That gap is what federal inspectors flagged when they completed a complaint survey at the Aiken facility on July 2, 2024.
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The system failed on Saturday, July 26, 2025.
That's what a staff member told inspectors who arrived at the facility in late July 2025 following multiple complaints.
The inspection, conducted on June 21, 2024, flagged the violation under F761, which covers the labeling and storage of drugs and biologicals.
Inspectors arrived at the shower room on the morning of August 11, 2025, just before nine o'clock.
The resident, identified in inspection records only as Resident R3, could not speak.
Inspectors arrived the next day.
That was one of several admissions inspectors collected on August 12, 2025, during a complaint inspection at the skilled nursing facility.
The inspection, conducted on August 12, 2025, caught the problem during a routine review of one of two medication carts at the facility.
The resident, identified in inspection records only as R5, uses an indwelling urinary catheter because of a neuromuscular dysfunction of his bladder.
Resident R1, a man with chronic kidney disease, urinary retention, and a freshly placed urinary catheter, was alone.
What happened next became the subject of a complaint, a facility investigation, and ultimately a federal inspection citation.