The nurse told inspectors she worked with the resident on September 12 and 13 but didn't know why she hadn't signed the medication record for brimonidine tartrate drops. When medication records aren't signed, it means the medication wasn't given.
"The potential effect of missing eye drops as ordered could increase the resident's eye pressure," the nurse acknowledged during the December inspection.
Federal inspectors found Central Nursing Home failed to administer medications as prescribed to two residents, putting them at risk for worsened medical conditions.
The glaucoma patient, identified only as a resident with anxiety disorder and major depression, told inspectors by phone that she missed required doses of her eye drops twice in September. Her physician had ordered the brimonidine tartrate solution to be instilled in both eyes every eight hours to manage her glaucoma.
Medication records confirmed missed doses on September 12 at 6 a.m. and September 13 at 10 p.m.
A second resident faced more serious consequences from missed medications. The patient, who had cellulitis in his left finger and a methicillin-resistant staph infection, didn't receive his prescribed IV antibiotic daptomycin on September 28 and October 1.
The facility's assistant director of nursing told inspectors the resident "should not miss his antibiotic medication to ensure proper treatment of his infection."
But insurance complications created additional gaps in treatment. On September 29, the pharmacy notified staff that the patient's insurance wouldn't cover daptomycin without prior authorization.
The nurse practitioner, who had been at the facility since June 2024, completed the authorization request that same day. When it wasn't approved, she ordered vancomycin as an alternative on October 2.
"R4 should not miss his antibiotic because it could worsen his infection," the nurse practitioner told inspectors.
The patient had been prescribed daptomycin daily from September 26 through October 29 to treat thumb cellulitis. Medication records showed he also missed his dose on October 2 at 9 a.m., even after the alternative antibiotic was ordered.
The resident was later transferred to a hospital, though the inspection report doesn't specify whether the missed medications contributed to his hospitalization.
Both residents affected by the medication failures had cognitive scores of 15 on their Brief Mental Status exams, suggesting they relied on nursing staff to properly manage their complex medication regimens.
The facility's own policies require medications to 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 who missed the glaucoma patient's eye drops worked the 3 p.m. to 11 p.m. shift, primarily on the first floor. 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.
Her inability to explain the missed doses highlighted a broader pattern of medication administration failures that put vulnerable residents at risk for serious complications.
The inspection, conducted in response to complaints, found that two out of five residents reviewed for medication administration had experienced these dangerous lapses in care.
For the glaucoma patient, missing prescribed eye drops could lead to increased intraocular pressure, potentially causing permanent vision damage. For the patient with the infected thumb and staph infection, missed antibiotic doses risked allowing dangerous bacteria to spread or develop resistance to treatment.
Both residents remained dependent on a nursing staff that had demonstrated it couldn't consistently deliver the basic medication management their conditions required.
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.