The violation at Pembroke Center, a skilled nursing facility at 310 E.
Nursing Home News — Page 626
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The incident happened on the evening of November 2, 2025, at PA Peterson at the Citadel.
The error happened on the morning of November 1, 2025.
The licensed practical nurse stationed at the desk facing the lounge confirmed it.
The failure at Nightingale Nursing and Rehab Center came to light during a complaint inspection completed November 25, 2025.
Not the facility's medical staff.
The maintenance man happened to be nearby.
The pharmacy kept not sending them.
The resident, identified in inspection records as R3, was described as confused at baseline.
The facility's own director of clinical services later acknowledged that staff should have asked the resident more questions sooner.
The citation issued to Helia Healthcare of Energy falls under F0839, a federal deficiency tag tied to the accuracy and completeness of nursing records.
Incontinence is not a minor inconvenience in a nursing home setting.