When the primary wound care nurse was away, the device came off.
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The medication had been ordered for Resident 28.
The deficiency was classified as causing minimal harm or potential for actual harm and identified as affecting some residents, not just one.
The culture would have shown whether the antibiotic she was taking was actually working against the specific bacteria causing her infection.
Inspectors cited the facility on August 12, 2025, following a complaint investigation.
The inspection was conducted on August 11, 2025.
Federal inspectors did not find that answer sufficient.
For the families who place relatives there, the name carries a certain institutional weight, a sense that size and history translate into safety.
Federal inspectors arrived at the facility on April 3, 2025, and began asking straightforward questions about bed rail safety.
The sequence is straightforward.
The breakroom microwave was for staff.
The back of the resident's hair, identified in inspection records as Resident #336, had become so matted that a certified nurse aide could not comb through it.