That's what a federal inspector documented at Glenburnie Rehab & Nursing Center on the morning of October 28, 2025.
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At Riverside, the Kardex was not matching the care plan.
The inspection, completed October 30, 2025, was triggered by a complaint.
The distinction matters less than it might sound.
What happened after that is what federal inspectors came to document.
The violation was documented as a pattern, meaning inspectors determined this wasn't a one-time lapse.
The resident, identified in inspection records as R1, used an EZ stand and required assistance with transfers.
The resident developed a wound to the groin and genital area.
The deficiency, tagged F0610, affected a small number of residents.
The Director of Nursing told inspectors that all the nurses know which patients are NPO and that the medication was given via tube.
The inspection report does not say how many.
It is among the first things taught in certified nursing assistant training.