The medication treats nerve pain and controls seizures.
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The most serious case involved a resident with diabetes and kidney disease whose second right toe had developed a pressure sore.
The incident at Lassen Nursing & Rehabilitation Center on September 3rd began when Resident 1 told staff she was uncomfortable and needed to use the bathroom.
Resident 1's family arrived at 11:00 a.m.
The incident at Infinity Care of East Los Angeles exposed gaps between the facility's written policies and actual practice when responding to potential falls.
Instead of her prescribed medications, the nurse provided blister packs containing drugs intended for two different patients.
Administrator V1 confirmed to inspectors on September 12 that no registered nurse worked in the facility on September 6.
The incident at Kennedy Care Center involved a cognitively impaired resident who requires maximum assistance with daily activities like bathing and dressing.
The facility's own policy required monthly notifications to the state ombudsman's office.
The facility operates with roughly half its required nursing staff, administrators admitted during a September complaint investigation.
Posted signs throughout the facility still displayed contact information for the former abuse coordinator, who had been terminated August 19.
The September inspection revealed far more than flying pests.