That was the morning of September 4, 2025, at Geneva Lake Manor on South Curtis Street.
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They told her she was being uncooperative.
She was documented as cognitively impaired and a fall risk.
The resident, identified in inspection records as R10, fell twice on September 26, 2025.
The problem was not isolated to one resident.
The resident had been discharged from a hospital with an order for ferrous sulfate 142 mg every Friday, to be given with vitamin C.
The Nursing Home Resident Care Staffing Report visible to anyone entering the facility that morning showed a date of November 2, day shift.
The declaration at The Lutheran Home: Belle Plaine was issued on October 22, 2025, and remained in place for nearly two weeks.
She did not notice he was carrying coffee.
Inspectors arrived on Halloween and found the gap that night.
That is what a federal inspector found at Castleton Health Care Center on November 6, 2025.
The deficiency, tagged at the actual harm level, affected a small number of residents.