The resident, identified in inspection records as R108, had been prescribed oxycodone 5 mg every six hours for pain.
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That's what a registered nurse told inspectors on August 21, 2025.
The resident, identified in inspection documents only as R6, signed out of Winston Manor at 1:30 p.m.
That assumption, inspectors found, was wrong.
Federal inspectors arrived on August 25, 2025, responding to a complaint.
Bacon and sausage cold — and raw.
Then a registered nurse walked out of the dining room and acknowledged what was obvious: the cart should have been locked.
He couldn't produce documentation of current dishwasher temperatures.
The milk incident happened on June 21, 2025, at approximately 8:20 in the morning.
The finding affected a small number of residents, according to the August 21, 2025 inspection report.
Resident E told inspectors that a couple of months before the visit, she had soiled herself in bed and needed to be changed.
When inspectors arrived on August 22, the Director of Nursing looked at it and said, "It could be damaged, it could be compromised." It was not a revelation.