That is what federal inspectors found when they arrived at the facility at 615 N.
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His situation had already been assessed as dire.
The deficiency was tagged at the "actual harm" level, meaning residents were hurt, not merely placed at risk.
The citation, tagged F0580, covered the facility's failure to inform a doctor of significant changes in a resident's pain level following an incident.
The dietary manager told inspectors the lapse could send residents to the hospital.
Federal inspectors cited the facility under F0842, a regulation governing the accuracy and completeness of medical records.
The deficiency carries a scope and severity level that indicates no actual harm was documented.
The bottle's cap, inspectors noted, is designed to hold exactly 17 grams of powder when filled to the brim.
The sinks were spread across two wings of the facility.
The procedure she missed was a post-void residual measurement, a test that checks how much urine remains in the bladder after a patient urinates.
The nurse was direct about what had happened.
That is what inspectors found when they investigated a complaint at San Luis Post Acute Center, a nursing home in San Luis Obispo.