The resident, identified in federal inspection records only as Resident #02, has lived at Riverside since February 2023.
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There was no documentation that anyone had toileted or changed Resident R2 before the aide's shift began.
She was dependent on staff for every activity of daily living.
The unit manager said the goal is four CNAs per twelve-hour shift.
The facility's electronic call light system had been failing for months.
The resident, identified in inspection records only as R1, had been showing signs of distress before he died.
The Director of Housekeeping told inspectors that window shades were part of the facility's deep-clean process.
The inspection, triggered by complaints, was classified as causing actual harm to a small number of residents.
Nobody could say exactly how he got it.
The inspection at The Villa at Green Lake Estates, triggered by a complaint, focused on the care of a single resident identified in records as R103.
The staff member at the center of the complaint was identified in the report only as Staff C, a certified nursing assistant.
Inspectors visited the facility on September 2 and 3, 2025, following a complaint.