The bugs were mostly concentrated on their roommate's bed, Resident 11, in their shared room.
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The violation surfaced during a complaint inspection completed November 20, 2025.
The deficiency fell under the category of Resident Assessment and Care Planning — a foundational component of skilled nursing facility operations.
His care plan specifically directed staff to make sure he had the oxygen on and was using it correctly.
The November inspection revealed actual harm to residents from what inspectors classified as preventable incidents.
The facility, which received **six total deficiencies** during the inspection, has not submitted a correction plan for any of the cited violations.
The injured resident was treating facial wounds with ice and taking Tylenol for pain when investigators arrived.
Resident #1 weighed 273.81 pounds during a September 23 hospital stay.
The medication delays occurred on October 12 when Resident #5 arrived at the facility with discharge paperwork ordering specific antibiotics.
The aide claimed she was short on funds and needed money to pay bills, promising to pay him back.
The resident, identified as R2 in inspection records, has an undated dietary card documenting his dislike of fish, chicken, beets, and squash.
The distinction between "no actual harm" and "potential for harm" is important in regulatory context.