Inspectors observed the nurse, identified in the report as RN #1, at 8:28 a.m.
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Inspectors noted the resident had bruising in several areas, which the facility's director of nursing attributed at least in part to anticoagulant therapy.
After inspectors made their findings, the Director of Nursing and Administrator consulted with the facility's Medical Director.
What followed was two days of emergency corrections.
Nobody at the facility had seen him leave.
Some healthcare workers, the CDC notes, need to clean their hands as many as 100 times during a single shift to keep residents and themselves safe.
The inspection at Caring Acres Nursing and Rehab Center, a 31-bed facility on Hillcrest Drive in Anita, Iowa, was completed October 14, 2025.
The medication was Bumex, a diuretic used to reduce dangerous fluid buildup in the body.
None of it had surfaced through the facility's quality oversight process.
The incident happened on October 4, 2025, between 7:00 and 7:30 in the evening.
The woman, identified in inspection records only as Resident 3, has diabetes and muscle weakness.
The inspection was triggered by a complaint.