That admission came from the director herself.
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The inspection, conducted November 20, 2025, was triggered by a complaint.
The lapse surfaced during a complaint inspection at Alhambra Healthcare & Wellness Centre on November 25, 2025.
The incident happened around 5:00 a.m.
Immediate jeopardy is not a routine finding.
Inspectors cited the facility following a complaint investigation completed November 20, 2025.
The inspection, triggered by a complaint and conducted on November 20, 2025, resulted in a citation under a federal deficiency category covering care planning.
It was the resident's first time ever wearing one.
That is what federal inspectors concluded after a complaint investigation completed November 20, 2025, at the facility on Holland Sylvania Road.
Inspectors cited the home for failing to protect Resident 14 from neglect, a deficiency that regulators tagged as carrying potential for actual harm.
The facility, operating under the name Avir at San Knoll at 5757 N Knoll, was cited under Tag F0563, which covers resident visitation rights.
The facility's own director of nursing acknowledged both failures.