Nursing Home News — Page 923

Federal inspectors flagged the language during a November 2025 complaint inspection, citing it as a violation.

Staff signed medication records showing they dispensed the controlled substance but failed to record administration on required tracking documents.

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.