The nurse was terminated two days later.
Federal inspectors found that RN #126 at Heights Rehabilitation and Healthcare Center failed to administer medications to Resident #1 on September 9, 2025, causing what regulators called a delay in care. The resident's medications were due at midnight, but the nurse decided not to wake them.
At 4:30 AM, Resident #1 began yelling and calling the nurse derogatory names.
The facility's Director of Nursing told inspectors that Resident #1 "tended to single-out one person and it happened to be RN #126 and there always was an issue with Resident #1 and RN #126." She confirmed that another nurse in the facility could have approached the resident to administer medications instead.
But that didn't happen.
CNA #129 told inspectors that around 4:00 AM, Resident #1 pushed their call light and "was very demanding and rude asking for her medications." RN #126 was on lunch break at the time, so the aide notified the nurse when she returned.
The Director of Nursing verified that RN #126 never called the resident's physician or nurse practitioner to ask about administering the midnight medications late. She also confirmed that Resident #1 could have been given as-needed pain medication.
RN #126 had texted the Director of Nursing asking how to proceed, but inspectors found no evidence she contacted the resident's medical providers.
When questioned by inspectors on September 15, RN #126 acknowledged "it was her duty to administer medications and Resident #1 usually received her as needed medications with her scheduled medications."
The facility had care-planned interventions specifically for Resident #1 regarding medication administration. The Director of Nursing said RN #126 was following the care plan by not waking the resident. But she also admitted that "the RN refusing to administer Resident #1's medications, further elevated her behaviors."
Facility policy requires medications to be administered "in accordance with the orders, including any required time frames." The policy is undated in inspection records.
A disciplinary action form dated September 9 stated that RN #126 "failed to administer scheduled medications causing a delay in care" and "failed to comply with standard nursing practices or facility policy and procedures."
RN #126 was terminated on September 11, 2025.
The facility's behavioral assessment policy calls for the interdisciplinary team to evaluate behavioral symptoms in residents to determine severity, distress, and potential safety risks. Interventions are supposed to be individualized and designed to "understand, prevent and relieve the resident's distress or loss of abilities."
But in this case, inspectors found the nurse's refusal to administer medications actually escalated the resident's distress rather than preventing it.
Federal inspectors investigated the incident as part of complaint number 2618274. They determined the facility failed to ensure medications were administered as ordered, citing minimal harm or potential for actual harm affecting few residents.
The inspection report shows a breakdown in communication and care coordination. While the facility had policies addressing both medication administration and behavioral interventions, staff failed to implement them effectively when Resident #1 needed their scheduled medications.
The Director of Nursing's acknowledgment that another nurse could have administered the medications raises questions about why that alternative wasn't pursued when the primary nurse encountered difficulties with the resident.
Resident #1 waited more than four hours past their scheduled medication time before their distress escalated to the point of yelling and name-calling. The delay occurred despite the resident having a documented history of behavioral issues and care-planned interventions specifically addressing medication administration challenges.
The termination of RN #126 came just two days after the incident, suggesting facility leadership viewed the medication refusal as a serious breach of nursing standards and facility policy.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Heights Rehabilitation and Healthcare Center, The from 2025-11-17 including all violations, facility responses, and corrective action plans.
Additional Resources
- View all inspection reports for Heights Rehabilitation and Healthcare Center, The
- Browse all OH nursing home inspections