The nurse was the Assistant Director of Nursing at Mi Casita Nursing and Rehabilitation Center on Quaker Avenue.
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Two dentists had already told the facility she needed new dentures.
Inspectors documented the lapse during a March 2026 survey.
The man, identified in inspection records as Resident 5, had no care plan addressing his poor vision at the time of a March 2026 complaint inspection.
The error sat in Resident 60's file for weeks.
The inspection took place on March 27, 2026.
The medications were administered each night at 9 p.m.
That is what state inspectors found when they visited the 210 East College facility on December 23, 2025, following a complaint.
The resident, identified in inspection records only as Resident 1, is a patient at Marina Pointe Healthcare & Subacute on Sepulveda Boulevard.
He came into a conference room that afternoon holding a piece of paper with the drug's generic name written on it.
The lapse was caught by federal inspectors during a complaint investigation on December 18, 2025.
Resident 54 had been showing increased hallucinations, delusions, and aggression toward other residents.