The violation was straightforward: food removed from its original packaging wasn't being labeled with the name of the food.
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The nurse who called his doctor after his fall never mentioned he was on Plavix.
The nurse, identified in inspection records only as Staff #120, was scheduled to work a shift that ended at 7:00 A.M.
She found out during an inspection.
The resident, identified in inspection records as Resident B, was already in the air when a nursing assistant the facility identifies as CNA 2 arrived.
She also hadn't put the wraps on that morning.
Hospitality aides at the facility pass water, deliver meal trays, change and remake beds, restock supplies, and answer call lights.
On August 11, 2025, a resident identified in inspection records as Resident 4, or R4, became upset after lunch.
Two grievances, one filed on August 6 and another on August 15, were marked resolved.
The resident described the sequence themselves during an interview with inspectors on August 21, 2025.
That finding, rated by federal inspectors as causing actual harm, was documented during a complaint inspection completed August 21, 2025.
The nurse, identified in the report only as Staff E, was hired on June 9, 2025.