Inspectors who arrived at The Lane House on September 9, 2025, found that assessment was wrong.
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Federal inspectors who arrived in September found out they were right.
All three told state inspectors the same thing, in interviews conducted within an hour of each other on September 10, 2025.
He didn't want to lie down, the nurse said, because he thought he might choke.
The wound the physician found that morning was deep.
The September 11 inspection, triggered by a complaint, found that the coffee burn rose to the level of actual harm.
The hospital's after-visit summary showed Augmentin, an antibiotic, had been prescribed.
The dentist, who visits the facility weekly, had last seen the resident in April 2024, when he recommended extracting two teeth.
Between the dates logged in her call light record, 19 calls went unanswered for anywhere from 15 to 63 minutes.
The resident had been sent to the hospital the day before after expressing suicidal ideation and making persistent demands for controlled medications.
The inspection at Care Pavilion Nursing and Rehabilitation Center, completed September 11, 2025, stemmed from a complaint.
The manufacturer's posted instructions, hanging in the kitchen, said to report anything below 120.