The citation, rated at a level of harm indicating minimal harm or potential for actual harm, affected some residents, according to the inspection report.
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Staff interpretations of the incidents varied dramatically.
The finding emerged during a complaint investigation at the Decatur facility.
When a facility fails to make these records accessible, **residents lose a primary tool for understanding and advocating for the quality of their own care**.
The facility has not filed a plan of correction.
The facility received **four total deficiencies**, including a citation for failing to meet federal pharmaceutical safety standards.
Federal inspectors observed Resident 126 using an oxygen concentrator at 2 liters per minute through a nasal cannula on November 16, 17, and 18.
The November 5 incident at Life Care Center of Waynesville involved Resident #5, who staff assessed as severely cognitively impaired with Parkinson's disease.
The incident unfolded on August 5, 2025, when LPN #2 heard Resident #1 cursing in his room at The Oaks Rehabilitation and Healthcare Center.
The unwitnessed fall occurred on November 7 at approximately 11:00 p.m.
The filthy conditions extended throughout the facility's kitchen.
The Director of Nursing acknowledged the resident's resistance during a September 19 interview.