Inspectors assigned it a scope and severity level of E, the federal rating for a pattern of deficient practice with potential for more than minimal harm.
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The facility's administrator and director of nursing were present when inspectors walked through their findings.
The difference between those two things — potential and actual — can be a matter of timing, or luck, or both.
The citation, issued September 18, 2025, fell under the regulatory category of Quality of Life and Care Deficiencies.
Two weeks passed before anyone discovered the stat CBC and CMP for Resident 1 had simply never happened.
Federal inspectors cited the 31-bed nursing home following a complaint inspection completed September 18, 2025.
When inspectors visited the unit, CNA 822 was there, seated in a chair to the left of the doorway to his room.
A missed treatment, a skipped step in a care plan, a preference ignored, these are not abstract failures.
The citation noted that few residents were affected.
The violation, cited under F0755, was classified as causing minimal harm or potential for actual harm and affected a small number of residents.
Level F is not a paperwork problem found in one wing or affecting one resident.
Residents who depend on oxygen, ventilators, nebulizers, or other breathing support have little margin for error.