Both went missing from the medication cart on multiple occasions, and nurses noted the gaps in progress notes rather than resolving them.
Nursing Home News — Page 81
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The inspection was triggered by a complaint.
Of all the shower forms reviewed, only two dates, November 9 and November 12, contained any information about skin assessments.
What inspectors documented was a failure of recordkeeping around something nursing homes are expected to track methodically.
Inspectors determined there was no documented actual harm, but concluded the potential for more than minimal harm existed across multiple residents.
The inspection, conducted November 29, 2025, was a complaint survey.
The inspection, completed November 25, 2025, identified the problem as affecting a few residents.
The Director of Nursing told inspectors that since the resident's admission, she had never been able to reach any family members at all.
Someone had written them down and sent them somewhere.
The inspection was triggered by a complaint.
The answer, documented in an inspection report completed in November, was that the facility had not done enough.
What they found when they arrived confirmed it.