The resident went without the sliding scale insulin.
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That detail emerged during a state inspection completed April 24, 2025, at the facility located at North 6025 Assembly in Spokane.
Downey Community Health Center, an 8425 Iowa Street facility serving many residents, was cited in April 2025 for failures tied to exactly that requirement.
That was one meal, on one tray, at Van Duyn Center for Rehabilitation and Nursing on West Seneca Turnpike.
The facility's Director of Nursing, interviewed by inspectors on the afternoon of August 12, did not dispute what happened.
Nobody wrote down how to get her there.
Federal inspectors cited the skilled nursing facility following an April 10, 2025 survey.
A second aide, Staff W, told her to ask a manager.
That admission came on April 24, 2025, the final day of a federal inspection at the North Assembly Street facility.
The error wasn't small in its implications.
The person responsible for that failure wasn't a front-line aide who missed a step.
There was no consent form for R1.