurse who spoke with inspectors.