Inspectors arrived at the resident's room on the morning of November 17, 2025, at 10:28 a.m.
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The resident who died, identified in inspection records as R3, had morphine remaining in the medication cart at the time of his death.
The antibiotic was Macrobid, typically used to treat urinary tract infections.
The pattern shows up in the resident council meeting minutes with unusual clarity.
Staff called the nursing home administrator, the NHA, directly.
The incident came to light during a complaint inspection completed November 21, 2025.
Federal inspectors cited the facility in November 2025 for failing to maintain comprehensive care plans that reflected residents' actual needs.
The admission came during a November 2025 federal inspection triggered by complaints.
The Director of Nursing confirmed the gaps on the spot.
That is what a federal inspector found on September 24, 2025, during a complaint inspection at the facility at 46 North Midland Boulevard.
The finding covered a small number of residents.
Federal inspectors arrived at the 925 W.