He called his family member to come pick him up.
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He is frequently incontinent of both bowel and bladder and entirely dependent on staff for incontinence care.
R49 said it felt like the concerns had been shrugged off.
The lorazepam, a controlled sedative, had expired on September 16, 2025.
"The definition of neglect is not providing care within standards of practice," the director of nursing told inspectors during an interview on April 28, 2026.
That finding sits at the center of a complaint inspection completed April 29, 2026, at the Norfolk nursing home.
The citation documents a pattern of failures, not an isolated incident.
Inspectors classified the deficiency as isolated, meaning it did not appear to be a pattern running through every unit or shift.
That same morning, inspectors were working through what a three-day stretch of staffing records actually showed.
By 2:50 AM, the nurse had called the Director of Nursing.
On each of those days, meal intake was either missing from the record entirely or the notes contained no explanation for why the resident hadn't eaten.
She needed a walker and a manual wheelchair and required maximum assistance to transfer from one surface to another.