Federal inspectors documented the contradiction during a complaint investigation completed October 21, 2025.
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Resident 35 turned on her call light at 11:00 AM on October 8, 2025.
The resident who had been hit, identified in inspection records as R2, was on the floor.
CNA-C's first day at Bethany Home was August 26, 2025.
The medication was stopped in July 2025 before a procedure to place a suprapubic catheter.
LPN-A, who had just returned from a week off, saw nothing alarming.
That's what inspectors found at Optalis Health and Rehabilitation of Three Rivers during a complaint inspection that wrapped October 22.
The inspection, completed October 23, 2025, was triggered by a complaint.
The failure was not a matter of missing paperwork on a single chaotic shift.
The resident had a urinary tract infection.
That is what federal inspectors found when they visited Signature Healthcare of Muncie on October 24, 2025.
When inspectors arrived on October 21, they asked a nursing assistant about the pillows.