The medication administration record, which nurses are supposed to fill out every time a controlled substance is given, showed nothing.
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Federal surveyors observed the practice during routine medication administration at Franciscan Woods.
The facility has not submitted a plan of correction for the cited deficiencies.
She told an inspector by phone on December 23 that she had not received all of her required doses twice in September.
Federal inspectors found multiple documentation failures in wound care at Center at Park West during an October 2025 complaint investigation.
The resident had arrived with multiple wounds, including pressure injuries at the sacrococcyx, both heels, and the left lower leg.
The missing equipment violated the facility's own care plans for residents who needed the rails to turn, reposition themselves, and transfer in and out of bed.
Resident #5 at Stone Cottage Care Center had negotiated an unusual arrangement with staff.
A patient with dementia and a documented history of wandering had walked off the secured unit with a group of visitors on November 19.
The administrator confirmed the shower should be clean and maintained in good condition.
The resident required a mechanical lift to move from bed to wheelchair.
The lapse surfaced during a complaint inspection completed December 30, 2025.