The incident happened on August 28, 2025.
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Not a phone call to the attending physician.
The next night, Resident 1 pushed Resident 2 out of his room.
The medication was logged, received, and then, at some point in the hours that followed, it was gone.
The violation, cited at a level of minimal harm or potential for actual harm, affected a small number of residents.
The facility had no security cameras that might have captured who took it.
The resident, identified in inspection records only as R1, was at a dialysis clinic when staff noticed blood.
"I looked at Point Click Care and told myself I was going to look at [Resident 1]," she said.
The Medication Administration Audit Report, timestamped 11:58 a.m.
The incident unfolded during a medication pass on the 300 hall.
He had told staff he wanted to go home to his family.
When inspectors arrived at Thornton Care Center on August 19, 2025, room temperatures throughout the building were running high.