The treatment nurse admitted during a September inspection that the resident was "no longer receiving treatment Ciclopirox 8% to the toenails and has not received it for some time now." When asked why, the nurse said she was "unsure why the resident was not receiving the treatment."
The medication lapse occurred even though the podiatrist had ordered continued treatment during a July office visit and reconfirmed the same order in September. The resident's condition showed no improvement during this period, with the doctor noting the "toenails continued to show fungal infection" at the September appointment.
Broadway by the Sea's Assistant Director of Nursing revealed the facility had stopped administering the prescribed Ciclopirox 8% nail lacquer on July 14. The resident should have been receiving daily applications for six months to one year, according to the podiatrist's treatment plan.
The nursing supervisor acknowledged multiple system failures that led to the missed medication. Office visit notes from the podiatrist weren't obtained until the day of the inspection, more than two months after some appointments. The Social Services Director had to specifically call and request the outpatient notes because "they were not in the resident's chart."
"The Office Visit Notes were obtained late for the 7/1/2025 podiatrist visit, and the orders should have been placed the same day or next day and not 11 days later," the Assistant Director of Nursing told inspectors.
She admitted the facility was "unaware of the process for following up on Office Visit Notes" and said it was "important to have the Office Visit Notes available right away for continuity of care."
The nursing supervisor confirmed that according to the doctor's orders, the resident "should still be receiving treatment for her toenails" and was "unsure why the orders were not carried out." She stated directly that "the physicians order for Ciclopirox 8% to the left and right great toes from July to September 2025 was missed and not implemented."
The Director of Nursing acknowledged the potential consequences of the oversight. She told inspectors the missed medication order created "a possibility of causing a delay of care or slowing the progression of healing." The Assistant Director of Nursing similarly stated the error "caused potential for a delay in healing for the resident's left and right great toenail fungus."
Both nursing supervisors emphasized that following physician orders was fundamental to resident care. "It was important to follow and carry out physician's orders because it was part of the care of the residents to promote healing," the Director of Nursing said.
The facility's own policies outlined clear expectations for nursing staff that weren't met in this case. According to the Registered Nurse Job Description, nurses were responsible for "reviewing medication orders for completeness of information and accuracy in the transcription of the physician's order."
The job description also required registered nurses to initiate "requests for consultations and referrals" and consult "with the physicians regarding resident evaluation and planning." Nurses were expected to develop "nursing services to be performed for the resident" and respond to "requests from the resident, physician, or nursing staff."
The Director of Nursing told inspectors the facility should obtain copies of office visit notes "within 72 hours to ensure all recommendations and orders were followed through and carried out." This timeline wasn't met for the resident's podiatrist appointments.
The resident had been seeing the podiatrist regularly for the fungal infection, with documented visits in April, July, and September. At each appointment, the condition persisted without improvement, leading the doctor to continue prescribing the same topical medication.
During the July visit, the podiatrist noted the resident's feet showed "no improvement" and that her "toenails continued to show fungal infection." The doctor ordered her to "continue daily application of Ciclopirox 8% for 6 months to one year on the toenails."
The September follow-up visit revealed the same lack of progress, with the resident reporting "the condition of her feet was the same with no improvement." The podiatrist again documented that her "toenails continued to show fungal infection" and renewed the order to "continue with Ciclopirox 8% on the toenails."
Federal inspectors found the facility violated requirements for ensuring residents receive proper medical care and treatment. The missed medication orders affected the resident's healing process during a critical treatment period when consistent daily applications were medically necessary.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Broadway By the Sea from 2025-09-16 including all violations, facility responses, and corrective action plans.