The resident depended on staff for all daily activities and had impairments affecting both upper and lower extremities on both sides of their body.
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Federal inspectors documented the medication security violations during a November 20 complaint investigation.
"I didn't know what is going on," the resident told inspectors the next day.
The resident was transferred to the hospital afterward to rule out a urinary tract infection.
Federal inspectors found the crumbling wall on November 17 during a complaint investigation.
Resident #29 arrived at Timber Springs Transitional Care in July with severe cognitive impairment and anxiety.
Staff A entered Resident #4's room at 10:05 AM on November 20, performed hand hygiene, and put on gloves.
The kitchen manager told inspectors on November 19 that he had seen gnats since February 2025 but never filed a report about the problem.
Resident #3 was on a pureed diet but received a regular meal during lunch on November 9, 2025, at Aviata at the Palms.
Resident #7 requires substantial or maximum assistance for bathing and is completely dependent on staff for toileting hygiene, according to facility records.
She said the facility provided no written notification at discharge and was unaware of her right to appeal or who to contact for support.
Resident 1 failed to return to Virgil Rehabilitation & Skilled Nursing Center on October 7, 2025, after leaving on what staff called an "out on pass" order.