The inspection report identifies the resident at the center of the incident only as Resident #1.
Nursing Home News — Page 203
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The drug regimen violation, documented August 29, falls under a category that nursing home regulators treat with particular seriousness.
Whether it had changed in size or condition during those 17 days, nobody could say with certainty, because nobody had properly staged it at admission.
Her own facility's records showed residents weren't always getting the diets meant to prevent exactly that.
A complaint inspection conducted on September 3, 2025, resulted in nine deficiencies cited against the facility.
A male resident was standing in front of her at the end of the bed, fully clothed.
The resident, identified in inspection records only as Resident 1, had multiple pressure injuries.
The resident, identified in inspection records only as R4, had been flagged as a fall risk with impaired cognition.
That admission came from the administrator himself, during an interview with inspectors on September 2, 2025.
The inspection, completed September 4, 2025, was triggered by a complaint.
The medication was lacosamide, a controlled substance used to treat seizure disorders.
The inspection record notes that a few residents were affected.