Because of that, his care orders required strict single room isolation with contact precautions.
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Three days later, he was on the floor.
That is what inspectors found when they visited Guardian Care and Rehabilitation Center on January 2, 2026.
The resident, identified in inspection records only as Resident 1, had a documented history of falling.
The resident who needed the drug, identified in inspection records as Resident 1, missed twelve doses of Valproic Acid 250 mg before anyone caught the error.
The assistant director of nursing, identified in inspection records only as ADON A, was suspended the day before inspectors completed their review.
Federal inspectors discovered the violation on December 30 during a complaint investigation.
Her pineapple allergy was clearly documented in her ongoing plan of care from October 3, 2024, and noted on her meal ticket.
Resident 9 tested positive for COVID on December 20 and again on December 29, yet remained roommates with Resident 10, who tested negative.
The man, identified in inspection records only as Resident #1, was in his sixties and had been admitted to the facility the previous December.
When a state inspector arrived on January 29, the Dietary Manager sat down with a test tray at 12:30 in the afternoon and demonstrated the problem herself.
The omission came to light during a complaint inspection on January 29, 2026.