The nurse, identified in inspection records as V49, worked the evening shift on September 12 and 13 when the medication administration records show no signature for the resident's brimonidine tartrate drops. She told inspectors during a December 30 phone interview that unsigned medication records mean the drugs weren't given.
"She does not know why she did not sign the MAR on both days for R2's eye drop," the inspection report states.
The resident, who has glaucoma along with anxiety and major depression, was supposed to receive one drop in both eyes every eight hours. Missing those doses could worsen her condition.
But medication failures at the facility weren't limited to eye drops.
Another resident missed three doses of a critical antibiotic used to treat a dangerous infection. The patient, identified as R4, was prescribed daily intravenous daptomycin from September 26 through October 29 to combat cellulitis in his left thumb and a methicillin-resistant staph infection.
Records show he didn't receive the antibiotic on September 28, October 1, and October 2.
The facility's Assistant Director of Nursing told inspectors that R4 "should not miss his antibiotic medication to ensure proper treatment of his infection." The nurse practitioner who prescribed the drug echoed that concern, stating R4 "should not miss his antibiotic because it could worsen his infection."
Insurance complications created part of the problem. The facility's nurse practitioner, V46, explained that the pharmacy sent a memo on September 29 saying R4's insurance wouldn't cover daptomycin without prior authorization. She completed the paperwork that same day, but when approval was denied, she ordered vancomycin as an alternative on October 2.
That gap in coverage meant R4 went without any antibiotic treatment for days while battling a serious infection.
The resident was eventually transferred to a hospital, though the inspection report doesn't specify when or why.
During a December 23 phone call, the resident with glaucoma told inspectors she wasn't given all required doses of her eye drops twice in September. Her account matched what medication records revealed about the missing September 12 and 13 doses.
Federal inspectors reviewed medication administration records for both residents as part of a broader examination of the facility's drug management practices. They found the failures affected two of five residents whose medication records they examined.
Central Nursing Home's own policies require medications be "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 18-year veteran nurse acknowledged those standards during her interview. She told inspectors that nurses "should follow doctors order to maintain health of the resident" and that medication records "should be signed once medication is given."
Yet she offered no explanation for why she failed to follow those basic protocols with the glaucoma patient on her shifts.
The inspection, conducted as a complaint investigation on January 2, found the facility failed to provide appropriate treatment according to physician orders. Federal regulators classified the violations as causing minimal harm or potential for actual harm.
Both residents affected by the medication failures have cognitive impairment, with Brief Mental Status scores of 15. The glaucoma patient also struggles with anxiety and depression. The infection patient faced additional challenges including homelessness and exposure to viral diseases, along with having cardiac and vascular implants.
For the glaucoma patient, those missed eye drops represented more than administrative oversight. Each skipped dose increased pressure in eyes already damaged by disease, potentially accelerating vision loss that proper medication could prevent.
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.