The September inspection found that staff gave Resident 10 Baclofen despite knowing the medication accumulates in patients with impaired kidney function and can cause severe neurological side effects including confusion, hallucinations and altered consciousness.
Federal inspectors cited the facility for immediate jeopardy violations after determining the medication error and failure to follow admission protocols put the resident at serious risk.
The facility's own pharmacist told inspectors that Baclofen causes central nervous system depression, dizziness and confusion. "Baclofen cannot be excreted well from the body when the kidneys are impaired and could increase a resident's risk of side effects," the pharmacist stated during a telephone interview.
A nephrologist from Greater Atlantic City Hospital confirmed that while Baclofen isn't directly toxic to kidneys, "it could accumulate in the blood when the kidneys were impaired and cause a resident to have an altered level of consciousness."
The Mayo Clinic warns that Baclofen "must be prescribed and used with caution" and should have "limit use in elderly because of age-related kidney, liver or heart problems." The medication can cause "hallucination, confusion, mental depression, and severe drowsiness" in patients with kidney disease due to "slower removal of medicine from the body."
Resident 10 developed what medical professionals call ALOC - altered level of consciousness - a dangerous condition where patients lose their normal state of awareness and alertness. The complications became life-threatening.
Multiple facility leaders acknowledged the medication error should never have happened.
The facility's Medical Director told inspectors it was "policy and common practice for the doctors and the licensed nurses to conduct a thorough reconciliation of the residents' discharge medications." He emphasized that "licensed nurses were not to transcribe any medication order without the approval of the primary care physician."
The Chief Clinical Officer was more direct during her interview: "Resident 10's complications and the life threatening complications could have been prevented if the admission process was followed."
Administrator stated that "the failure to reconcile the medications with Resident 10's physician should not have happened because the facility has ongoing policies and procedures related to admission medication reconciliation."
An on-call physician covering for Resident 10's attending doctor told inspectors that "the admitting nurse should have contacted the resident's attending physician to discuss the residents' discharge summary and discharge medications to identify and/or resolve any inconsistencies and discrepancies."
The facility's own written policy requires that transfer orders from hospitals "shall be verified with the current order attending physician before medications are administered." The policy specifically states that nurses who transcribe orders must document "the date, time and by whom the orders were noted."
None of this happened with Resident 10.
The inspection narrative indicates nurses simply administered the Baclofen without the required physician consultation, despite the resident's kidney problems making the medication particularly dangerous.
Federal inspectors determined the violation created immediate jeopardy - the most serious level of harm under Medicare regulations, reserved for situations that put residents at risk of serious injury, harm, impairment or death.
Sunnyside Nursing Center is disputing the citation.
The case illustrates how medication errors during nursing home admissions can have devastating consequences, particularly for vulnerable residents with multiple medical conditions. When staff bypass safety protocols designed to catch dangerous drug interactions, residents pay the price with their health and sometimes their lives.
For Resident 10, what should have been a routine admission became a medical emergency that facility leaders admitted was entirely preventable.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Sunnyside Nursing Center from 2025-09-10 including all violations, facility responses, and corrective action plans.