When inspectors assign a scope rating of "widespread" to a deficiency, they are saying the problem is not contained.
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The answer was: more than a month ago.
The citation, issued August 14 following a complaint investigation, falls under a category regulators call Resident Rights Deficiencies.
The citation, issued August 14, 2025, fell under a category covering resident assessment and care planning.
The visit took place on August 14, 2025, and was conducted as a complaint inspection.
The deficiency fell under the federal category governing freedom from abuse, neglect, and exploitation.
Her nasal cannula, the flexible tube her doctor had ordered to deliver continuous oxygen, was not in her nose.
The charge nurse never assessed the wound.
Inspectors noted the lapse carried potential for more than minimal harm to residents, even if no actual harm was documented.
By then, she had been outside for approximately 45 minutes.
Inspectors also found problems with how medications were labeled.
Inspectors classified the violation as isolated, with no documented actual harm, but with potential for more than minimal harm to the residents involved.