Resident 7 arrived at the facility in October with osteomyelitis of vertebrae, a bone infection.
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Resident 14's blood glucose level reached 528 by the time testing resumed on October 22, 2025.
The wound became infected, requiring antibiotics and specialized dressing changes.
Resident #3, who is cognitively intact, shouted for help until the Assistant Director of Nursing came to the dining room.
When inspectors asked whether wound assessment fell within an LPN's scope of practice, Staff E responded: "I never really thought of that, I am not sure.
The complaint investigation at Willard Care Center revealed a pattern of undocumented family communications across multiple residents.
Federal inspectors who watched nurses distribute medications over two days in November found a 7.14% error rate on the facility's first and second floors.
The resident told investigators that CNA #2 became upset when asked to be gentler during care on August 21, 2025.
The October 29 incident involved a resident who had been admitted just days earlier with congestive heart disease, anxiety, and Type 2 diabetes.
State inspectors found the violations during a November 14 visit to Aperion Care Midlothian.
Resident 9 sat on the edge of their bed without a call light within reach on November 14.
The specific nature of the violations was not detailed in available inspection records.