The core problem was procedural, but its consequences were not.
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The inspection, conducted September 29, 2025, focused on one resident whose care plan required maximum assistance with toileting hygiene.
They are painful, slow to heal, and in vulnerable patients, can become life-threatening.
On September 29, 2025, when inspectors arrived, that tube had no drainage bag connected to it.
That was the finding at the center of a federal complaint inspection completed at the Chicago facility on September 29, 2025.
The resident, who has since left Wisconsin Rapids Health Services, usually got up to eat meals.
The aide later told facility management he probably did say it.
Pain was documented again on June 13.
That list was dated September 18, 2025.
The inspection was completed October 2, 2025.
The inspection, conducted September 24, 2025, at Marietta Center for Nursing and Healing, caught the failures in real time.
The inspection at Pavilion at Glacier Valley, completed October 8, 2025, traced what happened after a hospice nurse visited on the morning of September 6.