The nurse, identified as LPN #3, attempted to wake Resident #9 to give him his medications but eventually gave up and placed the souffle cup containing the drugs on the bedside table. She told administrators she planned to return later but never did.
The abandoned medications included drugs for muscle spasticity. Resident #9 never took them.
Director of Nursing discovered the violation during the federal inspection on September 22. She found the medication cup still sitting on the resident's bedside table with all four pills inside. The DON told inspectors that leaving medications unattended created a risk that other residents could take the wrong drugs.
"She said if medications were left at a resident's bedside, there was a potential that another resident could take the medications," the inspection report states.
When questioned by administrators, LPN #3 admitted she had placed the medications on the nightstand after trying unsuccessfully to wake the resident. She said she intended to return but forgot.
The DON explained proper procedure to inspectors: nurses should make more effort to wake sleeping residents and stay with them to watch medications being swallowed. If a resident cannot be awakened, the nurse should destroy the unused medications, document they were not given, and notify the physician.
LPN #3 had no idea whether Resident #9 had actually taken his medications. She had already documented them as administered in his medical record.
Two other nurses at the facility described a completely different approach to medication administration. LPN #1 told inspectors she gave medication cups directly to residents and watched them swallow all pills before documenting anything. She said she followed this process because she didn't want to make corrections in medical records if residents refused medications or weren't available.
LPN #2 said she also waited to document medications until after residents had actually swallowed them. She watched residents take their pills "to ensure the resident actually took them and to ensure no one else took the resident's medications."
The facility scrambled to address the violation during the inspection itself. The DON started mandatory medication training for all nurses on September 22 at 1:00 p.m., focusing on the six rights of medication administration. She told inspectors the training would be ongoing, with each nurse receiving instruction before their next shift.
LPN #3 received her initial training over the telephone on September 22, then additional in-person training when she returned for her next scheduled shift.
Federal inspectors interviewed the DON, assistant director of nursing, registered nurse coordinator, and nursing home administrator together on September 23. The DON emphasized that nurses must follow physician orders and observe residents during medication administration to monitor for any adverse effects from taking or not taking prescribed drugs.
The facility implemented alert charting for Resident #9 after discovering he had missed his medications. According to the DON, there was no documentation that the resident experienced additional muscle spasticity from not receiving the drugs he was prescribed.
The violation occurred under federal regulations requiring nursing homes to ensure residents receive medications as prescribed by their physicians. Inspectors classified the harm level as minimal, affecting few residents.
The inspection was conducted in response to a complaint, though the report does not specify the nature of the original complaint that triggered the federal investigation.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Rehabilitation and Nursing Center of the Rockies from 2025-09-23 including all violations, facility responses, and corrective action plans.
Additional Resources
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