By the time the facility notified the California Department of Public Health, it was March 26.
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Inspectors found the cup on April 30, 2026, at 12:14 in the afternoon.
When a facility can't confirm what's in a package or how long it's been on the shelf, the margin for error disappears.
The inspection report lists at least one deficiency.
The electrodes had been applied at the hospital on April 13.
The facility's own policy, in place since 2001, requires exactly that.
A formal assessment completed in April rated her cognitive ability for daily decision-making as impaired.
The error happened when RN A searched for Torsemide, a common diuretic used for fluid retention, by typing "TOR" into the electronic system.
That is what inspectors found when they visited Meadowood Nursing Center at 3805 Dexter Lane in late April 2026.
He said he stayed with her during the visit and walked her back to the facility each time.
He was admitted to the facility June 1, 2023.
The inspection, conducted April 29 and 30, 2026, was triggered by a complaint.