The resident, identified in inspection records only as Resident 1, had a history of seizures and behavioral outbursts.
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The inspection at Big Spring Care Center for Rehab and Healthcare, tucked in Humansville in Polk County, was triggered by a complaint.
Inspectors cited the facility under F0583, which covers resident rights to dignity and respect.
Inspectors cited the facility under infection control standards after finding failures in its outbreak response.
The inspection, conducted following a complaint, examined what happened on September 24, 2025, in the room of a resident identified in records as Resident #50.
The medication was eszopiclone, a sedative used to treat insomnia.
The director of nursing told inspectors she had not been aware of how many signatures were missing from the shift count sheets.
Federal inspectors documented the failures after a complaint inspection completed November 19, 2025.
The level of harm inspectors assigned was minimal, and the number of residents affected was listed as few.
The citation covered two separate complaints, filed under numbers 2659561 and 2663004.
The deficiency was one of 11 cited during the complaint inspection.
The resident, identified in inspection records only as Resident 9, had a medical history that made a fall particularly dangerous.