The facility's own policy requires medications to be given within one hour of their scheduled time.
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The citation centered on two types of insulin with very different requirements.
The resident, identified as R9 in inspection records, has severe cognitive impairment with a score of zero out of 15 on cognitive testing.
Federal inspectors found the unlabeled Humalog insulin pen on December 16 during a medication cart review at Complete Care at Springbrook.
The facility's own policy was specific.
The records tell the story in clinical shorthand.
The complaint inspection, completed December 23, focused on what happened between Resident #1 and Resident #5 earlier that month.
The Director of Nursing entered the new order for hydroxyzine 25 mg twice daily on September 25.
The incident at Elderwood at Lancaster occurred on September 11, 2025, at 8:30 AM.
The missing narcotics were discovered weeks apart.
The resident arrived with two surgical drains attached to his liver following a medical procedure.
Nothing had changed from what the certified nursing assistant had seen moments earlier.