Inspectors visited the facility on August 19, 2025.
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Six drugs were scheduled to be administered at 8:00 AM.
The inspection was triggered by a complaint.
The August 25 inspection at Providence Living Center, a complaint investigation, centered on a single resident identified only as R1.
Getting those documents wrong, losing them, or failing to transmit them at the moment a resident is rushed to an emergency room is not a paperwork problem.
Federal inspectors documented the gaps during a complaint inspection completed August 22.
Receptionists had been told to ask her to leave and to call police if she refused.
A volunteer identified in the report had already seen it.
"Residents have complained to me about the staffing cuts that were made," the Director of Nursing said during an August 22 interview.
That resident woke up with burns.
The facility suspended at least one nurse while the investigation continued.
Each time, the call light was on the floor.