A cognitive assessment scored the resident at 15 out of 15, meaning fully intact.
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Not what staff were supposed to do when they found the prescribed dressings on the floor and homemade ones in their place.
For context, coffee served at 99 degrees is closer to body temperature than to what most people would recognize as a hot drink.
A mental status assessment completed in early April 2025 gave her a score of 4 out of 15, indicating severe cognitive impairment.
That is what federal health inspectors concluded after visiting Roane General Hospital in Spencer, West Virginia, on September 25, 2025.
A small number of residents were affected.
Pressure ulcers, sometimes called bedsores, develop when sustained weight against a surface cuts off blood flow to the skin.
That last part, the documentation, is not a clerical formality.
The citation, issued September 24, 2025, covered failures in both labeling and physical security of drugs and biologicals kept at the facility.
The citation, issued September 25, 2025, was one of five deficiencies inspectors documented during the visit.
The deficiency, tagged under pharmacy service failures, was classified as a pattern, meaning inspectors found this wasn't an isolated slip.
The resident, identified in inspection records as Resident 49, had a history of multiple falls.