Thornton Care Center: Missing Seizure Drug Records - CO
The breakdown occurred at Thornton Care Center in July, when LPN #1 was assigned to give medications to Resident #1, a cognitively impaired patient over 65 who requires levetiracetam twice daily to control seizures.
On July 8 and 9, the nurse marked code 9 on the medication administration record for the resident's levetiracetam doses. According to facility records, code 9 means "other/see progress notes" — directing staff to check additional documentation for details about what happened with the medication.
But no progress notes existed.
When federal inspectors reviewed Resident #1's electronic medical record, they found nothing to indicate whether the seizure medication was actually given on either day. The resident's physician had ordered levetiracetam 1000 milligrams twice daily at 6 a.m. and 4 p.m., specifically to treat the resident's epilepsy.
LPN #1 told inspectors on September 2 that he had been unable to locate the medication in order to administer it on both days. He said another nurse eventually found doses in the facility's emergency medication supply, and he gave the levetiracetam to the resident after receiving those doses.
The nurse admitted he should have documented a progress note in the electronic medical record after administering the medication.
Resident #1 was readmitted to Thornton Care Center in July after a hospital discharge on July 9. The resident's diagnoses include epilepsy, moderate cognitive impairment, an unspecified brain injury with loss of consciousness, insomnia, osteoarthritis, a pelvic fracture and a history of falling.
Despite the cognitive impairment, the resident remained independent for bed mobility, sitting, standing, transferring and walking with a walker, according to facility assessments.
The director of nursing confirmed that LPN #1 should have documented corresponding progress notes after the resident's levetiracetam was administered on both days. She told inspectors the nurse was new to the facility and had been unsure how to document that the medication was given after he had already entered code 9 on the medication administration record.
Facility policy requires that medications be administered safely, in a timely manner, and as prescribed. The policy states that each time a medication is administered, it must be documented, and only licensed or permitted persons may prepare, administer and document medication administration.
The documentation failure represents a significant gap in the resident's medical record. Levetiracetam is an anti-seizure medication used to treat epilepsy, and proper documentation of its administration is critical for tracking whether patients receive prescribed doses to control their seizure disorder.
Federal inspectors found the facility failed to maintain medical records in accordance with accepted professional standards for this resident's medication documentation. The violation affected the facility's ability to demonstrate that Resident #1 received proper care during a critical period when the nurse couldn't initially locate the prescribed seizure medication.
The inspection was conducted on September 2 following a complaint. Inspectors reviewed medication records for 14 residents and found documentation problems affecting one resident's epilepsy treatment.
For two consecutive days, there was no reliable record showing whether a cognitively impaired resident with a history of brain injury and falling received the medication prescribed to prevent seizures.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Thornton Care Center from 2025-09-02 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
THORNTON CARE CENTER in THORNTON, CO was cited for violations during a health inspection on September 2, 2025.
On July 8 and 9, the nurse marked code 9 on the medication administration record for the resident's levetiracetam doses.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.