Inspectors classified the level of harm as minimal harm or potential for actual harm, and noted that few residents were affected.
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The deficiency was one of seven cited during the inspection.
The resident, identified in inspection records only as Resident #5, has a cervical spinal cord injury and quadriplegia.
The administrator, confronted with the observation, did not dispute it.
The deficiency was documented during a complaint inspection on September 16, 2025 at the facility on Fleming Street.
That finding, logged under infection control, was categorized as isolated with no actual harm documented.
State inspectors had cited Mountain View for the identical deficiency on May 2, 2025.
The gait belt requirement at Windmill Manor is not new.
The facility's own policy, last reviewed November 21, 2024, described a resident-centered approach to safety built around individualized care.
It is not a designation regulators apply routinely or lightly.
That distinction matters less than it might appear.
The citation, issued September 16, 2025, is the only substantive finding available from the inspection record.