The facility had 119 residents at the time.
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The records violation, cited under a category covering resident assessment and care planning, was one of the more quietly consequential findings in the report.
The right to refuse a treatment.
The citation fell under what regulators classify as a pattern violation, meaning inspectors didn't find a single isolated lapse.
The inspection was triggered by a complaint.
And the resident at the center of multiple incidents, identified in inspection records as Resident #28, had not been seen by a counselor.
Immediate jeopardy is the most serious classification federal inspectors can assign.
Pressure ulcers, also called bedsores, are wounds that form when sustained pressure cuts off blood flow to skin and underlying tissue.
Federal health inspectors visited the facility on September 24, 2025, responding to a complaint.
Then she was allowed to come back.
The violation, documented on September 22, 2025, was not a one-time lapse.
The drug keeps blood from clotting too easily, which makes it effective for preventing strokes and dangerous clots.