The use-by date printed on each packet read October 29, 2023.
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The deficiency was classified as affecting many residents.
Federal inspectors documented the finding at F W Huston Medical Center on the morning of August 10, 2025, during an initial walkthrough of the facility.
By July 1, a physician classified it as a Stage 3 pressure ulcer.
Inspectors visited Accela Rehab and Care Center at Springfield on August 14, 2025, following a complaint.
Nobody came for twenty minutes.
Then the director of nursing looked.
He was receiving intravenous antibiotics through a PICC line, a catheter threaded into a large vein, along with insulin and a prescription nasal spray.
The facility's nurses typically work 12-hour shifts, either 7 AM to 7 PM or 7 PM to 7 AM, so the gap was not ambiguous.
R1 said it was too early for his medication.
Crenshaw Blvd., was cited for failing to maintain an environment that supports resident dignity and well-being.
The violation affected some residents and was classified as having minimal harm or potential for actual harm.