The resident, identified in inspection records only as R1, required two staff members for most activities of daily living.
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Inspectors who arrived at the 537 E.
The finding came from a complaint inspection completed November 19, 2025.
She depends on staff and a mechanical lift to move between her bed and her wheelchair.
The resident told the inspector themselves.
Spiriva is not an oral medication.
She refused Spironolactone every single day in October 2025.
He or she said checking on residents every two hours for toileting was about all that was possible.
Inspectors observed the aide, identified as TMA-A, crushing the capsules at 9:09 a.m.
Eight days earlier, on November 9, staff had also started the resident on a probiotic to supplement antibiotic therapy.
The inspection, conducted in response to a complaint, took place on November 17 and 18, 2025.
What they found was a facility that had accepted a medically complex patient without verifying it had the staff or supplies to keep him alive.