The resident's family caught it first.
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That was among 26 deficiencies federal health inspectors cited at Frostburg Village Rehab Center following a complaint inspection completed August 13.
The resident, identified in inspection records only as Resident 85, is diabetic and requires a mechanically altered therapeutic diet.
Controlled substances, which carry the highest requirements for secured storage, are supposed to be kept in separately locked compartments.
Federal inspectors documented the lapse at Autumn Care of Myrtle Grove during a visit on April 22, 2025, at 5:00 in the afternoon.
By that standard, Resident #28's 66-minute wait was nearly three times too long.
That is what a federal inspector found at Spokane Health & Rehabilitation on the morning of April 24, 2025, at just after nine o'clock.
Inspectors determined the problem wasn't isolated to a single incident or a single area.
Inspectors cited the facility on August 11, 2025 for failing to procure, store, prepare, distribute, or serve food in accordance with professional standards.
Inspectors found no documented actual harm, but concluded there was potential for more than minimal harm to residents.
The citation, issued August 11, 2025, falls under a federal category covering quality of life and care.
The resident at the center of it, identified in inspection records as Resident 220, had already been flagged as a high fall risk.