That detail sits at the center of a federal complaint inspection completed August 27, 2025, at the nursing home on Central Avenue Northeast.
Nursing Home News — Page 207
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The finding, tagged F0689 and affecting many residents, emerged from a complaint inspection completed August 27, 2025.
Inspectors walked through the kitchen at Avenue at Lyndhurst on the morning of August 18, 2025.
The nurse entered the room and found the resident, identified in inspection records as Resident R2, breathing slowly and shallowly.
The protocol is called Enhanced Barrier Precautions, and it applies regardless of whether a resident has already tested positive for a resistant organism.
Inspectors classified the harm level as minimal or potential, with few residents affected.
Federal inspectors documented the condition on August 25, 2025.
The patient, identified in the inspection report as Resident 4, said staff placed the wound vac on his left foot in mid-August 2025.
That was one of three food safety problems inspectors documented during a complaint inspection at the facility on August 26 and 27, 2025.
By the morning of the incident that triggered a federal complaint inspection, two residents had been sitting in distress for hours.
The physician's order had been clear: if the resident did not void within six hours, the catheter should be reanchored.
The incident occurred on July 11, 2025, at approximately 7:15 in the morning.