It touched enough of the facility's food handling that regulators assigned their broadest scope designation.
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LPN D said she didn't know who the new administrator was.
No actual harm was documented, but inspectors determined the pattern carried potential for more than minimal harm.
That finding carries a particular weight that softer violations do not.
The infection control citation, issued under regulatory tag F0880, was classified as a pattern-level deficiency.
No actual harm was documented during the inspection.
That absence is its own kind of problem.
The scope was rated widespread.
The cushion for Resident #30 was listed on the Kardex, the working care record that nursing staff consult daily.
The inspection, completed September 11, 2025, captured what that desperation looked like in real time.
That phrase carries specific regulatory weight.
Inspectors classified it as an isolated problem, meaning they did not find it affecting residents broadly across the facility.