Inspectors who visited the facility on September 5, 2025 reviewed the clinical records of five residents and found the same problem in all five.
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The resident was wearing a pink elopement band on his ankle.
The contradiction sat at the center of a complaint inspection completed September 5, 2025.
The punch landed at approximately 11:00 p.m.
A physician had ordered midodrine 5 mg to be given whenever the resident's systolic blood pressure dropped below 90.
The resident, identified in inspection records only as Resident #1, was nonverbal and entirely dependent on staff for her care.
That language, minimal harm, is the regulatory floor.
The allegation should have triggered mandatory notifications within two hours.
The shower room drew the most detailed findings.
When inspectors interviewed the cook, identified as Staff D, he said he didn't need tongs as long as he was wearing gloves.
Two certified nurse assistants, both working the 6:00 P.M.
What they found on each cart was roughly the same.