The incident at Winning Wheels occurred on September 30, when the licensed practical nurse assigned to the night shift reportedly dozed off instead of making medication rounds. Administrator V1 received a phone call at 7 a.m. from the Director of Nursing reporting that the agency nurse "had slept most of the night."
The sleeping nurse, identified as V5, also failed to complete wound treatments and didn't sign medications out of the electronic record system, according to the facility's incident report dated October 8.
Four residents went without their early morning medications that day. The medications skipped included serious prescriptions that require precise timing.
Resident R4 missed nine different medications scheduled for 5 a.m., including levetiracetam for seizures, diazepam for anxiety and muscle spasms, and Norco for pain. The resident also didn't receive fluoxetine for depression, baclofen for muscle spasticity, and omeprazole for acid reflux.
Resident R5 was supposed to receive 15 different medications at 5 a.m. but got none of them. The missed doses included Eliquis, a blood thinner that prevents dangerous clots, furosemide for heart failure, and metoprolol for blood pressure. The resident also missed doxycycline, an antibiotic, and gabapentin for nerve pain.
The third affected resident, R6, missed eight medications including levetiracetam for seizures at a high dose of 2,500 milligrams, Lyrica for nerve pain, and escitalopram for depression. She also didn't receive a scopolamine patch for motion sickness and tizanidine for muscle spasms.
Resident R14 was scheduled to receive five medications at 4 a.m. but received none. The missed medications included baclofen for muscle problems, propranolol for blood pressure, and amantadine, which treats Parkinson's disease symptoms.
When federal inspectors visited in December, Director of Nursing V2 acknowledged the facility had no way to determine whether residents actually received their medications that night. "If there is nothing documented in the residents MAR we would have to go through the medication cards to see if they were popped or not and that was not done," she said.
The medication cards, which would have shown whether pills were removed from their packaging, were dated and could have revealed which medications were actually given. But staff never checked them after discovering the nurse had slept through her shift.
V2 told inspectors she couldn't recall what medications were given and which weren't, but described the process the facility should have followed. "We would have been able to see if they were given or not and depending on time if they could receive it or not."
The electronic medication system created an additional problem. When shifts change, the computer system switches over and displays the next round of scheduled medications. This meant the incoming day shift nurse might not have seen that the previous medications were never administered.
For residents who couldn't communicate about their condition, staff simply watched for signs of pain after the incident rather than determining which medications they'd missed.
The facility's own medication policy requires immediate documentation after giving medications. "After the resident has taken the medication, immediately sign out on MAR. Never delay this action," the policy states.
Federal inspectors were unable to review the medication cards from September for any of the four affected residents during their December visit.
The sleeping incident represents a breakdown in multiple safety systems designed to ensure residents receive prescribed medications. Agency nurses are temporary staff brought in to cover shifts, often with less familiarity with facility procedures and residents' specific needs.
Missing seizure medications can trigger breakthrough seizures in residents who depend on consistent blood levels of the drugs. Skipping blood thinners like Eliquis can increase stroke risk, while missing heart medications can destabilize cardiovascular conditions.
The four residents affected represent a significant portion of the facility's population who depend on precise medication timing for their health conditions. Some residents received as many as 15 different medications in a single morning dose, indicating complex medical needs that require careful attention.
The facility reported the incident internally but the medication cards that could have determined the full scope of missed doses were never examined, leaving uncertainty about which residents received potentially life-sustaining medications and which went without.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Winning Wheels from 2025-12-21 including all violations, facility responses, and corrective action plans.