The resident, identified as R9 in inspection records, has severe cognitive impairment with a score of zero out of 15 on cognitive testing.
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Federal inspectors found the unlabeled Humalog insulin pen on December 16 during a medication cart review at Complete Care at Springbrook.
The facility's own policy was specific.
The records tell the story in clinical shorthand.
The complaint inspection, completed December 23, focused on what happened between Resident #1 and Resident #5 earlier that month.
The Director of Nursing entered the new order for hydroxyzine 25 mg twice daily on September 25.
The incident at Elderwood at Lancaster occurred on September 11, 2025, at 8:30 AM.
A formal smoking assessment completed in October 2025 confirmed she was safe to do so.
The resident arrived with two surgical drains attached to his liver following a medical procedure.
The CNA, identified in federal inspection records only as CNA 1, had changed Resident C's brief and repositioned her shortly before.
The facility received **three total deficiencies** during the inspection, including a citation under regulatory tag F0558 for resident rights violations.
Their family member submitted a written request for medical records on December 3.