The December 17, 2024 incident at Meadow View Nursing Center illustrates broader medication safety failures documented by federal inspectors during their February 2025 visit. Agency Licensed Practical Nurse 2 took medications to the beauty salon looking for Resident 93, who lived in one room but was found in another resident's room. The nurse asked the hairdresser which resident was Resident 93, and the hairdresser pointed to Resident 81.
"She then tried to administer the medication to Resident 81 thinking that she was Resident 93," the nurse's written statement revealed. "Resident 81 spit the medications out and would not take them."
Resident 81 had dementia and communication deficits related to cognitive impairments. When nurse aides found her in the wrong room and returned her to her assigned space, she had "a moderate-sized emesis of what appeared to be medications," according to nursing notes.
The agency nurse was placed on the facility's "do not return" list for failing to follow medication administration protocols that require checking resident identity three times before giving any medication.
But the medication problems extended far beyond one agency nurse's error.
Two residents received blood pressure medication when their readings were too high for safe administration. Resident 10 got Midodrine despite blood pressures of 130/75, 124/48, 126/60, 122/76, 169/83, and other readings that exceeded the physician's order to hold the medication if systolic pressure was above 120 or diastolic above 80. This happened repeatedly from December 2024 through February 2025.
Resident 57 faced the same problem, receiving Midodrine when blood pressure readings like 106/88, 116/82, 120/88, 128/66, and 126/64 should have triggered staff to withhold the medication.
"Resident 10's one 10 mg tablet of Midodrine should not have been administered on the above dates," the Director of Nursing confirmed to inspectors.
Transcription errors created additional medication hazards. Resident 9 received 30 milligrams of the antidepressant escitalopram instead of the ordered 20 milligrams for six days in late October and early November 2024. A pharmacy audit caught the error — staff had failed to discontinue the old 10 mg dose when increasing to 20 mg.
The same resident later missed doses entirely when a December order to decrease escitalopram from 20 mg to 10 mg daily was transcribed incorrectly. The new 10 mg order never made it into the clinical record, leaving the resident without the medication for two days until another audit discovered the problem.
Resident 3 received the blood thinner Xarelto for four days after physicians ordered it stopped and replaced with a different anticoagulant. Staff administered 20 milligrams of Xarelto on November 26, 27, 28, and 29, 2024, despite the November 25 order to discontinue it.
Controlled substance tracking broke down as well. Staff signed out seven doses of the narcotic Tramadol for Resident 80 between December 2024 and January 2025, but the resident's medical records contained no evidence the medication was actually given. The missing documentation involved doses on December 9, 20, 23, and 29, 2024, plus January 11, 12, and 16, 2025.
One resident's medication was discovered lying on top of bed covers. Resident 57's 100 mg Spironolactone tablet was found on his bed during a February 3 inspection, despite the resident not being approved for self-medication. The Director of Nursing confirmed "the Spironolactone should not have been on his bed."
Intravenous medication management proved equally problematic. Resident 8 was ordered to receive specific amounts of sodium chloride solution intravenously for low sodium and dehydration, but medication records showed no evidence the ordered fluids were administered. The same resident's IV line was supposed to be flushed with saline before and after antibiotic administration, but documentation was missing for multiple dates and shifts.
Resident 117's PICC line required flushing with saline every shift and heparin every night shift for six weeks, but records showed numerous missed flushes. The resident received IV antibiotics Vancomycin and Ceftriaxone without documented evidence of proper line flushing before and after administration.
The medication cart itself violated safety standards. An opened Trelegy Ellipta inhaler for Resident 76 lacked the required date marking to track when it was opened. The manufacturer's instructions specify the inhaler must be discarded six weeks after opening, but without a date, staff couldn't determine if it remained safe to use.
Assessment accuracy suffered alongside medication safety. Nine of 43 residents reviewed had inaccurate Minimum Data Set assessments that form the basis for care planning and Medicare payments. Resident 3's assessment incorrectly indicated no antibiotic use during a period when records showed piperacillin administration. Resident 9's assessment claimed opioid use when none occurred.
Resident 58, who had end-stage renal disease and received dialysis three times weekly, had an assessment incorrectly indicating no dialysis services. Resident 131's discharge assessment listed "home" as the destination when the resident actually went to a hospital.
Care planning gaps left residents without proper safety measures. Resident 88, identified as a fall risk who should wear protective hip pads called "hipsters" when out of bed, fell twice without wearing them. The November 9, 2024 fall occurred in the solarium, with nursing notes specifically documenting "hipsters were not on the resident." A January 31, 2025 fall happened under identical circumstances.
The Director of Nursing acknowledged the hip pads weren't on the nurse aide task list properly, so "the nurse aides were aware the resident should wear them."
Other residents lacked care plans entirely for their medical needs. Resident 45, who required oxygen therapy, had no documented care plan addressing oxygen use despite physician orders for 2 liters per minute via nasal cannula.
Care plans that did exist often weren't updated when conditions changed. Resident 8's care plan continued listing oxygen needs after his oxygen was discontinued in January 2025. Resident 26's care plan still referenced antibiotic therapy and contact precautions for C. difficile infection after both treatments ended.
Record-keeping problems extended beyond medication and care plans. Resident 45's shower documentation repeatedly showed "not applicable" for scheduled shower days with no indication whether showers were offered or refused. Resident 117's medication administration record lacked signatures for antibiotic doses that the pharmacy confirmed were delivered. Resident 122 had similar missing signatures for Vancomycin doses.
Hospice coordination failed for three residents receiving end-of-life care. The facility's policy required obtaining physician certification forms, hospice care plans, and visit documentation within 48-72 hours of hospice admission, but these records were missing for Residents 18, 57, and 93.
Staff performance evaluations weren't completed as required. Nurse Aide 4's annual evaluation was due by April 8, 2024, but no evaluation was documented between March 2023 and January 2025.
The facility had been cited for similar problems during a March 2024 survey, including inaccurate MDS assessments, care plan failures, nursing service deficiencies, medication storage issues, and infection control lapses. Despite developing quality assurance plans to address these issues, the February 2025 inspection found the same categories of violations recurring.
The repeated failures suggest the facility's Quality Assurance Performance Improvement committee has not effectively addressed the root causes of medication errors, assessment inaccuracies, and care planning deficiencies that continue to affect resident safety and care quality.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Meadow View Nursing Center from 2025-02-07 including all violations, facility responses, and corrective action plans.