Federal inspectors found systematic medication fraud and wound care failures at Trellis Centennial during a June inspection, documenting cases where nurses routinely signed off on treatments they never provided.
The most egregious case involved a morbidly obese resident who was supposed to receive compression stockings twice daily to prevent dangerous blood clots. Nurses signed medication records showing they applied the stockings every day for nearly a month. The stockings were never in the resident's room.
"The TED hose devices the facility had in stock were too small," the charge nurse admitted to inspectors. She had personally signed off on applying the stockings eight times in May and June, knowing they didn't exist.
The same resident was ordered to receive Heparin injections every 12 hours to prevent blood clots. Pharmacy records showed the facility received 112 vials of the medication. Nurses documented administering 150 doses — 57 more than the facility actually possessed.
"The number of recorded administrations cannot exceed the number of Heparin vials delivered," the consultant pharmacist told inspectors. The discrepancy "translated to missed doses regardless of whether the facility could provide an explanation or not."
The resident told inspectors the Heparin was "not administered at night," contradicting nursing records that showed twice-daily injections.
Director of Nursing staff confirmed there were "57 more Heparin administrations over the number of Heparin vial deliveries" and could not explain the discrepancy. The facility's medication dispensing system showed zero retrievals of additional Heparin for the resident.
Inspectors calculated a medication error rate of 10.34 percent based on direct observations — more than double the federal maximum of 5 percent. During one medication pass, a nurse gave a resident double the prescribed dose of sodium bicarbonate and administered a vitamin B12 injection into the abdomen when it was ordered for muscle injection.
"Wrong dose of medication could have potentially caused complications," the nurse acknowledged after being confronted.
Wound care violations put residents at additional risk. A resident with stage IV pressure ulcers had surgical wounds left uncovered and exposed to "urine and soft feces" for hours after staff changes soiled dressings.
The resident had undergone toe amputation due to diabetes. A physician ordered elastic bandages applied to the surgical site every shift, but nurses stopped applying them for more than a week without clarification.
"The ACE wrap was somehow reducing the swelling, but was wondering why it was no longer applied," the resident told inspectors while showing a swollen left foot with no bandage.
The wound care treatment nurse was "unsure for what indication" the bandage was ordered and confirmed "there was no previous assessment" of the resident's foot swelling. Weekly skin assessments ordered by physicians were not completed.
Another resident with multiple pressure ulcers had wound dressings soaked with bodily waste. Staff discovered the contaminated dressing during routine care but failed to inform nurses for hours.
"The wound should not be left open to prevent contamination with feces and urine, which could potentially worsen the wound or cause infection," the wound care treatment nurse explained.
Facility policy required wound dressings to be labeled with dates and initials, but inspectors found unlabeled dressings on residents. The wound care nurse admitted being "trained by the former trainer at the facility not to put dates on the dressing."
Pain management failures compounded resident suffering. One resident wore the same lidocaine pain patch for two days straight when it was ordered to be removed every 12 hours. Nursing records falsely showed the patch being removed and replaced daily.
"The Lidocaine patch was helping to alleviate the pain and the desire to receive the patch timely," the resident told inspectors.
A pain specialist warned that leaving patches on too long could cause skin burns, referencing "a previous incident where a resident's skin was burned due to the untimely removal of the patch."
Infection control breakdowns put the entire facility at risk. Staff and visitors routinely ignored contact precautions for residents with dangerous infections including MRSA and C. difficile.
A resident with MRSA bloodstream infection had contact precaution signs posted, but a nursing assistant entered without protective equipment. "Did not realize the resident was on contact precautions," the assistant said.
Family members caring for a resident with C. difficile — a highly contagious intestinal infection — were never informed about precaution requirements. Inspectors observed family members feeding the resident and sitting on the bed without gloves or gowns.
"Not being told by any staff member regarding being required to wear gloves and gown during visits," the family member explained.
An admissions director was observed entering the C. difficile patient's room without protective equipment, then placing arms around family members after leaving — creating what the infection preventionist called "risk for cross contamination."
Medication storage violations created additional safety hazards. Inspectors found loose pills scattered in medication carts, personal food items stored with medications, and an unlabeled cup of white powder sitting on clean supplies.
One nurse failed to log narcotic medication administration in required tracking books. The same cart contained chocolate bars and cheese crackers stored next to medical supplies.
The facility's own policies required medications to be "stored separately from food" and properly labeled, but staff routinely violated these basic safety measures.
These violations occurred despite facility policies that aligned with professional nursing standards. The Director of Nursing acknowledged that false documentation "went against the facility policy on following physician's orders and the five rights of medication administration" and violated the Nurse Practice Act.
Federal inspectors documented these failures across multiple departments, from direct care staff to nursing supervisors. The systematic nature of the violations suggests widespread breakdown in basic patient safety protocols at the 149-bed facility on West Rome Boulevard.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Trellis Centennial from 2024-06-07 including all violations, facility responses, and corrective action plans.