That's what inspectors found at Golden Rose Care Center during a complaint inspection completed August 19, 2025.
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The citation fell under a dietary and nutrition deficiency, regulatory tag F0814, which covers how a nursing home disposes of its garbage and refuse.
The sequence of events began on June 16, 2025, when a resident received a dispensed quantity of 60 Oxycodone 10-325mg tablets from the pharmacy.
The deficiency, cited under a category covering quality of life and care, is one of the more fundamental obligations a nursing home carries.
That distinction matters in nursing home oversight.
The inspection was triggered by a complaint and conducted on August 16, 2025.
The violation, documented on August 18, falls under the category of pharmacy service deficiencies.
The inspection took place on August 15, 2025.
Dialysis is not a treatment that tolerates error.
The specific finding: the facility failed to reasonably accommodate the needs and preferences of each resident.
That last part matters less than it might sound.
The facility, located at 16 Fusting Avenue, was cited after inspectors determined that physicians were not being notified when resident medications were held.