Federal inspectors documented the medication errors during a February inspection, finding that staff gave clonidine to the resident when his systolic blood pressure readings ranged from 131 to 177 — all below the physician's order that specified the medication should only be given when readings exceeded 180.
The resident, who has severe cognitive impairment and depends on kidney dialysis, was also taking three other blood pressure medications. A nurse reviewing the case told inspectors the parameters exist "for a reason" and warned of hypotension risks.
"The Resident could bottom out as he/she was also taking valsartan and amlodipine and was on dialysis," Nurse #4 told inspectors on February 18.
In January alone, nurses administered clonidine 27 times out of 93 opportunities when the patient's blood pressure was below the prescribed parameter. The pattern continued into February, with 10 additional improper administrations out of 52 opportunities.
The Director of Nurses acknowledged the safety issue during the inspection. "There is the danger of hypotension if given below range," she told inspectors. "If nursing is checking it off as given when it wasn't, that is not good practice, it's a safety issue."
But the medication records showed clear documentation that nurses had actually administered the drug, not simply failed to document properly. Each entry included nursing initials and checkmarks indicating the medication was given at specific blood pressure readings that fell short of the 180 threshold.
The facility's medication errors extended beyond blood pressure management. Inspectors found nurses failed to track fluid restrictions for two dialysis patients, potentially forcing them into longer dialysis sessions to remove excess fluid buildup.
One patient on a 1500-milliliter daily fluid restriction was observed with a large Styrofoam cup containing approximately 20 ounces of water at his bedside — despite physician orders specifying no water should be left accessible. The patient told inspectors staff sometimes gave him "too much" fluid.
Food service staff weren't notified of the restriction until two weeks after it was ordered, the Food Service Director told inspectors. Meanwhile, nursing staff documented compliance with checkmarks on medication records without recording actual fluid amounts consumed.
"If it's not documented anywhere then she wouldn't know what the fluid intake totals were," one nurse admitted.
A second dialysis patient regularly exceeded his 1200-milliliter restriction, with inspectors observing him consuming over 1000 milliliters of beverages during breakfast alone. Staff provided him with 16-ounce cups of ginger ale when he requested drinks, despite the restriction.
"The staff were clearly not following the fluid restriction as ordered," a unit manager concluded after reviewing the case.
The facility also failed to rotate insulin injection sites for a diabetic resident receiving multiple daily injections. Medical records showed no documentation of injection site rotation from December through February, despite professional standards requiring site rotation to prevent tissue complications that can interfere with medication absorption.
Pain medication was administered outside prescribed parameters to two residents. One patient received the opioid Ultram seven times when his pain levels were below the required threshold of 7-10 on a pain scale. Another received hydromorphone six times for pain levels ranging from 0-5, below the prescribed range of 6-10.
The facility's consultant pharmacist failed to identify these medication irregularities during required monthly reviews, inspectors found.
Staff also administered two different antibiotics simultaneously to a cognitively impaired resident without adequate clinical justification. The patient received both Augmentin and Bactrim for a suspected urinary tract infection that didn't meet the facility's own diagnostic criteria.
The infection preventionist acknowledged the patient "did not have enough criteria to indicate their illness met criteria for a UTI" using established McGeer criteria. The resident was treated with antibiotics before test results were available and continued receiving dual antibiotics even after a chest X-ray showed clear lungs.
"The Resident should not have been administered two antibiotic medications without clinical indications for their use," the Director of Nursing told inspectors.
Beyond medication safety, inspectors documented lapses in basic infection control. A nurse performing wound care failed to sanitize her hands between glove changes during a dressing change for a resident with a stage 4 pressure ulcer and feeding tube.
The facility also failed to maintain required physician visits for three residents. One patient hadn't been seen by a doctor or nurse practitioner for 110 days, far exceeding the required 60-day interval.
Food safety violations included improperly labeled beverages and expired yogurt stored in resident areas. Inspectors found unlabeled trays of prepared drinks and opened thickened beverages without date markings in kitchen refrigerators. Expired yogurt containers from December remained in a unit refrigerator in February.
The facility's quality assurance program lacked documentation and tracking mechanisms. The administrator admitted to inspectors that completed projects weren't monitored for effectiveness and no performance improvement projects were currently active.
"There was not a way to track if QAPI projects were effective or needed to be re-evaluated because they are not monitored," the administrator told inspectors.
The February 19 inspection resulted in citations affecting the majority of the facility's residents across multiple areas of care. The 120-bed facility serves patients requiring skilled nursing care and rehabilitation services.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Carvalho Grove Health and Rehabilitation Center from 2025-02-19 including all violations, facility responses, and corrective action plans.
Additional Resources
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