The nurse worked both shifts when the resident missed her prescribed brimonidine tartrate drops on September 12 and 13, according to inspection records from Central Nursing Home. Under facility policy, unsigned medication records mean the drugs weren't administered.
"The potential effect of missing eye drops as ordered could increase R2's eye pressure," the nurse told inspectors during a December interview about the September incidents.
The medication failures affected two residents at the facility. A second patient with methicillin-resistant staphylococcus aureus infection and cellulitis missed multiple doses of his prescribed antibiotic, daptomycin, which he was supposed to receive intravenously once daily through October 29.
That patient's medication administration record showed no daptomycin doses on September 28, October 1, and October 2. The resident was later transferred to a hospital.
The facility's nurse practitioner, who has worked there since June 2024, said the antibiotic patient "should not miss his antibiotic because it could worsen his infection." She explained that insurance complications initially prevented the facility from obtaining the prescribed daptomycin.
"On September 29, the pharmacy sent a memo that R4's insurance will not cover daptomycin without a prior authorization which she completed on September 29, but it was still not approved," inspection records state. The nurse practitioner ordered vancomycin as an alternative on October 2, but only after being told the original antibiotic wasn't approved.
The glaucoma patient, who has anxiety disorder and major depressive disorder, confirmed the medication lapses during a December 23 phone interview with inspectors. She told them that twice in September, she didn't receive all required doses of her eye drops.
Federal inspectors reviewed medication administration records with the facility's assistant director of nursing on December 30. The administrator confirmed that daptomycin wasn't given to the MRSA patient on the documented dates and acknowledged that "R4 should not miss his antibiotic medication to ensure proper treatment of his infection."
She also confirmed that unsigned medication records for the glaucoma patient's eye drops meant the medications weren't administered.
The glaucoma patient was prescribed brimonidine tartrate ophthalmic solution, with one drop in both eyes every eight hours. Her physician orders, active as of September 1, specifically related the medication to her glaucoma treatment.
The antibiotic patient carried multiple serious diagnoses beyond his MRSA infection and thumb cellulitis, including an open wound on his left thumb and the presence of cardiac and vascular implants. His physician had ordered daily daptomycin intravenous solution specifically for the thumb cellulitis treatment.
Both residents scored 15 on the Brief Mental Status exam, indicating they retained significant cognitive function to understand their treatment needs.
The 18-year veteran nurse who missed the eye drop administrations told inspectors that nurses "should follow doctors order to maintain health of the resident" and that medication administration records "should be signed once medication is given."
Central Nursing Home's own medication administration policy, dated September 2, requires that "medications are administered in a safe and timely manner, as prescribed." The facility's job descriptions for registered nurses 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 assistant director of nursing's acknowledgment that missing antibiotic doses could worsen infections highlights the clinical risks when prescribed medications aren't administered as ordered. For the glaucoma patient, missed eye drops could lead to increased intraocular pressure, potentially threatening her vision.
Federal inspectors classified the violations as causing minimal harm or potential for actual harm, affecting two of five residents whose medication administration they reviewed during the complaint investigation.
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.