The inspection, completed September 19, 2025, was triggered by a complaint.
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The inspection, conducted on September 15, 2025, was triggered by a complaint.
Inspectors classified it as a pattern, meaning this wasn't a single lapse on a single shift.
Resident council minutes from July 7, 2025, documented the problem by name, under a section labeled "Nursing," with a note that ice water was not being passed.
That is the core of what federal health inspectors found when they arrived at the facility on a complaint inspection last fall.
The care plan requirement exists because residents in long-term care are, by definition, people with complex needs.
Inspectors classified the violation as isolated, with no documented actual harm, but with potential for more than minimal harm.
The inspection, conducted September 15, 2025, was triggered by a complaint.
She soiled herself shortly after.
The citation, issued September 17, found that the facility failed to develop and implement care plans that fully addressed residents' needs.
Federal health inspectors visited the facility on September 17, 2025, responding to a complaint.
The incident happened on August 28, 2025.