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The Reflections Unit Manager told the inspector that a leak on the 100-wing had been reported and fixed the same day.

That incident was one of two separate resident-to-resident abuse episodes at Clearwater this summer.

Federal inspectors classified the incident as Immediate Jeopardy.

When inspectors toured the kitchen on September 17, a fly was observed circling the room.

The dates, confirmed by the facility's own administrator during a September inspection, were April 20, April 26, May 11, May 18, May 31, and June 21, 2025.

Both were documented as given at 9:57pm.

That is what federal inspectors found when they arrived at Arcadia Care Toulon on September 17, 2025.

Six months later, a federal inspector asked the same question.

The medical director explained to inspectors why he wrote the order in the first place.

on September 12, inspectors entered the room of Resident 2 and found a couch with multiple dark stains across the seat cushion.

The resident is identified in inspection records only as Resident K.

That gap was at the center of a complaint inspection completed September 18, 2025.