The deficiency was cited at a level of actual harm, affecting many residents.
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Federal inspectors visited the facility on May 19, 2025, at 8:00 in the morning and could not locate the required daily staffing information for that day.
The citation issued March 28 targeted pharmaceutical services, one of the most fundamental obligations a nursing home carries.
Her explanation: she was not clinical.
The infection was ESBL, extended-spectrum beta-lactamase, a multi-drug-resistant organism detected in a resident's urine.
The finding applied to many residents.
The inspection that prompted that conversation was a complaint survey.
The drug was lorazepam, a benzodiazepine used to treat anxiety.
The wounds were serious enough to have their own entries in the resident's Comprehensive Care Plan, which had been in place since at least May 2023.
That is what the resident told inspectors three days after it happened.
An unstageable wound is one so covered in dead tissue or slough that its full depth cannot be determined.
Copies went to her, to the director of nursing, and to the office manager who handled scheduling.