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The facility's administrators did.

A federal inspector was one of those people passing by.

On May 1, 2025, a male aide named Employee E9 was assigned to her anyway.

A CT scan showed his colon was severely impacted.

Inspectors visited Ybor City Center for Rehabilitation and Healing on October 21, 2025, following a complaint.

That is the core of what federal inspectors documented when they visited the facility at 9401 South Ridgeland Avenue on October 22, 2025.

The order was specific: do not manipulate, flush, or exchange the catheter.

None of it was written down anywhere a caregiver could find it.

She told inspectors she thought the hydration and snack issue was being tracked.

The October 21 inspection, triggered by the complaint, found no current violations.

The problems inspectors identified cut across multiple layers of the facility's safety system.

Two other staff members, V9 and V10, were similarly unaware that a walker was part of her care plan or why it had been prescribed.