The medication mistakes affected residents with chronic kidney disease and autism spectrum disorder. Federal inspectors found a 11.11% error rate when regulations cap nursing home medication errors at 5%.
Licensed Practical Nurse #100 administered an expired bladder medication to Resident #20 at 8:56 A.M. on November 18. The oxybutynin prescription had ended the day before.
Resident #20 entered the facility five days earlier with chronic kidney disease and atrial fibrillation. The physician had ordered 10 milligrams of extended-release oxybutynin daily through November 17. The nurse gave the medication anyway.
When interviewed three hours later, LPN #100 confirmed the oxybutynin order was no longer active.
Thirty-one minutes after the first error, Licensed Practical Nurse #101 made two medication mistakes with a single resident. She gave Resident #21 the wrong dose of Vitamin B6 and underdosed Tylenol for pain management.
Resident #21 had lived at the facility since March with diagnoses including stroke, autistic disorder and peripheral vascular disorder. The physician's November 2 orders specified Vitamin B6 "one tablet by mouth daily" but listed no dosage amount. A second order called for 1,000 milligrams of Tylenol every six hours as needed for pain.
LPN #101 administered 100 milligrams of Vitamin B6 without physician clarification on the correct dose. She also gave one 325-milligram Tylenol tablet instead of the prescribed 1,000 milligrams.
During her interview, LPN #101 acknowledged she should have called the physician to clarify the Vitamin B6 dosage before administering it. She also verified giving only 325 milligrams of Tylenol when the order specified 1,000 milligrams.
The inspection reviewed 27 opportunities for medication errors across two residents. Three errors occurred, creating the 11.11% rate.
Federal regulations require nursing homes to maintain medication error rates below 5%. The Springfield facility's rate exceeded that threshold by more than 120%.
Both residents had intact cognition according to their assessments. Resident #20's admission evaluation on November 13 showed no cognitive impairment.
The facility housed 108 residents at the time of inspection. Inspectors conducted the review following a complaint filed under number 2666022.
Medication administration errors can cause serious harm to nursing home residents, particularly those with multiple chronic conditions requiring precise dosing. Resident #20's chronic kidney disease makes proper medication management critical, as the kidneys process many drugs.
For Resident #21, the Tylenol underdose meant receiving less than one-third of the prescribed pain relief. The unauthorized Vitamin B6 dose could interact with other medications or exceed safe levels without physician oversight.
The inspection occurred during morning medication rounds when nurses typically distribute the highest volume of daily medications. Both errors happened within a 31-minute window, suggesting systemic issues with medication verification procedures.
Neither nurse appeared to cross-reference active orders before administering medications. The oxybutynin error indicates LPN #100 relied on outdated information or failed to check current prescriptions.
LPN #101's dual mistakes with Resident #21 suggest inadequate attention to dosing requirements. Administering Vitamin B6 without knowing the prescribed amount violates basic medication safety protocols.
The facility must submit a correction plan to continue participating in Medicare and Medicaid programs. Federal officials will monitor compliance with medication administration standards during future inspections.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Aventura At Oakwood Village from 2025-11-18 including all violations, facility responses, and corrective action plans.