Central Nursing Home failed to properly administer medications to two residents during September, according to a federal inspection completed this month. The violations involved a patient fighting methicillin-resistant staphylococcus aureus infection who missed antibiotic doses and a glaucoma patient who didn't receive prescribed eye drops.
The resident with MRSA infection, identified as R4 in inspection records, was prescribed daily intravenous daptomycin from September 26 through October 29 to treat cellulitis in his left finger and an open wound on his left thumb. Medication records show he missed doses on September 28, October 1, and October 2.
"R4 should not miss his antibiotic because it could worsen his infection," the facility's nurse practitioner told inspectors during a December 30 phone interview.
The medication gaps occurred because of an insurance coverage dispute. On September 29, the pharmacy notified the facility that the patient's insurance wouldn't cover daptomycin without prior authorization. The nurse practitioner completed the authorization request that same day, but approval never came through.
She didn't order an alternative antibiotic until October 2, when she prescribed vancomycin after learning the daptomycin wouldn't be approved. During those critical days, the patient received no antibiotic treatment for his MRSA infection.
The resident was later transferred to a hospital, though inspection records don't specify when or why.
The second medication failure involved a resident with glaucoma who missed prescribed eye drops on two consecutive days in September. The patient, R2, requires brimonidine tartrate drops in both eyes every eight hours to control eye pressure and prevent vision loss.
"Twice in September, she was not given all required doses of her eye drops," the resident told inspectors during a December 23 phone interview.
Medication records confirmed missing doses on September 12 at 6 a.m. and September 13 at 10 p.m. The registered nurse who worked those shifts acknowledged she failed to sign the medication administration record for both missed doses.
"She does not know why she did not sign the MAR on both days for R2's eye drop," according to the inspection report. The nurse, who has worked at the facility for 18 years, confirmed that unsigned medication records mean the medication wasn't given.
Missing glaucoma medications carries serious consequences. "The potential effect of missing eye drops as ordered could increase R2's eye pressure," the nurse told inspectors.
Increased eye pressure is the primary mechanism that damages the optic nerve in glaucoma patients, potentially leading to irreversible vision loss or blindness.
The assistant director of nursing reviewed both residents' medication records with inspectors and confirmed the missed doses. She emphasized that the antibiotic patient "should not miss his antibiotic medication to ensure proper treatment of his infection."
Both medication failures violated the facility's own policies. The nursing home's medication administration policy, dated September 2, requires that "medications are administered in a safe and timely manner, as prescribed." Job descriptions for registered and licensed practical nurses specify they must "carry out medical providers orders according to the order and in accordance with local, state, federal, and facility policies and procedures."
The inspection found that out of five residents reviewed for medication administration, two experienced significant failures in receiving prescribed treatments. Both affected residents have cognitive impairment, with Brief Mental Status scores of 15, making them particularly vulnerable to medication errors.
Federal inspectors classified the violations as causing minimal harm or potential for actual harm, but the missed medications could have led to serious complications. Untreated MRSA infections can spread to other parts of the body, while uncontrolled glaucoma progressively destroys vision.
The facility's failure to maintain consistent medication administration put both residents at unnecessary risk during a month when proper treatment was critical for their conditions.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Central Nursing Home from 2026-01-02 including all violations, facility responses, and corrective action plans.