Staff signed medication records showing they dispensed the controlled substance but failed to record administration on required tracking documents.
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The inspection was triggered by a complaint.
The facility has not submitted a corrective action plan.
"If there are any blank spaces on the CNA reports, that meant that CNA documentation was not done," CNA #4 said in a telephone interview on October 1.
Nobody interviewed the staff who were present.
The incident occurred on a Friday evening when Staff 3, a certified nursing assistant, discovered the residents together.
The deficiency was classified at **Scope/Severity Level D**, meaning the issue was isolated in nature and did not result in documented actual harm.
## Why Dementia Care Training Is a Federal Requirement Dementia affects a substantial proportion of nursing home residents nationwide.
When inspectors raised the issue, a second CNA, not assigned to R9, took one look and confirmed they needed to be trimmed and cleaned.
At one point, she appears to pop a single pill directly into her hand and then walk into the nurses' station with it.
The x-ray revealed a broken tibia.
A Level G citation confirms that investigators verified real, documented harm occurred — not merely a risk of harm or a paperwork deficiency.