By January 2025, inspectors were back.
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No formal corrective plan was ever written.
The facility's administrator acknowledged the gap to inspectors during a March 2025 recertification survey.
It was the second time inspectors had cited the facility for the same deficiency.
She said so herself, minutes after it happened.
When inspectors asked the administrator whether she knew this was happening, she said she didn't.
The February 27 inspection, triggered by a complaint, resulted in a citation under F744, the federal standard that governs dementia care.
The findings came from a June 21, 2024 inspection by the Centers for Medicare and Medicaid Services.
The administrator acknowledged it directly.
The son was told the resident had the right to request a change in guardianship.
The Director of Nursing, interviewed by inspectors at 5:20 p.m.
The administrator himself, during an interview with inspectors on the afternoon of August 9, confirmed the core facts.