The citation, recorded under federal tag F761, was not the facility's first encounter with this problem.
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The problems were not isolated to a single resident or a single lapse.
The plan wasn't a regulatory abstraction handed down from outside.
The medication at the center of the violation was divalproex sodium, sold under the brand name Depakote.
The resident had no adverse reactions.
The declaration came on February 12, 2025, at 4:23 in the afternoon.
He was found unresponsive in his bed just after midnight on May 13.
The citation, issued under F867, targets the facility's QAPI program directly.
His legs were resting directly on a disposable pad.
Her blood pressure was 144/68 that morning.
The resident, identified in inspection records only as R901, had been admitted to the facility with a broken left femur, diabetes, and hypertension.
Inspectors from the Centers for Medicare and Medicaid Services visited the facility on May 27, 2026, and reviewed care planning for two residents.