The resident, identified in inspection records only as Resident 102, lived in the facility's memory care unit.
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Federal inspectors declared immediate jeopardy on October 17, 2025, following a complaint inspection at the facility at 435 East Henrietta Road.
What she got instead, in at least one resident's case, was none of that.
The citation affected many residents, according to the inspection report.
She confirmed she never documented an assessment of the wound on September 11.
Federal inspectors documented the incident during a complaint inspection on October 29, 2025.
For patients who depend on it, dialysis is not optional and it is not something that can be paused for nearly two weeks without consequence.
The first order came on September 17, 2025.
The resident, identified in inspection records only as R1, had fallen and sustained fractures before being readmitted to Central Todd County Care Center.
The resident, identified in the inspection report only as Resident 12, had lived at Caroline Nursing and Rehab on Kerr Avenue since November 2023.
The resident had chronic wounds and a Foley catheter, a tube inserted into the urethra to drain urine from the bladder.
LPN E told the inspector that a blood sugar over 400 would prompt a physician call.