The incident at Cedar Creek Nursing and Rehabilitation Center involved a male resident with moderate cognitive impairment who was recovering from cataract surgery. Inspectors discovered the violation during a December 20 complaint investigation.
RN B admitted to leaving Resident #2's Prolensa eye drops at his bedside, acknowledging the resident "was not supposed to have his eye drops at bedside even though he may be able to administer them himself."
The resident had been prescribed one drop daily in his left eye following cataract surgery that began December 8. His medical records showed a BIMS cognitive assessment score of 11 out of 15, indicating moderate impairment that affects memory, thinking and social abilities.
When confronted about the practice, RN B told inspectors it "could be possible that a resident could overdo their eye drops medication but this resident was aware so this would not happen."
Nobody could prove the resident was authorized for self-administration.
The Director of Nursing and Administrator revealed during interviews they "were not aware if Resident #2 could self-administer his medications." When inspectors asked for documentation showing the resident had been assessed as capable of managing his own medication, no records were found.
The facility's own medication policy explicitly prohibits the practice. The 2025 guidelines state that "only the licensed or legally authorized personnel who prepare a medication may administer it" and must record administration immediately on the resident's medical chart.
The Director of Nursing acknowledged that if Resident #2 could not self-administer medication, "they needed to keep these medications on the medication carts and doctor's orders needed to be followed."
Resident #2's care plan, initiated in May 2024, specifically addressed his visual impairment from cataracts and included an intervention to "review medications for side effects which affect vision." The plan made no mention of self-administered eye drops.
The resident wore glasses and had been living at Cedar Creek since his initial admission earlier in the year, with a recent readmission in December coinciding with his cataract surgery treatment.
Federal inspectors noted the deficient practice "could affect residents who received medications for treatments and could result in less potent or adverse effects and drug diversion." Unsupervised access to prescription medications in nursing homes creates opportunities for residents to take incorrect doses or for medications to be stolen or misused by others.
The violation occurred despite the resident's documented cognitive impairment and the facility's clear policies requiring licensed staff supervision of all medication administration. Eye drops, while seemingly benign, can cause serious complications if overused, particularly medications prescribed for post-surgical care.
RN B's admission that the resident "could overdo" the medication while simultaneously claiming it wouldn't happen because the resident was "aware" highlights the contradiction in leaving prescription drugs with a cognitively impaired patient.
The facility failed to follow basic medication safety protocols designed to protect vulnerable residents. The inspection found no evidence that Resident #2 had been properly assessed for self-administration capabilities or that appropriate safeguards were in place.
Cedar Creek's medication policy requires licensed personnel to not only administer drugs but also document each dose immediately. The policy specifically states that medication administrators cannot report off-duty without first recording all administered medications on residents' charts.
The December 21 inspection identified this as a systemic failure affecting medication management practices that could impact other residents receiving treatments. Federal regulations require nursing homes to ensure all drugs and biologicals are stored in locked compartments and labeled according to professional standards.
Resident #2 continues to require daily eye drops as part of his post-surgical cataract treatment, but inspectors found no documentation establishing his cognitive capacity to safely manage this medication independently.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Cedar Creek Nursing and Rehabilitation Center from 2025-12-21 including all violations, facility responses, and corrective action plans.
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